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Health Promotion

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Title: Health Promotion


1
Health Promotion
Corso di Laurea in Scienze dellEducazione e
della FormazioneUniversità degli Studi di Roma
La Sapienza
  • by Stefania Borgo
  • Second semester Unit Academic Year 2004-2005
  • In collaboration with B. Marshall K.A. Moore
  • Deakin University (Melbourne, Australia)

2
Introduction
3
Aims and Objectives of the Course
  • The aim of this Course is to equip students with
    an understanding of health promotion concepts and
    frameworks as they relate to contemporary health
    issues in Italy and internationally.

4
this will include
  • To examine and apply the range of theoretical and
    practical intervention frameworks used in
    contemporary health promotion
  • To investigate through case study examples
    evidence of health promotion successes and
    failures of health within Italy, Europe and
    internationally
  • To gather and critically analyse sources of
    health information and data relevant to
    contemporary health promotion practice
  • To develop English language skills appropriate to
    health promotion theory and practice

5
Structure of the Course
  • Lecture 12 Understanding health and health
    promotion health promotion concepts, frameworks
    and key documents
  • Lecture 34 The determinants of health
    behavioural, social and environmental
  • Lecture 56 Social and societal determinants of
    health
  • Lecture 78 Models of practice in health
    promotion
  • Lecture 910 Behaviour change theories and
    practice from individuals to communities
  • Lecture 1112 Case studies of health promotion
    practice - guest speakers
  • Lecture 1314 Community engagement and community
    action for health
  • Lecture 1516 Summary. Evidence and evaluation
    in health promotion

6
Lecture 1
7
Health Promotion
  • Health promotion is the process of enabling
    people to increase control over the determinants
    of their health, in order to achieve better
    health.

8
The bio-medical model of health
  • All disease is caused by a specific aetiological
    agent, such as a virus or bacterium.
  • The patient as passive recipient the body is a
    machine that needs fixing, rather than a person
    in a complex social environment.
  • Restoring health (a state of equilibrium in the
    body the parts all working appropriately)
    requires medical technology/intervention.

9
Definitions of Health Promotion
  • Sandy Gifford The action arm of public health.
  • WHO The process of enabling people to exert
    control over the determinants of their health, to
    improve their health.
  • Green Any combination of health education and
    related organisational, economic and political
    changes to promote change at individual, social
    and environmental levels.


10
Health promotion is
  • A process it leads to something, it is a means
    to an end, not an outcome in its own right
  • Enabling it is done WITH and FOR people, not ON
    for T0 them
  • Aimed at strengthening the skills and capacity of
    people to take action about the determinants of
    their health
  • A combination of approaches, so that single
    strand, one-offs are not health promotion

11
Components of personal health
  • Physical health
  • Mental health
  • Social health
  • Emotional health
  • Sexual health
  • Spiritual health

12
Health promotion glossary
13
For the complete list of terms, see
  • Health Promotion Glossary
  • www.wpro.who.int/hpr/docs/
  • glossary.pdf

14
Work in groups
  • www.who.int/en
  • www.who.int/hpr
  • www.wpro.who.int/hpr
  • www.wpro.who.int/hpr/docs/
  • glossary.pdf

15
Lecture 2
16
Health promotion glossary
  • List of Basic Terms

17
Health
  • Health is defined in the WHO constitution of 1948
    as
  • A state of complete physical, social and mental
    well-being, and not merely the absence of disease
    or infirmity.
  • Within the context of health promotion, health
    has been considered less as an abstract state and
    more as a means to an end which can be expressed
    in functional terms as a resource which permits
    people to lead an individually, socially and
    economically productive life.
  • Health is a resource for everyday life, not the
    object of living. It is a positive concept
    emphasizing social and personal resources as well
    as physical capabilities.

18
Health for All
  • The attainment by all the people of the world of
    a level of health that will permit them to lead a
    socially and economically productive life.

19
Public health
  • The science and art of promoting health,
    preventing disease, and prolonging life through
    the organized efforts of society.

20
Primary health care
  • Primary health care is essential health care
    made accessible at a cost a country and community
    can afford, with methods that are practical,
    scientifically sound and socially acceptable.

21
Disease prevention
  • Disease prevention covers measures not only to
    prevent the occurrence of disease, such as risk
    factor reduction, but also to arrest its progress
    and reduce its consequences once established.

22
Health education
  • Health education comprises consciously
    constructed opportunities for learning involving
    some form of communication designed to improve
    health literacy, including improving knowledge,
    and developing life skills which are conducive to
    individual and community health.

23
Health Promotion GlossaryExtended List of Terms
24
Advocacy for health
  • A combination of individual and social actions
    designed to gain political commitment, policy
    support, social acceptance and systems support
    for a particular health goal or programme.

25
Alliance
  • An alliance for health promotion is a
    partnership between two or more parties that
    pursue a set of agreed upon goals in health
    promotion.

26
Community
  • A specific group of people, often living in a
    defined geographical area, who share a common
    culture, values and norms, are arranged in a
    social structure according to relationships which
    the community has developed over a period of
    time. Members of a community gain their personal
    and social identity by sharing common beliefs,
    values and norms which have been developed by the
    community in the past and may be modified in the
    future. They exhibit some awareness of their
    identity as a group, and share common needs and a
    commitment to meeting them.

