Title: Health Promotion in schools, the workplace and the community
1Health Promotion in schools, the workplace and
the community
2Schools
3Walter et al., 1985
- Some school programs have been effective. An
experiment in 22 elementary schools introduced a
carefully designed curriculum with emphasis on
nutrition and physical fitness (Walter et al.,
1985). The schools were randomly assigned so that
their students either participated in the program
or served as a control group.
4Walter et al., 1985
- The researchers compared the two groups after a
year. Relative to the control subjects, the
children who participated in the program showed
improvements in their blood pressure and
cholesterol levels.
5Edwards and Hartwell (2002)
- Edwards and Hartwell (2002) investigated whether
children, aged 8-11 years could correctly
identify commonly available fruit and vegetables
to assess the acceptability of these and to gain
a broad understanding of children's perceptions
of 'healthy eating'. Fruit and vegetables used
were those readily available in retail outlets in
the UK.
6Edwards and Hartwell (2002)
- Data were collected from 221 children using a
questionnaire supported by semistructured
interviews and discussions. Overall, fruit was
more popular than vegetables and recognition of
fruit better melons being the least well
identified.
7Edwards and Hartwell (2002)
- Recognition of vegetables increased with age the
least well identified being cabbage which was
confused with lettuce by 32, 16 and 17 of pupils
in their respective age groups. Most children
(75) were familiar with the term healthy eating,
citing school (46) as the most common source of
information.
8Edwards and Hartwell (2002)
- Pupils showed an awareness and understanding of
current recommendations for a balanced diet,
although the message has become confused. If
fresh fruit and vegetables are to form part of a
balanced diet, the 'health message' needs to be
clear.
9Edwards and Hartwell (2002)
- Fruit is well liked vegetables are less
acceptable with many being poorly recognized,
factors which need to be addressed.
10Parcel, Bruhn, Cerreto, 1986
- Another study found that more children practiced
safety behaviour if they were taught about health
and safety in a 4-year program than if they were
not (Parcel, Bruhn, Cerreto, 1986).
11Kolbe Iverson, 1984
- But many schools do not provide health education
at all, or their programs are under funded,
poorly designed, and taught by teachers whose
interests and training are in other areas (Kolbe
Iverson, 1984).
12Coates et al. (1985)
- Coates et al. (1985) examined the effectiveness
of a 4-week school-based intervention for
decreasing consumption of salty snack foods and
increasing consumption of heart healthy snacks
among African American adolescents.
13Coates et al. (1985)
- One hundred fifty-four students from one high
school received the treatment program, whereas
130 students from another high school served as
the no-treatment control group. The program
incorporated parental involvement, a school wide
media program, and a classroom instruction
program.
14Coates et al. (1985)
- The classroom instruction program included
setting written goals for substituting
heart-healthy snacks for salty snacks. The
treatment program was effective in producing
reductions in salty snack foods, however,
long-term changes were only significant for
students who participated in the classroom
instruction program that incorporated written
objectives.
15Bush et al. (1989)
- Relatedly, Bush et al. (1989) examined the
effects of a 4-year program for reducing coronary
heart disease risk factors among 1,041 African
American adolescents. Participants were randomly
assigned to either a treatment program or a
control program (no treatment).
16Bush et al. (1989)
- The treatment program involved goal setting,
modelling, rehearsal, feedback of screening
results, and reinforcement of healthful eating
behaviours. Treatment participants showed
significant decreases in cholesterol and blood
pressure, which were maintained over a 2-year
follow-up.
17Perry et al. (1989)
- In Perry et als (1989) study, younger children
(ages 89 years) participated in either a
treatment or control school-based program
designed to increase healthy eating habits. The
intervention program included modelling through
stories and role-playing, self-monitoring of
behaviours, behavioural contracting, and material
rewards.
