The population health approach in historical perspective

The origin of the population health approach is an historic debate over the relationship between economic growth and human health. In Britain and France, the Industrial Revolution disrupted population health and stimulated pioneering epidemiological studies, informing the early preventive public health movement. A century-long process of political adjustment between the forces of liberal democracy and propertied interests ensued. The 20th-century welfare states resulted as complex political mechanisms for converting economic growth into enhanced population health. However, the rise of a "neoliberal" agenda, denigrating the role of government, has once again brought to the fore the importance of prevention and a population health approach to map and publicize the health impacts of this new phase of "global" economic growth.     

新医改政策制定过程中的协商民主

通过考察四家报纸对于新医改政策制定过程的报道,本文发现,在新医改的议题提出、决策方案备选以及征求社会意见过程中,新闻报道与行政决策形成了一定程度的关联互动。而新闻报道所普遍持有的民间／社会价值立场则促使这场发生在大众传媒话语空间的公共商讨得以持续并引发中央政府的高度关注。新医改的决策个案表明,在中国现有的主导政治模式中,大众传媒上所进行的政策协商,可以为中央政府的政策决策提供新的正当性管道,但又深受政治管控的制约。     

Advertising health: the case for counter-ads.

Public service advertisements have been used by many in hopes of "selling" good health behaviors. But selling good behavior--even if it could be done more effectively--is not the best goal for using mass media to prevent health problems. Personal behavior is only part of what determines health status. Social conditions and the physical environment are important determinants of health that are usually ignored by health promotion advertising. Public service advertising may be doing more harm than good if it is diverting attention from more effective socially based health promotion strategies. Counter-ads are one communications strategy that could be used to promote a broader responsibility for rectifying health problems. In the tradition of advocacy advertising directly promoting policy rather than products, counter-ads promote views consistent with a public health perspective. Counter-ads set the agenda for health issues, conferring status on policy-oriented strategies for addressing health problems. The primary purpose of counter-ads is to challenge the dominant view that public health problems reflect personal health habits. They are controversial because they place health issues in a social and political context. Advertising strategies for health promotion range over a spectrum from individually oriented public service advertising to socially oriented counter-advertising. The recent anti-tobacco campaign from the California Department of Health Services represents advertisements across the spectrum. Counter-ads that focus on a politically controversial definition for health problems are an appropriate and necessary alternative to public service advertising.     

Governing childhood obesity: Framing regulation of fast food advertising in the Australian print media

Childhood obesity is widely constructed as reaching epidemic proportions with consumption of fast food viewed as a contributing factor. This paper analyses media reporting of the regulation of fast food consumption to children. A media search of five Australian newspapers for the period January 2006 to June 2008 elicited 100 articles relating to the regulation of fast food advertising to children. Content and thematic analysis of the articles reveal conflicting perspectives on the role of the state; the level of accountability of the food and advertising industries; and responsibilities of parents for regulating fast food consumption in children. The Federal Government, food and advertising industries and free to air broadcasters favour industry self-regulation and personal responsibility for fast food consumption while the proponents of government regulation include consumer groups, state government health ministers, nutrition and public health academics and medical and health foundations. The regulation of fast food advertising to children is discussed in relation to ideas about governance and the public health strategies which follow from these ideas. The paper argues that all proposed solutions are indicative of a neoliberal approach to the governance of health insofar as the responsibility for regulation of food marketing is viewed as lying with industry and the regulation of lifestyle risk is viewed as an individual responsibility.     

Nanny or steward? The role of government in public health

The past year has witnessed contentious debates about public health in England around smoking bans, alcohol licencing, food labelling and junk food advertising. Some people argue that any government intervention in these areas is ‘nanny statist’—an unnecessary intrusion into people's lives and what they do, eat and drink. Others argue that only the state can alter the environment that shapes people's decisions and behaviour. This paper suggests that there is a strong argument to be made for government intervention to safeguard public health. Legislation brings about changes that individuals on their own cannot, and sets new standards for the public good. Rather than condemning such activity as ‘nanny statist’, it might be more appropriate to view it as a form of ‘stewardship’. The paper draws on international evidence about alcohol use, smoking and road safety to show how taxation, advertising bans, regulations proscribing behaviour and education create a public health framework and shape individual choices towards healthier and safer behaviour.     

