Health Promotion

1
Health Promotion
Corso di Laurea in Scienze dellEducazione e
della FormazioneUniversità degli Studi di Roma
La Sapienza

• by Stefania Borgo
• Second semester Unit Academic Year 2004-2005
• In collaboration with B. Marshall K.A. Moore
• Deakin University (Melbourne, Australia)

2
Introduction
3
Aims and Objectives of the Course

• The aim of this Course is to equip students with
  an understanding of health promotion concepts and
  frameworks as they relate to contemporary health
  issues in Italy and internationally.

4
this will include

• To examine and apply the range of theoretical and
  practical intervention frameworks used in
  contemporary health promotion
• To investigate through case study examples
  evidence of health promotion successes and
  failures of health within Italy, Europe and
  internationally
• To gather and critically analyse sources of
  health information and data relevant to
  contemporary health promotion practice
• To develop English language skills appropriate to
  health promotion theory and practice

5
Structure of the Course

• Lecture 12 Understanding health and health
  promotion health promotion concepts, frameworks
  and key documents
• Lecture 34 The determinants of health
  behavioural, social and environmental
• Lecture 56 Social and societal determinants of
  health
• Lecture 78 Models of practice in health
  promotion
• Lecture 910 Behaviour change theories and
  practice from individuals to communities
• Lecture 1112 Case studies of health promotion
  practice - guest speakers
• Lecture 1314 Community engagement and community
  action for health
• Lecture 1516 Summary. Evidence and evaluation
  in health promotion

6
Lecture 1
7
Health Promotion

• Health promotion is the process of enabling
  people to increase control over the determinants
  of their health, in order to achieve better
  health.

8
The bio-medical model of health

• All disease is caused by a specific aetiological
  agent, such as a virus or bacterium.
• The patient as passive recipient the body is a
  machine that needs fixing, rather than a person
  in a complex social environment.
• Restoring health (a state of equilibrium in the
  body the parts all working appropriately)
  requires medical technology/intervention.

9
Definitions of Health Promotion

• Sandy Gifford The action arm of public health.
• WHO The process of enabling people to exert
  control over the determinants of their health, to
  improve their health.
• Green Any combination of health education and
  related organisational, economic and political
  changes to promote change at individual, social
  and environmental levels.

10
Health promotion is

• A process it leads to something, it is a means
  to an end, not an outcome in its own right
• Enabling it is done WITH and FOR people, not ON
  for T0 them
• Aimed at strengthening the skills and capacity of
  people to take action about the determinants of
  their health
• A combination of approaches, so that single
  strand, one-offs are not health promotion

11
Components of personal health

• Physical health
• Mental health
• Social health
• Emotional health
• Sexual health
• Spiritual health

12
Health promotion glossary
13
For the complete list of terms, see

• Health Promotion Glossary
• www.wpro.who.int/hpr/docs/
• glossary.pdf

14
Work in groups

• www.who.int/en
• www.who.int/hpr
• www.wpro.who.int/hpr
• www.wpro.who.int/hpr/docs/
• glossary.pdf

15
Lecture 2
16
Health promotion glossary

• List of Basic Terms

17
Health

• Health is defined in the WHO constitution of 1948
  as
• A state of complete physical, social and mental
  well-being, and not merely the absence of disease
  or infirmity.
• Within the context of health promotion, health
  has been considered less as an abstract state and
  more as a means to an end which can be expressed
  in functional terms as a resource which permits
  people to lead an individually, socially and
  economically productive life.
• Health is a resource for everyday life, not the
  object of living. It is a positive concept
  emphasizing social and personal resources as well
  as physical capabilities.

18
Health for All

• The attainment by all the people of the world of
  a level of health that will permit them to lead a
  socially and economically productive life.

19
Public health

• The science and art of promoting health,
  preventing disease, and prolonging life through
  the organized efforts of society.

20
Primary health care

• Primary health care is essential health care
  made accessible at a cost a country and community
  can afford, with methods that are practical,
  scientifically sound and socially acceptable.

21
Disease prevention

• Disease prevention covers measures not only to
  prevent the occurrence of disease, such as risk
  factor reduction, but also to arrest its progress
  and reduce its consequences once established.

22
Health education

• Health education comprises consciously
  constructed opportunities for learning involving
  some form of communication designed to improve
  health literacy, including improving knowledge,
  and developing life skills which are conducive to
  individual and community health.

23
Health Promotion GlossaryExtended List of Terms
24
Advocacy for health

• A combination of individual and social actions
  designed to gain political commitment, policy
  support, social acceptance and systems support
  for a particular health goal or programme.

25
Alliance

• An alliance for health promotion is a
  partnership between two or more parties that
  pursue a set of agreed upon goals in health
  promotion.

26
Community

• A specific group of people, often living in a
  defined geographical area, who share a common
  culture, values and norms, are arranged in a
  social structure according to relationships which
  the community has developed over a period of
  time. Members of a community gain their personal
  and social identity by sharing common beliefs,
  values and norms which have been developed by the
  community in the past and may be modified in the
  future. They exhibit some awareness of their
  identity as a group, and share common needs and a
  commitment to meeting them.