18Perry et al. (1989)
- Treatment participants showed significant
reductions in the use of salt. Together, these
studies reviewed above provide evidence that
incorporating directly observable behavioural
objectivessuch as setting written goals,
modelling behaviours, and providing feedbackcan
successfully result in long-term dietary change.
19Staff support
- Another important aspect of school-based
interventions has been obtaining support from
school staff (e.g., teachers) and school
cafeteria providers.
20Staff support
- Bush et al. (1989) reported that young African
American adolescents who were part of a coronary
heart disease prevention program and were judged
to have the best teachers showed significant
decreases in total serum cholesterol at a 2-year
follow-up.
21Staff support
- Resnicow, Cross, and Wynder (1991) also examined
the effects of a comprehensive school health
education program designed to decrease total
cholesterol in young adolescents. They conducted
three studies with a combined sample of Whites,
African Americans, and Hispanics.
22Staff support
- The program incorporated a teacher component, a
health-screening component, and extracurricular
activities. The teacher component advocated
decision-making, goal setting, and communication
skills. The extracurricular activities included
modifying the school cafeteria, developing recipe
books, and holding heart-healthy bake sales.
23Staff support
- The intervention schools reported significantly
less consumption of high-fat foods in comparison
with no-treatment schools. The intervention
participants also showed 47 decreases in total
cholesterol level across all ethnic groups.
24Staff support
- Although Bush et al. and Resnicow et al. did not
specifically determine which components of their
programs were most effective in creating dietary
change, their findings do provide evidence for
the importance of obtaining support from school
staff and cafeteria providers when designing
dietary interventions for adolescents.
25Healthier food options
- Other investigators have more specifically
modified school cafeteria programs to provide
healthier food options. Parcel, Simons-Morton,
OHara, Baranowski, and Wilson (1989) worked with
the food service personnel to institute specific
goals for dietary change in several school
cafeterias in Houston, Texas.
26Healthier food options
- Their study sample was 62 White, 2I Mexican,
15 African American, and 2 Asian American and
Native American. Participants ranged in age from
5 to 10 years.
27Healthier food options
- School lunches were modified to decrease the
sodium content to less than 600 mg per average
school lunch and to decrease the total fat to 30
and saturated fat to 100 or less of the total
calories per day. New recipes were tested for
taste, texture, appearance, and appeal. The
results demonstrated significant decreases in the
use of salt.
28Healthier food options
- Similarly, in a recent review by Stevens and
Davis (1988) it was found that effective dietary
programs modified the offerings of school
cafeterias to include salad bars, fresh fruit,
and whole grain breads. Continued research is
needed to better understand how programs such as
these might affect specific adolescent minority
groups.
29Pricing
- French et al (2001) examined the effects of
pricing and promotion strategies on purchases of
low-fat snacks from vending machines. Low-fat
snacks were added to 55 vending machines in a
convenience sample of 12 secondary schools and 12
worksites.
30Pricing
- Four pricing levels (equal price, 10 reduction,
25 reduction, 50 reduction) and 3 promotional
conditions (none, low-fat label, low-fat label
plus promotional sign) were crossed in a Latin
square design. Sales of low-fat vending snacks
were measured continuously for the 12-month
intervention.
31Pricing
- Results show that price reductions of 10, 25,
and 50 on low-fat snacks were associated with
significant increases in low-fat snack sales
percentages of low-fat snack sales increased by
9, 39, and 93, respectively. Promotional
signage was independently but weakly associated
with increases in low-fat snack sales.
32Pricing
- Average profits per machine were not affected by
the vending interventions. It is concluded that
reducing relative prices on low-fat snacks was
effective in promoting lower-fat snack purchases
from vending machines used by both adult and
adolescent populations.
33Culturally relevant information
- More recently, investigators have integrated
culturally relevant information into their
school-based dietary interventions. For example,
Schinke, Moncher, and Singer (1994) developed a
cancer risk-reduction program that included a
nutrition focus on reducing fat intake and
increasing such nutrients as fibre and carotene.
