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Friday, September 01, 2006

Methods of Promoting Health

Health promotion is any event, process or activity which facilitates the protection or improvement of the health status of individuals, groups, communities or populations. Its objective is to prolong life and to improve quality of life, that is to prevent or reduce the effects of impaired physical and/or mental health on those individuals who are directly (e.g. patients) or indirectly (e.g. carers) affected. Health promotion includes both environmental and behavioural interventions.

Environmental interventions target the built environment (e.g. fencing around dangerous sites) and involve legislation to safeguard the natural environment (e.g. maximum water pollution targets) as well as the production of goods (e.g. the ban on certain beef products). Behavioural interventions are primarily concerned with the consequences of individuals' actions. Behavioural interventions include raising awareness and knowledge about health hazards, teaching technical (e.g. how to floss one's teeth; how to use a condom) and social skills (e.g. how to say no to drugs; how to negotiate condom use), as well as cognitive behavioural techniques (e.g. how to practise progressive muscle relaxation; how to re-focus one's thoughts). All of these measures require the active co-operation of those who benefit from them and the use of persuasive and effective communication.

There are three main approaches to promoting health, all of which use a number of methods to aid in this process-

Behaviour change approach

  • Objective: To bring about changes in individual behaviour through changes in individuals' cognitions.
  • Aim: To increase individuals' knowledge about the causes of health and illness.
  • Process: Provision of information about health risks and hazards.
  • Assumption: Humans are rational decision-makers whose cognitions inform their actions.

Methods used -

Provision of information: The central idea here is that if people are provided with accurate information they will make informed and rational decisions concerning their health behaviours. A good example of how this can work is provided by Cowpe (1989). He reported how, when asked about chip pan fires, people claimed that they always adopted safe practices, although fire brigade statistics, and the ideas which the survey uncovered, showed that this was not always the case. Consequently, the television advertising campaign which was developed took a different tack, showing a dramatic sequence of pictures which showed exactly how these fires develop and how people should deal with them. The adverts ended with a simple statement, such as, 'Of course, if you don't overfill your chip pan in the first place, you won't have to do any of this.' By comparing fire brigade statistics for the areas which had received the advertisements and those for the areas which had not, the advertisers found that the advertisements had produced a 25% reduction in the number of chip pan fires in some areas, with a 12% reduction overall. Surveys taken after the series of advertisements showed that people had more accurate knowledge about what they should do in the event of a chip pan fire than before.

Fear campaigns: According to the health belief model, people are likely to practise healthful behavior if they believe that by not doing so they are susceptible to serious health problems. In other words, they are motivated by fear to protect their health. How threatening should the warning be? There is some controversy about this. Irving Janis (1984) has argued that each person and circumstance has an optimal level of fear arousal to motivate a change in attitude or behavior. Too much fear may stimulate the person to use intrapsychic processes to cope—by ignoring, minimizing, or denying the threat. For example, Janis and Feshbach (1955) divided college students into three groups and gave them messages designed to produce low, medium or high fear about the relationship between teeth brushing and gum decay. The most effective message was moderate fear appeal when accompanied by instructions on effective tooth brushing. High fear, it would appear, tends to have a negative effect on behavioural change.

In two more recent studies. Job (1988), and Self & Rogers (1990) explored the use of fear in health promotion. Job's report concluded that fear-provoking messages detailing the unpleasant consequences of a behavior are unlikely to change it. Self and Rogers found that attempts to frighten people, without reassuring them about their ability to cope, had a negative effect on their health behaviors. Job contended that fear can be useful under the following certain circumstances: the people are fearful before they receive the health communication; the fear-arousing event appears imminent; specific guidelines are provided on what behaviors one should perform to reduce the fear; the people begin with a low level of fear that can realistically be reduced by performing a desirable health-related behavior; and a strong possibility exists that reducing fear and a strong possibility exisis. Carefully designed campaigns can include these elements, but Job concluded that positive reinforcement is probably more effective than the use of fear.

Changing behaviours: Behavioral methods focus directly on enhancing people's performance of the preventive act itself. These methods include providing specific instructions or training for performing the behavior, calendars to indicate when to perform infrequent preventive actions, and reminders of appointments. Research has shown that these techniques enhance the effectiveness of programs for health promotion (Kegeles, 1983; Winett, King, & Altman, 1989). Behavioral methods in health promotion also include manipulating the consequences of people's health-related behavior, particularly by providing reinforcers for practicing preventive action, such as giving praise for adopting healthy behaviours in school.

