Theories of the policy process in health promotion research: a review

The Ottawa Charter laid the ground work for a new research and practice agenda by urging health promoters to advocate for healthy public policies. After more than 20 years, it is now time to reflect on the state of policy research in health promotion and to examine how rigorously theories are applied. The review of the literature was
conducted on 11 peer-reviewed journals. The journals were selected for their solid track record in publishing health promotion articles and by using a set of predefined
inclusion and exclusion criteria. The articles, published between January 1986 and June 2006, were searched using Medline and CINAHL databases. The selected papers feature search terms related to ‘politics’, ‘policy’, ‘advocacy’ and ‘coalition’. We examined the theoretical grounding of each paper and whether it focuses on policy content (e.g. nature, impact, evolution of the policy), policy processes (e.g. advocacy capacity building and strategies) or theoretical/methodological issues in policy analysis. This review demonstrates that policy research in health promotion is still largely an a theoretical enterprise. Out of the 119 articles that were found eligible, 39 did apply to some degree a theoretical framework, of which 21 referred to a theoretical framework from political science. We conclude that the field has yet to acknowledge critical concepts that would help to shed light on the policy process, and that validated rigorous theoretical frameworks to inform research and practice are hardly applied. Recommendations are formulated to improve policy research in health promotion.

Reliability assessments in qualitative health promotion research

This article contributes to the debate about the use of reliability assessments in qualitative research in general, and health promotion research in particular. In this article, I examine the use of reliability assessments in qualitative health promotion research in response to health promotion researchers’ commonly held misconception that reliability assessments improve the rigor of qualitative research. All qualitative articles published in the journal Health Promotion International from 2003 to 2009 employing reliability assessments were examined. In total, 31.3% (20/64) articles employed some form of reliability assessment. The use of reliability assessments increased over the study period, ranging from ,20% in 2003/2004 to 50% and above in 2008/2009, while at the same time the total number of qualitative articles decreased. The articles were then classified into four types of reliability assessments, including the verification of thematic codes, the use of inter-rater reliability statistics, congruence in team coding and congruence in coding across sites. The merits of each type were discussed, with the subsequent discussion focusing on the deductive nature of reliable thematic coding, the limited depth of immediately verifiable data and the usefulness of such studies to health promotion and the advancement of the qualitative paradigm.

Football's culture of intoxication : implications for health promotion

Objectives: The objective of this is article is to examine some of the strategies and interventions designed to encourage responsible alcohol consumption within Australian Rules football clubs.
Design: Qualitative research was undertaken with fans of four fans of football teams who compete in the South Australian National Football League (SANFL). In total, 93 interviews were conducted with male (80) and female (13) fans across these clubs. Interview data were thematically analysed with the assistance of the NVIVO software package. To elicit additional insight about the social meanings of drinking, researchers visited football games and a range of social functions.
Results: Analysis of the qualitative data suggests that formal interventions implemented by football clubs often prove ineffectual in encouraging responsible alcohol consumption, with more effective strategies aimed at dissuading heavy drinking being operationalized at an informal level by drinkers themselves through a number of ‘everyday’ or ‘lay’ strategies. Such strategies correspond to the broad analytical categories of ‘keeping safe’, ‘minimising damage’ and ‘taking charge’.
Conclusion: This focus on the role of lay strategies in informing health behaviours makes an important contribution to how we understand health promotion initiatives in relation to harmful drinking in sport and other contexts.

Core health promotion competencies in Australia : are they compatible with climate change action?

Issues addressed: Health promotion principles for practice are closely aligned with that of environmental sustainability. Health promotion practitioners are well positioned to take action on climate change. However, there has been scant discussion about practice synergies and subsequently the type and nature of professional competencies that underpin such action.

Methods: This commentary uses the Australian Health Promotion Association (AHPA) national core competencies for Health Promotion Practitioners as a basis to examine the synergies between climate change and health promotion action.