27
Community action for health
  • Community action for health refers to collective
    efforts by communities which are directed towards
    increasing community control over the
    determinants of health, and thereby improving
    health.

28
See Appendix 1 in Appendices
29
Lecture 3
30
The determinants of health
  • If we are going to improve peoples health, we
    need to identify and target those factors that
    cause / determine their health.
  • There are a number of models of identifying the
    determinants of health.
  • Traditional biomedical.
  • Others.

31
The pre-requisites for health
  • The Ottawa Charter for Health Promotion indicates
    that the fundamental resources and conditions for
    health arepeace, shelter, education, food,
    income, a stable ecosystem, sustainable
    resources, social justice and equity.

32
Marc Lalondes (1974) determinants of health model
  • human biology

lifestyle
environment
health care
33
Some comments on these four determinants
  • Human biology / genetics how much control do we
    have over these? Whose role?
  • Lifestyle and behaviour how much control do
    individuals have over these? How successful have
    we been in changing these?
  • Environmental impacts physical and biological
    environments, but also social, economic etc
  • Health care how much of an impact?

34
The determinants of Health
  • The basic question is WHY does the issue arise.
  • Lets do a mindmap of the issue heart disease
    asking the question WHI? All the time.

35
Health Iceberg(Ryan Travis 1988)
  • Heart
  • State of health Disease
  • Contributing factors genetics,
    high BP,
  • high chol, obesity
  • Lifestyle behaviours smoking,
    alcohol, stress
  • inactivity, poor diet
  • Psycho-sociocultural poor access to
    services/
  • environmental information no support
  • determinants network/resources poor
    self image re exercise
  • poor local facilities dark streets

36
The Health Iceberg
  • Visible above the waterline - the state of health
    we are concerned with.
  • Just below the surface are the known risk factor
    for this health issue.
  • What sets up these risk factors? Lifestyles. What
    are their lives like?
  • But the real question is what creates their
    lifestyles - the psycho-socio-cultural
    environment.

37
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38
The bottom layer of the iceberg
psycho-socio-cultural determinants
  • Individual
  • Values
  • Attitudes
  • Beliefs
  • Resources
  • Skills
  • Knowledge
  • Feelings
  • Community
  • Resources
  • Opportunities
  • Culture
  • Settings
  • Legislation
  • Politics
  • Discrimination

39
The Iceberg Model of the Determinants of Health
  • What conclusions can we draw about the
    determinants of health from the examples we have
    worked through.

40
Environments for health
  • A study in Glasgow compared a rich neighbourhood
    with a poor one.
  • Physical activity
  • nearly twice as many facilities per capita in the
    rich area
  • far lower levels of car ownership in the poorer
    area
  • far less public transport in the poorer area
  • streets in the poor area were less well
    maintained, more litter, more derelict buildings,
    more street crime, especially after dark

41
Glasgow study continued Nutrition
  • People in the poorer area less likely to eat
    well.
  • Shopping basket survey a less healthy and a
    more healthy basket
  • In both areas, the more healthy basket was
    dearer than the less healthy
  • But the difference between them was greater in
    the poorer area healthy food was dearer in the
    poorer area.
  • Availability of less healthy same in both
    areas, but more healthy not nearly as
    accessible in the poorer area.

42
Social geography
  • Macintyre and Ellaway article (Health Promotion
    Journal of Australia 9(3) 165-170).
  • Compare richer and poorer areas of Glasgow
  • Physical activity
  • Resources for physical activity 1.05
    facilities/1000 people in richer versus 0.6
  • Cars 58 in richer have access vs 38 in poorer
  • Bus routes markedly lower in the poorer area
  • Local area poorer had significantly more street
    crime, litter, syringes, derelict houses, so was
    less attractive for walking etc.

43
Social geography cont.
  • Healthy eating
  • Poorer area had significantly poorer diet
  • Richer had far greater range of food shops
  • Shopping basket survey both the more healthy
    and the less healthy basket cost more in the
    poorer area and the difference b/w these is
    greater in the poorer area
  • Healthier items had a much lower availability in
    the poorer area.

44
Social geography cont.
  • Community resources
  • Fewer community services, such as bank, GP,
    shops, in the poorer area
  • Far greater distance to travel to use community
    facilities

45
Groups Work Health data in Italy www.euro.who.int
/hfadb www.who.dk/countryinformation àItalyàcount
ry profile (Highlights on health in Italy)
46
Lecture 4
47
Marc Lalondes (1974) determinants of health model
  • human biology

lifestyle
environment
health care
48
Determinants of health and illness
  • Two main approaches
  • Epidemiological
  • Social
  • Both see health as arising from the everyday
  • Social
  • Physical
  • Environmental, and
  • Economic lives of people

49
Epidemiological approach
  • A focus on risk
  • Health determinants are entities that influence
    health from the perspective of risk. These
    include
  • Risk factors that result from behaviour or
    environmental exposure
  • Risk conditions that are more fundamental causes
    of ill health, such as social deprivation and
    powerlessness

50
Social science approaches
  • The inter-relationships between social
    circumstances that inter-relate, eg
  • Poverty, wealth and income distribution
  • Psycho-social health or deprivation
  • Powerlessness
  • Social factors age, sex, race, etc
  • Level and quality of education and literacy
  • Personal health resources and coping
  • Socio-ecological environments.