Self-empowerment approach

  • Objective: To empower individuals to make healthy choices.
  • Aim: To increase control over one's physical, social and internal environments.
  • Process: Participatory learning techniques.
  • Assumption: Power is a universal resource which can be mobilized by every individual.

Methods used: These can include role play, social skills training, and self-awareness raising. Examples of these are seen in a range of HIV-preventive interventions for young people that have been informed by a self-empowerment rationale (Abraham and Sheeran, 1994). These include rehearsal of communication and interaction sequences which might be involved in condom purchase or sexual negotiation, questioning and challenging sexual scripts which do not allow space for negotiation of contraceptive use, peer education programmes, as well as group-based cognitive-behavioural programmes aiming to identify and then modifv personal obstacles to HIV prevention.

Collective action approach

  • Objective: To improve health by addressing socio-economic and environmental causes of ill health.
  • Aim: To modify social, economic and physical structures which generate ill health.
  • Process: Individuals organize and act collectively in order to change their physical and social environments.
  • Assumption: Communities of individuals share interests which allows them to act collectively.

This is a very different approach to health promotion than those outlined above, because it works on a community rather than individual level, thus the methods employed are varied and not easy to encapsulate. However according to Raeburn and Rootman (1998), the process of community development contains seven steps, which for our purposes can be viewed as a series of methods:

  1. Participatory formulation of a philosophy of action and overall objectives.
  2. Participatory planning of action through community needs assessment.
  3. Consensual setting of time-limited goals.
  4. Consensually agreed resource plans.
  5. Allocation of tasks and actions to as many participants as possible.
  6. Regular review of all major project goals and processes in a public forum.
  7. Periodic assessment of outcomes.

A good example of this process in operation is the Junkiebonden, a federation of Dutch self-help groups, who's aim is to initiate community change through campaigning for the modification of local and national drug policy. The Junkiebonden was involved in the setting up of the first syringe exchange in the Netherlands in 1984. Since then, it has distributed education and prevention materials to drug users and sex workers through outreach techniques. The Junkiebonden was set up from within the drug-using community and is run predominantly by current drug users. This was a grass-roots initiative which did not require external facilitation. Evaluation of the needle exchange programme in Amsterdam has been positive. Since the establishment of the needle exchange network, the number of injectors has remained constant whilst the number of people joining treatment schemes has increased. The rate of infections decreased.

(Marks et al, 2000)

Health Promotion in Schools, Worksites and Communities

Health promotion in schools

Schools are an ideal place to undertake health promotion activities due to the large numbers of young people all in one place. Further if healthy behaviours can be encouraged in early life, the more likely we are to have a healthy population in later years. One area of significant concern has been over drug use. In the last 20 or so years there have been large numbers of drug education programmes put in place, in theory to combat the rising use of drugs in the younger population. Education would seem to be an effective method since the target population is often still in education and are aware of how to learn from standard educational practices.

Young people constitute one of the high risk groups who experiment with or recreationally use legal and illicit psychoactive substances. Within this age group, primary prevention initiatives are the most appropriate in motivating young people to avoid drug experimentation. The aim of preventive health education in schools is to raise young people's awareness of the facts about drug misuse and associated risks, emphasise the benefits of life-styles and develop skills needed to make informed and responsible decisions to resist drug misuse (Department of Health 1995).

The Tackling Drugs Together (1995) report on A Strategy for England 1995-1998 has been introduced by the government to tackle drug misuse. One of the aims of the strategy is to reduce the accessibility (demand) and availability (supply) of drugs to young people. The objectives of the strategy are:

  • To discourage young people from using drugs.
  • To raise awareness among staff, governors and parents of issues related to drug misuse.
  • To ensure that schools offer effective programmes of drug education and the availability and accessibility of a range of services: advice, counselling, treatment, rehabilitation and after care services.

The plan of action in relation to young people and substance misuse includes the training of teachers, the support of innovative projects in drug education and prevention, the development of school policies on managing drug related incidents and drug education. Other initiatives focus on new (Government) interdepartmental publicity campaigns with advertising and media expertise, and role models aimed at helping young people to resist drugs. (Rassool, 1998)

However according to De Haes (1987) from a review of various studies, which themselves have selectively identified drug education programmes that fit the criteria for decent research (reliable, use of control groups and follow-up studies), it can be concluded that they have either had no significant effect or in some cases a detrimental one. In other words by discussing and enlightening young people about drug abuse some of them have taken an active interest!

