Emerging health issues: the widening challenge for population health promotion

The spectrum of tasks for health promotion has widened since the Ottawa Charter was signed. In 1986, infectious diseases still seemed in retreat, the potential extent of HIV/AIDS was unrecognized, the Green Revolution was at its height and global poverty appeared less intractable. Global climate change had not yet emerged as a major threat to development and health. Most economists forecast continuous improvement, and chronic diseases were broadly anticipated as the next major health issue. Today, although many broadly averaged measures of population health have improved, many of the determinants of global health have faltered. Many infectious diseases have emerged; others have unexpectedly reappeared. Reasons include urban crowding, environmental changes, altered sexual relations, intensified food production and increased mobility and trade. Foremost, however, is the persistence of poverty and the exacerbation of regional and global inequality. Life expectancy has unexpectedly declined in several countries. Rather than being a faint echo from an earlier time of hardship, these declines could signify the future. Relatedly, the demographic and epidemiological   transitions have faltered. In some regions, declining fertility has overshot that needed for optimal age structure, whereas elsewhere mortality increases have reduced population growth rates, despite continuing high fertility. Few, if any, Millennium Development Goals (MDG), including those for health and sustainability, seem achievable. Policy-makers generally misunderstand the link between environmental sustainability (MDG #7) and health. Many health workers also fail to realize that social cohesion and sustainability—maintenance of the Earth’s ecological and geophysical systems—is a necessary basis for health. In sum, these issues present an enormous challenge to health. Health promotion must address population health influences that transcend national boundaries and generations and engage with the development, human rights and environmental movements. The big task is to promote sustainable environmental and social conditions that bring enduring and equitable health gains.

Local health policy development processes in the Netherlands: an expanded toolbox for health promotion

Although much research has been done on the existence and formation of risk and issue based health policies, there is only little insight in health policy development processes in a broader context. This hampers intervention in these policy processes to adequately develop integrated and effective health policies.

Legislation in the Netherlands requires municipalities to develop and implement local health policies. These policies are supposed to aim at the promotion of health across sectors and with a strong community involvement. Health policy development processes have been studied in four Dutch municipalities. For each case, we identified a range of stakeholders and monitored the change or stability of their characteristics over 3 years. In addition, for each case, three overlaying maps of networks were made addressing communication and collaboration actions within the defined set of stakeholders. We point out a number of barriers which impede integrated policy development at the local level: the importance given to local health policy, the medical approach to health development, the organizational self-interest rather than public health concern, the absence of policy entrepreneurial activity.

Furthermore, this article advocates the use of complementary theoretical frameworks and the expansion of the methodological toolbox for health promotion. The value of stakeholder and network analysis in the health promotion domain, at this stage, is two-fold. First, mapping relevant actors, their positions and connections in networks provides us with insight into their capacity to participate and contribute to health policy development. Second, these new tools contribute to a further understanding of policy entrepreneurial roles to be taken up by health promotion professionals and health authorities in favour of the socio-environmental approach to health.

Notwithstanding the value of this first step, more research is required into both the practical application as well as in the theoretical connections with, for example, Multiple Streams theory.

A role for workforce competencies in evidence-based health promotion education

Education programs should be based on research about the knowledge and skills required for practice, rather than on intuition or tradition, but there is limited published curriculum research on health promotion education. This paper describes a case study of how workforce competencies have been used to assist evidence-based health promotion education in the areas of curriculum design, selection of assessment tasks and continuous quality assurance processes in an undergraduate program at an Australian university. A curriculum-competency mapping process successfully identified gaps and areas of overlap in an existing program. Previously published health promotion workforce competencies were effectively used in the process of selecting assessment items, providing clear guidelines for curriculum revision and a useful method to objectively assess competency content in an evidence informed framework. These health promotion workforce competencies constituted an additional tool to assess course quality. We recommend other tertiary institutions consider curriculum-competency mapping and curriculum based assessment selection as quality and evidence based curriculum review strategies.