51
Children Environmental Health
  • An Italian priority within an international
    perspective

See Appendix 2 in Appendices
52
Lecture 5
53
The Social Determinants of Health
54
Growing awareness since 1970s
  • Black Report (1980) stunned Britain with its
    revelations about health inequalities
  • Lalonde Report (Canada 1974) revealed similar
    inequalities
  • US - shocking variations in level of health and
    access to health care
  • In all countries - health and wealth are linked.
    SES a prime predictor of health

55
A better understanding of the social determinants
of health
  • Clearly the social situation in which people live
    their lives significantly affects their health
    poorer people have significantly worse health
    than wealthier people.

56
The Solid Facts
  • Social gradient
  • Stress
  • Early life
  • Social exclusion
  • Work
  • Unemployment
  • Addiction
  • Food
  • Transport
  • Social support
  • Discrimination

http//www.who.dk/document/e59555.pdf
57
Occupational class differences in life
expectancy, England and Wales, 1997-1999
58
Risk of diabetes in men aged 64 years by birth
weigtht Adjusted for body mass index
59
Proportion of children living in poor households
(below 50 of the national average income)
60
Self-repoted level of job control and incidence
of coronary heart disease in men and women
61
Effect of job insecurity and unemployment on
health
62
Socioeconomic deprivation and risk of dependence
on alcohol, nicotine and drugs, Great Britain,
1993
63
Groups Work
  • The solid facts
  • http//www.who.dk/document/e59555.pdf

64
Lecture 6
65
Social capital
  • One of a range of capitals economic, cultural
    and social. Likely to be linked.
  • Despite confusion about the term, there is
    agreement of the importance of networks between
    people because they build trust and encourage
    cooperation for mutual benefit.
  • Complex link to health.

66
Active organizational involvment, 1973-1994
67
Four decades of dwindling trust Adults and
teenagers, 1960- 1999
68
Schools work better in high social capital states
69
Health is better in high social capital states
70
Death rate vs level of comunity trust
Percent Responding Most people would try to
take advantage of you if they got the chance.
71
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72
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73
Depression link to hearth disease
  • Depression and loneliness are bigger risk factors
    for heart disease than stress, ranking alongside
    smoking, high blood pressure and cholesterol.
  • National Heart Foundation
  • Expert working group
  • The Age, page 6. 17 March 2003

74
Bunker et al, MJA 178, pp272-276
  • Strong consistent evidence of an independent
    causal association b/w depression, social
    isolation, and lack of quality social support and
    the causes and prognosis of CHD.
  • No strong or consistent evidence for causal
    association between chronic life events,
    work-relate stressors, Type A behaviour,
    hostility, anxiety disorders or panic disorders,
    and CHD.

75
Bunker et al, MJA 178, pp272-276 cont.
  • The increased risk contributed by these
    psychosocial factors is of similar order to the
    more conventional CHD risk factors such as
    smoking, dyslipidaemia and hypertension.
  • The identified psychosocial risk factors should
    be taken into account in individual CHD risk
    assessment and have implications for public
    health policy and research.

76
Measuring social capital
  • Baums questionnaire in SA
  • - Social participation, informal
  • - Social participation, activities in public
    spaces
  • - Social participation, group activities
  • - Civic participation, individual activities
  • - Civic participation, group activities
  • - Community group participation, mix of civic
    and social

77
Social capital and health
  • Population health
  • Income distribution and health are both linked to
    social involvement and trust
  • Lynchs work on income inequality vs life
    expectancy
  • Individual health
  • Social connectedness protective of health

78
The dark side of social capital
  • Is social connectedness and inclusion sometimes
    established and maintained by defining the us
    and them, of establishing boundaries and
    barriers that exclude some so that those inside
    can feel part of a strong network or community?
  • Can you think of any groups in Italy who
    establish identity, belonging and connectedness
    in this manner?

79
NHPAs Risk and Protective Factors
P ESTABLISHED ASSOCIATED/COMORBIDITY ?
POSSIBLE
80
Protective Factors Healthy Conditions
Psychosocial Effective Health
Healthy Lifestyles Environments
Factors Services safe
physical enviros. social networks
preventative services reg.physical act. healthy
public policy power control
culturally approp. pos. mental health
Quality of life, functional independence,
wellbeing, mortality, morbidity, disability
Risk Conditions Psychosocial
Behavioral Risk Physiological
Risk Factors Factors
Factors poverty isolation
smoking high BP low
social status low sense of purpose
poor nutrition high cholesterol
Risk Factors
81
The patient and the urban environment
  • See Appendix 3 in Appendices

82
Lecture 7
83
Strategies and Methodsin Health Promotion
84
Some fundamental considerations
  • What are the priority health issues? Who
    determines? What criteria?
  • Prevalence
  • Severity
  • Amenability to intervention
  • Special groups
  • Addressing the major determinants of the health
    issue those that can be modified

85
What approach?
  • Socio-environmental vs individual
  • Poverty
  • Lack of education
  • Unemployment
  • Policy change
  • Problematic behaviours
  • Knowledge
  • Personal beliefs
  • Values
  • High risk vs low risk/whole population

86
Which population group to choose?
87
Downs Syndrome
88
Downs Syndrome
89
Another esample CHD
90
High risk vs whole population?
  • Where will we get most impact?
  • Do we/can we screen to identify high risk
    individuals or initiate whole-population
    approaches?
  • The paradox of prevention occurs when a large
    number of people at small risk may give rise to
    more cases of a disease than the small number at
    high risk.