It can also be concluded that “…programmes paying attention to young people, who they are and how they live, teaching them how to overcome day-today difficulties and so forth, are effective not only in reducing drug use, but also in reducing other rebellious or attention-seeking behaviour.” (De Haes, 1987)

Thus we need to adopt a balanced view to drug abuse bearing in mind these factors –

  • All substances have an effective, toxic and lethal dose.
  • All drugs have varied effects
  • Drug use can only be viewed in light of the legal status of the drug
  • Experimenting is a part of adolescence
  • Every user has there own history
  • There is a distinction between recreational, occasional, regular, and heavy/compulsive use
  • Drug use can be negatively influenced by the intervention of others
  • Destructive drug use is related to other destructive behaviour

(Nowlis 1975)

To add confusion to this debate there are four main perspectives through which people look at the ‘problem’ of drug abuse –

  1. Moral-Legal Model. Drugs are prohibited by law, therefore drug use is a crime and so users and sellers must be prosecuted.
  2. Disease/Public Health Model. Drugs are harmful to the body, people using them have a kind of illness, they need medical treatment.
  3. Psycho-Social Model. Users have personality disturbances/problems. They need psychotherapy to help them.
  4. Socio-Cultural Model. Users are the victims of a badly organised and unjust society. Society need to change before any decrease in drug abuse will be seen.

According to De Haes (1987) all of these models contain some validity. Therefore only a view which takes account of them all can be useful. What he claims we do know is that programmes which pay attention to young people in their maturation phase are more effective than simple drug information programmes. Thus helping young people to develop the skills they need to deal with difficulties they face would be a crucial first step in reducing drug use. Such programmes could easily incorporate the essence from each model to address the issue and be of use to young peoples lived experience.

Health promotion in worksites

Given that for people in full time employment the place they spend most time outside of the home is in their workplace. Thus it makes sense to encourage positive health behaviours in such settings, however the direct costs involved mean that this is often only viable for larger companies.

The work place is an ideal environment for the capture of sizeable numbers of adults as recipients for promotional information on health and prevention of the use and misuse of tobacco smoking, alcohol and drugs. In a review of current approaches to health promotion in the work place and their effectiveness in preventing and controlling alcohol and drug related problems, the WHO (1993) drew attention to the need for workers' participation in programme development and implementation, and for the needs of specific occupational groups and the diversity of cultural settings to be taken into account. Compared to other countries, the UK has a low rate of work place health promotion practice (Fhilo et al., 1993) and only 40% of the work places studied were involved in health promotion (Health Education Authority 1993).

However, health promotion activities are slowly being introduced in the work setting. For instance, the occupational health service of British Rail developed an advisory unit for those with an alcohol or drug problem in 1992 (McHugh 1995), and a new and updated drug and alcohol policy was introduced in 1993 with the full support of the trade unions.

Another good example of health promotion in a workplace (this time in the USA) is outlined below -

Johnson & Johnson is the USA's largest producer of health care products. They began the Live for Life program in 1978, and it is one of the largest, bestfunded, 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. 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.

For each participating employee. Live for Life begins with a health screen—a detailed assessment of the person's current health and health-related behavior, 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. Follow-up contacts are made with each participant during the subsequent year. The company also provides a work environment that supports and encourages healthful behavior: it has designated no-smoking areas, established exercise facilities, and made nutritious foods available in the cafeteria, for example.

Evaluation of Live for Life involves ongoing studies, using quasi-experimental research methods. These studies generally compare the health and behavior of employees from different Johnson & Johnson companies that either did or did not offer the Live for Life program (Fielding, 1990; Nathan, 1984). 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 behavior, ability to handie job stress, absenteeism, and hospital medical claims.

(Sourced from Sarafino, 1994).

Health promotion in communities

Often health promotion is 'done to' people, as in advertising campaigns, workshops, etc, however an alternative approach is to get groupings of people to work together for their own benefit in regards to improving their health and the health of others close to them. This means that health promotion officials may only play a minor, certainly a less central, role in such health promotion activities.

A good example of health promotion undertaken in and by communities is the WHO's Healthy Cities Project, which attempts to combine a community focus with an acknowledgement of the need to challenge pervasive inequalities in society. Set up in the mid-1980s, the Healthy Cities Project has involved over 400 communities to date. Its aim is to promote health in the urban context by identifying and counteracting aspects of urban life which impair health. Consistent with a collective action model of health promotion, this requires the active involvement of local communities, representatives of whom meet on a regular basis for a period of one year in order to identify health objectives and targets for change. This is followed by a two-year period of implementation and evaluation.

For example, in one German city, the community group identified weight as a health problem in the community and decided to approach butchers in the city with the request to develop a new low-fat sausage (Conner, 1994). In addition, the Healthy Cities Project aims to develop new ideas in public health. For example, research into the impact of poor housing on health (Hunt, 1993) found that levels of mould in the air had a direct and independent effect upon the health of children living in the dwellings. This study's findings were used to campaign for changes in housing conditions.