Results: We demonstrate that AHPA core competencies, such as program planning, evaluation and partnership building, are highly compatible for implementing climate change mitigation and adaptation strategies. We use food security examples to illustrate this case.

Conclusions: There appears to be considerable synergy between climate change and health promotion action. This should be a key focus of future health promotion competency development in Australia.

It's here! Are we ready? Five case studies of health promotion practices that address climate change from within Victorian health care settings

Issue addressed: Climate changes and environmental degradation caused by anthropogenic activities are having an irrefutable impact on human health. The critical role played by health promotion in addressing environmental challenges has a history in seminal charters − such as the Ottawa Charter for Health Promotion − that explicitly link human well-being with the natural environment. The lack of documented practice in this field prompted an investigation of health promotion practice that addresses climate change issues within health care settings.

Methods: This qualitative study involved five case studies of Victorian health care agencies that explicitly identified climate change as a priority. Individual and group interviews with ten health promotion funded practitioners as well as document analysis techniques were used to explore diverse practices across these rural, regional and urban health care agencies.

Results: Health promotion practice in these agencies was oriented toward: active and sustainable transport; healthy and sustainable food supply; mental health and community resilience; engaging vulnerable population groups such as women; and organisational development.

Conclusion: Despite differences in approach, target population and context, the core finding was that health promotion strategies, competencies and frameworks were transferable to action on climate change in these health care settings.

Health promotion and climate change : exploring the core competencies required for action

Climate change poses serious threats to human health and well-being. It exacerbates existing health inequities, impacts on the social determinants of health and disproportionately affects vulnerable populations. In the Australian region these include remote Aboriginal communities, Pacific Island countries and people with low incomes. Given health promotion’s remit to protect and promote health, it should be well placed to respond to emerging climate-related health challenges. Yet, to date, there has been little evidence to demonstrate this. This paper draws on the findings of a qualitative study conducted in Victoria, Australia to highlight that; while there is clearly a role for health promotion in climate change mitigation and adaptation at the national and international levels, there is also a need for the engagement of health promoters at the community level. This raises several key issues for health promotion practice. To be better prepared to respond to climate change, health promotion practitioners first need to re-engage with the central tenets of the Ottawa Charter, namely the interconnectedness of humans and the natural environment and, secondly, the need to adopt ideas and frameworks from the sustainability field. The findings also open up a discussion for paradigmatic shifts in health promotion thinking and acting in the context of climate change.

Association of adolescent symptoms of depression and anxiety with alcohol use disorders in young adulthood : findings from the Victorian Adolescent Health Cohort Study

Objective: To examine the association of adolescent depression and anxiety symptoms with alcohol abuse or dependence in young adulthood.

Design, setting and participants: Cohort study of the health and wellbeing of adolescents and young adults in Victoria, assessed at 8 waves (periods) of data collection, from age 14 to 24 years, between 1992 and 2003. Young people who participated in the cohort study at least once during the six adolescent assessment points (conducted 6 months apart, from age 14 to 17 years), at least once during young adulthood and who were alive at Wave 8 (n = 1758).

Main outcome measure: Alcohol abuse or dependence assessed using the alcohol and substance abuse modules of the Composite International Diagnostic Interview at age 24 years.

Results: Adolescents with moderate to high levels of depression and anxiety symptoms (measured by the revised Clinical Interview Schedule) had an increased risk of alcohol abuse or dependence in young adulthood, compared with young adults with low levels of adolescent depression and anxiety symptoms, after adjusting for potential confounding factors. Risk was higher for those with symptoms at more than two adolescent assessment points (odds ratio [OR] 1.9; 95% CI, 1.7–2.0) and for those with symptoms at one or two assessment points (OR 1.3; 95% CI, 1.2–1.4), compared with those with no above-threshold symptoms in adolescence.

Conclusions: Adolescents with depression and anxiety symptoms are at increased risk for alcohol use disorders into young adulthood. They warrant vigilance from primary care providers in relation to alcohol use well into adulthood.