27
Community action for health

• Community action for health refers to collective
  efforts by communities which are directed towards
  increasing community control over the
  determinants of health, and thereby improving
  health.

28
See Appendix 1 in Appendices
29
Lecture 3
30
The determinants of health

• If we are going to improve peoples health, we
  need to identify and target those factors that
  cause / determine their health.
• There are a number of models of identifying the
  determinants of health.
• Traditional biomedical.
• Others.

31
The pre-requisites for health

• The Ottawa Charter for Health Promotion indicates
  that the fundamental resources and conditions for
  health arepeace, shelter, education, food,
  income, a stable ecosystem, sustainable
  resources, social justice and equity.

32
Marc Lalondes (1974) determinants of health model

• human biology

lifestyle
environment
health care
33
Some comments on these four determinants

• Human biology / genetics how much control do we
  have over these? Whose role?
• Lifestyle and behaviour how much control do
  individuals have over these? How successful have
  we been in changing these?
• Environmental impacts physical and biological
  environments, but also social, economic etc
• Health care how much of an impact?

34
The determinants of Health

• The basic question is WHY does the issue arise.
• Lets do a mindmap of the issue heart disease
  asking the question WHI? All the time.

35
Health Iceberg(Ryan Travis 1988)

• Heart
• State of health Disease
  
• Contributing factors genetics,
  high BP,
• high chol, obesity
• Lifestyle behaviours smoking,
  alcohol, stress
• inactivity, poor diet
• Psycho-sociocultural poor access to
  services/
• environmental information no support
• determinants network/resources poor
  self image re exercise
• poor local facilities dark streets

36
The Health Iceberg

• Visible above the waterline - the state of health
  we are concerned with.
• Just below the surface are the known risk factor
  for this health issue.
• What sets up these risk factors? Lifestyles. What
  are their lives like?
• But the real question is what creates their
  lifestyles - the psycho-socio-cultural
  environment.

37
(No Transcript)
38
The bottom layer of the iceberg
psycho-socio-cultural determinants

• Individual
• Values
• Attitudes
• Beliefs
• Resources
• Skills
• Knowledge
• Feelings

• Community
• Resources
• Opportunities
• Culture
• Settings
• Legislation
• Politics
• Discrimination

39
The Iceberg Model of the Determinants of Health

• What conclusions can we draw about the
  determinants of health from the examples we have
  worked through.

40
Environments for health

• A study in Glasgow compared a rich neighbourhood
  with a poor one.
• Physical activity
• nearly twice as many facilities per capita in the
  rich area
• far lower levels of car ownership in the poorer
  area
• far less public transport in the poorer area
• streets in the poor area were less well
  maintained, more litter, more derelict buildings,
  more street crime, especially after dark

41
Glasgow study continued Nutrition

• People in the poorer area less likely to eat
  well.
• Shopping basket survey a less healthy and a
  more healthy basket
• In both areas, the more healthy basket was
  dearer than the less healthy
• But the difference between them was greater in
  the poorer area healthy food was dearer in the
  poorer area.
• Availability of less healthy same in both
  areas, but more healthy not nearly as
  accessible in the poorer area.

42
Social geography

• Macintyre and Ellaway article (Health Promotion
  Journal of Australia 9(3) 165-170).
• Compare richer and poorer areas of Glasgow
• Physical activity
• Resources for physical activity 1.05
  facilities/1000 people in richer versus 0.6
• Cars 58 in richer have access vs 38 in poorer
• Bus routes markedly lower in the poorer area
• Local area poorer had significantly more street
  crime, litter, syringes, derelict houses, so was
  less attractive for walking etc.

43
Social geography cont.

• Healthy eating
• Poorer area had significantly poorer diet
• Richer had far greater range of food shops
• Shopping basket survey both the more healthy
  and the less healthy basket cost more in the
  poorer area and the difference b/w these is
  greater in the poorer area
• Healthier items had a much lower availability in
  the poorer area.

44
Social geography cont.

• Community resources
• Fewer community services, such as bank, GP,
  shops, in the poorer area
• Far greater distance to travel to use community
  facilities

45
Groups Work Health data in Italy www.euro.who.int
/hfadb www.who.dk/countryinformation àItalyàcount
ry profile (Highlights on health in Italy)
46
Lecture 4
47
Marc Lalondes (1974) determinants of health model

• human biology

lifestyle
environment
health care
48
Determinants of health and illness

• Two main approaches
• Epidemiological
• Social
• Both see health as arising from the everyday
• Social
• Physical
• Environmental, and
• Economic lives of people

49
Epidemiological approach

• A focus on risk
• Health determinants are entities that influence
  health from the perspective of risk. These
  include
• Risk factors that result from behaviour or
  environmental exposure
• Risk conditions that are more fundamental causes
  of ill health, such as social deprivation and
  powerlessness

50
Social science approaches

• The inter-relationships between social
  circumstances that inter-relate, eg
• Poverty, wealth and income distribution
• Psycho-social health or deprivation
• Powerlessness
• Social factors age, sex, race, etc
• Level and quality of education and literacy
• Personal health resources and coping
• Socio-ecological environments.

