Health Promotion International - recent issues

Have the health services reoriented at all?

de Leeuw, E. — 2009-05-08

Sexual behavior and drinking style among teenagers: a population-based study in Finland

Lavikainen, H. M., Lintonen, T., Kosunen, E. — 2009-05-08

In this large-scale study, we examined the relationship between an adolescent’s sexual behavior and drinking style. Three aspects of sexual risk-taking were included: early activity, unprotected sexual intercourse and having sex with multiple partners. A distinction was made between different drinking styles, i.e. alcohol drinking and drunkenness-related drinking. Cross-sectional school survey data from the School Health Promotion Study was collected in Finland in 2002–2003. The national sample consisted of adolescents from the eighth and ninth grades (n = 100 790). The mean ages were 14.8 and 15.8 years. Using logistic regression analysis, we investigated the association between sexual behavior and drinking style among teenagers. The likelihood of engaging in sexual intercourse increased with the frequency of alcohol use. In particular, frequent drunkenness-related drinking increased the probability that the teenager had experienced sexual intercourse. The likelihood of engaging in unprotected sex and/or having multiple sexual partners was many-fold for adolescents drinking frequently until they were in a state of drunkenness. Particularly for girls, weekly drunkenness-related drinking was associated with multiple partners. The vast majority of sexually experienced under-aged adolescents drink alcohol, many of them until they are drunk. Thus, it could be effective to combine both alcohol education and sex education, including contraceptive counseling, in early adolescence.

Consumer testing of the acceptability and effectiveness of front-of-pack food labelling systems for the Australian grocery market

2009-05-08

The placement of nutrition information on the front of food packages has been proposed as a method of providing simplified and visible nutrition information. This study aimed to determine the most acceptable and effective front-of-pack food labelling system for Australian consumers. Consumers' preferences and ability to compare the healthiness of mock food products were assessed for different front-of-pack labelling systems. Four systems were tested, including two variations of the Percentage Daily Intake system (Monochrome %DI and Colour-Coded %DI), which displays the proportion of daily nutrient contribution that a serve of food provides; and two variations of the Traffic Light (TL) system (Traffic Light and Traffic Light + Overall Rating), which uses colour-coding to indicate nutrient levels. Intercept surveys with 790 consumers were conducted, where each participant was exposed to a single labelling system for performance testing. Participants indicated strong support for the inclusion of nutrient information on total fat, saturated fat, sugar and sodium on the front of packages, and a consistent labelling format across all products. Using the TL system, participants were five times more likely to identify healthier foods compared with the Monochrome %DI system [odds ratio (OR) = 5.18; p < 0.001], and three times more likely compared with the Colour-Coded %DI system (OR = 3.01; p < 0.05). Consumers supported the introduction of consistent front-of-pack food labelling. The TL system was the most effective in assisting consumers to identify healthier foods. Mandatory TL labelling regulations are recommended to assist consumers in making healthy food choices.

Wellness appraisal among adolescents in Jordan: a model from a developing country: a cross-sectional questionnaire survey

Haddad, L. G., Owies, A., Mansour, A. — 2009-05-08

The demographic and economic transition that many developing countries, including Jordan, are undergoing is producing important changes in diet and lifestyle that greatly impact the development of chronic illness. The health behavior of adolescents in developing countries constitutes one of the most serious global challenges we face. The purpose of this study was to explore the wellness appraisal of Jordanian adolescents. It specifically describes the (i) self-care and health history pattern, (ii) to assess physical activity and nutrition appraisal, (iii) quality of life appraisal and (iv) school and outside activities appraisal. A self-administrated questionnaire collected the data from adolescent groups (boys and girls.). A multi-stage stratified random sample was obtained from six public schools by first selecting the educational directorate located in the city of Irbid, which is located in the north of Jordan. A random sub sample of six individual schools was then selected. Individual classes were then selected. A total of 269 boys and 261 girls (12–17-year old) were included in the analysis. The results showed that the students engaged in risky health behaviors which could lead to short- and long-term health problems. The most alarming finding of this study was students’ nutritional habits, including less than the daily requirements of fruits, vegetables, milk and meat, while the intake of fast food, soft drinks and sweets were higher than recommended. School-based health promotion and wellness programs should be established in Jordan to influence the health behaviors of adolescents and parents and to avoid further deterioration of their health. Jordanian school curriculum needs to integrate more precise health education programs about diet, exercise, self care and other life style behaviors. More detailed studies are needed with more elaborate instruments about food habits, physical activities and psycho social life.