Adolescent depressive symptoms and subsequent pregnancy, pregnancy completion and pregnancy termination in young adulthood : findings from the Victorian Adolescent Health Cohort Study

Study Objective: To examine relationships between depressive symptoms in adolescence (14-18 years of age) and becoming pregnant, completing a pregnancy (live birth) and terminating a pregnancy in young adulthood (21-24 years of age).

Participants and Design: Data from 1000 females were drawn from a larger sample of 1943 young Australians participating in a longitudinal study of adolescent health and development, followed across 8 waves from adolescence (waves 1-6) to young adulthood (waves 7 and 8).

Setting: Victoria, Australia.

Main Outcome Measures: Pregnancy, pregnancy completion and pregnancy termination between 21-24 years of age.

Results: We observed a twofold increase in the odds of becoming pregnant in those reporting persisting patterns of depressive symptoms during adolescence (2þ waves); however, after staged adjustment for adolescent antisocial behaviour, drug use and socioeconomic disadvantage, there was no evidence of association. Of particular note, and consistent with previous research, adolescent antisocial and drug use behavior were strongly associated with becoming pregnant and pregnancy termination in young adulthood.

Conclusions: Adolescent antisocial and drug use behavior, not depressive symptoms, independently predict pregnancy outcomes in young adulthood.

Association between the COMT Val158Met polymorphism and propensity to anxiety in an Australian population-based longitudinal study of adolescent health

Objectives: Catechol-O-methyltransferase plays a central role in the metabolism of biogenic amines such as norepinephrine, dopamine and serotonin. Functional studies have demonstrated a dose relationship between Val158Met genotypes and catechol-O-methyltransferase activity. Compared with the Val158Val genotype, the Val158Met and Met158Met genotypes result in two- and four-fold reductions in catechol-O-methyltransferase activity, respectively. Two recent reports have observed the association between the Met158Met genotype and risk of anxiety in adult populations. We examined the association between the Val158Met genotypes and propensity to anxiety across adolescence.

Methods: Participants were drawn from an eight-wave study of the mental and behavioural health of over 2000 young Australians followed from 14 to 24 years of age (Victorian Adolescent Health Cohort Study, 1992 to present). DNA was received from 962 participants using a cheek swab collection method.

Results: The odds of reporting persistent episodic anxiety (phobic avoidance, panic attacks) were doubled among carriers of the Met158Met genotype (odds ratio 2.0, 95% confidence interval 1.1-3.4, P=0.014). A dose relationship between additional copies of the Met158 allele and persistent episodic anxiety was also observed (1.5, 1.1-1.94, P=0.007). Stratification by sex showed that the risk effect of the Met158 allele was among females only. No association was observed for measures of neuroticism, persistent generalized anxiety, or a composite measure of psychiatric distress.

Conclusion: These data replicate previous findings suggesting association between the Val158Met polymorphism and specific expressions of anxiety among females.

COMT Val158Met and 5HTTLPR functional loci interact to predict anxiety across adolescence : results from the Victorian Adolescent Health Cohort Study (1992-2006)

We investigated whether a composite genetic factor, based on the combined actions of catechol-O-methyltransferase (COMT) (Val158Met) and serotonin transporter (5HTTLPR) (Long-Short) functional loci, has a greater capacity to predict persistence of anxiety across adolescence than either locus in isolation. Analyses were performed on DNA collected from 962 young Australians participating in an eight-wave longitudinal study of mental health and well-being (Victorian Adolescent Health Cohort Study). When the effects of each locus were examined separately, small dose–response reductions in the odds of reporting persisting generalized (free-floating) anxiety across adolescence were observed for the COMT Met158 [odds ratio (OR) = 0.85, 95% confidence interval (CI) = 0.76–0.95, P = 0.004] and 5HTTLPR Short alleles (OR = 0.88, CI = 0.79–0.99, P = 0.033). There was no evidence for a dose–response interaction effect between loci. However, there was a double-recessive interaction effect in which the odds of reporting persisting generalized anxiety were more than twofold reduced (OR = 0.45, CI = 0.29–0.70, P < 0.001) among carriers homozygous for both the COMT Met158 and the 5HTTLPR Short alleles (Met158Met + Short-Short) compared with the remaining cohort. The double-recessive effect remained after multivariate adjustment for a range of psychosocial predictors of anxiety. Exploratory stratified analyses suggested that genetic protection may be more pronounced under conditions of high stress (insecure attachments and sexual abuse), although strata differences did not reach statistical significance. By describing the interaction between genetic loci, it may be possible to describe composite genetic factors that have a more substantial impact on psychosocial development than individual loci alone, and in doing so, enhance understanding of the contribution of constitutional processes in mental health outcomes.