Turning negative into positive: public health mass media campaigns and negative advertising

Literature suggests that 'negative advertising' is an effective way to encourage behavioral changes, but it has enjoyed limited use in public health media campaigns. However, as public health increasingly focuses on non-communicable disease prevention, negative advertising could be more widely applied. This analysis considers an illustrative case from tobacco control. Relying on internal tobacco industry documents, surveys and experimental data and drawing from political advocacy literature, we describe tobacco industry and public health research on the American Legacy Foundation's "truth" campaign, an example of effective negative advertising in the service of public health. The tobacco industry determined that the most effective advertisements run by Legacy's "truth" campaign were negative advertisements. Although the tobacco industry's own research suggested that these negative ads identified and effectively reframed the cigarette as a harmful consumer product rather than focusing solely on tobacco companies, Philip Morris accused Legacy of 'vilifying' it. Public health researchers have demonstrated the effectiveness of the "truth" campaign in reducing smoking initiation. Research on political advocacy demonstrating the value of negative advertising has rarely been used in the development of public health media campaigns, but negative advertising can effectively communicate certain public health messages and serve to counter corporate disease promotion.     

Gone viral? Heard the buzz? A guide for public health practitioners and researchers on how Web 2.0 can subvert advertising restrictions and spread health information

Many nations have banned or curtailed advertising of potentially harmful products to protect public health, particularly in the area of chronic disease control. The growth in Internet-based marketing techniques is subverting these advertising regulations. Explosive rises in use of social networking and user-generated content websites is further fuelling product promotion through electronic media. In contrast, there is a very limited body of public health research on these "new media" advertising methods. This paper provides an overview of these advertising methods and details examples relevant to chronic disease control. There is a vast untapped potential for health practitioners and researchers to exploit these same media for health promotion.     

When two sides go to war: newspaper reporting of ‘television food advertising restrictions’ as a solution to childhood obesity

Childhood overweight and obesity is a major public health problem in Australia and overseas. Food advertising during children's television programmes has been identified as one contributing factor to childhood obesity. The media plays an important role in informing the public and presenting arguments supporting and opposing solutions to childhood obesity. The aim of this study was to analyse newspaper coverage of the debate over restricting television food advertising as a solution to preventing childhood obesity. A newspaper search was conducted over the period July 2002 to July 2005. One hundred and sixty-six articles were analysed for article characteristics, speakers quoted, causes and solutions of childhood obesity and arguments presented. The majority of the articles (82, 49%) took a positive slant towards restricting television food advertising to children while 35 (21%) had a negative slant. The main causes of childhood obesity presented were: television advertising of unhealthy foods, lack of physical activity, increased screen time and time stretched parents. The main areas presented as solutions of childhood obesity were: policy changes to food advertising, supportive environments for physical activity, supportive environments for healthy eating and healthy eating policies. Strong arguments and strong language dominated the debate which remained polarised between health professionals and Federal government and industry. In spite of opposition towards restrictions on television food advertising to children, the media's stories played an important part in keeping the issue on the public and political agenda.     

Using public relations strategies to prompt populations at risk to seek health information: the Hanford Community Health Project

The Hanford Community Health Project (HCHP) addressed health concerns among "downwinders" exposed to releases of radioactive iodine (I-131) from the Hanford Nuclear Reservation in the 1940s and 1950s. After developing educational materials and conducting initial outreach, HCHP had to decide whether to apply its limited resources to an advertising or public relations approach. The decision to apply public relations strategies was effective in driving awareness of the risk communication message at the community level, reinvigorating the affected community, and ultimately increasing the number of people who sought information about their risk of exposure and related health issues. HCHP used a series of communication tools to reach out to local and regional media, medical and health professionals, and community organizations. The campaign was successful in increasing the number of unique visitors to HCHP Web site and educating and activating the medical community around the releases of I-131 and patient care choices.     

