7022.pdf
Media
- extracted text
-
The Evidence
of Health
Promotion
Effectiveness
[ Assessing 20 years
[ Evidence of the
Health, Social,
Economic and
i Political Impacts of
> Health Promotion,
I and
I Recommendations
i for Action.
Shaping Public Health
in a New Europe
Aw
f&s’ Ate/®
and Education
r
v
The Evidence ►
of Health
Promotion
Effectiveness
Assessing 20 years
Evidence of the
Health, Social,
Economic and
Political Impacts of
Health Promotion,
and
Recommendations
for Action.
Shaping Public Health
in a New Europe
A Report for
the European
Commission
by the International
Union for Health
Promotion
and Education
Contents
The Main Players & The IUHPE.............................................. pH
Symbol Key
.............................................................................. pm
The Evidence of Health Promotion Effectiveness
— Shaping Public Health in a New Europe................................ pl
Chapter
1
Health Promotion - a part to play in
New Europe’s Public Health Framework......... p4
Chapter 2 Taking the Health Promotion Pulse.................. p9
Chapter 3
Bridging the Gap................................................ p21
Chapter 4 Making the Journey........................................... p26
Index of symbols....................................................................... p30
PART TWO of this report can be read in conjunction with Part One, which
provides a summary of the main evidence, and puts forward a case for
ensuring that Health Promotion is properly resourced. This will enable Health
Promotion to play its full part in the public health policy framework which is
currently being shaped by the European Commission to meet the health,
social, economic and political challenges of a developing European Union.
This project has received financial support from the European Commission.
Neither the European Commission nor any person acting on its behalf is responsible for any use that
might be made of the following information.
Notice to readers
The information contained in this publication does no$ necessarily reflect the opinion or position of the
European Commission.
©ECSC-EC-EAEC, Brussels - Luxembourg, 1st edition 1999, 2nd edition January 2000
Reproduction is authorised, except for commercial purposes, provided the source is acknowledged.
Designed and produced by ML Design, London, UK 44 (0)20 7721 7254
Printed by Jouve Composition & Impression, Paris, France 33 (0)1 44 76 54 40
Hpcs
Contents
DOO
The Main Players
In order to contribute to the debate on Europe’s developing public health policy, the
International Union for Health Promotion and Education (IUHPE) decided to undertake an
ambitious and innovative project which would assess and collect the evidence of 20 years of
health promotion effectiveness.
As an integral part of the project, which received financial assistance from the European
Commission, the IUHPE created forums which allowed wide consultation beyond the health
promotion community, entering into dialogue with representatives from political groupings,
non-government organisations, the private sector and academia.
Two international meetings were held in Brussels and Paris with an invited audience - a
‘Witness Group’ - who engaged in dialogue with health promoters on the health, social, eco
nomic and political impacts of 20 years of health promotion activity.
Under the guidance of Director of Programmes, Anne Bunde-Birouste, who first conceived
the project, the IUHPE invited a group of experts from around the world, and from a variety
of disciplines, to join an Advisory Group to oversee the work. This included health promoters
from Europe, Canada, the United States and Australia. The IUHPE also invited leading
European health lobbyist, David Boddy, to participate as Project Editor, and in addition, as part
of the bridge-building process between the political and health promotion communities, to
draft Part One of this report.
The IUHPE President, Professor Spencer Hagard, acted as Chairman of the Project
Advisory Group. Professor Maurice Mittelmark (Norway) and Professor Don Nutbeam
(Australia) provided special technical assistance to Mr Boddy.
This project has also benefited greatly from the contribution and collaboration of the US
Centers for Disease Control and Prevention, Atlanta, Georgia, USA, and from the Department
of Health Promotion, Social Change and Mental Health Cluster, WHO Headquarters, Geneva.
The IUHPE
The International Union for Health Promotion and Education (IUHPE) is the only
international NGO in the field of health promotion and brings together individuals and
organisations from more than 90 countries worldwide, with seven different regional offices.
The mission of the IUHPE is to promote global health and to contribute to the achievement of
equity in health between and within the countries of the world. The IUHPE fulfills its mission
by building and operating an independent, global, professional network of people and
institutions to encourage the free exchange of ideas, knowledge, know-how, experience and the
development of relevant collaborative projects, both at global and regional levels.
