Paper one: Social cognition models as a framework for health promotion: Necessary,but not sufficient

Much of health promotion is premised on the notion that health-related behaviours are under individual control, and strongly influenced by intra-psychic factors, including knowledge and attitudes. The emphasis placed on such factors has led to a neglect of the social and material context in which the individual is situated. This paper describes a number of psychological theories which have influenced health promotion, and suggests ways in which a wider set of psychological theories and methods, which take into account social and material factors, may more usefully inform health promotion initiatives.     

Subjektive Gesundheitstheorien: Inhalt, Dynamik und ihre Bedeutung für das Gesundheitshandeln im Alltag

The paper aims at a contribution to an empirically grounded conception of health promotion. It studies lay health beliefs, in particular lay theories of health, to explain preventive health behaviours. A qualitative interview study of healthy adults working in artisan and adminstrative occupations results in a typology of lay health theories that combine two dimensions in complex ways, perceived areas of influence and processes of influence on health. It is shown that these lay theories are essential cognitive and motivational conditions of health behaviours and of health life style. Nevertheless, health beliefs have to be seen in their biographical and social context; health as a value and perceived chances of integration in everyday life are reconstructed as further conditions to explain whether an intended change in behaviour or life style can be established in everyday life. The results are seen as first steps to a psychosocial theory of health action.     

Portrayal of health-related behaviours in popular UK television soap operas

BACKGROUND: Evidence suggests that health-related story lines in popular television programmes may lead to increased viewer knowledge or behaviour change. However, little is currently known about the portrayal of common health-related behaviours on UK television soap operas. METHODS: The portrayal of 11 key health-related behaviours on the 4 most popular soap operas set and broadcast in the UK over 4 weeks in spring 2005 was assessed. RESULTS: Seven of the 11 behaviours of interest were recorded a total of 959 times during 32 h of programming (or 30 behaviours per programming hour). The behaviour most frequently recorded was alcohol-related behaviours, recorded 619 times (19.3 per programming hour). No instances of four behaviours of interest were observed: driving soon after drinking, drinking during pregnancy, smoking during pregnancy or smoking around children. CONCLUSIONS: Popular television serials offer the chance to portray "healthy" behaviours as normal, and so help change attitudes and shape behavioural norms among the viewing public. Engaging the makers of these programmes in a health promotion agenda may be a fruitful method of promoting healthy behaviours.     

A model of mechanisms underlying the influence of media on health behaviour norms

Media-based interventions are common in health promotion, yet their conceptual underpinnings tend to be based on a simple linear model of direct influence on individuals' health behaviour. Recent studies have suggested that the processes through which media influence health behaviours are actually far more complex. This paper presents a conceptual model of how the medias influence the emergence and maintenance of the social norms that can contribute to shaping health behaviours. Through positive (amplifying) and negative (dampening) loops, a total of six potential influence pathways are proposed, and the role of opinion leaders and specialists is specified. Future directions for empirical tests of the model are identified.     

Effectiveness of alliances and partnerships for health promotion

This paper assesses the impact of alliances or partnerships for health promotion in northern and southern nations, as described in published papers and through contemporary accounts of best practice. The balance of evidence from published literature and case study accounts is clear. Alliance or partnership initiatives to promote health across sectors, across professional and lay boundaries and between public, private and non-government agencies, do work. They work in tackling the broader determinants of health and well-being in populations in a sustainable manner, as well as in promoting individual health-related behaviour change. The greater the level of local community involvement in setting agendas for action and in the practice of health promotion, the larger the impact. Volunteer activities, peer programmes and civic activities ensure the maximum benefit from community approaches. In addition, durable structures which facilitate planning and decision-making, such as local committees and councils, are key factors in successful alliances or partnerships for health promotion. Such mechanisms also support the sharing of power, responsibility and authority for change, the maintenance of order and of programmatic relevance, and allow local people one means of reflection and for dissent. At a national, regional, district, village and local community or neighbourhood level, this review found that the existence and implementation of policies for health promotion activities were also crucial to sustainability. The evidence from the review suggests the need for new 'social' indicators to measure the effects of health promotion. Indicators for success which focus only upon benefits for individuals cannot capture adequately the extent of the impact of the many and varied collective, collaborative health promotion initiatives, alliances or partnerships currently underway around the world. These have been shown to affect families, communities, institutions and aspects of the organisation of social and civic life. This paper posits the notion of social capital as one important new framework for organising our thinking about the broader determinants of health and how to influence them through community based approaches to reduce inequalities in health and well-being.Key words: alliances; health promotion; partnerships      

The lifestyle concept and health education with young people. Results from a WHO international survey

This article draws upon data from a unique, 11-country study of young people's health behaviour, facilitated by the WHO Regional Office for Europe. Analyses of the data available on individual health behaviours cluster into two groups: (i) health enhancing behaviours; and (ii) health-compromising behaviours. The results were analysed to identify the strength and consistency of these lifestyles across countries. A relatively modest proportion of the variance of the original variables was explained by these two lifestyle factors, but a consistent pattern emerged between countries. This consistency indicates that the health-related lifestyles of young people may not vary greatly between the countries in the study, a finding which might be used as an encouragement for greater international cooperation in the development and use of health education materials for young people, which may be easily transferable between countries. The data also support a more integrated approach to health education based on the promotion of healthy lifestyles, rather than a focus on individual health behaviours.     

