Health Promotion in schools, the workplace and the community

1
Health Promotion in schools, the workplace and
the community

• Health Psychology

2
Schools
3
Walter 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.

4
Walter 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.

5
Edwards 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.

6
Edwards 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.

7
Edwards 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.

8
Edwards 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.

9
Edwards and Hartwell (2002)

• Fruit is well liked vegetables are less
  acceptable with many being poorly recognized,
  factors which need to be addressed.

10
Parcel, 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).

11
Kolbe 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).

12
Coates 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.

13
Coates 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.

14
Coates 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.

15
Bush 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).

16
Bush 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.

17
Perry 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.

18
Perry 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.

19
Staff support

• Another important aspect of school-based
  interventions has been obtaining support from
  school staff (e.g., teachers) and school
  cafeteria providers.

20
Staff 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.

21
Staff 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.

22
Staff 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.

23
Staff 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.

24
Staff 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.

25
Healthier 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.

26
Healthier 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.

27
Healthier 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.

28
Healthier 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.

29
Pricing

• 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.

30
Pricing

• 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.

31
Pricing

• 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.

32
Pricing

• 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.

33
Culturally 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.

34
Culturally relevant information

• The study included 368 Native American
  adolescents whose schools participated in either
  an intervention or a control program.

35
Culturally 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).

36
Culturally 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.

37
Culturally 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.

38
Culturally 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.

39
Aerobic 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.

40
Aerobic 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.

41
Peer-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.

42
Peer-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.

43
Peer-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.

44
Peer-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.

45
WORKSITE WELLNESS PROGRAMS
46
Health 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.

47
Health 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.

48
Health 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.

49
Health 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.

50
Health 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.

51
Health 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).

52
Health 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

53
Health 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

54
Health 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

55
Health 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).

56
Johnson 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.

57
Johnson 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.

58
Johnson 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.

59
Johnson 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.

60
Johnson 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.

61
Control 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.

62
Control 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.

63
Smoking 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.

64
Smoking 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.

65
Smoking 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).

66
Smoking 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.

67
Smoking 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.

68
Smoking 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).

69
Smoking 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.

70
Smoking 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.

71
Smoking 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).

72
Smoking 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.

73
Smoking 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).

74
COMMUNITIES

• 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.

75
Coronary 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.

76
Coronary 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.

77
Coronary 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.

78
Coronary 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.

79
Coronary 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.

80
Coronary 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.

81
Reducing skin cancer risk
82
Reducing skin cancer risk
83
Reducing 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.

84
Reducing 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).

85
Reducing 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.

86
Reducing 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.

87
Reducing 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.

88
Reducing 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.

89
Reducing 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.

90
Homelessness

• 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.

91
Homelessness

• 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.

92
Homelessness

• 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.

93
Homelessness

• 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

94
Homelessness

• 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

95
Homelessness

• 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.

96
The end