A retrospective analysis of a community-based health program in Papua New Guinea

Ashwell, H. E. S., Barclay, L. — 2009-05-08

The Women and Children's Health Project was a large Australian funded aid Project that sought to improve the health of women and children in Papua New Guinea between 1998 and 2004. Community development and health promotion interventions aimed to increase community support for attended birth and children's health. Green and Kreuter's [Green, L. W. and Kreuter, M. W. (2005) Health Program Planning: An Educational and Ecological Approach, 4th edition. McGraw-Hill, New York] precede–proceed model of health program planning was applied retrospectively to critique the design, implementation and evaluation of the Project. An outcome evaluation (2006) provided data for this analysis and investigated long-term impact using a multi-methods approach. Application of the precede–proceed model was useful, but the model fails to sufficiently well identify ‘inhibiting factors’ as part of the educational and ecological assessment during the planning phase. Pre-defined objectives and contractually obligated outputs in a donor funded business model negatively influenced Project activity and outcomes. Despite this and the challenging context for implementation, Project interventions improved interaction between the community and health systems, and improved use of maternal child health services.

A comparative study on resilience level between WHO health promoting schools and other schools among a Chinese population

Wong, M. C.S., Lee, A., Sun, J., Stewart, D., Cheng, F. F.K., Kan, W., Ho, M. — 2009-05-08

The WHO health promoting school (HPS) approach covers key areas including school-based programmes improving students' psychological health, but there have been few studies evaluating the resilience performance of these schools. This study compared the resilience scores between schools within the healthy school award (HSA) scheme (HPS group) and those not (non-HPS group). We conducted a cross-sectional survey of grade-one students (aged 12), all teachers and parents of mainstream secondary schools recruited by stratified random sampling in one large Territory of Hong Kong using validated resilience questionnaires during November–December 2005. Four non-HPS and four HPS secondary schools were recruited, respectively, involving 1408 students, 891 parents and 91 teachers, with similar baseline characteristics. The HPS students were found to have better scores than non-HPS students (average age 12.4 year-old in both groups) in all dimensions with significantly higher scores in ‘Peer Support’ (p = 0.013), ‘Making a Difference’ (p = 0.011), ‘About Me’ (p = 0.027) and ‘Generally Happy’ (p = 0.011). There was no difference in the scores between non-HPS and HPS parents. The HPS teachers reported significantly higher scores in ‘Health Policies’ (p = 0.023), ‘Social Environment’ (p = 0.049), ‘School Community Relations’ (p = 0.048), ‘Personal Skills Building’ (p = 0.008) and ‘Partnership & Health Services’ (p = 0.047). The secondary HPS students and teachers reported significantly higher resilience scores than those of non-HPS. This study shows that the HSA scheme under WHO has the potential to exert positive changes in students and teachers and the concept of HPS is effective in building resilience among major school stakeholders.

Understanding suicidality and correlates among Chinese secondary school students in Hong Kong

Lee, A., Wong, S.Y.S., Tsang, K.K., Ho, G.S.M., Wong, C.W., Cheng, F. — 2009-05-08

Suicide has become a leading cause of mortality and morbidity for adolescents in Hong Kong. This study investigated the factors associated with suicidal ideation and attempt among the secondary school students in Hong Kong by studying a representative sample of 3383 students with a self-administered questionnaire and analysed by multiple logistic regressions analysis. Youth risk behaviours, such as heavy smoking, episodic heavy alcohol drinking, early sexual experience, and feeling hopeless, were found to be associated with both suicidal thoughts and attempts, with ‘misuse of drugs’ as discriminating factor that solely related to attempt and ‘involvement in physical fight’ solely related to suicidal thoughts. Addition of suicidal ideation is a significant explanatory variable of suicidal attempt over and above health risk behaviours. Stratified analysis of upper and lower secondary students would give better understanding of significance of various risk factor for different age groups. The disturbing prevalence of suicidal behaviour and its coexistence with other high-risk behaviour in secondary school students have implications for teachers, youth workers and public health practitioners to develop and evaluate programmes for suicide prevention.

Health promoting schools in urban, semi-urban and rural Lao PDR

2009-05-08

Health promoting school activities have been implemented in developing countries, but their experiences have not been fully shared. Our objective is to explore the differences of health promoting school status in urban, semi-urban and rural areas in Lao PDR. To accomplish this we evaluated 138 schools in three provinces using a checklist developed by the government school health taskforce. We interviewed first through fifth grade pupils, school principals, food vendors, community chiefs, and observed school environments. We found that urban and semi-urban schools had higher scores than rural schools in the areas of, "personal health and life skills," "healthy school environment," "health and nutrition services," and "common disease control and prevention." However, semi-urban and rural schools showed better results than urban schools for some questions within the "school and community partnerships" component. When the results of individual schools were examined, there was considerable variation. We found a tendency for higher scores in urban areas, which went down for semi-urban areas and further decreased for rural areas. However, we also found differences among schools within each study site. In conclusion, we found not only a large difference among urban, semi-urban and rural schools but also clear differences in health promoting school status among schools within each study site in Lao PDR. Based on the results, we recommend that each school adopt a tailored approach for the health promoting school programme based upon an analysis of its own scores.