The Wheels on the Bus Go “Buy Buy Buy”: School Bus Advertising Laws

School buses, a practical necessity for millions of children, are at the center of new efforts to raise revenue. School bus advertising laws bring public health and commercialization concerns to the school setting. In doing so, they potentially expose school districts to First Amendment lawsuits.I examined various school bus advertising bills and laws. I reviewed First Amendment “forum analysis” as applied in the transit and school settings to clarify how this legal test may affect school districts subject to such laws.I have made recommendations for school districts to enact appropriate policies to ensure that such advertising does not undermine public health and to enable the districts to maintain control over their property.School buses, a practical necessity for millions of children across the country, are increasingly at the center of controversial efforts to raise revenue for distressed public school districts. Commercialization of the school setting is not new,1,2 and school buses have been the subject of contentious marketing strategies in the past.3 New school bus advertising bills and laws have brought commercialization concerns back to the forefront, and may have unwittingly exposed school districts to First Amendment lawsuits.School bus advertising is intended to generate revenue for the state, usually for school-related needs.4,5 In states with enacted laws, revenues are reportedly modest.6 However, supporters believe any level of income is meaningful,6 and have called bus advertisers “local heroes” for investing in schools.7 Not all public officials and parents agree.6 Bills have been voted down over safety concerns and disagreement with the commercialization of the school setting.8In addition to raising concerns about safety and commercial exploitation, such proposed state legislation may be unintentionally setting up school districts to be the target of First Amendment lawsuits.9 Public school buses are government property akin to public transportation and school campuses. When they have opened their facilities to advertisers, public transit authorities are regularly required to fend of First Amendment lawsuits,10–14 and public school districts have faced similar legal challenges.15,16 School buses may represent the next frontier of litigation over permissible speech on government property. School districts generally want to maintain control over what can be displayed on the interior and exterior of school buses. Therefore, an understanding of First Amendment jurisprudence related to government property and of the applicable legal test, forum analysis, are essential.17I examined various proposed and enacted school bus advertising bills and laws. I also reviewed First Amendment forum analysis as applied in the public transit and public school settings to clarify how this body of law may affect school districts subject to school bus advertising laws. I have made recommendations for school districts to enact appropriate policies to maintain control over their property and avoid litigation.     

Vaccination, smallpox, and a culture of immunization in Brazil

The aim of this paper is to discuss the emergence and establishment of a "culture of immunization" in the contemporary Brazil from the eradication of smallpox. This culture is associated with a long process of introduction of vaccines, vaccination campaigns and mass vaccination undertaken by the Brazilian government since the late nineteenth century. Particular importance is attributed to the campaign to eradicate smallpox in Brazil (1966-1973). The experience of mass vaccination of the population against smallpox is contrasted with episodes of resistance as the "revolt against the vaccine", and regarded as crucial in shaping new policies and new understandings about the role of immunization in public health and its place in society Brazil.     

Venereal disease control by health departments in the past: lessons for the present.

Programs of venereal disease (VD) control developed from the outset of World War I, through the 1930s and then World War II and its aftermath, are examined for their relevance to the problems posed today by AIDS. In light of past experience, "control" of AIDS, not eradication, is the most that can be expected from the public and health community reaction of increased federal funding in support of research and treatment, promotion of self-protective sexual behavior, and the attempt by public health professionals to approach the problem as one of health and related economic costs, rather than to assume a judgmental attitude. The involvement of all levels of government; the community at large; and the medical, educational, industrial, and social work sectors is essential for the success of a public health program which not only integrates new medical discoveries but also responds to the panicky reactions of the public and some health professionals to the AIDS patient.     