34Culturally relevant information
- The study included 368 Native American
adolescents whose schools participated in either
an intervention or a control program.
35Culturally relevant information
- The intervention involved using an interactive
computer program to present information in the
context of a Native American story. The story
emphasised the culturally relevant traditional
advantages of sound nutrition (e.g., natural and
whole foods).
36Culturally relevant information
- A second aspect of the computer program focused
on problem solving and helping adolescents to
offset negative pressures within the context of
the story. The students received positive
feedback on what they had learned through a
computerised post-test.
37Culturally relevant information
- Students in the intervention program showed a
greater increase in knowledge regarding positive
dietary changes than students from schools who
did not receive the intervention. This study did
not include behavioural measures to determine if
this acquired knowledge would generalise to
adolescents behaviour.
38Culturally relevant information
- Nevertheless, this type of program may be
especially effective with minority adolescents
because it is culturally and developmentally
appropriate and has a game like quality.
39Aerobic exercise
- Ewart, Loftus and Hagberg (1995) evaluated the
efficacy of school-based aerobic exercise program
for lowering blood pressure in a high-risk urban
sample of ninth-grade African American girls.
Girls in the intervention group received a
one-term aerobics class of fitness instruction
and training designed to be enjoyable and
engaging for high-risk girls.
40Aerobic exercise
- Eighteen 50-min class periods involved lecture
and discussion and 60 class periods were spent
performing aerobic exercise. Girls assigned
randomly to the control group just received the
regular PE curriculum. After completing the
course 81 wished to continue for another term,
demonstrating their enjoyment and a developing
commitment to regular exercise.
41Peer-based programmes
- We prefer to take advice from people like
ourselves or from people who we respect. It seems
reasonable to suggest, then, that health
education programmes led by your peers will be
more successful than programmes led by adult
strangers or by teachers.
42Peer-based programmes
- Bachman et al. (1988) looked at a health
promotion programme where students were asked to
talk about drugs to each other, to state their
disapproval of drugs and to say that they didnt
take drugs. The idea was to create a social norm
that was against drug taking and also give people
practice in saying no.
43Peer-based programmes
- It was claimed that the programme changed
attitudes towards drugs and led to a reduction in
cannabis use. A similar programme was reported by
Sussman et al. (1995) who compared the
effectiveness of teacher-led lessons with lessons
that required student participation. The study
looked at around 1000 students from schools in
the US.
44Peer-based programmes
- Results suggested that there were significant
changes in attitudes to drugs and intentions to
use drugs in the active participation lessons,
but not in the teacher-led lessons.
45WORKSITE WELLNESS PROGRAMS
46Health hazard appraisal
- An example of a work-based health programme was
introduced at a glass product company in Santa
Rosa, California (Rodnick, 1982, cited in
Feuerstein, 1986, p. 271). A health hazard
appraisal counselling session was carried out
with nearly 300 employees at the company.
47Health hazard appraisal
- As part of the programme, full-time staff were
offered a comprehensive health examination which
included - health history
- weight and height measurement
- blood pressure measurement
- range of blood tests including cholesterol,
liver enzyme level, calcium, protein etc. - TB skin test
- stool test
- physical examination.
48Health hazard appraisal
- This information was used to provide feedback on
the risks of contracting various diseases
including specific cancers and cardiovascular
disease. About two weeks after the tests, the
workers attended a group session where they
received feedback about their health-risk
profiles. They were also given information about
hypertension, heart disease and cancer.
49Health hazard appraisal
- One year later the workers were tested again and
the following improvements in their general
health were observed - decrease in blood pressure (particularly in
individuals with mild hypertension) - reduction in cholesterol levels in men
- decrease in cigarette smoking
- increase in exercise
- increase in breast self-examination (BSE)
- decrease in alcohol consumption in men
- increase in seat-belt use by men.