91
High risk vs whole population?
  • For many health issues, get better results from
    whole population approaches e.g. heart disease,
    mental health, safe sex
  • Reducing risk factors in one person does nothing
    to stop others entering the high-risk pool no
    change in the distribution of the disease,
    because non attention to the forces that lead to
    risk factor.

92
High risk vs whole population?
  • Ethical and social implications we are asking
    the majority to change their behaviour when many
    of them will see no benefit, in fact may
    experience some harm (e.g. sporting injury)

93
Strategies and Methods
  • Ottawa Charter
  • Build healthy public policy
  • Create supportive environments
  • Strengthen community action
  • Develop personal skills
  • Reorient health services
  • Action verbs enable, mediate an advocate

94
  • Read glossary terms
  • Enabling
  • Mediation
  • Advocacy for health

95
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96
Groups work Find and comment Ottawa Charter
97
Lecture 8
98
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99
Types of intervention
  • Medical approach
  • Improving physiological risk factors eg high
    blood pressure, early cancer detection
  • Behaviour / Lifestyle approach
  • Improving behavioural risk factors eg smoking
    poor nutrition, inactivity
  • Socio-environmental approach
  • Determinants of health in the enviros where we
    live, work , play,
  • Risk conditions, eg poverty
  • Psychosocial factors, eg poor social connections

100
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101
Level of intervention
  • Focus on individuals
  • Generally secondary prevention
  • Health care services, eg patient education
  • Shop fronts
  • Risk factors assessment
  • Self education materials
  • counselling

102
Level of intervention
  • Focus on groups
  • Adult education
  • Self help groups
  • Community action groups
  • Focus on populations
  • Social marketing and the media
  • Community development
  • Health promoting settings and environments

103
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104
An Italian program
Stress Management in School Teachers personal
and/or worksite change?
See Appendix 4 in Appendices
105
Lecture 9
106
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107
Going to practicechanging peoples behaviour
  • Can we do it?
  • How do we do it?
  • Should we do it?

108
Our early attempts
  • Knowledge of risk would lead to behaviour change
  • Increased knowledge ?change in attitudes ?
    behaviour change
  • Teach decision making skills ? healthy behaviour
  • Not particularly successful

109
Behaviour change theories
  • How do we explain why people dont necessarily
    take action to improve their health?
  • Behaviour change theories arising from social and
    behavioural psychology

110
Health belief model
  • Behaviours is guided by perceptions of the
    consequences of our actions positive, negative
  • Considering behaviours change involves a
    cost-benefit analysis
  • Feel threatened, vulnerable, susceptible
  • The issue is serious
  • Recognise that change would be beneficial
  • Recognise the barriers and how much it costs us
    to overcome them
  • Feel competent to carry out the change

111
Health belief model in action
  • Some of the strategies
  • People like me
  • Experience of those suffering or used to
    suffering (e.g. ex addicts)
  • Fear, guilt
  • Change is possible
  • Problems stimulate interest, e.g. drugs
  • Effective for recruitment to one-off events e.g.
    screening, immunization
  • You will use it in todays tutorial

112
Theory of reasoned action
  •  People are rational, so behaviour can be
    predicted from intentions.
  • Intentions a function of attitude and subjective
    norms - what significant others think you should
    do (e.g. peers, sports heroes)
  • Short-terms consequences are of more importance
    to people
  • Different from Health Belief Model in that is
    stresses the importance of the attitudes of
    others, the motivation to comply with perceived
    social pressure from significant others- peer
    group pressure.

113
Stages of change model
  • Change is a process, not an event
  • Precontemplation not aware or concerned about
    the dangers no thought of changing behaviour
  • Contemplation Aware of the benefits of change,
    and may be seeking information to help make the
    decision.

114
Stages of change model cont.
  •  Preparing to change consider that benefits
    outweigh costs. Experiment with change
  • Action the early stages of change require a
    clear goal realistic plan, support and rewards
  • Maintenance behaviour sustained
  • Not linear people swap between phases

115
Critique of the Stages of Change model
  • Very individualistic all to do with motivation
    and willingness/readiness to change. Ignores the
    impact of social advantage, access to resources
    etc
  • Are there discrete stages, or is it a continuum?
  • Not much research to see how useful it is in
    delivering behaviour change
  • Bunton et al, 2000, in Critical Public
    Health, 10(1), 55-70

116
Working in groups
How to prepare a program from proposal to
dissemiantion.
117
Lecture 10
118
Behaviour change theories
1. Health belief model 2. Theory of reasoned
action 3. Stages of change model 4. Social
learning model
119
Social learning theory
  • The most complex and complete of the models
    interaction between the individual and their
    environment
  • Beliefs about how things are linked, causal
  • People model behaviours not trial and error
  • Look for positive outcomes of change
  • Feel capable of making the change locus of
    control and self efficacy

120
Social learning theoryimplementation
  • Motivation, role modelling
  • Provide skills training
  • Support networks
  • Maintenance through reinforcement

121
The prerequisites for change
  • The change must be self-initiated
  • The behaviour must be called into question,
    become salient
  • The salience of the behaviour must appear over a
    period of time
  • The behaviour is not part of the persons coping
    strategy too hard to change

122
Problems with these models
  • Top down, expert driven
  • Focus on the individual in isolation from their
    social setting
  • Victim blaming
  • Behaviour makes most difference to peoples
    health when other conditions in their liver ere
    favourable
  • View health decisions as based on reason and
    rational choice. But health is just one of
    peoples concerns.