On a hiding to nothing? assessing the corporate governance of hospital and health services in New Zealand 1993–1998

In New Zealand the governance of public sector hospital and health services has changed significantly over the past decade. For most of the century hospitals had been funded by central government grants but run by locally elected boards. In 1989 a reforming Labour government restructured health services along managerialist lines, including changing governance structures so that some area health board members were government appointments, with the balance elected by the community. More market oriented reform under a new National government abolished this arrangement and introduced (1993) a corporate approach to the management of hospitals and related services. The hospitals were established as limited liability companies under the Companies Act. This was an explicitly corporate model and, although there was some modification of arrangements following the election of a more politically moderate centre-right coalition government in 1996, the corporate model was largely retained. Although significant changes occurred again after the election of a Labour government in 1999, the corporate governance experience in New Zealand health services is one from which lessons can, nevertheless, be learnt. This paper examines aspects of the performance and process of corporate governance arrangements for public sector health services in New Zealand, 1993-1998.     

Experiences from the Swedish determinants-based public health policy

A comprehensive Swedish public health policy was adopted by the Swedish Parliament, the Riksdag, in April 2003. It pushes health up on the political agenda and affords equity in health high priority. The first phase of implementation of the policy, 2003-5, is described in the 2005 Public Health Policy Report published by the Swedish National Institute of Public Health (SNIPH). For the purpose of investigating the implementation, SNIPH has monitored the development of 42 determinants and used reports from 22 central agencies and eight county administrative boards together with interviews with all Sweden's county councils (21) and a questionnaire sent out to all municipalities (290). The experiences from the implementation of the policy are that: the determinants approach - focusing on structural factors in society, people's living conditions and health behaviours that affect health - is in general well understood and emphasises the role of other sectors in public health; the use of indicators to follow up exposures to determinants is of key importance; the support to actors outside the health service is needed to identify their public health role; a continuous steering from the government and other political bodies is of vital importance; public health promotion on the regional level needs a higher level of co-ordination; municipalities need more skills development; Sweden has a new government that was elected in September 2006; the new government has retracted the former government's public health policy communication submitted to the Riksdag in the spring of 2006, but does not intend to change the public health policy.     

Tobacco control law implementation in a middle-income country: Transnational tobacco control network overcoming tobacco industry opposition in Colombia

The objective of this paper is to examine the implementation of Colombia's tobacco control law. Methods involved are triangulated government legislation, news sources, and interviews with policy-makers and health advocates in Colombia. Colombia, a middle-income country, passed a tobacco control law in 2009 that included a prohibition on tobacco advertising, promotion, and sponsorship; and required pictorial health warning labels, ingredients disclosure, and a prohibition on individual cigarette sales. Tobacco companies challenged the implementation through litigation, tested government enforcement of advertising provisions and regulations on ingredients disclosure, and lobbied local governments to deprioritise policy responses to single cigarette sales. A transnational network including international health groups and funders helped strengthen domestic capacity to implement the law by; promoting public awareness of Ley [Law] 1335; training local health department staff on enforcement; facilitating health agencies’ sharing of educational strategies; and providing legal defence assistance. This network included vigilant efforts by local health groups, which continuously monitored and alerted the media to noncompliance, engaged government officials and policy-makers on implementation, and raised public awareness. Support from international health NGOs and funders and continuous engagement by local health groups enhanced implementation capacities to counter continued tobacco industry interference and ensure effective tobacco control implementation.     

Protecting Young People From Junk Food Advertising: Implications of Psychological Research for First Amendment Law