For more information, please contact:
IUHPE
2 rue Auguste Comte
92170 Vanves
France
tel: 33.1.46.45.00.59
fex: 33.1.46.45.00.45
e-mail: iuhpemcl@worldnet.fr
web: www.iuhpe.org
usrri-atNAriONAL union
FOR I lEAltt 111'ROMOnON
and EiauoxnoN
The Main Players & The IUHPE
Symbol Key
The symbols used throughout the text are designed to help the reader follow and
understand faster and with greater ease, the main points being made in each section.
They have been identified and positioned solely at the discretion of the Project Editor,
and do not represent any comment on the text by any other party. The main symbols
represent:
Action Point. Ideas identified with such a symbol could form a positive
basis for action by either a political, health or social grouping.
Consider Carefully. Paragraphs or sections marked with this symbol are
particularly thought-provoking, and require special or particularly careful
consideration.
More Research. Parts of the text marked with this symbol show that
further research is necessary to gain clarity or fulfil the understanding of
health promotion effectiveness.
Open Debate. These are points for political, social, or economic debate.
They either serve to stimulate new debate, or are worthy of contributing to
existing debate.
Concerted Action. Sections marked with this symbol show the
effectiveness of more than one strand of health promotion activity uniting
for better results.
>+<
Health Added Value. Parts of the report showing this symbol indicate where
health promotion moves have added new dimensions of social, economic
or political value.
Also available
Improvement of the Effectiveness of Health Education and Promotion
A Series of Publications and a Database
This project was carried out by the European Regional Office of the IUHPE in close collaboration
with the NIGZ (the Netherlands Institute for Health Promotion and Disease Prevention), and was
financed by a grant from the European Commission.
Within the project, a database with structured information on evaluations of health promotion and
education interventions was developed, and is available on diskette. A series of thematic
publications consisting of information on relevant studies, resource articles, as well as the
publication. An Instrument for Analysing Effectiveness Studies on Health Promotion: Development.
Use and Recommendations are also available.
For more information, please contact:
NIGZ
PO Box 500
3440 AM Woerden, The Netherlands
Tel: 31 348 43 76 00: Fax: 31 348 43 76 66
Hi
Symbol Key
The Evidence of Health Promotion Effectiveness
Shaping Public Health in a New Europe
A Report by The International Union for Health Promotion &
Education for the European Commission DGV
What is this Report and Who is it for?
This two-part report is the product of 12 months research and study of the
effectiveness of what has become known as ‘health promotion’.
Leading academics from around the world were asked to research the
known evidence of health promotion and disease prevention strategies and
programmes, conducted over the last 20 years. They were not asked to conduct
new or original research, but they were asked to use their expert knowledge to
comment on their findings.
As the research findings began to emerge, other expert witnesses from the
political, economic, social and health sectors were invited to enter a debate
with the health promotion community and comment on their discoveries.
International meetings were held in Brussels and Paris. The aim was to find
ways to bridge the divide of understanding between the political audiences of
decision-takers and advisers, and the academic and scientific practitioners of
health promotion. The common question in focus was: What is the evidence
that health promotion works and is an effective strategy in public health?
Part One of this report seeks to crystallise the evidence and makes
recommendations for action. It is designed as a guide to decision makers.
Part Two of the report presents in detail the Evidence. It is designed for
public policy advisers who wish to study in greater depth either the general
issues or certain specific topics. It also carries an international case history of
health promotion in Canada, outlining how a structural framework for health
promotion played a part in focussing and revitalising that country’s health
services.
This report does not aim to ‘educate’ readers on the art of health
promotion. Rather, it seeks to concentrate on what health promotion actually
does, and how effective that is. Each chapter in the Evidence Book (Part Two)
therefore examines the health, social, economic and political impacts of the
strategies, and the authors draw conclusions.
The aim is to stimulate debate as Europe heads towards framing its new
Public Health Framework.
The Evidence of Health Promotion Effectiveness
1
A Short Guide to Health Promotion
The practice of professional health promotion gained its first international
recognition and framework for development with the Ottawa Charter for Health
Promotion in 1986.