123
Community interventions
  • Many community interventions, particularly large
    scale ones, are really just individual
    interventions applied on a large scale.
  • Targeted community-based prevention programs are
    much more successful.

124
Lecture 11
125
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126
Last week
  •  We examined the left hand end of this diagram -
    how we might attempt to change individual
    behaviour.
  • Today we want to look at action that moves us to
    the right, to addressing the broader
    environmental influences on health

127
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128
Health education, counselling and skills
development
  • Goes further than health information
  • Aims to increase knowledge, change attitudes,
    develop skills and self-efficacy
  • Individual and group

129
Social marketing
  •  Designed to influence voluntary behaviour of the
    target group
  • Mass media
  • Persuasive, not just information

130
Organisational development
  •  Targets organisations rather then individuals
    and groups of people
  • Change the organisation so that is more health
    promoting
  • Healthier schools, workplaces hospitals etc
  • Will return to this in the lecture on health
    promoting settings

131
Community action
  • Encourage and empower communities to build their
    capacity to develop and sustain improvements in
    their social physical environments and in their
    access to services

132
Economic and regulatory activity
  • Financial and legislative
  • Incentive and disincentives to support healthy
    choices by individual
  • Incentive and disincentives to support healthy
    action by organization

133
Of course
  • Health promotion requires a strategic approach
    that links a number of these action areas

134
Why do we need this range of approaches?
  • Complementary approaches allow us to support and
    reinforce individual health promotion actions - a
    concerted effort
  • Many of the determinants of health lie outside
    the realm of individual choice - they are the
    powerful social determinants of health. So we
    need to move the right-hand end of the chart and
    to address these determinants. We need to work
    upstream the problems.

135
Working at community/population level
  • Two main reasons
  • Complex aetiology of contemporary heath issues
    think back to our lecture on the Social
    Determinants of Heath
  • Fostering individual behavioural change is very
    limited success behavioural psychology,
    community psychology

136
Community
  • Communities have the capacity to tackle their own
    problems
  • Focus on strengths not just deficits
  • A different concept of the role of the health
    professional
  • A competent community which can care for its
    members and help them to cope with or to change
    external forces harness skills, collective
    energy and external resources for community
    determined solutions
  • A psychological sense of community

137
Empowerment
  • The process by which people, organisations and
    communities gain mastery over their lives
  • If a competent community and a psychological
    sense of community are the goals, empowerment is
    the way of getting there

138
Characteristics of a community development
approach
  • User led
  • Defining the issues of importance often more
    complex social issues than medical problems
  • Active role for the health worker getting to
    know key individuals and groups, linking,
    building networks, creating a sense of community

139
Characteristics of a community development
approach
  • Focus on process
  • Community building is a process, worthy in its
    own right and not just as a means to an end self
    confidence, self esteem, feelings of being in
    control
  • Skill development

140
Characteristics of a community development
approach
  • Focus on the needs of disadvantaged and
    vulnerable groups
  • Acknowledge health inequalities
  • Prioritise activity with disadvantaged and
    vulnerable groups
  • Address the social determinants of health

141
Advantages and Disadvantages
  • Disadvantages
  • Time consuming
  • Results are often not tangible or quantifiable
  • Evaluation is difficult
  • Without evaluation, gaining funding is difficult
  • Advantages
  • Starts with peoples concerns
  • Focuses on the root cause, not symptoms
  • Creates awareness of the social causes of ill
    health
  • The process of involvement is enabling and leads
    to greater confidence

142
Advantages and Disadvantages
  • Disadvantages
  • Health promoters may find their role
    contradictory. To whom are they ultimately
    accountable?
  • Work is usually with small groups of people
  • Draws attention away from macro issues and may
    focus on local neighbourhood
  • Advantages
  • The process involves gaining skills which are
    transferable
  • If health worker and people meet as equals, it
    extends the principle of democratic
    accountability

143
Group Work Working on a HP program
144
Lecture 12
145
Population-based strategies
  •  Mass media
  • Policy
  • Environments/settings

146
Mass mediaapproaches
  • Approaches that reach groups of individuals using
    a medium other than personal contact
  • Possibly more cost-effective than face-to-face
    individual approaches

147
  • Health promotion messages can also be
    disseminated without the use of mass media
  • Health promotion campaigns may be conducted
    through product labeling (driven by public health
    policy initiatives) or through sponsorship
    programs

148
  • E.G. in the mid-1980s health warning labels on
    cigarette packages were introduced, in the mid-
    1990s tougher, bolder warnings, with explanatory
    messages including information on contacting quit
    advice smoking lines
  • Who can think of a more recent suggestion to
    label packaging in a different product?