In the United States, one third of children and adolescents are overweight or obese, yet food and beverage companies continue to target them with advertising for products that contribute to this obesity crisis.When government restrictions on such advertising are proposed, the constitutional commercial speech doctrine is often invoked as a barrier to action. We explore incongruities between the legal justifications for the commercial speech doctrine and the psychological research on how food advertising affects young people.A proper interpretation of the First Amendment should leave room for regulations to protect young people from advertising featuring calorie-dense, nutrient-poor foods and beverages.NUMEROUS STUDIES HAVE documented the volume and poor nutritional quality of foods and beverages marketed to children and adolescents. The food industry spends more than $1.6 billion per year in child- and teen-targeted marketing of their products.1 The average child in the United States views 13 food ads on television each day,2 and food advertising represents approximately 30% of all paid television advertising viewed by children.3 Food companies also target children directly on the Internet, product packaging, social media, and numerous other marketing venues.1 Nearly all foods featured in advertising targeted toward young people have high levels of calories, total fat, saturated fat, sugar, or sodium (i.e., they are unhealthy, calorie-dense, nutrient-poor foods, or “junk” foods) and are often nutritionally inferior to products targeting adults.4–9Research has consistently demonstrated the effects of food advertising on children''s brand preferences, food choices, and requests to parents.10,11 Recent studies suggest that food advertising may also have a broader impact on children''s and adolescents’ diet and health, including increased consumption of snack foods, sugar-sweetened beverages, and fast food12–14 and higher body mass indexes.14,15One third of children and adolescents in the United States are overweight or obese,16 and rates of diet-related diseases among young people are unprecedented.10,17,18 Public health experts conclude that this epidemic of childhood obesity and poor diet cannot be resolved without dramatic changes in the obesogenic food environment that surrounds young people and to which food advertising is a major contributor.1,10,19,20Advocates have proposed a range of public health tools to protect young people from exposure to unhealthy food advertising, including nutrition and media literacy education, public health and industry advertising to promote consumption of healthy foods, industry self-regulation, government legislation and regulation, and litigation.19 However, education and counteradvertising alone cannot compete with the $1.6 billion spent annually by industry to target young people with continuous reminders about the rewards of consuming primarily unhealthy foods1,19; significant reductions in the volume of unhealthy food advertising directed at young people are necessary.It is unlikely that the food and beverage industry will voluntarily make these changes. Seventeen food and beverage companies in the United States21 participate in the Children''s Food and Beverage Advertising Initiative and have pledged to improve their advertising directed at children; however, these pledges have been criticized for numerous limitations in the types of marketing and products covered.22 For example, “child-targeted” advertising is defined as advertising that appears in media in which 50% or more of the audience is between the ages of 2 and 11 years,21 yet this definition excludes many types of media that appeal to and are viewed primarily by nonadults.22 Similarly, most pledges do not restrict advertising for “better-for-you” foods,21 but these criteria are defined by the companies themselves and often allow advertising of products high in saturated fat, sodium, or sugar.22 Evaluations of the effectiveness of these pledges demonstrate minimal improvements at best.23–26In the absence of effective industry self-regulation, it is imperative for the government to step in; however, governmental bodies have been timid about attempting to limit young people''s exposure to food advertising.19,27 An oft-cited barrier to action is the constitutional commercial speech doctrine, which affords significant First Amendment protection to advertising, defined by the US Supreme Court as “speech proposing a commercial transaction.”28 (It is beyond the scope of this article to speculate how courts would parse out which promotional activities involve advertising versus non-speech-related marketing that is unprotected by the First Amendment. Our analysis applies to “advertising” however construed.) The commercial speech doctrine presumes that advertising restrictions harm consumers and the overall economy by obstructing the free flow of information needed to facilitate informed commercial transactions.19,29We discuss key premises underlying the commercial speech doctrine and psychological research on how food advertising affects young people. Examining both legal and psychological theories of advertising effects, we demonstrate that the commercial speech doctrine, in its current form, has little relevance to the actual techniques used to encourage the purchase and consumption of nutritionally poor foods by children and adolescents. As applied to unhealthy food advertising to young people, the commercial speech doctrine is outdated and inadequate and should not stand as an impediment to well-crafted government restrictions on such advertising. Although this premise has not been tested in the courts, there should be constitutional room for governments at the local, state, and federal levels to use laws, regulations, and enforcement actions to curb advertising of junk foods to children.     

Advertising for all by the year 2000: public health implications for less developed countries.

This paper argues that the development of global advertising has significant implications for the public health of less developed countries. These implications can be seen in three areas. First, it is clear that advertising and marketing of lethal or health-compromising products like alcohol and tobacco not only can increase the level of death and disease, but can also produce serious indirect effects upon families, communities, and entire societies. Second, advertising promotes a consumption ethic which can have far-reaching effects that go beyond individual behavior, significantly altering social relationships, and influencing public policies and allocation of scarce resources. Third, advertising can restrict the public's knowledge about health issues by substituting distorted and manipulative sales messages for vital, accurate health information. In addition, revenues from advertising are a primary support for many mass media systems and this further limits the presentation of critical information.     