It was appropriate that the Charter should emerge in Canada. At the start of the
1970s, the then Minister of Health and Welfare launched a controversial report
claiming that medicine and the health care system play only a small role in
determining health status, and suggesting health promotion as a key strategy for
improving health and the quality of life. ► See Lessons from Canada - Evidence Book. Cb 12
The Ottawa Charter identified five key strategies. These have formed the
spinal cord of health promotion practice and policy development. The
strategies urged:
►
Building healthy public policy
► Creating supportive environments
► Strengthening community action
► Developing personal skills; and
► Reorienting health services
The Charter also defined health promotion as:
'the process of enabling people to exert control over the determinants of
health and thereby improve their health.’
It is important to recognise health promotion as ‘a process’. This is not just an
academic definition; in practice, it is the way it is. If someone quits smoking, for
example, did they do it because they had seen an advertisement, talked to a doctor,
suffered peer pressure from friends as a result of special initiatives, or had a family
relative die of lung cancer? The fact is, it is very hard to tell. The point is, however,
that the person actually stopped smoking. Health promotion is therefore directed at
achieving an outcome. Specific outcomes differ, but they nearly always involve
improvement in quality of life, and sometimes over a long period. Health promotion
is not a quick fix.
Effective health promotion strengthens the skills and capabilities of individuals to
take action, and the capacity of groups or communities to act collectively to exert control
over the determinants of health. ► See The Questions to be Answered — Evidence Book, Cb I
Effective health promotion leads to changes in the determinants of health, both
those within the control of individuals (such as health behaviours and the use of
health services), and those outside of their direct control such as social, economic and
environmental conditions. Poverty, housing standards, clean water, war; all these
affect the health status of people. Over the last 20 years, health promotion has been
a strategy used to deal with the consequences of the inequalities that such
determinants inevitably produce. ► See Equity in Health. Evidence Book, Ch 14
2
The Evidence of Health Promotion Effectiveness
The platform provided by the Ottawa Charter has been built on progressively with
international conferences in Adelaide, Australia (1988), Sundsvall, Sweden (1991)
and Jakarta, Indonesia (1997). Throughout this time, several key ingredients aimed
at lifting the health status of people, improving their quality of life, and providing
cost-effective solutions to health problems, have been clarified. Evidence clearly
indicates that:
Comprehensive approaches using all five Ottawa strategies are the most
effective
Certain ‘settings’, such as schools, workplaces, cities and local communities,
offer practical opportunities for effective health promotion
People, including those most affected by health issues, need to be at the
heart of health promotion action programmes and decision making processes
to ensure real effectiveness
Real access to education and information, in appropriate language and styles,
is vital
Health promotion is a key ‘investment’ - an essential element of social and
economic development
A declaration made at the Fourth International Conference on Health Promotion
in Jakarta called for new players to form new partnerships in developing health
promotion strategies, and to adopt an evidence-based approach to policy and
practice. This report therefore forms the next milestone in the journey of health
promotion.
The Evidence of Health Promotion Effectiveness
3
Chapter One
Health Promotion - a part to play in New Europe’s
Public Health Framework
“ So, my friends, I strongly urge yon all, in no way to stint time, money or labour,
so that yon may embrace with all your might this most wholesome art, the preserver
of human life. ”
Marsilio Ficino, Statesman, Philosopher, Priest & ‘Health Promoter’, 1433-1499
Actually, health promotion has been with us forever.
Historically, it was the preserve of the philosophers who drew close connection
between the body, the mind and the soul, and propounded remedies. The health, they
said, of the soul, and the vitality of the mind had a direct effect on the state of the
body. The evidence of effectiveness, they said, was by virtue of observation.
This report, after 20 years of professional health promotion activity and an
evolving international acceptance and supporting infrastructure ► See A Short Guide to
Health Promotion, page 2, attempts to bring together the evidence of its effectiveness, and
to formulate what this means in meeting Europe’s health challenges. The health
promotion community clearly understands that policy makers need to know this
before providing either additional resources, or diverting more of existing ones,
towards health promotion policies and strategies.