51
Children Environmental Health

• An Italian priority within an international
  perspective

See Appendix 2 in Appendices
52
Lecture 5
53
The Social Determinants of Health
54
Growing awareness since 1970s

• Black Report (1980) stunned Britain with its
  revelations about health inequalities
• Lalonde Report (Canada 1974) revealed similar
  inequalities
• US - shocking variations in level of health and
  access to health care
• In all countries - health and wealth are linked.
  SES a prime predictor of health

55
A better understanding of the social determinants
of health

• Clearly the social situation in which people live
  their lives significantly affects their health
  poorer people have significantly worse health
  than wealthier people.

56
The Solid Facts

• Social gradient
• Stress
• Early life
• Social exclusion
• Work
• Unemployment

• Addiction
• Food
• Transport
• Social support
• Discrimination

http//www.who.dk/document/e59555.pdf
57
Occupational class differences in life
expectancy, England and Wales, 1997-1999
58
Risk of diabetes in men aged 64 years by birth
weigtht Adjusted for body mass index
59
Proportion of children living in poor households
(below 50 of the national average income)
60
Self-repoted level of job control and incidence
of coronary heart disease in men and women
61
Effect of job insecurity and unemployment on
health
62
Socioeconomic deprivation and risk of dependence
on alcohol, nicotine and drugs, Great Britain,
1993
63
Groups Work

• The solid facts
• http//www.who.dk/document/e59555.pdf

64
Lecture 6
65
Social capital

• One of a range of capitals economic, cultural
  and social. Likely to be linked.
• Despite confusion about the term, there is
  agreement of the importance of networks between
  people because they build trust and encourage
  cooperation for mutual benefit.
• Complex link to health.

66
Active organizational involvment, 1973-1994
67
Four decades of dwindling trust Adults and
teenagers, 1960- 1999
68
Schools work better in high social capital states
69
Health is better in high social capital states
70
Death rate vs level of comunity trust
Percent Responding Most people would try to
take advantage of you if they got the chance.
71
(No Transcript)
72
(No Transcript)
73
Depression link to hearth disease

• Depression and loneliness are bigger risk factors
  for heart disease than stress, ranking alongside
  smoking, high blood pressure and cholesterol.
• National Heart Foundation
• Expert working group
• The Age, page 6. 17 March 2003

74
Bunker et al, MJA 178, pp272-276

• Strong consistent evidence of an independent
  causal association b/w depression, social
  isolation, and lack of quality social support and
  the causes and prognosis of CHD.
• No strong or consistent evidence for causal
  association between chronic life events,
  work-relate stressors, Type A behaviour,
  hostility, anxiety disorders or panic disorders,
  and CHD.

75
Bunker et al, MJA 178, pp272-276 cont.

• The increased risk contributed by these
  psychosocial factors is of similar order to the
  more conventional CHD risk factors such as
  smoking, dyslipidaemia and hypertension.
• The identified psychosocial risk factors should
  be taken into account in individual CHD risk
  assessment and have implications for public
  health policy and research.

76
Measuring social capital

• Baums questionnaire in SA
• - Social participation, informal
• - Social participation, activities in public
  spaces
• - Social participation, group activities
• - Civic participation, individual activities
• - Civic participation, group activities
• - Community group participation, mix of civic
  and social

77
Social capital and health

• Population health
• Income distribution and health are both linked to
  social involvement and trust
• Lynchs work on income inequality vs life
  expectancy
• Individual health
• Social connectedness protective of health

78
The dark side of social capital

• Is social connectedness and inclusion sometimes
  established and maintained by defining the us
  and them, of establishing boundaries and
  barriers that exclude some so that those inside
  can feel part of a strong network or community?
• Can you think of any groups in Italy who
  establish identity, belonging and connectedness
  in this manner?

79
NHPAs Risk and Protective Factors
P ESTABLISHED ASSOCIATED/COMORBIDITY ?
POSSIBLE
80
Protective Factors Healthy Conditions
Psychosocial Effective Health
Healthy Lifestyles Environments
Factors Services safe
physical enviros. social networks
preventative services reg.physical act. healthy
public policy power control
culturally approp. pos. mental health
Quality of life, functional independence,
wellbeing, mortality, morbidity, disability
Risk Conditions Psychosocial
Behavioral Risk Physiological
Risk Factors Factors
Factors poverty isolation
smoking high BP low
social status low sense of purpose
poor nutrition high cholesterol
Risk Factors
81
The patient and the urban environment

• See Appendix 3 in Appendices

82
Lecture 7
83
Strategies and Methodsin Health Promotion
84
Some fundamental considerations

• What are the priority health issues? Who
  determines? What criteria?
• Prevalence
• Severity
• Amenability to intervention
• Special groups
• Addressing the major determinants of the health
  issue those that can be modified

85
What approach?

• Socio-environmental vs individual
• Poverty
• Lack of education
• Unemployment
• Policy change
• Problematic behaviours
• Knowledge
• Personal beliefs
• Values
• High risk vs low risk/whole population

86
Which population group to choose?
87
Downs Syndrome
88
Downs Syndrome
89
Another esample CHD
90
High risk vs whole population?