Childhood sexual abuse and adolescent eating disorder : findings from the Victorian Adolescent Health Cohort study

Objective: To examine the relationship between childhood sexual abuse (CSA) before the age of 16 years and later onset of bulimia and anorexia nervosa symptoms in females.

Design: A longitudinal cohort study of adolescents observed from August 1992 to March 2003. The cohort was defined in a 2-stage cluster sample using 44 Australian schools in Victoria.

Setting: Population based.

Participants: A total of 1936 persons participated at least once and survived to the age of 24 years, including 999 females. The mean (SD) age of females at the start of follow- up was 14.91 (0.39) years; and at completion, 24.03 (0.55) years.

Main Exposure: Self-reported CSA before the age of 16 years was ascertained retrospectively at the age of 24 years.

Outcome Measures: Incident Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition)–defined partial syndromes of anorexia and bulimia nervosa were identified between waves 4 (mean age, 16.3 years) and 6 (mean age, 17.4 years) using the Branched Eating Disorder Test.

Results: The incidence of bulimic syndrome during adolescence was 2.5 (95% confidence interval, 0.80-8.0) times higher among those who reported 1 episode of CSA and 4.9 (95% confidence interval, 1.9-12.7) times higher among those who reported 2 or more episodes of CSA, compared with females reporting no episodes, adjusted for age and background factors. The association persisted after adjusting for possible confounders or mediators measured 6 months earlier, including psychiatric morbidity and dieting behavior. There was little evidence of an association between CSA and partial syndromes of incident anorexia nervosa.

Conclusion: Childhood sexual abuse seems to be a risk factor for the development of bulimic syndromes, not necessarily mediated by psychiatric morbidity or severe dieting.

Association between dependent smoking and a polymorphism in the tyrosine hydroxylase gene in a prospective population-based study of adolescent health

This study reports pilot data on an association between tobacco dependence and a five-allele tetranucleotide repeat polymorphism in the first intron of the tyrosine hydroxylase (TH) gene. One hundred and twenty-six Australian adolescents who had participated in the Health in Transition Study (1993–1997), and who showed patterns of either dependent or nondependent smoking across four waves of data collection, consented to participation in the pilot study. The smoking status of those recruited was confirmed using a telephone-administered drug use questionnaire during 2000. Tobacco dependence was defined as smoking more than 6 days per week and more than 10 cigarettes per day during wave 5 (year 2000) and at lfeast one prior wave (n = 58). A second, more stringent phenotype included smoking within an hour of waking (n = 37). The control group comprised adolescents who had used tobacco but had remained low-level social smokers across each wave of data (n = 56). DNA was collected using a mouthwash procedure. Using the more strictly defined tobacco dependence phenotype, and after adjusting for sex, a significant protective association was found between the K4 allele and tobacco dependence (OR 0.27, 95% confidence interval [CI] 0.09, 0.82). No association was found using the liberal criteria of tobacco dependence (OR 0.51, 95% confidence interval [CI] 0.23, 1.2). These preliminary results replicate a previous association between tobacco use and the K4 allele of the TH gene (Lerman et al., 1997). The potential significance of including time to first cigarette in definitions of tobacco dependence and the possible role that these TH variants might play in tobacco dependence are discussed.