The process of generating this report has allowed the political audience to let the
health promoters know what they are looking for. Firstly, there is the need to know
that health promotion is a sensible, safe and efficient use of public resources.
Secondly, there is the need to know that it will produce better health for people and
a better quality of life.
This report should act as a catalyst for a new debate; a debate in
which the political audiences and the health promoters look towards
each other as natural allies in finding ways together on how to cope politically, socially, economically, and health-wise, with developments in
V
‘The New Europe’.
The ‘New Europe’
As this report is finalised, the horrifying spectacle of the greatest forced migration
of European peoples since the Second World War is unfolding nightly before our eyes.
Into our ears pour the horror stories of hundreds of thousands of refugees who, until
the marauding butchers of enemy forces invaded their homes, had a measure of self
responsibility for the health and welfare of themselves and their families.
Now, they have become a political, social - and a health - problem. For the whole
of Europe. The inequities of health have dramatically risen, and there will be an
4
Health Promotion - a part to play in New Europe's Public Health Framework
impact both within the immediate European Union, as well as throughout the
countries of its near neighbours, some of whom seek to become members of that
Union as soon as they can.
Already, about 120 million people in the wider Europe, including countries of the
Commonwealth of Independent States (CIS) live below a poverty line of US$4 a day.
In 10 countries across the wider Europe in the 1990s, average life-span varies by 15.3
years between Iceland (at 79.3 years) and Turkmenistan (64 years). (Source: WHO
‘Health 21’)
All of this will be exacerbated by the most recent Balkans
developments. Yet, whilst uncertainties abound, there are also major
issues policy planners already do know about, and are preparing for.
These include:
A redefined political map which will embrace many Central and Eastern European
states in an expanded European Union, creating one of the largest political, economic
and trading blocks in the world, with perhaps in excess of 500 million people.
A Union that will contain more older people than any other region in the world,
with fewer people available for employment but required to generate economic
output to sustain, support and provide for greater numbers than at any time in
modern history.
At the same time, this new and expanded Union will have to cope with not only
new disease threats - but also with the return of diseases we all thought had been
eliminated, such as TB. In the midst of all of this, our political and health systems will
have to manage a problem which has always been with us, but which has only
recently been acknowledged for what it is - the burden of mental illness. One in five
teenagers today suffer some sort of mental illness. They will be mature adults within
the operational time frame of the new public health framework. The problem is not
going away.
Other issues such as rising unemployment, illicit drug use, stress and alcoholism,
plus continuing high numbers of smokers, will pose extraordinary challenges to
health decision makers over the next 25 years. Violence, especially against women, is
on the increase everywhere. In industrialised countries, domestic assaults have been
reported to cause more injury to women than traffic accidents, rape and muggings
combined.
The questions this report seeks to address are:
► What relevance has health promotion in tackling these issues?
► What levels of resource are needed?
► What strategies work?
►
Is the evidence strong enough to allow policy makers to embrace the
health promotion processes fully, and with real confidence, in the
development of a public health policy mix, and to provide the necessary
resources to make it happen with measurable effectiveness?
Health Promotion - a part to play in New Europe's Public Health Framework
5
Standing the Test
Measuring health promotion effectiveness is not like taking the temperature of a
patient.
Measuring health promotion effectiveness is more like waiting for spring crops to
appear after preparing the ground in autumn and winter. Time is always involved
before the effects of an interweave of coherent and related health promotion
strategies and processes begin to show measurable results.
Don Nutbeam, Professor of Public Health at Sydney University, and an
international authority on health promotion effectiveness, urges the political and
expert audiences reading this book to see beyond the ‘randomised clinical trial
process’. ► See: Ch 1. Evidence Book. ‘In the short-term, a successful outcome from
coronary bypass surgery is different from the outcome that would be expected
following an educational programme to help a person improve knowledge and skills
to adopt a healthy lifestyle. In the long term, both are directed towards reducing the
impact of coronary heart disease,’ he says.
Some of what is presented in the Evidence Book might therefore not seem as ‘pure’
as some ‘scientists’ would like, nor as ‘scientific’ as some ‘purists’ would like.