• Where will we get most impact?
• Do we/can we screen to identify high risk
  individuals or initiate whole-population
  approaches?
• The paradox of prevention occurs when a large
  number of people at small risk may give rise to
  more cases of a disease than the small number at
  high risk.

91
High risk vs whole population?

• For many health issues, get better results from
  whole population approaches e.g. heart disease,
  mental health, safe sex
• Reducing risk factors in one person does nothing
  to stop others entering the high-risk pool no
  change in the distribution of the disease,
  because non attention to the forces that lead to
  risk factor.

92
High risk vs whole population?

• Ethical and social implications we are asking
  the majority to change their behaviour when many
  of them will see no benefit, in fact may
  experience some harm (e.g. sporting injury)

93
Strategies and Methods

• Ottawa Charter
• Build healthy public policy
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Reorient health services
• Action verbs enable, mediate an advocate

94

• Read glossary terms
• Enabling
• Mediation
• Advocacy for health

95
(No Transcript)
96
Groups work Find and comment Ottawa Charter
97
Lecture 8
98
(No Transcript)
99
Types of intervention

• Medical approach
• Improving physiological risk factors eg high
  blood pressure, early cancer detection
• Behaviour / Lifestyle approach
• Improving behavioural risk factors eg smoking
  poor nutrition, inactivity
• Socio-environmental approach
• Determinants of health in the enviros where we
  live, work , play,
• Risk conditions, eg poverty
• Psychosocial factors, eg poor social connections

100
(No Transcript)
101
Level of intervention

• Focus on individuals
• Generally secondary prevention
• Health care services, eg patient education
• Shop fronts
• Risk factors assessment
• Self education materials
• counselling

102
Level of intervention

• Focus on groups
• Adult education
• Self help groups
• Community action groups
• Focus on populations
• Social marketing and the media
• Community development
• Health promoting settings and environments

103
(No Transcript)
104
An Italian program
Stress Management in School Teachers personal
and/or worksite change?
See Appendix 4 in Appendices
105
Lecture 9
106
(No Transcript)
107
Going to practicechanging peoples behaviour

• Can we do it?
• How do we do it?
• Should we do it?

108
Our early attempts

• Knowledge of risk would lead to behaviour change
• Increased knowledge ?change in attitudes ?
  behaviour change
• Teach decision making skills ? healthy behaviour
• Not particularly successful

109
Behaviour change theories

• How do we explain why people dont necessarily
  take action to improve their health?
• Behaviour change theories arising from social and
  behavioural psychology

110
Health belief model

• Behaviours is guided by perceptions of the
  consequences of our actions positive, negative
• Considering behaviours change involves a
  cost-benefit analysis
• Feel threatened, vulnerable, susceptible
• The issue is serious
• Recognise that change would be beneficial
• Recognise the barriers and how much it costs us
  to overcome them
• Feel competent to carry out the change

111
Health belief model in action

• Some of the strategies
• People like me
• Experience of those suffering or used to
  suffering (e.g. ex addicts)
• Fear, guilt
• Change is possible
• Problems stimulate interest, e.g. drugs
• Effective for recruitment to one-off events e.g.
  screening, immunization
• You will use it in todays tutorial

112
Theory of reasoned action

•  People are rational, so behaviour can be
  predicted from intentions.
• Intentions a function of attitude and subjective
  norms - what significant others think you should
  do (e.g. peers, sports heroes)
• Short-terms consequences are of more importance
  to people
• Different from Health Belief Model in that is
  stresses the importance of the attitudes of
  others, the motivation to comply with perceived
  social pressure from significant others- peer
  group pressure.

113
Stages of change model

• Change is a process, not an event
• Precontemplation not aware or concerned about
  the dangers no thought of changing behaviour
• Contemplation Aware of the benefits of change,
  and may be seeking information to help make the
  decision.

114
Stages of change model cont.

•  Preparing to change consider that benefits
  outweigh costs. Experiment with change
• Action the early stages of change require a
  clear goal realistic plan, support and rewards
• Maintenance behaviour sustained
• Not linear people swap between phases

115
Critique of the Stages of Change model

• Very individualistic all to do with motivation
  and willingness/readiness to change. Ignores the
  impact of social advantage, access to resources
  etc
• Are there discrete stages, or is it a continuum?
• Not much research to see how useful it is in
  delivering behaviour change
• Bunton et al, 2000, in Critical Public
  Health, 10(1), 55-70

116
Working in groups
How to prepare a program from proposal to
dissemiantion.
117
Lecture 10
118
Behaviour change theories
1. Health belief model 2. Theory of reasoned
action 3. Stages of change model 4. Social
learning model
119
Social learning theory

• The most complex and complete of the models
  interaction between the individual and their
  environment
• Beliefs about how things are linked, causal
• People model behaviours not trial and error
• Look for positive outcomes of change
• Feel capable of making the change locus of
  control and self efficacy

120
Social learning theoryimplementation

• Motivation, role modelling
• Provide skills training
• Support networks
• Maintenance through reinforcement

121
The prerequisites for change

• The change must be self-initiated
• The behaviour must be called into question,
  become salient
• The salience of the behaviour must appear over a
  period of time
• The behaviour is not part of the persons coping
  strategy too hard to change

122
Problems with these models

• Top down, expert driven
• Focus on the individual in isolation from their
  social setting
• Victim blaming
• Behaviour makes most difference to peoples
  health when other conditions in their liver ere
  favourable
• View health decisions as based on reason and
  rational choice. But health is just one of
  peoples concerns.