149
Awareness by Type of Message WA (1999/00)
150
Total action by Type of Message WA (1999/00)
151
Social Marketing
152
Social Marketing
  • The application of commercial and marketing
    technologies to the analysis planning, execution
    and evaluation of programs designed to influence
    the voluntary behaviour of target audiences in
    order to improve their personal welfare and that
    of society.
  • Often equated to mass media campaigns

153
The 4 Ps of Social Marketing
  • Product the product or behaviour and its key
    characteristics
  • Place where the product is available
  • Price the value of the product and how important
    it is to the audience
  • Promotion the means by which the product is
    promoted

154
Product
  • Anything that can be offered to a market that
    might satisfy a need or a want.
  • Social marketing is distinguished by its
    non-tangible products, e.g. ideas, attitudes,
    lifestyle change, social causes
  • There are three levels of product core, tangible
    and augmented

155
The three levels of product
  • A fitness program is the tangible product.
  • The core product is looking better, an immediate
    solution to a health problem an increase in self
    esteem, prevention of injury. More important than
    the tangible product.
  • The augmented product is tied to longterm
    adherence and includes social support after the
    program, such as incentives reduced fees, rebates
    etc.

156
Place
  • Distribution channels
  • High access points
  • Consideration of convenience of location, ease of
    access

157
Price
  • Traditionally the cost of the product (), but in
    Social Marketing, we are more concerned with
    breeder range of costs - time, inconvenience,
    energy, loss of valued behaviours.
  • To be attractive, we must decrease perceived
    costs and increase perceived benefits.
  • Incentives have been shown to be effective,
    especially tangible and shortly after the
    behaviour.

158
Promotion
  • Getting the right message
  • Getting the message right
  • Best and most appropriate channel / medium-reach,
    cost, suitability to the complexity of the message

159
Important differences between marketing and
social marketing
  •  Commercial products usually offer immediate
    gratification health product are usually
    delayed
  • Social marketing tries to replace undesirable
    behaviours with ones that are often more time
    consuming, involve more effort or are less
    pleasant

160
Important differences between marketing and
social marketing
  • Commercial marketing usually targets groups who
    are already positive to the massage. Social
    marketing is often directed at hard-to-reach,
    at-risk groups who may be antagonistic to the
    massage.
  • Health behaviours are often far more complex than
    the simple responses in commercial marketing
  • Often disagreement between experts rebate the
    product in social marketing

161
Important differences between marketing and
social marketing
  • Many health behaviours in social marketing are
    inconsistent with social pressures
  • Ethical issues and issues of equity are far more
    complex in social marketing
  • Social marketing should be directed not just at
    changes in individual behaviour and attitudes but
    at changes in social system and structures

162
What the mass media can do
  • In general the mass media can
  • Raise consciousness about health issues
  • Help place health on the public agenda
  • Convey simple information and single messages
  • Change behaviours if other enabling factors are
    present
  • Effective if
  • Part of an integrated campaign
  • Info is new end presented in an emotional context
  • The info is relevant to people like me

163
What the mass media cannot do
  • The mass media cannot
  • Convey complex information
  • Teach skills
  • Shift peoples attitudes or beliefs by itself
  • Change behaviour in the absence of other enabling
    factors

164
Environmental policy strategies
  • These types of approaches have considerable
    potential for promoting physical activity,
    because they are designed to have an impact on
    large groups populations
  • Changes in policy the environment have been
    shown to support and sustain changes in
    individual behaviour (who can think of some
    examples?)

165
Policies
  • May be defined as laws, regulations, formal and
    informal rules and understandings that are
    adopted on a collective basis to guide individual
    and collective behaviour

166
Organisational policies are
  • Policies implemented within specific
    organisations that define establish appropriate
    behaviour within the realms of the organisation
  • They have been shown to have a significant impact
    on public health
  • E.G. smoking prevalence was found to be reduced
    in smoke-free workplaces other public
    smoke-free localities

167
But
  • Organizational approaches will only be effective
    when the policies are enforced

168
Environmental strategies
  • Environmental strategies used in health promotion
    involve change in both the social and physical
    environment and address availability,
    accessibility social norms

169
  • E.G. the opening of gymnasiums and swimming
    pools before and after business hours, which may
    lead to an increase in physical activity through
    increase accessibility

170
Use of signs
  • Messages to encourage people to undertake
    physical activity have been promoted at
    localities where people can choose whether they
    ride or walk
  • This approach involves placing signs in public
    places such as bus and train stations

171
Stair study
  • Brownwell et al., (1980) were among the first to
    demonstrate that a simple, low-cost intervention
    could significantly increase physical activity in
    a specific behaviour setting
  • This study was conducted at a train station with
    adjacent escalators and stairs
  • The intervention involved the posting of a sign
    stating, Your heart needs exercise, heres your
    chance.

172
Findings
  • At baseline, approximately 5 of patrons were
    walking up the stairs
  • The number of patrons who used the stairs more
    than doubled, but this number declined once the
    sign was removed
  • The findings from this study suggest that modest,
    environmental changes in key behaviour settings
    have the potential to promote an increase in
    physical activity

173
  • Environmental changes can have a broad impact on
    populations maybe less costly more lasting
    than education based programs
  • Policy interventions use the strength of law
    regulation to change behaviour social norms, as
    opposed to achieving change by individual
    remediation

174
Multi-level, inter-sectoral strategies
  • without support of public policy, less likely
    that population-wide behaviour change will be
    achieved
  • Evidence is limited BUT physical environments are
    also potentially important
  • However evidence shows that behaviour
    modification is the most effective method for
    achieving initial behaviour change in individuals

175
Conclusions
  • Thus, modification of individual behaviour is
    most likely an important strategy to use in
    combination with environmental and policy
    approaches
  • Quote Prof Jim Sallis if we concentrate on
    getting the environment right, then we can focus
    on the individual

176
Group Work Working on a HP program
177
Lecture 13
Guest speakerLucio SIBILIASee Appendix Guest
speaker 1
178
Lecture 14
179
Settings approaches to health promotion
180
Where is health created?
  • The ecological answer is that health is created
    where people live, love, work and play. It is
    created by human beings in their interactions
    with each other and with their physical
    environments. The consequence for public health
    is to commence with the settings of everyday life
    within which health is created (rather than start
    with disease categories) and to begin with
    strengthening the health potential of the
    respective settings.