Participation, resource mobilization and financial incentives in community-based health promotion: an economic evaluation perspective from Sweden

Johansson, P. M., Eriksson, L. S., Sadigh, S., Rehnberg, C., Tillgren, P. E. — 2009-05-08

Local community participation is an important objective for many health promotion interventions, but it hinges on the incentives for local organizations to participate. Both aspects might be explored with information obtained from economic evaluations, illustrated in this study with data from a cost-effectiveness analysis of an elderly safety promotion programme implemented in Sweden. Previously, resource mobilization has been used as a process indicator for successful community participation. We propose that resource mobilization can be measured as the proportion of total intervention costs paid by collaborators. In the case presented here, local collaborators contributed 50 per cent of the total intervention costs (SEK 6.45 million, in Swedish krona 2004; 1 USD = 7.35 SEK), while participants, i.e. the elderly in the intervention area, contributed 13 per cent and the remainder, 37 per cent, was paid by project funds. In a subsector financial analysis, the distribution of costs and financial benefits from interventions among different sectors in society is described. The estimated financial benefits in the case were divided between the health-care system (SEK 2.5 million), the local authority (SEK 3.7 million) and the elderly and their relatives (SEK 0.3 million). The only net beneficiary was the local authority. In the case presented here, the health promotion objective of local community participation was achieved as half of the total costs was mobilized from local collaborators. The local community participation objective was supported by financial incentives for at least one key collaborator.

The historical origins of the basic concepts of health promotion and education: the role of ancient Greek philosophy and medicine

Tountas, Y. — 2009-05-08

Although it is commonly accepted that the basic concepts of ‘Health Promotion’ have been developed in the last two decades, they have their roots in ancient civilizations and in particular in Greek antiquity. As evident from medical and philosophical documents of the sixth to fourth centuries B.C., the ancient Greeks were the first to break with the supernatural conceptions of health and disease that had so far dominated human societies. The ancient Greeks developed the physiocratic school of thought, realizing that maintaining good health and fighting illness depend on natural causes and that health and disease cannot be dissociated from particular physical and social environments nor from human behavior. In this context, they defined health as a state of dynamic equilibrium between the internal and the external environment, they took under consideration the physical and social determinants of health, they empowered individuals and communities through new democratic and participatory institutions, they gave emphasis in health education and skill development, they recognized the importance of supportive environments and of healthy public policy and they re-oriented medicine toward a more naturalistic and humanistic perspective. The aim of the present study is to highlight such core concepts from these early times that helped establishing the foundations for health promotion and education in the modern era according to the Ottawa Charter.

Escaping from the Phantom Zone: social determinants of health, public health units and public policy in Canada

Raphael, D. — 2009-05-08

Despite the Canadian record of concern with the social determinants of health (SDOH), actual public health activities consistent with such an approach are sporadic at best. Canadian research and advocacy activities in the service of strengthening the SDOH are so divorced from everyday public policy activity, media discourse and public awareness as to metaphorically suggest that SDOH researchers and advocates exist in a Phantom Zone of irrelevance. Why this might be the case and means of escaping from such irrelevance are presented. Implications for jurisdictions where the situation appears to be even worse—such as the USA—and for those where the situation may be somewhat better are also presented.

Advancing the 'science of delivery' of health promotion: not just the 'science of discovery'

Catford, J. — 2009-01-26

The DREAM model's effectiveness in health promotion of AIDS patients in Africa

2009-01-26

This study evaluates the effectiveness of a holistic model for treating people living with AIDS in Africa; the model aims to improve knowledge about AIDS prevention and care, increase trust in the health centre, impact behaviour, and promote a high level of adherence to HAART. The study took place in the context of the DREAM (Drug Resource Enhancement against AIDS and Malnutrition) programme in Mozambique, designed by the Community of Sant'Egidio to treat HIV patients in Africa. It provides patients with free anti-retroviral drugs, laboratory tests (including viral load), home care and nutritional support. This is a prospective study involving 531 patients over a 12-month period. The patients, predominantly poor and with a low level of education, demonstrated a good level of knowledge about AIDS (more than 90% know how it is transmitted) and trust in the treatment, with a relatively small percentage turning to traditional healers. Overall the patients had a low level of engaging in risky sexual behaviour and a very good level of adherence to HAART (69.5% of the 531 subjects had a pill count higher than 95%). The positive results of the programme's educational initiatives were confirmed with the patients' good clinical results.