50Health hazard appraisal
- A survey of over 1,300 worksites with 50 or more
employees found that nearly two-thirds offered
some form of health promotion activity, such as
for fitness and weight control (Fielding
Piserchia, 1989). Some programs award prizes for
losing weight, or pay employees for stopping
smoking, or give bonuses for staying well.
51Health hazard appraisal
- By doing this, employers are helping their
workers and saving a great deal of money. Workers
with poor health habits cost employers
substantially more in health benefits and other
costs of absenteeism than those with good habits.
These savings offset and often exceed the expense
of running a wellness program (Winett, King,
Altman, 1989).
52Health hazard appraisal
- Worksite wellness programs vary in their aims,
but they usually address some or all of the
following risk factors hypertension, cigarette
smoking, unhealthy diets and overweight, poor
physical fitness, alcohol abuse, and high levels
of stress. Housing these programs in workplaces
has several advantages
53Health hazard appraisal
- (a) Most employees go to the workplace on a
regular schedule, facilitating regular
participation in the programs - (b) contact with co-workers can provide
reinforcing social support
54Health hazard appraisal
- (c) the workplace offers many opportunities for
environmental supports, such as healthy food in
the cafeteria and office policies regarding
smoking - (d) opportunities abound for positive
reinforcement for individuals participating in
the programs
55Health hazard appraisal
- (e) programs in the workplace are generally
less expensive for the employee - (f) programs in the workplace are convenient.
(Cohen, 1985, p. 215). - Unfortunately, the employees who do not
participate are often the ones who need it most -
those who report having poor health and fitness
(Alexy, 1991).
56Johnson Johnson's "Live for Life" Program
- Johnson Johnson is America's largest producer
of health care products. They began the Live for
Life program in 1978, and it is one of the
largest, best funded, and most effective worksite
programs yet developed (Fielding, 1990 Nathan,
1984). The number of employees covered by the
program has grown over the years and now exceeds
31,000.
57Johnson Johnson's "Live for Life" Program
- The health goal of the program is to help as many
employees as possible live healthier lives by
making improvements in their health knowledge,
stress management, and efforts to exercise, stop
smoking, and control their weight.
58Johnson Johnson's "Live for Life" Program
- For each participating employee, Live for Life
begins with a health screen - a detailed
assessment of the person's current health and
health-related behaviour, which is shared with
the individual later. After taking part in a
lifestyle seminar, the employee joins action
groups for specific areas of improvement, such as
quitting smoking or controlling weight.
Professionals lead sessions of these action
groups, focusing on how the employees can alter
their lifestyles and maintain these improvements
permanently.
59Johnson Johnson's "Live for Life" Program
- Follow-up contacts are made with each participant
during the subsequent year. The company also
provides a work environment that supports and
encourages healthful behaviour it has designated
no-smoking areas, established exercise
facilities, and made nutritious foods available
in the cafeteria, for example.
60Johnson Johnson's "Live for Life" Program
- All the employees studied completed a health
screen in the initial year and then again in
later years. Compared with the employees at the
companies where Live for Life was not offered,
those where it was have shown greater
improvements in their physical activity, weight,
smoking behaviour, ability to handle job stress,
absenteeism, and hospital medical claims.
61Control Data's "StayWell" Program
- Each StayWell participant completes a health
screening, receives a resulting confidential
health risk profile, and attends a workshop that
focuses on interpreting the profile. The person
can then join courses taught by professionals
that provide information about lifestyle and
health and teach the skills needed to change
unhealthful behaviors. There are courses in
physical fitness, nutrition, weight control,
stopping smoking, and stress management.
62Control Data's "StayWell" Program
- The individual can also join action teams that
focus on two things - (1) making the work environment more healthful,
- (2) forming support groups whereby members help
one another in changing their behaviour. - Evaluation of the StayWell program uses two
approaches. - Some sites did not offer the Staywell program,
and therefore could be used as controls. - Employess exhibited varying degrees of
participation in the Staywell program so
comparisons could be made.