123
Community interventions

• Many community interventions, particularly large
  scale ones, are really just individual
  interventions applied on a large scale.
• Targeted community-based prevention programs are
  much more successful.

124
Lecture 11
125
(No Transcript)
126
Last week

•  We examined the left hand end of this diagram -
  how we might attempt to change individual
  behaviour.
• Today we want to look at action that moves us to
  the right, to addressing the broader
  environmental influences on health

127
(No Transcript)
128
Health education, counselling and skills
development

• Goes further than health information
• Aims to increase knowledge, change attitudes,
  develop skills and self-efficacy
• Individual and group

129
Social marketing

•  Designed to influence voluntary behaviour of the
  target group
• Mass media
• Persuasive, not just information

130
Organisational development

•  Targets organisations rather then individuals
  and groups of people
• Change the organisation so that is more health
  promoting
• Healthier schools, workplaces hospitals etc
• Will return to this in the lecture on health
  promoting settings

131
Community action

• Encourage and empower communities to build their
  capacity to develop and sustain improvements in
  their social physical environments and in their
  access to services

132
Economic and regulatory activity

• Financial and legislative
• Incentive and disincentives to support healthy
  choices by individual
• Incentive and disincentives to support healthy
  action by organization

133
Of course

• Health promotion requires a strategic approach
  that links a number of these action areas

134
Why do we need this range of approaches?

• Complementary approaches allow us to support and
  reinforce individual health promotion actions - a
  concerted effort
• Many of the determinants of health lie outside
  the realm of individual choice - they are the
  powerful social determinants of health. So we
  need to move the right-hand end of the chart and
  to address these determinants. We need to work
  upstream the problems.

135
Working at community/population level

• Two main reasons
• Complex aetiology of contemporary heath issues
  think back to our lecture on the Social
  Determinants of Heath
• Fostering individual behavioural change is very
  limited success behavioural psychology,
  community psychology

136
Community

• Communities have the capacity to tackle their own
  problems
• Focus on strengths not just deficits
• A different concept of the role of the health
  professional
• A competent community which can care for its
  members and help them to cope with or to change
  external forces harness skills, collective
  energy and external resources for community
  determined solutions
• A psychological sense of community

137
Empowerment

• The process by which people, organisations and
  communities gain mastery over their lives
• If a competent community and a psychological
  sense of community are the goals, empowerment is
  the way of getting there

138
Characteristics of a community development
approach

• User led
• Defining the issues of importance often more
  complex social issues than medical problems
• Active role for the health worker getting to
  know key individuals and groups, linking,
  building networks, creating a sense of community

139
Characteristics of a community development
approach

• Focus on process
• Community building is a process, worthy in its
  own right and not just as a means to an end self
  confidence, self esteem, feelings of being in
  control
• Skill development

140
Characteristics of a community development
approach

• Focus on the needs of disadvantaged and
  vulnerable groups
• Acknowledge health inequalities
• Prioritise activity with disadvantaged and
  vulnerable groups
• Address the social determinants of health

141
Advantages and Disadvantages

• Disadvantages
• Time consuming
• Results are often not tangible or quantifiable
• Evaluation is difficult
• Without evaluation, gaining funding is difficult

• Advantages
• Starts with peoples concerns
• Focuses on the root cause, not symptoms
• Creates awareness of the social causes of ill
  health
• The process of involvement is enabling and leads
  to greater confidence

142
Advantages and Disadvantages

• Disadvantages
• Health promoters may find their role
  contradictory. To whom are they ultimately
  accountable?
• Work is usually with small groups of people
• Draws attention away from macro issues and may
  focus on local neighbourhood

• Advantages
• The process involves gaining skills which are
  transferable
• If health worker and people meet as equals, it
  extends the principle of democratic
  accountability

143
Group Work Working on a HP program
144
Lecture 12
145
Population-based strategies

•  Mass media
• Policy
• Environments/settings

146
Mass mediaapproaches

• Approaches that reach groups of individuals using
  a medium other than personal contact
• Possibly more cost-effective than face-to-face
  individual approaches

147

• Health promotion messages can also be
  disseminated without the use of mass media
• Health promotion campaigns may be conducted
  through product labeling (driven by public health
  policy initiatives) or through sponsorship
  programs

148

• E.G. in the mid-1980s health warning labels on
  cigarette packages were introduced, in the mid-
  1990s tougher, bolder warnings, with explanatory
  messages including information on contacting quit
  advice smoking lines
• Who can think of a more recent suggestion to
  label packaging in a different product?