Substance use prevention for adolescents: the Icelandic Model

2009-01-26

Data from the European School Survey Project on Alcohol and other Drugs have shown that adolescent substance use is a growing problem in western and particularly Eastern European countries. This paper describes the development, implementation and results of the Icelandic Model of Adolescent Substance Use Prevention. The Icelandic Model is a theoretically grounded, evidence-based approach to community adolescent substance use prevention that has grown out of collaboration between policy makers, behavioural scientists, field-based practitioners and community residents in Iceland. The intervention focuses on reducing known risk factors for substance use, while strengthening a broad range of parental, school and community protective factors. Annual cross-sectional surveys demonstrate the impact of the intervention on substance use among the population of 14- to 16-year-old Icelandic adolescents. The annual data from two cohorts of over 7000 adolescents (>81% response rate) show that the proportions of those who reported being drunk during the last 30 days, smoking one cigarette or more per day and having tried hashish once all declined steadily from 1997 to 2007. The proportions of adolescents who reported spending time with their parents and that their parents knew with whom they were spending their time increased substantially. Other community protective factors also showed positive changes. Although these data suggest that this adolescent substance use prevention approach successfully strengthened a broad range of parental, school and community protective factors, the evidence of its impact on reducing substance use needs to be considered in light of the correlational data on which these observations are based.

Health promotion profile of youth sports clubs in Finland: club officials' and coaches' perceptions

Kokko, S., Kannas, L., Villberg, J. — 2009-01-26

The purpose of this article is to examine the current health promotion orientation of youth sports clubs in Finland in view of the standards created previously for the health promoting sports club (HPSC). Ninety-seven youth sports clubs participated, and 273 sports club officials and 240 coaches answered the questionnaires. To describe clubs health promotion orientations, an HPSC index was created. The HPSC index was formulated on sub-indices by factor analysis. The sub-indices were: policy, ideology, practice and environment indexes. The results indicate that youth sports clubs are fairly health promoting in general. On average, the clubs fulfilled 12 standards for HPSC out of 22. Every fourth club was categorized as higher health promoting (≥ 15 fulfilled standards), and every third as lower health promoting (<11 fulfilled standards). The variation between clubs was wide. The clubs that had been recognized as exemplary and hence certified by the Young Finland Association were more likely to recognize health promotion than non-certified clubs (OR = 2.36, p = 0.016). The sports club officials were twice as likely to evaluate their clubs as higher health promoting than the coaches (OR = 2.04, p = 0.041). Under the sub-indices, ideologies were recognized best, others less. These findings indicate that minority of the youth sports clubs have realized health promotion comprehensively as a part of their activities. There is a lot of need for development, especially in the area of health promotion policies and practices. The instruments used proved valid and reliable and can therefore be recommended for international use.

Impact of health education on health-related quality of life among elderly persons: results from a community-based intervention study in rural Bangladesh

Rana, A.K.M. M., Wahlin, A., Lundborg, C. S., Kabir, Z. N. — 2009-01-26

This study examines the change in health-related quality of life (HRQoL) among (≥60 years) elderly persons as a result of health education intervention. A community-based intervention study was performed in eight randomly selected villages (Intervention: n = 4; Control: n = 4) in rural Bangladesh. A total of 1135 elderly persons was selected for this study. The analyses include 839 participants (Intervention: n = 425; Control: n = 414) who participated in both baseline and post-intervention surveys. Participants in the intervention area were further stratified into compliant (n = 315) and non-compliant (n = 110) groups based on the reported compliance to the intervention activities. The intervention includes, for example, physical activity, advice on healthy food intake and other aspects of management. To create an enabling environment, social awareness was provided by means of information about the contribution of and challenges faced by elderly persons at home and the community, including information about elderly persons' health and health care. The intervention activities were provided to the elderly persons, caregivers, household members and community people for 15 months. The HRQoL was assessed using a multi-dimensional generic instrument designed for elderly persons. Multivariate analyses revealed that in the non-compliant group the probabilities of increased scores were less likely in overall HRQoL (OR 0.52, 95% CI 0.32–0.82). Among the Control group, increased scores were less likely in the physical (OR 73, 95% CI 0.54–0.99), social (OR 0.37, 95% CI 0.27–0.50), spiritual (OR 0.60, 95% CI 0.34–0.94), environment (OR 0.36, 95% CI 0.26–0.49) dimensions and overall HRQoL (OR 0.44, 95% CI 0.32–0.59) (adjusted for age, sex, literacy, marital status and economic status). This study concludes that provision of community-based health education intervention might be a potential public health initiative to enhance the HRQoL in old age.