Understanding childrens' health behaviour: the implications for health promotion for young people

Understanding the causes and determinants of young people's health behaviour is central to the development of relevant and effective health promotion programmes. This paper traces the development of health education programmes in the past two decades, identifying the influence of a range of concepts and theories which emerged during that period. Drawing on results from a WHO Cross-National Study of children's health behaviour, the relationships between individual behaviours and a range of social and environmental influences are illustrated, together with the inter-relationship between individual behaviours as 'lifestyles'. The implications for health education programmes from the results are identified and special emphasis is given to the need to communicate effectively with young people through a range of networks and through the media, as well as through traditional school health education. The need to continue research into 'lifestyles' is also stressed.     

Gender norms and social norms: differences,similarities and why they matter in prevention science

Two streams of theory and practice on gender equity have begun to elide. The first is work conducted to change social norms, particularly using theory that emerged from studies in social psychology. The second is work done on gender norms, emerging historically from feminist scholars working to counter gender inequality. As these two streams of work intersect, conceptual clarity is needed to understand differences and similarities between these two traditions. Increased clarity will improve efforts to address harmful norms and practices. In this article, we review similarities and differences between social and gender norms, reviewing the history of the concepts and identifying key tension points of contrast. We identified six areas of comparison that might be helpful for practitioners working for the promotion of global health as they make sense of social and gender norms. We then offer a definition of gender norms for practitioners and researchers working at the intersection between these two theories. Our definition draws from the two different streams of thought of how norms influence people's actions, acknowledging the double nature of gender norms: beliefs nested in people's minds and embedded in institutions that profoundly affect health-related behaviours and shape differential access to health services.     

Health logic and health-related behaviours

In this paper, the author develops the notion of health logic, which prescribes ‘judgemental’ and ‘cause–effect’ logic to the way that smoking, eating, drinking alcohol and exercise as health-related behaviours are approached within the field of health promotion. The problem, which is raised through the concept of health logic, is concerned with the utilization of health-enhancing or damaging classifications for ‘everyday’ issues (e.g. spending time with peers, eating out) relevant to smoking, eating, drinking alcohol and exercise. While such classifications can be rationalized under the field of health promotion, which aims at the promotion of healthy choices, they can be relatively misguiding. The emphasis on just a binary concept of health promotion conceals the understanding of these behaviours in people's everyday lives. The health logic critique is established first through a discussion of three main health promotion concepts: ‘lifestyle’, ‘choice’ and ‘empowerment’. Second, the health logic is highlighted through the empirical tendency within the field of health promotion that favours separating aspects of the everyday life of individuals into positive and negative influences. This paper suggests a different viewpoint of health-related behaviours by centring on people's everyday lives and avoiding the binary divisions created by the health logic, such as healthy/unhealthy, or the role of an enhancing or obstructing social context. Such a strongly value-laden approach seems unlikely to tell us very much about how people make sense of health-related behaviours within the context of their everyday lives.     

Promoting and protecting the health of children and young people

BACKGROUND: The health-related behaviours adopted by children and young people can have both immediate and long-term health effects. Health promotion interventions that target children and young people can lay the foundations of a healthy lifestyle that may be sustained into adulthood. This paper is based on a selective review of evidence relating to health promotion in childhood, carried out to support the external working group on the 'Healthy Child' module of the Children's National Service Framework. METHODS: This is a selective review of mainly secondary research. It focuses on injury prevention, support for parenting and the promotion of good mental health, and promoting a healthy diet and physical activity amongst children and young people. FINDINGS: In many areas, the quality of primary research into health promotion interventions aimed at children and young people is poor. Interventions are heterogeneous and not described in sufficient detail. Sample sizes tend to be small, and there are commonly problems of bias. Despite these difficulties, there is good evidence for a range of interventions, including (1) area road safety schemes; (2) combining a variety of approaches to the promotion of the use of safety equipment, including legislation and enforcement, loan/assisted purchase/giveaway schemes, education, fitting and maintenance of safety equipment; (3) school-based mental health promotion; (4) parenting support; (5) interventions that promote and facilitate 'lifestyle' activity for children, such as walking and cycling to school, and those that aim to reduce sedentary behaviours such as parent education to reduce the time children spend watching TV and using computers; and (6) controlling advertising of unhealthy food that is aimed at children. CONCLUSIONS: There are effective interventions to promote and protect the health of children and young people that require action across the five areas described in the Ottawa Charter. Health, social care and education services have a direct role in the delivery of many of these interventions and, in other areas, a role in collaborative work with other agencies, in lobbying for policy change and in raising the profile of child health promotion. Further research is needed using larger study populations, and closely defined interventions, both targeted and universal, in order to fill some of the current gaps in the evidence base for health promotion in children and young people.     