149
Awareness by Type of Message WA (1999/00)
150
Total action by Type of Message WA (1999/00)
151
Social Marketing
152
Social Marketing

• The application of commercial and marketing
  technologies to the analysis planning, execution
  and evaluation of programs designed to influence
  the voluntary behaviour of target audiences in
  order to improve their personal welfare and that
  of society.
• Often equated to mass media campaigns

153
The 4 Ps of Social Marketing

• Product the product or behaviour and its key
  characteristics
• Place where the product is available
• Price the value of the product and how important
  it is to the audience
• Promotion the means by which the product is
  promoted

154
Product

• Anything that can be offered to a market that
  might satisfy a need or a want.
• Social marketing is distinguished by its
  non-tangible products, e.g. ideas, attitudes,
  lifestyle change, social causes
• There are three levels of product core, tangible
  and augmented

155
The three levels of product

• A fitness program is the tangible product.
• The core product is looking better, an immediate
  solution to a health problem an increase in self
  esteem, prevention of injury. More important than
  the tangible product.
• The augmented product is tied to longterm
  adherence and includes social support after the
  program, such as incentives reduced fees, rebates
  etc.

156
Place

• Distribution channels
• High access points
• Consideration of convenience of location, ease of
  access

157
Price

• Traditionally the cost of the product (), but in
  Social Marketing, we are more concerned with
  breeder range of costs - time, inconvenience,
  energy, loss of valued behaviours.
• To be attractive, we must decrease perceived
  costs and increase perceived benefits.
• Incentives have been shown to be effective,
  especially tangible and shortly after the
  behaviour.

158
Promotion

• Getting the right message
• Getting the message right
• Best and most appropriate channel / medium-reach,
  cost, suitability to the complexity of the message

159
Important differences between marketing and
social marketing

•  Commercial products usually offer immediate
  gratification health product are usually
  delayed
• Social marketing tries to replace undesirable
  behaviours with ones that are often more time
  consuming, involve more effort or are less
  pleasant

160
Important differences between marketing and
social marketing

• Commercial marketing usually targets groups who
  are already positive to the massage. Social
  marketing is often directed at hard-to-reach,
  at-risk groups who may be antagonistic to the
  massage.
• Health behaviours are often far more complex than
  the simple responses in commercial marketing
• Often disagreement between experts rebate the
  product in social marketing

161
Important differences between marketing and
social marketing

• Many health behaviours in social marketing are
  inconsistent with social pressures
• Ethical issues and issues of equity are far more
  complex in social marketing
• Social marketing should be directed not just at
  changes in individual behaviour and attitudes but
  at changes in social system and structures

162
What the mass media can do

• In general the mass media can
• Raise consciousness about health issues
• Help place health on the public agenda
• Convey simple information and single messages
• Change behaviours if other enabling factors are
  present
• Effective if
• Part of an integrated campaign
• Info is new end presented in an emotional context
• The info is relevant to people like me

163
What the mass media cannot do

• The mass media cannot
• Convey complex information
• Teach skills
• Shift peoples attitudes or beliefs by itself
• Change behaviour in the absence of other enabling
  factors

164
Environmental policy strategies

• These types of approaches have considerable
  potential for promoting physical activity,
  because they are designed to have an impact on
  large groups populations
• Changes in policy the environment have been
  shown to support and sustain changes in
  individual behaviour (who can think of some
  examples?)

165
Policies

• May be defined as laws, regulations, formal and
  informal rules and understandings that are
  adopted on a collective basis to guide individual
  and collective behaviour

166
Organisational policies are

• Policies implemented within specific
  organisations that define establish appropriate
  behaviour within the realms of the organisation
• They have been shown to have a significant impact
  on public health
• E.G. smoking prevalence was found to be reduced
  in smoke-free workplaces other public
  smoke-free localities

167
But

• Organizational approaches will only be effective
  when the policies are enforced

168
Environmental strategies

• Environmental strategies used in health promotion
  involve change in both the social and physical
  environment and address availability,
  accessibility social norms

169

• E.G. the opening of gymnasiums and swimming
  pools before and after business hours, which may
  lead to an increase in physical activity through
  increase accessibility

170
Use of signs

• Messages to encourage people to undertake
  physical activity have been promoted at
  localities where people can choose whether they
  ride or walk
• This approach involves placing signs in public
  places such as bus and train stations

171
Stair study

• Brownwell et al., (1980) were among the first to
  demonstrate that a simple, low-cost intervention
  could significantly increase physical activity in
  a specific behaviour setting
• This study was conducted at a train station with
  adjacent escalators and stairs
• The intervention involved the posting of a sign
  stating, Your heart needs exercise, heres your
  chance.

172
Findings

• At baseline, approximately 5 of patrons were
  walking up the stairs
• The number of patrons who used the stairs more
  than doubled, but this number declined once the
  sign was removed
• The findings from this study suggest that modest,
  environmental changes in key behaviour settings
  have the potential to promote an increase in
  physical activity

173

• Environmental changes can have a broad impact on
  populations maybe less costly more lasting
  than education based programs
• Policy interventions use the strength of law
  regulation to change behaviour social norms, as
  opposed to achieving change by individual
  remediation

174
Multi-level, inter-sectoral strategies

• without support of public policy, less likely
  that population-wide behaviour change will be
  achieved
• Evidence is limited BUT physical environments are
  also potentially important
• However evidence shows that behaviour
  modification is the most effective method for
  achieving initial behaviour change in individuals

175
Conclusions

• Thus, modification of individual behaviour is
  most likely an important strategy to use in
  combination with environmental and policy
  approaches
• Quote Prof Jim Sallis if we concentrate on
  getting the environment right, then we can focus
  on the individual

176
Group Work Working on a HP program
177
Lecture 13
Guest speakerLucio SIBILIASee Appendix Guest
speaker 1
178
Lecture 14
179
Settings approaches to health promotion
180
Where is health created?