63Smoking reduction
- An attempt to encourage people to quit smoking
was carried out at five worksites. All the sites
received a six-week programme in cognitive
behaviour therapy which focused on the skills of
giving up. The workers who enrolled in the
programmes in four of the sites were put into
competing teams, with the workers at the fifth
site acting as a control. At the end of the
programme 31 per cent of the people in the
programme at the control site and 22 per cent at
the competition sites had stopped smoking.
64Smoking reduction
- A follow-up study after six months found that 18
per cent of the control group and 14 per cent of
the competition groups had stayed off the
cigarettes. This appears to suggest that the
control group were doing better than the
competition groups, but this was not the case. At
the competition sites 88 per cent of the smokers
joined the programme, but only 54 per cent did so
at the control site, suggesting that the
incentive of competition encouraged more people
to attempt to give up.
65Smoking reduction
- When the data was compared for the total number
of smokers at each site to give up, there was an
overall reduction of 16 per cent at the
competition sites and only 7 per cent at the
control site (Klesger et al. 1986).
66Smoking reduction
- A worksite intervention that has grown in
popularity is to ban smoking at work. One of the
questions to consider about this policy is
whether smokers reduce their consumption because
of the ban, or whether they simply adjust their
behaviour and smoke at different times.
67Smoking reduction
- A smoking ban in Australian ambulance crews was
monitored by self-report measures, and also by
physiological measures such as blood and exhaled
carbon dioxide. The measures were taken just
before the ban, just after it, and again six
weeks later.
68Smoking reduction
- The self-report results showed that the ambulance
crews reported less smoking both at the start of
the ban and after six weeks. The physiological
measures, however, returned to the baseline
measures after six weeks, suggesting that the
smokers were finding other times to smoke, or
were maybe finding secret places to smoke while
at work (Gomel et al., 1993).
69Smoking reduction
- This suggests that worksite smoking bans might
well be useful in changing behaviour at work, and
also improving the quality of life for
non-smokers, but their overall effectiveness in
reducing smoking is far less clear.
70Smoking reduction
- The problem of measuring the effectiveness of
worksite health promotion is a general one that
goes beyond quit smoking programmes. A review
of over 100 programmes of worksite health
promotion found that only a quarter of them were
initiated in response to the needs or views of
the workers, and very few involved partnerships
between workers and employers.
71Smoking reduction
- Most of the programmes were aimed at changing
individual behaviour and did not include any
changes in the working environment or working
practices to encourage these behaviours. The
review also noticed a gap between what was
regarded as good practice and what has been
found to be effective in research studies
(Harden, et al., 1999).
72Smoking reduction
- I guess this means that, as with many other
health interventions, people do what they believe
to be the right thing, rather than what research
has told us is the best thing.
73Smoking reduction
- However, health promotion at the workplace has
been successful in reducing absenteeism, health
insurance claims and in improving health
behaviours in weight control, exercise, smoking,
nutrition, and stress management (Jose
Anderson, 1990 Naditch, 1984).
74COMMUNITIES
- Coronary heart Disease and mass media appeals
- It is difficult to evaluate the effect of mass
media appeals. In the case of product advertising
the effect can be measured in sales. In the case
of health behaviour it is difficult to come up
with appropriate measures since there are so many
influences on us every day.
75Coronary heart Disease and mass media appeals
- One of the most famous studies on the
effectiveness of mass media messages was the
Stanford Heart Disease Prevention Programme (see,
for example Farquhar et al., 1977). This study
looked at three similar small towns in the US.
76Coronary heart Disease and mass media appeals
- Two of the towns received a massive media
campaign concerning smoking, diet and exercise
over a two-year period. This campaign used
television, radio, newspapers, posters and
mailshots. The third town had no campaign and so
acted as a control.
77Coronary heart Disease and mass media appeals
- The researchers interviewed several hundred
people in the three towns between the ages of 35
and 60. They were interviewed before the campaign
began, after one year, and again after two years
when the campaign ended.