Development of behaviorally-based policy guidelines for the promotion of exercise

We describe the results of a project to develop policy guidelines to promote increased levels of participation in regular physical activity in Australia. Theories of behavior change, and research findings concerning factors influencing the adoption and maintenance of exercising, were used as an information base for policy development. This information was presented and organized in the form of eleven behaviorally-based principles designed to be of use to practitioners, administrators and policy makers. Nine policy recommendations were developed from these principles, and from the contributions of people with practical administrative and political expertise in the field. Specific, focused campaigns, the provision of pleasant and convenient facilities, and an awareness of the process of behavior change and of the limitations imposed by environmental and social factors were emphases of the final recommendations. These may have relevance for similar work in North America and other developed countries. Some comments on the process involved in moving from an interpretation of behavior-change theories and basic research to the development of usable recommendations are offered. The project illustrates an approach to using a behavioral-science knowledge base for the development of public health principles and policies which have the potential to be of practical use.     

Health education–the case for rehabilitation

The emergence of health promotion in the 1980s was a direct response to critiques of health education which centred on its victim-blaming orientation and a growing appreciation of the need to address the wider determinants of health and health-related behaviour. This paper argues a priori that such critiques centre on a preventive model of health education and overlook its broader potential. It reviews a number of alternative models of health education and locates these within the core values of equity and empowerment which underpin the Ottawa Charter and subsequent WHO documents. It suggests that, despite the rhetoric of health promotion, practice frequently remained focused on individual behaviour change and the use of persuasive health education. The move to health promotion effectively stifled further debate about the broader role of health education in achieving individual empowerment and social change. This paper calls for a broader conceptualisation of health education–the New Health Education–and concludes that this should be the driving force behind health promotion.     

Primary prevention: educational approaches to enhance social and emotional learning

The 1995 publication of Goleman's Emotional Intelligence triggered a revolution in mental health promotion. Goleman's examination of Gardner's work on multiple intelligences and current brain research, and review of successful programs that promoted emotional health, revealed a common objective among those working to prevent specific problem behaviors: producing knowledgeable, responsible, nonviolent, and caring individuals. Advances in research and field experiences confirm that school-based programs that promote social and emotional learning (SEL) in children can be powerful in accomplishing these goals. This article reviews the work of the Collaborative to Advance Social and Emotional Learning (CASEL), its guidelines for promoting mental health in children and youth based on SEL, key principles, and examples of exemplary programs.     

Challenges to changing health behaviours in developing countries: a critical overview

This overview of recent research on health behaviour change in developing countries shows progress as well as pitfalls. In order to provide guidance to health and social scientists seeking to change common practices that contribute to illness and death, there needs to be a common approach to developing interventions and evaluating their outcomes. Strategies forming the basis of interventions and programs to change behaviour need to focus on three sources: theories of behaviour change, evidence for the success and failure of past attempts, and an in-depth understanding of one's audience. Common pitfalls are a lack of attention to the wisdom of theories that address strategies of change at the individual, interpersonal, and community levels. Instead, programs are often developed solely from a logic model, formative qualitative research, or a case-control study of determinants. These are relevant, but limited in scope. Also limited is the focus solely on one's specific behaviour; regardless of whether the practice concerns feeding children or seeking skilled birth attendants or using a latrine, commonalities among behaviours allow generalizability. What we aim for is a set of guidelines for best practices in interventions and programs, as well as a metric to assess whether the program includes these practices. Some fields have approached closer to this goal than others. This special issue of behaviour change interventions in developing countries adds to our understanding of where we are now and what we need to do to realize more gains in the future.     

Changing micronutrient intake through (voluntary) behaviour change. The case of folate

The objective of this study was to relate behaviour change mechanisms to nutritionally relevant behaviour and demonstrate how the different mechanisms can affect attempts to change these behaviours. Folate was used as an example to illuminate the possibilities and challenges in inducing behaviour change. The behaviours affecting folate intake were recognised and categorised. Behaviour change mechanisms from "rational model of man", behavioural economics, health psychology and social psychology were identified and aligned against folate-related behaviours. The folate example demonstrated the complexity of mechanisms influencing possible behavioural changes, even though this only targets the intake of a single micronutrient. When considering possible options to promote folate intake, the feasibility of producing the desired outcome should be related to the mechanisms of required changes in behaviour and the possible alternatives that require no or only minor changes in behaviour. Dissecting the theories provides new approaches to food-related behaviour that will aid the development of batteries of policy options when targeting nutritional problems.     