Promoting Health of a Specific Problem

Cardiovascular Disease is one of the most pressing health problems faced in the Western worls, so it is not surprising to find that significant amount of health promotion activities are focused on this problem. The first major community-wide program for the prevention of cardiovascular disease started in 1972 in North Karelia, a mostly rural county in eastern Finland with 180,000 inhabitants (Puska, 1984). This county had a very high rate of cardiovascular disease due to the high-risk behaviors of its inhabitants. The Finnish government organized a program that aimed at (1) reducing smoking, serum cholesterol levels, and blood pressure through mass health communication; (2) organising individual and group services; (3) training local health oersonnel; and (4) bringing about changes in the environment. The program also sought to avoid fear appeals and to emphasize practical ways to accomplish behavior changes.

The initial evaluation, which occurred five years after the project started, compared the residents of North Karelia to those of another county in eastern Finland. Five years is not long enough to show reductions in cardiovascular morbidity and mortality, but it is sufficient time to demonstrat changes in CVD risk factors, such as cigarette smoking, serum cholesterol, and systolic and diastolic blood pressure. The five-year follow-up showed that health-related behaviors of North Karelia residents changed in the desired diretion. Middle-aged men experienced a 17.4 %greater decrease in cardiovascular risks and women an 11.5% greater decrease compared to the comparison county. A 10-year evaluation showed maintenance or further decreases in these target factors, with the result that men in North Karelia experienced a 22% decrease in cardiovascular mortality; the men in the comparison county experienced only a 12% decrease (Puska, 1984). Furthermore, the rate of disability payments for cardiovascular disease changed, and five years into the program North Karelia had a 10% lower rate of payment for cardiovascular disabilities than the comparison region. This savings more than paid for the entire community intervention programme.

A similar approach was adopt in the Stanford Five-City Project. In this project, two communities received educational intervention, and three cities served as controls. The goal of the project has been to stimulate and maintain lifestyle changes that result in a community-wide reduction of cardiovascular disease. Farquhar et al. (1990) reported on a fiveyear follow-up study that found small but significant decreases for two treatment cities in cholesterol levels, resting pulse rate, and blood pressure. The smoking cessation rate was an impressive 13% greater in the intervention cities than in the control cities. In addition, the treatment cities showed greater decreases in overall mortality rates and risk factor scores for coronary heart disease.

What we can conclude from these studies is that mass appeal campaigns at a target audience for a specific health problem do seem to have significant positive effects on the health behaviours being focused upon. It would also seem that this is a cost-effective way of promoting health in regards to cardiovascular disease.

Evaluation Points You Should Know for Health Promotion

Point 1: Methodology; establishing causation.

There are two main problems -

1) establishing causation

2) correlation

Many studies in this area use natural experiments as their method, meaning the IV as a health promotion activity is naturally occurring; e.g. whether people are exposed to the health promotion activity or not. Given that in such studies not all variables can be controlled and there are so many confounding variables that the one which contributes to the alteration cannot be singled out/identified.

We need to establish the cause in order to find out if something is working or not. How do you measure what you are doing? It is important to attempt to answer this as these experiments are often very expensive. If the causation cannot be established, is the experiment useful? People might improve or alter behaviour due to a change in habits, lifestyle, changing personal circumstances or even another health promotion activity running at the same time. If we cannot establish causation, we should at least evaluate the usefulness of such research.

Also, we need baseline data of a control population to measure any success against. This population needs to be matched on various important factors (ethnicity, class, age, etc) for a valid comparison to be made. This in itself is no small task. If not done well then the validity of any conclusions can be questioned.

There are significant problems in measuring the success of health promotion activities that are targeted at ‘invisible’ problems that are by their nature hard to measure. For example, contraceptive use, or improvement of mental health. Thus not all health promotion activities are open to measurement through an experimental approach.

Often, researchers will correlate their health promotion activity with improvement in health behaviour. For example, finding a correlation with x activity and y improvement in behaviour, e.g. health and safety adverts on telly resulted in less chip pan fires in the home. This is particularly true in national campaigns which will look at big trends; a certain behaviour will be investigated over a long period of time. However the problem here is that correlation does not mean causation.

There are other problems with the measurement of the effectiveness of health promotion activities due to not being able to measure the health behaviour in a reliable or valid fashion. For example in relation to smoking cessation campaigns, smokers might hide and smoke somewhere else, or smoke in private. This does not mean they have given up the behaviour but rather it is now hidden. This means we have an invalid measure, we can’t see them smoking but it doesn’t mean they are not doing it. Thus people may adjust their lifestyle to fit with a health promotion campaign rather stop or reduce a negative health behaviour.