78Coronary heart Disease and mass media appeals
- The interviews included questions about health
behaviours, knowledge about the risks of heart
disease, and physical measures such as blood
pressure and cholesterol levels. In one of the
two campaign towns, the researchers used the
interview data to identify over one hundred
people who were at high risk of heart disease and
offered them one-to-one counselling.
79Coronary heart Disease and mass media appeals
- The people in the control town showed a slight
increase in risk factors for heart disease, and
the people in the campaign towns showed a
moderate decrease. The campaign produced
increased awareness of the dangers of heart
disease but produced relatively little change in
behaviour.
80Coronary heart Disease and mass media appeals
- The exception to this was the people who had been
offered one-to-one counselling this group
showed significant changes in behaviour. This
study suggests that mass media campaigns by
themselves produce only small changes in
behaviour, but they can act as a cue to positive
action if further encouragement is offered.
81Reducing skin cancer risk
82Reducing skin cancer risk
83Reducing skin cancer risk
- Over the past twenty years there has been a large
growth in the incidence of skin cancers, which
might be due to a combination of changes in the
environment and changes in lifestyles. There are
a number of health promotion campaigns to
encourage safe behaviours in the sun.
84Reducing skin cancer risk
- A study on the effectiveness of these programmes
was carried out by McClendon and Prentice (2001).
White students who chose to tan were given a
health promotion intervention based on protection
motivation theory (PMT).
85Reducing skin cancer risk
- The intervention was made up of brief lectures,
an essay, short discussions and a video about a
young man who died of melanoma (a particularly
dangerous form of skin cancer). There were two
sessions, each just over one hour long and taking
place two days apart.
86Reducing skin cancer risk
- The researchers used psychometric tests to
estimate responses to a range of variables
including - vulnerability
- severity of the threat
- self-efficacy
- costs and rewards
- intentions.
87Reducing skin cancer risk
- With the exception of self-efficacy, these
variables all showed some significant change
after the intervention and remained effective one
month later. However, the issue is not whether
people intend to change their behaviour, but
whether they actually do change their behaviour.
This is always more difficult to measure.
88Reducing skin cancer risk
- In this study, however, they took photographs of
the participants at the start of the study and
again after one month. These pairs of photographs
were then judged by four blind-raters (judges who
did not know whether the pictures were before or
after) to see whether the students skin had
tanned further or become lighter.
89Reducing skin cancer risk
- The students were not aware that this judgement
would take place. Of the 32 individuals
photographed, 23 (72 per cent) were judged to
have lighter skin tone after one month, 4 (12.5
per cent) were rated as having no change and 5
(16 per cent) were judged to have darker skin.
90Homelessness
- Not everybody has equal access to healthcare.
Some members of our society are socially excluded
from the wealth and health that most people
enjoy. One group of people who fall into this
category is the homeless, and one of the
challenges for health promotion is to create
initiatives that deal with their needs.
91Homelessness
- The health status of homeless people is very poor
compared to the general population (Plearce and
Quilgares, 1996). This is true for diet,
malnutrition, substance misuse, mental health
problems, infectious diseases such as
tuberculosis), cardiovascular disease, accidents
and hypothermia.
92Homelessness
- Homeless people commonly come to the attention of
health workers only when they develop an illness
rather than through screening procedures, and
they often use accident and emergency departments
to deal with their health problems (Power et al.,
1999). As a result the regular health promotion
programmes often miss them.
93Homelessness
- There are a number of barriers to health
promotion for homeless people including (Power et
al., 1999) - workers with homeless people are often isolated
and there is not very much collaboration between
the various agencies that work with the homeless
94Homelessness
- health promotion units do not set up many
initiatives aimed specifically at homelessness
and housing - homeless people can feel alienated from health
education messages as they often require a high
level of literacy
95Homelessness
- although homeless people are concerned about
health problems, issues such as low self-esteem
and low expectations can prevent them from taking
part in heath promoting activities.
96The end