• The ecological answer is that health is created
  where people live, love, work and play. It is
  created by human beings in their interactions
  with each other and with their physical
  environments. The consequence for public health
  is to commence with the settings of everyday life
  within which health is created (rather than start
  with disease categories) and to begin with
  strengthening the health potential of the
  respective settings.

181
Settings approaches cont

• Health promotion recognises the idea that people
  live in social, cultural, political, economic,
  and environmental contexts. The Ottawa Charter
  stresses that the creation of supportive
  environments is a key action area if people are
  to increase control over their health.
• Has grown out of WHO initiatives around Healthy
  Cities

182
What is a setting?

• Traditionally a geographical area or an
  institution containing a captive audience for us
  to do things to. For example
• Health education in schools
• Food samplings in supermarkets
• Exercise programs in work places

183
What is a setting? cont

•  spatial, temporal and cultural domains of
  face-to-face interaction in everyday-life. These
  domains seem to be crucial for the development of
  lifestyles and living conditions for health. ...
  Health related behaviours is one outcome of the
  interplay between individuals, their social
  reference groups and their specific living and
  working conditions.

184
What is a setting? cont

• So, settings are the situations in which we can
  work to change behavioural aspects of health.
• Just as importantly, if not more so, settings can
  be changed so that they are directly supportive
  of health.

185
Some different settings

• Health promoting schools
• Health promoting hospitals
• Health promoting workplaces
• Health promoting prisons
• Health promoting markets
• Health promoting brothels
• Health promoting transport

186
Where are they?

• Most settings lie outside the formal health
  sector. They are the responsibility of many
  different organisations and groups, who are
  unlikely to have health as their prime concern.
• Consequences
• Health action is settings must be intersectoral
  in nature.
• We must take account of the priorities,
  structures and dynamics of each setting.

187
How useful are settingsapproaches?
188
Strengths

• Most settings ore major social structures in
  their own right. Advantages include
• Direct access to particular target groups
• Potential far increased impact via social
  influence
• Formal settings lend themselves to policy and
  structural initiatives - potential for big impact
• Improved likelihood of program sustainability
• Opportunities for sustained and frequent
  interaction with target group
• Usually good communication channels
• Potential to use the culture/tradition to promote
  health

189
Problems

• Too easy to just use them as ways of reaching
  captive audiences.
• Health may not be on the agenda of the people
  running the setting need to establish that
  health can be their core business.
• Intersectoral action hard to set up and maintain.
• Hard for outsiders to get to know the culture
  and ways of operating in the setting.
• Simplistic way of defining a population group
• Hides differences between the people in the
  setting.

190
HP program at Worksite (F. Kittel S. Maes) see
Silbilia L. Borgo S. (Eds.) Health Psychology
in Cardiovascular Health and Disease Chapt. 19
191
Home works three groups Each group read and
summarize one of the following McQueen, D.
(2001). "Strengthening the evidence base for
health promotion." Health Promotion International
16(3) 261-268. Nutbeam, D. (1998). "Evaluating
health promotion - progress, problems and
solutions." Health Promotion International 13(1)
27-44. Raphael, D. (2000). "The question of
evidence in health promotion." Health Promotion
International 15(4) 355-367.
192
Group Work Working on a HP program
193
Lecture 15
194
Summary
195
Lecture 12
196

• Health Promotion
• Health promotion is the process of enabling
  people to increase control over the determinants
  of their health, in order to achieve better
  health.

Disease prevention Disease prevention covers
measures not only to prevent the occurrence of
disease, such as risk factor reduction, but also
to arrest its progress and reduce its
consequences once established.
(See Glossary)
197
Components of personal health

• Physical health
• Mental health
• Social health
• Emotional health
• Sexual health
• Spiritual health

198
Lecture 34
199
Marc Lalondes (1974) determinants of health model

• human biology

lifestyle
environment
health care
200
See bookChapt. 5, 6, 7, 8, 14
201
Lecture 5 6
202
The Solid Facts

• Social gradient
• Stress
• Early life
• Social exclusion
• Work
• Unemployment

• Addiction
• Food
• Transport
• Social support
• Discrimination

(See Wilkinson Marmot, Eds., 1998)
203
Social capital

• One of a range of capitals economic, cultural
  and social. Likely to be linked.
• Despite confusion about the term, there is
  agreement of the importance of networks between
  people because they build trust and encourage
  cooperation for mutual benefit.
• Complex link to health.