Does more medicine make us sicker? Ivan Illich revisited

A proper understanding of health is a social and political challenge, the modern social medicine approach to public health and health approaches more generally tend to minimise this, making the isolated individual the primary unit of health. Ivan Illich, social critic and philosopher, was at the forefront of arguing for a collective health approach and challenging medical hegemony. His theories of institutional counter-productivity, proportionality and his critique of the medical model which he argued was entrenched within an economics of scarcity are as relevant today as they were at their height of popularity, in the 1970s. Applying his analysis to current trends in health approaches I conclude, as did he, that beyond a certain institutional scale or intensity more medicine is making us sicker. Therefore public health requires a dramatic shift away from a focus on individual deficits, lifestyle diseases, behaviour change and health promotion approaches towards genuine community building and significant political investment in the health creation of local communities. Moreover, there is need for more resolute regulation of the marketplace to prevent the health-harming behaviours of industrial and other institutional interests, including public sector and third sector organisations engaged in institutional overreach.     

Health promotion and the common good: Towards a politics of practice

One of the ethical dilemmas facing health promotion and disease prevention (HP/DP) practitioners is ensuring that programmes undertaken in the name of health as a ‘common good’ do not unnecessarily restrict individual liberties. This dilemma is compounded by theories of the common good being essentially normative and broadly categorized as libertarian (individual rights) or social justice (collective responsibilities). Both of these common good theories are described and critiqued. While the libertarian theory offers an important caution against the tendency of state institutions to undermine individual autonomy, a social justice theory is more consistent with research on health determinants and the historical practice of public health. The problem of individual liberties becomes most acute when HP/DP is restricted to efforts to curb or proscribe individual health behaviours. A social justice approach to HP, however, must be complemented by a ‘deliberative democratic’ practice. Such a practice recognizes the contingency involved in most HP/DP decision making, and the need for inequalities in opportunity for poor or socially disadvantaged (oppressed) groups in order to achieve greater equality in health outcomes. The argument presented draws primarily from debates within the public health, health promotion and disease prevention literature, and is illustrated by reference to two recent attempts in Canada to formulate ethical principles for health promotion practice.     

The health effects of taxi driving: the case of visible minority drivers in Toronto

OBJECTIVE: To examine the relationship between work and health among visible minority taxi drivers. METHODS: In-depth semi-structured interviews with taxi drivers (10) and industry informants (5), document analysis, and participant observation. Data analysis followed the principles of grounded theory. RESULTS: The data suggest that factors such as racism/discrimination, the nature of their social position (e.g., immigrant status, language barriers, lack of access to economic resources, lack of 'Canadian' work experience), and the social and organizational characteristics of work (e.g., employment contracts and the nature of work) constituted threats to taxi drivers' health and influenced their health-related behaviours. They experienced economic exploitation, economic uncertainty, occupational violence, fatigue, and high levels of competition, and they engaged in risky behaviours on the job. Taxi drivers also employed various health-protective behaviours in an effort to manage the threats to health. DISCUSSION: These findings are consistent with extant studies of taxi drivers. However, further research is needed to more clearly discern the influence of ethnicity in work-health relationships. The study has implications for population health and is suggestive of areas for further research; e.g., other service-oriented occupations where workers have limited control and little is known about their health or health-related behaviours.     

Gesundheitsförderung bei Auszubildenden

Background

Because of their age and the entry into working life, trainees are in a phase of change. As health-related behaviours also consolidate in this part of life, sensitization for corresponding topics can contribute to health promotion of the future employees in the long term.

Methods

This study examines nutritional behaviour and physical activity as well as the general self-effectiveness expectations of trainees of a major company of the metal industry who participated in a health promotion program over an 11-month period. The participants’ satisfaction with the program was evaluated. In addition, health-related data of 51 male trainees were collected by a questionnaire.

Results

Significant results can be seen in the decrease of consumed portions of “extras” (soft drinks, snacks, chocolate) per day and in a significant increase of general self-effectiveness expectations. There were no changes relating to the intake of fruits, vegetables, whole-grain bread, fast food or physical activity. Overall, the program received highly positive feedback. The trainees acquired health-related knowledge skills. The majority of the trainees could be motivated to continue their occupation with the topics discussed and now has the intention to change some aspects of health-related behaviour in their daily routine.

Conclusion

The program has not shown direct and sudden effects on health behaviour in all of the investigated health-related topics. However, the early sensitization of the participants of corresponding topics as well as the increase in general self-effectiveness expectations might probably contribute to long-term health promotion of young employees.