Mental health promotion and socio-economic disadvantage: lessons from substance abuse, violence and crime prevention and child health

Issue addressed: Mental health promotion aimed at populations with low socio-economic status (SES) may benefit by investigating prevention strategies that effectively address related child and adolescent problems.
Methods: Evidence from a number of literature reviews and program evaluations was synthesised. First, the impact of SES on development from childhood to adulthood is considered in light of research on substance
abuse, violence, crime, and child development problems. Second, evaluations of interventions are reviewed to identify those that have shown outcomes in research studies (efficacy) or in real-world settings (effectiveness) in reducing developmental problems associated with low SES. Low SES is measured in different ways including low levels of education and/or income or definitions that combine several variables into a new indicator of low SES.
Results: Factors associated with low SES are also associated to varying extent with the development of violence and crime, substance abuse and child health problems. Interventions that address underlying determinants of low SES show strong efficacy in decreasing adolescent crime and violence and effectiveness in improving child health outcomes. Although there is limited efficacy evidence that substance abuse prevention can be effectively addressed by targeting low SES, programs designed to improve educational pathways show some efficacy in reducing aspects of adolescent substance use.
Conclusion: Mental health promotion strategies can draw on the approaches outlined here that are associated with the prevention of child and adolescent problems within low SES communities. Alternatively, such interventions could be supported in mental health promotion policy as they may assist in preventing related problems that undermine mental health.

Development of a collaborative model to improve school health promotion in the Netherlands

In recent decades, school health promotion programs have been developing into whole-school health approaches. This has been accompanied by a greater understanding among health promoters of the core-business of schools, namely education, and how health promotion objectives can be integrated into this task. Evidence of the positive impact of school health promotion on health risk behavior of students is increasing. This article focuses on the processes and initial results of developing a collaborative model tailored for whole-school health in the Netherlands, named schoolBeat. The Dutch situation is characterized by fragmentation, a variety of health and welfare groups supporting schools, and a lack of sound integrated youth policies. A literature review, observations, and stakeholder consultation provided a clear picture of the current situation in school health promotion, and factors limiting a comprehensive and needs-based approach to school health. This revealed that a health promotion team within a school is fundamental to an effective approach to tailored school health promotion. A respected member of school staff should chair this team. To strengthen the link with the school care team, the school care coordinator should be a member of both teams. To provide coordinated support to all schools in a region, participating organizations decided to share advisory tasks. These tasks are included in the regular health promotion work of their staff. This means working with one advisor representing all school-health organizations per school, and using a comprehensive overview of possible support and projects promoting health. Empowering schools in needs assessments and comprehensive school health promotion is an important element of the developed approach. This article concludes with an examination of emerging issues in evaluating collaborative school health support during the first 18 months of development, and implementation and future perspectives regarding sustainable collaboration and quality improvement.

Criteria for the systematic review of health promotion and public health interventions

Systematic reviews of public health interventions are fraught with challenges. Complexity is inherent; this may be due to multi-component interventions, diverse study populations, multiple outcomes measured, mixed study designs utilized and the effect of context on intervention design, implementation and effectiveness. For policy makers and practitioners to use systematic reviews to implement effective public health programmes, systematic reviews must include this information, which seeks to answer the questions posed by decision makers, including recipients of programmes. This necessitates expanding the traditional evaluation of evidence to incorporate the assessment of theory, integrity of interventions, context and sustainability of the interventions and outcomes. Unfortunately however, the critical information required for judging both the quality of a public health intervention and whether or not an intervention is worthwhile or replicable is missing from most public health intervention studies. When the raw material is not available in primary studies the systematic review process becomes even more challenging. Systematic reviews, which highlight these critical gaps, may act to encourage better reporting in primary studies. This paper provides recommendations to reviewers on the issues to address within a public health systematic review and, indirectly, provides advice to researchers on the reporting requirements of primary studies for the production of high quality systematic reviews.

Gender and health promotion: A multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male–female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.

The sustainability of health promotion interventions for different levels of social organization

In health promotion, enthusiasm for sustainability has frequently overshadowed critical reflection with regard to whether this aim is warranted, let alone feasible. Consequently, the not insubstantial body of literature on sustainability in health promotion is not particularly helpful to decision makers. In this paper we seek to provide some guidance for the development of sustainability for health promotion interventions, arguing that it is necessary to be able to differentiate between (i) levels of social organization which are the focus of change, (ii) the programmes and agencies which are the means employed to achieve change, and (iii) the outcomes or effects that are achieved. Furthermore, funding allocations need to be congruent with programme characteristics if one is serious about achieving sustainability.

Health promotion and evaluation - a programmatic approach

Health promotion has evolved significantly in the past twenty years. Its emphasis has shifted from relatively simple monocausal models focused on behavioural risk factors to a greater emphasis on broader social determinants of health. Single method, single risk factor interventions have increasingly been replaced with multiformat, multiple risk factor interventions and extended campaigns, with whole-of-govemment implications. Health promotion structures have developed from ad hoc single shot activity to large dedicated agencies with continuing responsibilities and a wide ambit.