Self Report Methods may be used as alternative ways of measuring the effectiveness of a health promotion activity. Unfortunately people embellish the truth. They may forget things, deny things to themselves and others, they may want to present a positive image of themselves. People are more likely to lie when they feel threatened and feel as though they will be persecuted. (e.g. heroin addiction).

A further problem is that the effect of a health promotion activity may take some time to show itself. Thus a longitudinal design is required. Without this the effects may go unnoticed due to the short length of the follow up study. Again this would reduce the validity of such investigation.

Point 2: Determinism.

Assuming that it is the health promotion activity that alters behaviour rather than any other possible factor(s). This could in some way be accounted for be an experimental design, however this is very hard when dealing with large populations. Correlation designs are often used to investigate the effectiveness of a health promotion activity however finding a correlation does not tell us anything about cause.

Further, some people argue that taking a deterministic approach to health promotion i.e. this health promotion activity causes X outcome, is a fundamentally flawed approach to adopt for use in this area. Given that there are numerous factors that affect one’s health, it would be somewhat naïve to think that a health promotion would be the determining factor in an improvement in a health behaviour. We must therefore assume that a health promotion activity is merely ONE of the many contributing variables. The measurement tools we use should reflect this, we should look at how the health promotion activity has affected or interacted with the other variables that affect people’s health. Then we may be able to see it’s usefulness.

Point 3: Validity.

The construct here is health. What is health? How can we define it? Seeing as we have problems defining health, we may have problems defining health promotion as a whole. For example – what do we mean by a reduction in smoking? 40 a day to 10 a day? Heavy to light use? Cutting out completely? Which of these is ‘healthy’. This needs to be clear in order to be able to measure it. Given the many problems we have defining health then health promotion activities will always face the difficulty of defining what it is they are measuring. However the more specific a researcher can be in regards to what they define as health and what is involved with this, the more likely they are to measure what they set out to measure.

If health is more than just the absence of illness then health promotion can legitimately focus on many areas of our lives and attempt to promote many types of behaviours and activities. But does this stretch health promotion so far that it becomes meaningless? Are teachers, social workers, police, etc, involved in health promotion?

Point 4: Ethics.

If we can’t adequately measure what is meant by health and healthy behaviours, is it right to tell people that they are unhealthy or that they have unhealthy behaviours? Is this health defined by drug companies, teachers, parents? In other words, whose agenda is this?

For example, thalidomide was given to pregnant women to reduce symptoms of morning sickness. This was very effective, thus it was an effective health promotion activity, however the children were born with stunted growth of one or more limbs. Another example is jogging, which has now been shown to be very dangerous for people’s joints. Therefore, many health behaviours may be promoted which are later (or even at the time) shown to cause serious problems in the future for individuals who undertake them.

Further, health promotion can contribute to making people’s attitudes more negative if a person sees themselves as not be doing any of the things promoted in health promotions. Is health promotion becoming a form of social control? For example, are teenage girls anorexic because of a massive complex about being overweight caused by numerous health promotions in, for example, teenage magazines? Health promotions may cause anxiety on a national level and they are very hard to avoid – on the television, bill boards, magazines, films etc.

Are people merely led to believe that we need health promotion when what we need is less of it due to the negative effects it has on us collectively by generating a culture of fear surrounding health behaviours.

Does informing people about drug use, etc, promote this activity simply through discussing it – does it normalise such behaviours to an extent that some people may no longer attach concern or stigma to such health behaviours and therefore more likely to take an active interest? In other words, is the absence of a moral message in some current health promotion activities by default advocating such activities?

Point 5: Problems of worksite health promotion activities.

Nathan (1984) discussed the advantages and disadvantages of health promotion in the workplace. He pointed out that prevention efforts benefit from a captive audience. In addition, programs in the workplace are typically convenient for employees, with many programs scheduled before and after work and even during lunchtime. Some companies allow employees to participate in health programs during work time. One problem with workplace programs is directly related to the advantage of having a captive audience: Employees may not feel free to decline participation, even if the program is ostensibly voluntary. Workers sometimes feel uneasy about attending programs that include treatment for drug or alcohol abuse. Employees may also feel pressured to participate in their company's programs to lose weight, stop smoking, and exercise more. Nathan recommended that participation records be kept separate from their employment records to ensure privacy, and Kizer (1987) argued that all employee participation should be voluntary.