Staying connected: neighbourhood correlates of social participation among older adults living in an urban environment in Montreal, Quebec

Richard, L., Gauvin, L., Gosselin, C., Laforest, S. — 2009-01-26

Alongside community involvement, promoting social participation has been identified as a key strategy of fostering empowerment, one of the central tenets of the health promotion movement. Engagement in social and productive activities appears to be particularly beneficial to older adults, as it has been found to be associated with positive outcomes on a variety of health indicators. It is therefore critical to identify factors that might lead to greater social participation within these age groups. The objective of this study was to investigate the relationship between perceptions of neighbourhood user-friendliness and social participation while controlling for personal characteristics in a sample of seniors living in an urban environment. A convenience sample of older adults (n = 282) was recruited through community organizations located in high- average- and low-income Montreal neighbourhoods. Data were collected via an interviewer-administered questionnaire assessing social participation and various variables at the neighbourhood level (e.g. housing and social environment, walking environment and transportation, and services and amenities) and at the individual-level (e.g. health status and socio-demographic characteristics). Five variables emerged as independent predictors of social participation. Positive predictors retained in the final regression model included frequent walking episodes (almost every day), higher Vitality and General Health SF-12v2 scores, and perceived accessibility to key resources for older adults. Also included was a negative predictor: age (R² of the final model = 0.28). Implications of the findings for research and action pertaining to ecological, health promotion interventions for older adults are identified.

Intersectoral debate on social research strengthens alliances, advocacy and action for maternal survival in Zambia

Manandhar, M., Maimbolwa, M., Muulu, E., Mulenga, M. M., O'Donovan, D. — 2009-01-26

The Health Promotion Research Centre of the National University of Ireland, Galway and the University of Zambia's School of Medicine conducted operational research to understand and address the socio-cultural and gender contexts of maternal survival. Together with an analytical policy and programming review and qualitative research, the project process also involved the convening of ‘Interest Group’ meetings involving intersectoral stakeholders at Central (Lusaka) and Provincial (Kasama) levels. These meetings aimed to catalyse debate and stimulate advocacy on the project theme by using discussion of qualitative research as entry point. Participants came from government departments, civil society groups, the indigenous health system, academia, technical provider associations, and media, advocacy and human rights organisations.

We found that engagement in Interest Groups was successful at Provincial level with lively participation from civil society, media and advocacy stakeholders and strong engagement by the health system. The process was welcomed as an opportunity to fill gaps in understanding about underlying social determinants of health and jointly explore intervention approaches. Overburdened government staff at central level faced with disease-focused interventions rather than underlying contextual determinants, and a weak culture of health sector engagement with civil society, academics and activists, contributed to less successful functioning in Lusaka. Final Dissemination and Discussion Events incorporated material from Interest Group Meetings to stimulate wider discussion and make recommendations.

This project highlights the potential value of intersectoral stakeholder discussions from the inception stage of research to stimulate intersectoral exchange and alliance building, inform advocacy, and catalyse the process of research into action.

Schools for health, education and development: a call for action

2009-01-26

In 2007, the World Health Organization, together with United Nations and international organization as well as experts, met to draw upon existing evidence and practical experience from regions, countries and individual schools in promoting health through schools. The goal of the meeting was to identify current and emerging global factors affecting schools, and to help them respond more effectively to health, education and development opportunities. At the meeting, a Statement was developed describing effective approaches and strategies that can be adopted by schools to promote health, education and development. Five key challenges were identified. These described the need to continue building evidence and capturing practical experience in school health; the importance of improving implementation processes to ensure optimal transfer of evidence into practice; the need to alleviating social and economic disadvantage in access to and successful completion of school education; the opportunity to harness media influences for positive benefit, and the continuing challenge to improve partnerships among different sectors and organizations. The participants also identified a range of actions needed to respond to these challenges, highlighting the need for action by local school communities, governments and international organizations to invest in quality education, and to increase participation of children and young people in school education. This paper describes the rationale for and process of the meeting and the development of the Statement and outlines some of the most immediate efforts made to implement the actions identified in the Statement. It also suggests further joint actions required for the implementation of the Statement.

Six essential roles of health promotion research centres: the Atlantic Canada experience

Langille, L. L., Crowell, S. J., Lyons, R. F. — 2009-01-26

Over the past 20 years, the federal government and universities across Canada have directed resources towards the development of university-based health promotion research centres. Researchers at health promotion research centres in Canada have produced peer-reviewed papers and policy documents based on their work, but no publications have emerged that focus on the specific roles of the health promotion research centres themselves. The purpose of this paper is to propose a framework, based on an in-depth examination of one centre, to help identify the unique roles of health promotion research centres and to clarify the value they add to promoting health and advancing university goals. Considering the shifting federal discourse on health promotion over time and the vulnerability of social and health sciences to changes in research funding priorities, health promotion research centres in Canada and elsewhere may need to articulate their unique roles and contributions in order to maintain a critical focus on health promotion research. The authors briefly describe the Atlantic Health Promotion Research Centre (AHPRC), propose a framework that illustrates six essential roles of health promotion research centres and describe the policy contexts and challenges of health promotion research centres. The analysis of research and knowledge translation activities over 15 years at AHPRC sheds light on the roles that health promotion research centres play in applied research. The conclusion raises questions regarding the value of university-based research centres and challenges to their sustainability.