Inevitably, it spans a very broad range of disciplines and study methods, from
international ecological analyses that depend on statistics, to community
demonstration projects that depend on qualitative methods. Some of the answers
political audiences would wish for simply cannot be provided because over the past
20 years, the questions simply have not been asked, or if they have, they have not
been asked in rhe way that budget managers in governmental finance departments
now demand. But the research is honest and faithful.
After 20 years of professional practices, it does provide a wide-ranging body of
evidence in support of the argument that health promotion is effective, and should
have its place confirmed as an integral aspect of the public health policy mix.
That being so, rhe rational political response should be to devote
adequate financial and manpower resources to health promotion and
disease prevention processes.
Tipping the Balance
At a time when health care budgets across Europe are being carefully examined,
and politically acceptable means of reducing budget percentages on health care are
being sought, there need to be sound arguments for devoting more resources to health
promotion. Crudely, the protagonists (including some from other parts of the medical
community) would lay down the challenge that 100 Euros spent on new drugs would
produce more ‘political and health impact’ than a similar sum spent on dietary advice
to elderly people; and a political compromise, forced by electoral pressure, could be
all too easily arrived at in support of such a view.
This is why this report does not make extravagant demands for new resources.
What it does demand, however, is a far better understanding, and a larger vision, of
the impacts of the weave of inter related health promotion activities on people and
their environments. With that understanding will come an appreciation of how in
6
Health Promotion - a part to play in Neia Europe’s Public Health Framework
health terms, health promotion can often tip the balance towards achieving better
quality of life, the availability of healthier and more productive human resources to
enhance the well-being of society, and play a crucial social and political part in
removing inequalities in society.
Health is a fundamental human right. Health promotion is therefore not the
answer to the budget-cutter’s prayers. But the money spent on it goes a long way, and
over a long time. It is low risk, high value expenditure.
Politicians who are convinced that health promotion is worthy of development
should be asking of their colleagues in finance and all other governmental
departments questions such as:
► What expenditures will be necessary to sustain the New
VXxy
Europe's rising elderly population; how much in direct health
care costs will be needed; how much in indirect costs? If
health promotion can help keep people healthier and more
’
active contributors to society for longer, is it not worthy of support?
► What political and social impact will there be, and how much will it cost, to
keep safe in the community millions of young people suffering mental
illness? If health promotion can reduce the incidence of mental illness; if it
can reduce stress and help return to the workforce quickly those
psychologically affected by losing their jobs, is it not worthy of support?
► As the productive force in society can be kept healthy and at work by
legislation banning smoking in public places, or preventing injury by
the wearing of helmets, or keeping children fitter and healthier through
better nutrition, why is more political attention not given to such
developments? Should these and other issues not become a priority in
and across all areas of government?
In summary, can governments afford NOT to spend more on health promotion?
Developing a Framework
If policy makers become convinced that health promotion has an enhanced role,
and agree to divert additional resources in the direction of programmes and strategies
with known effectiveness, where can the most impact be made? What are the first
steps?
A structural framework for progress and development is already (
underway. The European Commission’s current review of the public
health framework is driven by the fact that eight of the existing public health
programmes are heading towards a conclusion next year. In the light of the new
health threats, budget pressures and enlargement process, and now in light also of the
growing refugee crisis in Eastern Europe, is the current framework satisfactory, or
does it need to change?
Health Promotion - a part to play in New Europe’s Public Health Framework
7
Three policy strands have evolved so far: improving information for development
of public health; rapid reaction to health threats; and tackling health determinants
through health promotion and disease prevention.
The platform upon which the Commission can build, and which can inspire
European Union member state governments to act, is Article 152 of the Amsterdam
Treaty. This Treaty widens the scope for action through health promotion as never
before. The Article ensures a high level of human health protection in definition and
implementation in all policy areas. In other words, there is a health-benefits test in
new policy, across the board.
The international leader in health promotion experience is Canada.
Inspired leadership in the health ministry was effective because of a
strong conceptual basis for action provided by the Ottawa Charter and also because
of early and financially-meaningful Federal government commitment, bringing
regional and local commitment in its wake. A further driver - some would argue the
main one - was political concern about rising costs of health care, and the need for
health care reform. The parallels in Europe today are clear. The lessons for the ‘New
Europe’ tomorrow could be equally clear.