The development of health promotion research and evaluation has followed these trends. The early epidemiology studies linked behavioural risks such as smoking, diet and physical activity with systemic conditions such as cancer and cardiovascular disease. A raft of small and large scale intervention studies aimed at demonstrating that these behavioural risk factors could be modified and that modification would lead to improved health outcomes followed with mixed results.

More recent evidence suggests that behavioural risks are not the onIy social factors that influence health outcomes. There is now strong evidence that social determinants such as income, education and employment have highly significant direct effects on health outcomes, which are not mediated by behavioural risks, and that behavioural risks are also correlated with these broader determinants.

Health promotion now operates in a variety of ways at different scales and different levels of the health system (and the wider social system). The goals of health promotion, and the measures that assess whether a project, campaign, or general strategy has met its goals, differ accordingly.

Arguably, where local, state and federal governments begin to coordinate their efforts systematically across settings, intervention strategies, health action areas and population groups, health promotion becomes more
programmatic, sustainable and effective. A programmatic approach also integrates knowledge generation, the development of health promotion capacity, practice and evaluation together.

However, programmatic approaches to health promotion are comparatively new. Only recently have governments begun to develop and resource
comprehensive and sustained health promotion programs that address a range of health issues using multiple intervention strategies. The scope of a more programmatic approach and its functions and purposes is still developing.

Although evaluation has a key role to play in this respect, the development of programmatic strategies for health promotion has generally outpaced evaluation theory and practice. While we now have reasonable technologies for measurement of behavioural risks and individual attitudinal and cognitive influences on them, strategies to evaluate organisational and community interventions are still emerging.

Similarly, while new approaches to evaluate small scale community and organisational interventions have been developed, comprehensive models to monitor and evaluate health promotion programs and strategies across multiple intervention sites over extended periods have not yet emerged. Nor have we resolved the methodological problems of teasing out the relative contribution of different intervention strategies to observed change in health outcomes.

More programmatic approaches to health promotion require a more programmatic approach to health promotion evaluation. This paper represents an issues based examination of the evidence base for a more programmatic health promotion and the evaluation issues that arise

Prevalence of health promotion policies in sports clubs in Victoria, Australia

In recent years, some health agencies offered sponsorship to sporting associations to promote healthy environments by encouraging clubs to develop health-related policies. However, the extent to which these sponsorship contracts reach their stated aims is of concern. This study aimed to quantify levels of policy development and practice in sports clubs for each of five key health areas, namely smoke-free facilities, sun protection, healthy catering, responsible serving of alcohol and sports injury prevention. Representatives from 932 Victorian sports clubs were contacted by telephone with 640 clubs (69%) participating in the survey. Results suggested that the establishment of written policies on the key health areas by sports clubs varied widely by affiliated sport and health area: 70% of all clubs with bar facilities had written policies on responsible serving of alcohol, ranging from 58% of tennis clubs to 100% of diving and surfing clubs. In contrast, approximately one-third of sports clubs had a smoke-free policy, with 36% of tennis, 28% of country football and 28% of men's cricket clubs having policy. Moreover, 34% of clubs overall had established sun protection policy, whereas clubs competing outside during summer months, [diving (86%) and life-saving (81%)] were most likely to have a written sun protection policy. Injury prevention policies were established in 30% of sports clubs, and were most common among football (56%), diving (43%) and life-saving (41%). This study suggests that policy development for health promotion can be achieved in sports clubs when it is well supported by health agencies and consideration is given to the appropriateness of the specific behaviours to be encouraged for a given sport. Communication between associations and clubs needs to be monitored by health agencies to ensure support and resources for policy development to reach the club level.

Action research in health promotion

Objectives This article aims to define what is action research and where it fits in with health promotion practice, through drawing upon associated literature and personal action research experience. It also seeks to investigate the possible reasons why it is that health promotion researchers have not readily taken on the processes of action research strategies.

Rationale The place of action research in health promotion programmes is an important yet relatively unacknowledged and understated activity. It has proven to be very popular with other professional groups, such as in the education, management and social sciences. In terms of health service activity, it is widely established in the fields of nursing and mental health and is beginning to establish itself in medicine. While there are a few health promotion examples to draw upon, they tend to be isolated, dated and often lie outside of the mainstream literature. It is suggested that this continuing state of affairs denies many health promotion researchers a valuable resource for managing effective change in practice.

Conclusion The authors suggest that action research is both a valid and
important research method for health promotion researchers, who are advised to further consider its merits in future studies. This article draws attention to the National Health Service (NHS) South West Regional Office-commissioned Our Healthier Nation: Improving the Competence of the Workforce in Health Promotion participatory action research project, as a means of promoting and validating action research strategy. The authors were all actively involved in this project.