Obesity, stigma and public health planning

MacLean, L., Edwards, N., Garrard, M., Sims-Jones, N., Clinton, K., Ashley, L. — 2009-01-26

Given the rise in obesity rates in North America, concerns about obesity-related costs to the health care system are being stressed in both the popular media and the scientific literature. With such constant calls to action, care must be taken not to increase stigmatization of obese people, particularly of children. While there is much written about stigma and how it is exacerbated, there are few guidelines for public health managers and practitioners who are attempting to design and implement obesity prevention programs that minimize stigma. We examine stigmatization of obese people and the consequences of this social process, and discuss how stigma is manifest in health service provision. We give suggestions for designing non-stigmatizing obesity prevention public health programs. Implications for practice and policy are discussed.

Water, ecology and health: ecosystems as settings for promoting health and sustainability

Parkes, M. W., Horwitz, P. — 2009-01-26

Despite the proposed ecological and systems-based perspectives of the settings-based approach to health promotion, most initiatives have tended to overlook the fundamental nature of ecosystems. This paper responds to this oversight by proposing an explicit re-integration of ecosystems within the healthy settings approach. We make this case by focusing on water as an integrating unit of analysis. Water, on which all life depends, is not only an integral consideration for the existing healthy settings (schools, hospitals, workplaces) but also highlights the ecosystem context of health and sustainability. A focus on catchments (also know as watersheds and river basins) exemplifies the scaled and upstream/downstream nature of ecosystems and draws into sharp focus the cross-sectoral and transdisciplinary context of the social and environmental determinants of health. We position this work in relation to the converging agendas of health promotion and ecosystem management at the local, regional and global scales—and draw on evidence from international initiatives as diverse as the WHO Commission on Social Determinants of Health, and the Millennium Ecosystem Assessment. Using water as a vehicle for understanding the systemic context for human wellbeing, health promotion and disease prevention draws inevitable attention to key challenges of scale, intersectoral governance and the complementary themes of promoting resilience and preventing vulnerability. We conclude by highlighting the importance of building individual and institutional capacity for this kind of integration—equipping a new generation of researchers, practitioners and decision-makers to be conversant with the language of ecosystems, capable of systemic thought and focused on settings that can promote both health and sustainability.

Health Promotion International

2009-01-26

Evaluating community-based health promotion initiatives: an ongoing necessity and challenge

St Leger, L. — 2008-11-04

Employees' job satisfaction after the introduction of a total smoke-ban in bars and restaurants in Norway

Hetland, J., Hetland, H., Mykletun, R. J., Aaro, L. E., Matthiesen, S. B. — 2008-11-04

The aim of the study was to investigate possible effects of a total smoke-ban in Norwegian bars and restaurants (introduced on June 1st 2004) on employees' job satisfaction. A national representative sample was randomly selected from the public registry of all companies in the hospitality business. A baseline survey was conducted in May 2004, follow-up measurements were performed in September/October 2004 and May 2005. Altogether, 1525 employees agreed to participate in the baseline survey. Among respondents at baseline, 894 (59.4%) remained in the sample at the first follow-up and 758 (49.7%) at the second follow-up. Analysis of variance for repeated measures revealed a significant three-way interaction between personal smoking behaviour, attitudes towards the ban before it was enacted and time from baseline to the second follow-up. A small decline in job satisfaction was found between baseline and the first follow-up among employees who were daily smokers and had a negative attitude towards the ban. There was, however, an increase in job satisfaction between the first and second follow-up among the others (non-smokers and smokers with a positive attitude towards the ban). While job satisfaction was higher among smokers with negative attitudes towards the ban than among other employees before the ban entered into force, the opposite was the case one year later. The work environments in bars and restaurants seem to have changed towards being more satisfactory for non-smokers and smokers with positive attitudes towards the ban before it was enacted. In contrast, a small but persisting worsening of job satisfaction was found among employees that were daily smokers and had a negative attitude towards the ban.