181
Settings approaches cont
  • Health promotion recognises the idea that people
    live in social, cultural, political, economic,
    and environmental contexts. The Ottawa Charter
    stresses that the creation of supportive
    environments is a key action area if people are
    to increase control over their health.
  • Has grown out of WHO initiatives around Healthy
    Cities

182
What is a setting?
  • Traditionally a geographical area or an
    institution containing a captive audience for us
    to do things to. For example
  • Health education in schools
  • Food samplings in supermarkets
  • Exercise programs in work places

183
What is a setting? cont
  •  spatial, temporal and cultural domains of
    face-to-face interaction in everyday-life. These
    domains seem to be crucial for the development of
    lifestyles and living conditions for health. ...
    Health related behaviours is one outcome of the
    interplay between individuals, their social
    reference groups and their specific living and
    working conditions.

184
What is a setting? cont
  • So, settings are the situations in which we can
    work to change behavioural aspects of health.
  • Just as importantly, if not more so, settings can
    be changed so that they are directly supportive
    of health.

185
Some different settings
  • Health promoting schools
  • Health promoting hospitals
  • Health promoting workplaces
  • Health promoting prisons
  • Health promoting markets
  • Health promoting brothels
  • Health promoting transport

186
Where are they?
  • Most settings lie outside the formal health
    sector. They are the responsibility of many
    different organisations and groups, who are
    unlikely to have health as their prime concern.
  • Consequences
  • Health action is settings must be intersectoral
    in nature.
  • We must take account of the priorities,
    structures and dynamics of each setting.

187
How useful are settingsapproaches?
188
Strengths
  • Most settings ore major social structures in
    their own right. Advantages include
  • Direct access to particular target groups
  • Potential far increased impact via social
    influence
  • Formal settings lend themselves to policy and
    structural initiatives - potential for big impact
  • Improved likelihood of program sustainability
  • Opportunities for sustained and frequent
    interaction with target group
  • Usually good communication channels
  • Potential to use the culture/tradition to promote
    health

189
Problems
  • Too easy to just use them as ways of reaching
    captive audiences.
  • Health may not be on the agenda of the people
    running the setting need to establish that
    health can be their core business.
  • Intersectoral action hard to set up and maintain.
  • Hard for outsiders to get to know the culture
    and ways of operating in the setting.
  • Simplistic way of defining a population group
  • Hides differences between the people in the
    setting.

190
HP program at Worksite (F. Kittel S. Maes) see
Silbilia L. Borgo S. (Eds.) Health Psychology
in Cardiovascular Health and Disease Chapt. 19
191
Home works three groups Each group read and
summarize one of the following McQueen, D.
(2001). "Strengthening the evidence base for
health promotion." Health Promotion International
16(3) 261-268. Nutbeam, D. (1998). "Evaluating
health promotion - progress, problems and
solutions." Health Promotion International 13(1)
27-44. Raphael, D. (2000). "The question of
evidence in health promotion." Health Promotion
International 15(4) 355-367.
192
Group Work Working on a HP program
193
Lecture 15
194
Summary
195
Lecture 12
196
  • Health Promotion
  • Health promotion is the process of enabling
    people to increase control over the determinants
    of their health, in order to achieve better
    health.

Disease prevention Disease prevention covers
measures not only to prevent the occurrence of
disease, such as risk factor reduction, but also
to arrest its progress and reduce its
consequences once established.
(See Glossary)
197
Components of personal health
  • Physical health
  • Mental health
  • Social health
  • Emotional health
  • Sexual health
  • Spiritual health

198
Lecture 34
199
Marc Lalondes (1974) determinants of health model
  • human biology

lifestyle
environment
health care
200
See bookChapt. 5, 6, 7, 8, 14
201
Lecture 5 6
202
The Solid Facts
  • Social gradient
  • Stress
  • Early life
  • Social exclusion
  • Work
  • Unemployment
  • Addiction
  • Food
  • Transport
  • Social support
  • Discrimination

(See Wilkinson Marmot, Eds., 1998)
203
Social capital
  • One of a range of capitals economic, cultural
    and social. Likely to be linked.
  • Despite confusion about the term, there is
    agreement of the importance of networks between
    people because they build trust and encourage
    cooperation for mutual benefit.
  • Complex link to health.