(See book Chapt. 11)
204
Protective Factors Healthy Conditions
Psychosocial Effective Health
Healthy Lifestyles Environments
Factors Services Safe
physical enviros. social networks
preventative services reg.physical act. Healthy
public policy power control
culturally approp. Pos. mental health
Quality of life, functional independence,
wellbeing, mortality, morbidity, disability
Risk Factors Risk Conditions Psychosocial
Behavioral Risk
Physiological Risk
Factors Factors Factors
poverty isolation
smoking high BP Low social
status low sense of purpose poor
nutrition high cholesterol
205
Lecture 7 8
206
(No Transcript)
207
Types of intervention

• Medical approach
• Improving physiological risk factors eg high
  blood pressure, early cancer detection
• Behaviour / Lifestyle approach
• Improving behavioural risk factors eg smoking
  poor nutrition, inactivity
• Socio-environmental approach
• Determinants of health in the enviros where we
  live, work , play,
• Risk conditions, eg poverty
• Psychosocial factors, eg poor social connections

See book Chapt. 4
208
Level of intervention

• Focus on individuals
• Generally secondary prevention
• Health care services, eg patient education
• Shop fronts
• Risk factors assessment
• Self education materials
• counselling

209
Level of intervention

• Focus on groups
• Adult education
• Self health groups
• Community action groups
• Focus on populations
• Social marketing and the media
• Community development
• Health promoting settings and environments

210
Lecture 9 10
211
Behaviour change theories
1. Health belief model 2. Theory of reasoned
action 3. Stages of change model 4. Social
learning model
See book Chapt. 3
212
Lecture 11 12
213
Social marketing

•  Designed to influence voluntary behaviour of the
  target group
• Mass media
• Persuasive, not just information

214
Organisational development

•  Targets organisations rather then individuals
  and groups of people
• Change the organisation so that is more health
  promoting
• Healthier schools, workplaces hospitals etc
• Will return to this in the lecture on health
  promoting settings

215
Community action

• Encourage and empower communities to build their
  capacity to develop and sustain improvements in
  their social physical environments and in their
  access to services

216
Economic and regulatory activity

• Financial and legislative
• Incentive and disincentives to support healthy
  choices by individual
• Incentive and disincentives to support healthy
  action by organization

217
Population- based strategies

•  Mass media
• Policy
• Environments/settings

218
Lecture 13 14
219
Settings approaches to health promotion
220
What is a setting?

• Traditionally a geographical area or an
  institution containing a captive audience for us
  to do things to. For example
• Health education in schools
• Food samplings in supermarkets
• Exercise programs in work places

221
Some different settings

• Health promoting schools
• Health promoting hospitals
• Health promoting workplaces
• Health promoting prisons
• Health promoting markets
• Health promoting brothels
• Health promoting transport

See book Chapt. 16, 17, 18, 19
222
Lecture 15Summary
223
Lecture 16
224
Future directionsWhat do we know?

• Economic, environmental and social factors
  influence health status
• Awareness of the impact of the social is
  increasing
• Consumers more informed, empowered and have
  higher expectations

• Treatments are improving but costs are escalating
• Ageing population
• Costs will increase 15 by 2006 and by 30 by
  2016 to maintain the current level of care for
  ageing population

225
Burning issues

• What can we do about lifestyle and behaviours
  that we know contribute to poor health and
  disease outcomes?
• Understand the new paradigm of health within a
  social context
• What does this mean for health professionals?

226
Emerging challenges

• Redressing health inequalities must be an
  important social aim
• Recognise health promoting opportunities as they
  evolve
• Attend to prevention and early intervention
• Build partnerships
• Informed consumers
• Other health professionals
• Across sectors

227
Conclusions on evidence and evaluation in HP and
discussions of the HP programdeveloped in group
228

• Advised book Sibilia L. Borgo S., Eds. (1993)
  HEALTH PSYCHOLOGY IN CARDIOVASCULAR HEALTH AND
  DISEASE. C.R.P., Roma.
• Web sites http//www.euro.who.int/hfadb
  http//www.who.int/en http//www.who.int/hpr
  http//www.wpro.who.int/hpr http//www.wpro.who.
  int/hpr/docs/glossary.pdf
•  
• Key documents
• Students will be provided with a set of key
  documents, and will be expected to gather other
  relevant information from electronic and print
  sources. This form of active learning is a
  feature of the unit. 
• Key documents will include the following
• Ø      McQueen, D. (2001). "Strengthening the
  evidence base for health promotion." Health
  Promotion International 16(3) 261-268.
• Ø      Nutbeam, D. (1998). "Evaluating health
  promotion - progress, problems and solutions."
  Health Promotion International 13(1) 27-44.
• Ø      Nutbeam, D. (1998). "Health promotion
  glossary." Health Promotion International 13(4)
  349-364.
• Ø      Raphael, D. (2000). "The question of
  evidence in health promotion." Health Promotion
  International 15(4) 355-367.
• Ø      Wilkinson, R. and M. Marmot, Eds. (1998).
  The Solid Facts The Social Determinants of
  Health. Copenhagen, World Health Organisation,
  Regional Office for Europe.
• Ø      World Health Organisation (1986). The
  Ottawa Charter for Health Promotion. Geneva,
  World Health Organisation.
• Ø      World Health Organisation (1997). The
  Jakarta Declaration on Health Promotion into the
  21st Century. Fourth International Conference on
  Health Promotion - New Players for a New Era
  Leading Health Promotion into the 21st Century,
  Jakarta, World Health Organisation.