Setting the stage for school health-promoting programmes for Deaf children in Spain

2008-11-04

Implementing health-promoting programmes for the most excluded and at-risk social groups forms a key part of any efforts to address underserved populations and reduce health inequalities in society. However, many at-risk children, particularly children in Deaf communities, are not reached, or are poorly served, by health-promoting programmes within the school setting. This is so because schools are effective as health-promoting environments for d/Deaf children only to the extent that they properly address their unique communication needs and ensure they are both able and enabled to learn in a communication-rich and supportive psycho-social environment. This article examines how the usually separate strands of school health promotion and d/Deaf education might be woven together and illustrates research with Deaf community members that involves them and gives their perspective. The primary objective of this study was to map Deaf pilot bilingual education programmes in Spain—one of the first countries to ratify the Convention on the Rights of Persons with Disabilities (United Nations. (2006) Convention on the Rights of Persons with Disabilities, Resolution A/RES/61/106.)—with particular attention to their compliance to the Convention's article 24. Following pre-testing, 516 key informants were surveyed by mail (response rate: 42.08%) by using a snow-ball key-informant approach, within a Participatory Action Research framework, at a national, regional and local level. The results show that although some schools have achieved recommended standards, bilingual programmes are in various stages of formulation and implementation and are far from being equally distributed across the country, with only four regions concentrating more than 70% of these practices. This uneven geographical distribution of programmes probably reflects more basic differences in the priority given by regions, provinces, and municipalities to the Deaf community's needs and rights as an important policy objective and may reinforce or widen inequalities by favouring or discriminating rather than achieving access and equity for this noticeably overlooked community.

Preventing childhood obesity: the sentinel site for obesity prevention in Victoria, Australia

Bell, A. C., Simmons, A., Sanigorski, A. M., Kremer, P. J., Swinburn, B. A. — 2008-11-04

In spite of greater awareness of the need for action to reduce obesity, the evidence on sustainable community approaches to prevent childhood and adolescent obesity is surprisingly sparse. This paper describes the design and methodological components of the Sentinel Site for Obesity Prevention, a demonstration site in the Barwon-South West region of Victoria, Australia, that aims to build the programs, skills and evidence necessary to attenuate and eventually reverse the obesity epidemic in children and adolescents.

The Sentinel Site for Obesity Prevention is based on a partnership between the region's university (Deakin University) and its health, education and local government agencies. The three basic foundations of the Sentinel Site are: multi-strategy, multi-setting interventions; building community capacity; and undertaking program evaluations and population monitoring. Three intervention projects have been supported that cover different age groups (preschool: 2–5 years, primary school: 5–12 years, secondary school: 13–17 years), but that have many characteristics in common including: community participation and ownership of the project; an intervention duration of at least 3 years; and full evaluations with impact (behaviours) and outcome measures (anthropometry) compared with regionally representative comparison populations.

We recommend the Sentinel Site approach to others for successfully building evidence for childhood obesity prevention and stimulating action on reducing the epidemic.

Persuasive food marketing to children: use of cartoons and competitions in Australian commercial television advertisements

Kelly, B., Hattersley, L., King, L., Flood, V. — 2008-11-04

While there is a recognized link between high levels of exposure to advertising of unhealthy foods and overweight and obesity among children, there is little research on the extent to which these exposures include persuasive marketing techniques. This study aimed to measure children’s exposure to the use of persuasive marketing within television food advertisements.

Advertisements broadcast on all three commercial Australian television channels were recorded for an equivalent 1 week period in May 2006 and 2007 (714 h). Food advertisements were analysed for their use of persuasive marketing, including premium offers, such as competitions, and the use of promotional characters, including celebrities and cartoon characters. Advertised foods were categorized as core, non-core or miscellaneous foods. Commercial data were purchased to determine children’s peak viewing times and popular programs.

A total of 20 201 advertisements were recorded, 25.5% of which were for food. Significantly more food advertisements broadcast during children’s peak viewing times, compared to non-peak times, contained promotional characters (P < 0.05) and premium offers (P < 0.001). During programs most popular with children, there were 3.3 non-core food advertisements per hour containing premium offers, compared to 0.2 per hour during programs most popular with adults. The majority of advertisements containing persuasive marketing during all viewing periods were for non-core foods.

Persuasive marketing techniques are frequently used to advertise non-core foods to children, to promote children’s brand recognition and preference for advertised products. Future debate relating to television advertising regulations must consider the need to restrict the use of persuasive marketing techniques to children.

Problem and solution trees: a practical approach for identifying potential interventions to improve population nutrition

Snowdon, W., Schultz, J., Swinburn, B. — 2008-11-04

Population nutrition problems have a diversity of contributory factors and, ideally, multi-sectoral solutions should be developed by the relevant stakeholders, based on a common understanding of these factors. The problem and solution tree approach is a participatory process of working through the layers of determinants and then developing potential interventions for a specific issue, using the available data and expertise. We tailored this approach for non-communicable disease-related nutrition problems in Pacific Islands and applied it in several countries. The process led to the identification of a considerable range of determinants of unhealthy diets and potential interventions to improve the situation. This practical approach also offered the additional benefit of developing stakeholder awareness in the issues. Problem trees are a relatively simple tool to implement, easy to adapt to differing needs, can generate a wealth of information and can be more widely used.