(See book Chapt. 11)
204
Protective Factors Healthy Conditions
Psychosocial Effective Health
Healthy Lifestyles Environments
Factors Services Safe
physical enviros. social networks
preventative services reg.physical act. Healthy
public policy power control
culturally approp. Pos. mental health
Quality of life, functional independence,
wellbeing, mortality, morbidity, disability
Risk Factors Risk Conditions Psychosocial
Behavioral Risk
Physiological Risk
Factors Factors Factors
poverty isolation
smoking high BP Low social
status low sense of purpose poor
nutrition high cholesterol
205
Lecture 7 8
206
(No Transcript)
207
Types of intervention
  • Medical approach
  • Improving physiological risk factors eg high
    blood pressure, early cancer detection
  • Behaviour / Lifestyle approach
  • Improving behavioural risk factors eg smoking
    poor nutrition, inactivity
  • Socio-environmental approach
  • Determinants of health in the enviros where we
    live, work , play,
  • Risk conditions, eg poverty
  • Psychosocial factors, eg poor social connections

See book Chapt. 4
208
Level of intervention
  • Focus on individuals
  • Generally secondary prevention
  • Health care services, eg patient education
  • Shop fronts
  • Risk factors assessment
  • Self education materials
  • counselling

209
Level of intervention
  • Focus on groups
  • Adult education
  • Self health groups
  • Community action groups
  • Focus on populations
  • Social marketing and the media
  • Community development
  • Health promoting settings and environments

210
Lecture 9 10
211
Behaviour change theories
1. Health belief model 2. Theory of reasoned
action 3. Stages of change model 4. Social
learning model
See book Chapt. 3
212
Lecture 11 12
213
Social marketing
  •  Designed to influence voluntary behaviour of the
    target group
  • Mass media
  • Persuasive, not just information

214
Organisational development
  •  Targets organisations rather then individuals
    and groups of people
  • Change the organisation so that is more health
    promoting
  • Healthier schools, workplaces hospitals etc
  • Will return to this in the lecture on health
    promoting settings

215
Community action
  • Encourage and empower communities to build their
    capacity to develop and sustain improvements in
    their social physical environments and in their
    access to services

216
Economic and regulatory activity
  • Financial and legislative
  • Incentive and disincentives to support healthy
    choices by individual
  • Incentive and disincentives to support healthy
    action by organization

217
Population- based strategies
  •  Mass media
  • Policy
  • Environments/settings

218
Lecture 13 14
219
Settings approaches to health promotion
220
What is a setting?
  • Traditionally a geographical area or an
    institution containing a captive audience for us
    to do things to. For example
  • Health education in schools
  • Food samplings in supermarkets
  • Exercise programs in work places

221
Some different settings
  • Health promoting schools
  • Health promoting hospitals
  • Health promoting workplaces
  • Health promoting prisons
  • Health promoting markets
  • Health promoting brothels
  • Health promoting transport

See book Chapt. 16, 17, 18, 19
222
Lecture 15Summary
223
Lecture 16
224
Future directionsWhat do we know?
  • Economic, environmental and social factors
    influence health status
  • Awareness of the impact of the social is
    increasing
  • Consumers more informed, empowered and have
    higher expectations
  • Treatments are improving but costs are escalating
  • Ageing population
  • Costs will increase 15 by 2006 and by 30 by
    2016 to maintain the current level of care for
    ageing population

225
Burning issues
  • What can we do about lifestyle and behaviours
    that we know contribute to poor health and
    disease outcomes?
  • Understand the new paradigm of health within a
    social context
  • What does this mean for health professionals?

226
Emerging challenges
  • Redressing health inequalities must be an
    important social aim
  • Recognise health promoting opportunities as they
    evolve
  • Attend to prevention and early intervention
  • Build partnerships
  • Informed consumers
  • Other health professionals
  • Across sectors

227
Conclusions on evidence and evaluation in HP and
discussions of the HP programdeveloped in group
228
  • Advised book Sibilia L. Borgo S., Eds. (1993)
    HEALTH PSYCHOLOGY IN CARDIOVASCULAR HEALTH AND
    DISEASE. C.R.P., Roma.
  • Web sites http//www.euro.who.int/hfadb
    http//www.who.int/en http//www.who.int/hpr
    http//www.wpro.who.int/hpr http//www.wpro.who.
    int/hpr/docs/glossary.pdf
  •  
  • Key documents
  • Students will be provided with a set of key
    documents, and will be expected to gather other
    relevant information from electronic and print
    sources. This form of active learning is a
    feature of the unit. 
  • Key documents will include the following
  • Ø      McQueen, D. (2001). "Strengthening the
    evidence base for health promotion." Health
    Promotion International 16(3) 261-268.
  • Ø      Nutbeam, D. (1998). "Evaluating health
    promotion - progress, problems and solutions."
    Health Promotion International 13(1) 27-44.
  • Ø      Nutbeam, D. (1998). "Health promotion
    glossary." Health Promotion International 13(4)
    349-364.
  • Ø      Raphael, D. (2000). "The question of
    evidence in health promotion." Health Promotion
    International 15(4) 355-367.
  • Ø      Wilkinson, R. and M. Marmot, Eds. (1998).
    The Solid Facts The Social Determinants of
    Health. Copenhagen, World Health Organisation,
    Regional Office for Europe.
  • Ø      World Health Organisation (1986). The
    Ottawa Charter for Health Promotion. Geneva,
    World Health Organisation.
  • Ø      World Health Organisation (1997). The
    Jakarta Declaration on Health Promotion into the
    21st Century. Fourth International Conference on
    Health Promotion - New Players for a New Era
    Leading Health Promotion into the 21st Century,
    Jakarta, World Health Organisation.
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