Politics and prospects for health promotion in England: mainstreamed or marginalised?

This paper critically examines the public policy environment that underpins the politics of health promotion in England. English health policy from the late 1970s to the mid 1990s was not receptive to health promotion. The new Labour government elected in 1997 claimed to embrace a ‘Third Way’ between the free market and socialism that would appear to embrace a community-centred approach to health promotion that would through partnership-building promote equity; perversely, however, the election of this government rhetorically committed to healthy public policy was accompanied by a crisis in health promotion delivery. Despite apparent commonalities between the Third Way and health promotion, the Third Way was in many respects a neoliberal ideology and so has contributed to the marginalisation of health promotion. Although some might argue that health promotion has been mainstreamed, it is argued here that in terms of the crucial National Health Service infrastructure underpinning the health promotion movement, that the organisational capacity for health promotion has been significantly weakened. Thus the question is how you revive a movement that has lost its way? The answer must include taking a historically informed approach to analysing the problem and identifying solutions. Wider systems issues in England include the emergence of multidisciplinary public health, the sequence of changes to national health promotion organisations and the wider marginalisation of the public health movement. It is only by critically analysing and addressing these systemic issues that the prospects for health promotion in England can be revived.     

Community pharmacy and public health in Great Britain, 1936 to 2006: how a phoenix rose from the ashes

The pharmacy profession in Great Britain has identified public health as a key area for future development; at the same time the government has been keen to make full use of pharmacists in pursuing its public health goals. To date, pharmacy has focused on microlevel activities such as health promotion, medicines management and prescribing advice, rather than on wider public health issues such as health inequalities. The role in health promotion has its origins in the traditional advisory role of the pharmacist, which largely died out following the establishment of the National Health Service in 1948, and was resurrected only following ministerial intervention in 1981. This article traces the origins of the pharmacist's role in public health, illustrating both shifting definitions of public health and changes in pharmacy practice. It describes how the profession was able to re-establish its advisory role and to develop it into a wider contribution to public health, indicating that this process came about as a result of convergence between a professional imperative to develop its role, on the one hand, and state recognition of the need to draw a broader range of health professionals and lay people into public health activities, on the other. Convergence required the securing of government support, confirmed in policy documents; the recognition by pharmacy's professional body that embracing public health is a desirable activity; incentives for community pharmacists to carry out such activities; and support from the wider public health community. This article describes how each of these was achieved.     

Towards a new system of health: The challenge of western disease

Over the last three decades, the concept of Western disease has become well established. Medicine has approached this group of diseases by searching for new cures but has achieved relatively little success. We argue that medicine should now accept the failure of this strategy and place a major emphasis on prevention. The key objective is to change the climate of opinion so that prevention is taken seriously by the general population. The chief activity should be a wide ranging public education campaign so as to persuade people to live a healthier lifestyle. Medicine will require restructuring in order to carry out this work. Medical education needs to be reformed so that medical students receive the necessary training. This must be done as part of an integrated approach in which government, industry and medical research all play a major role. Governments should use taxation and subsidies in areas such as food and tobacco so as to shift consumption patterns towards healthier products. Governments must also tighten laws on tobacco sales and advertising, support health education, and improve food labelling. Industry must be made far more responsive to the health needs of the population. This should be done both by public education, so as to alter demand, and by government action. Medical research should change its emphasis from studying the detailed mechanisms of disease (complex research) to studying the role of lifestyle factors (simple research).Norman J. Temple, PhD, Animal Sciences Division, Alberta Environmental Centre, Vegreville, Alberta TOB 4LO, Canada. He is Associate Professor of Nutrition, Athabasca University. Denis P. Burkitt, MD, FRCS, FRS, Hartwell Cottage, Wells Road, Bisley, Glos GL6 7AG, England (U.K.).