Effectiveness of a capacity-building program for community leaders in a healthy living environment: a randomized community-based intervention in rural Vietnam

Hien, L. T. T., Takano, T., Seino, K., Ohnishi, M., Nakamura, K. — 2008-11-04

This randomized controlled study was performed to evaluate the effectiveness of an educational program entitled ‘Capacity building for community leaders in a healthy living environment,’ and to assess the usefulness of a participatory style of education and the applicability of an intersectoral approach in the educational process. An intervention group and a control group (consisting of 150 and 154 community leaders, respectively) were both evaluated, after the intervention group took part in a 5-day participatory-style educational program. Healthy living environment promotion competency (HPC) was evaluated by an instrument consisted of four competency areas: identifying the steps required for a healthy living environment; understanding the principles to reduce potential health risks; providing public health management to improve the living environment; and applying the principles of health communication skills. Scores between the intervention and control groups were examined to identify changes between the baseline and post-intervention periods. A qualitative evaluation of the educational program by participants and facilitators was conducted to assess the appropriateness of the intervention. The results indicated significant increases in the total HPC score and scores of individual HPC competency areas in the intervention group. Thus, the effectiveness of a capacity building program for community leaders in a healthy living environment was demonstrated. Qualitative evaluation revealed that the participatory-style and intersectoral collaboration approach facilitated the educational process. Community leaders, who are representatives of various sectors and mass organizations within the community, can be important implementers in the promotion of a healthy living environment.

Partnership lessons from the Global Programme for Health Promotion Effectiveness: a case study

Corbin, J. H., Mittelmark, M. B. — 2008-11-04

It is an article of faith in health promotion that health challenges cannot be confronted successfully by actors working in isolation. The synergy produced through collaboration is seen as vital. Yet, collaboration is arduous and many collaborations fade before their goals are met. Research is needed to identify factors and processes that promote as well as inhibit the production of synergistic outcomes. To this end, a case study was undertaken of the Global Programme for Health Promotion Effectiveness (GPHPE). The GPHPE reviews and disseminates evidence for the effectiveness of health promotion. Interviews with 20 GPHPE participants were conducted, transcribed and analyzed, and GPHPE documentation provided additional data. The results were used to develop the Bergen Model of Collaborative Functioning. It is a systems model (input, throughput, output) building on earlier research, that adds three new elements suggested by the findings of this study. First, the partnership's mission -- to disseminate evidence of effectiveness -- was identified as a significant input (alongside the conventional inputs of partner resources and financing) that affected the GPHPE's functioning in fundamental ways. Second, positive and negative cycles of interaction were identified that simultaneously strengthened and weakened the GPHPE's ability to sustain itself and produce the desired outcomes. Third, the construct ‘antagony’ was introduced as a unique type of output, in addition to synergy and additive results, representing unwanted and disturbing outcomes. The Model is constructed to have wide applicability, and further research now underway tests its utility in the study of local and national collaborations.

Transferring disease management and health promotion programs to other countries: critical success factors

Azarmina, P., Prestwich, G., Rosenquist, J., Singh, D. — 2008-11-04

Governments and health service providers around the world are under pressure to improve health outcomes while containing rising healthcare costs. In response to such challenges, many regions have implemented services that have been successful in other countries—but ‘importing’ initiatives has many challenges. This article summarizes factors found to be critical to the success of adapting a US disease management and health promotion programme for use in Italy and the UK. Using three illustrative case studies, it describes how in each region the programme needed to adapt (i) the form and content of the disease management service, (ii) the involvement and integration with local clinicians and services and (iii) the evaluation of programme outcomes. We argue that it is important to implement evidence-based practice by learning lessons from other countries and service initiatives, but that it is equally important to take into consideration the ‘3Ps’ that are critical for successful service implementation: payers, practitioners and patients.

Beyond evidence--to ethics: a decision-making framework for health promotion, public health and health improvement

Tannahill, A. — 2008-11-04

Echoing the rise of ‘evidence-based medicine’, the concept of evidence-based policy and practice in the inter-related fields of health promotion, public health and health improvement has attracted increasing attention over the past two decades. More recently, again with roots traceable to biomedical thinking, there has been growing interest in ethics in relation to these fields. This paper links these two topical themes in a practical way. It explores the extent to which policies and activities ‘on the ground’ can and should be based on evidence, and considers the relative places of evidence and ethics in decision-making. It goes on to present the ‘decision-making triangle’, a framework that gives primacy to a set of ethical principles—with available evidence and plausible theory being used to inform the application of these. After introducing the concept of ‘ethical logic modelling’, the paper concludes by suggesting an ‘ethical imperative’ for health promotion, public health and health improvement: to make decisions based on the explicit application of ethical principles, using available evidence and theory appropriately.