Evidence of health promotion effectiveness must now be examined in the light of
these dynamics.
8
Health Promotion - a part to play in New Europe’s Public Health Framework
Chapter Two
Taking the Health Promotion Pulse
Introducing the Evidence
International experts from a variety of health promotion disciplines were invited
to examine the literature and published research documentation of numerous
interventions across the world. They were not asked to conduct new research. Their
job was to analyse, critically, and within the boundaries of scientific tolerance, what
had worked and what had not.
They were then asked to tread new ground. In order to build a bridge between the
health promotion discipline and the political community, our panel of international
professors, academics and acknowledged world-leaders in health promotion practice
were then asked to formulate a series of Impact Assessments. In their view, as experts,
what health, social, economic and political impacts did the interventions under
consideration achieve? ► These impacts are analysed in Chapter Three of this Part; each chapter in
the Evidence Book carries sub/ect-specific assessments.
Traditionally, health promotion interventions have either been targeted within
defined settings (such as schools, workplaces, cities) or with identified population
groups (such as elderly people or youth). Inevitably, programmes and strategies cross
boundaries. In order to best illuminate and demonstrate the work of various
strategies, we decided to report on topics of political relevance as well as healthcare
and social relevance. Some are settings-based; others are populations-based; still
others straddle both. The report, especially the Evidence Book in Part Two, is not
designed as a comprehensive best-practice manual, but it is designed to be a rounded
analysis of health promotion effectiveness, demonstrating where and how it is
relevant to decision makers.
We therefore asked our research team to look at the major political challenges in
the New Europe: ageing, mental health, and the challenge of coping with
disenfranchised groups such as out-of-school youth. We asked others to look at major
health issues, such as heart health and rhe impact of tobacco, alcohol and illicit drug
use. We researched areas where health promotion has gained high public profiles,
such as nutrition and safety issues. We examined two key settings where health
promotion activity has a particularly important social and economic impact - in the
workplace, and in schools. We asked for a case history on oral health, an often
neglected issue in many countries, but one where major health gains have been made.
And we asked about health promotion in the health care sector itself: what role can
doctors, nurses and other health sector practitioners play in promoting better health.
Finally, we looked at the heated issue of Equity. Put simply, the health of lower
economic and social groups is significantly poorer than higher groups, right across
Europe. With poverty comes disease. And with poor education, poor housing, poor
family stability comes violence, substance abuse, mental illness, heart disease and
increased morbidity and mortality. The evidence shows that inequity in social and
Taking the Health Promotion Pulse
9
economic conditions is a key determinant in health and human welfare.
Politicians want to make a difference. Our evidence concludes, therefore, with a
case history of Canada, leaders in international practice of health promotion, where
frameworks have been structured at the federal, regional and local levels to deliver
better health. ► See Lessons from Canada - Evidence Book. Ch 12. The lessons are clear and
provide an important guide in structuring the development of health promotion
everywhere.
Evidence Highlights
Political Challenges 1: The Ageing Issue
1
Disability in elderly people accounts for around 50% of health care costs in EU
countries. The challenge to the Europe of the new millennium is to capture the
energy and experience of this important sector of society, keep it healthy and
active, and allow people to continue to contribute to the development and welfare
of the communities in which they live. Much research supports the fact that older
people want this. Many health promotion programmes specifically
targeted at this group clearly show not only the positive health benefit
for the people concerned, but the positive contributory effect on the society of
such people continuing a healthy lifestyle for longer. Instead of regarding this
exploding population group as a ‘burden’, policies and initiatives could be
formulated to acknowledge, value and enhance their many formal and informal
social and economic roles.
2 The development of best-practice for the management of an ageing workforce is
identified as a priority by the Economic & Social Committee of the EU, the
European Parliament and the Commission. Data from a pan-European study of
60-69 year olds, co-ordinated by WHO-EURO, indicated significantly worsening
health status over a ten year period for accidents, trauma and chronic disease
affecting daily life, hearing, use of drugs, use of sleeping tablets and functional
ability.
3 The real key to healthy ageing is to begin health promotion early, and to embrace
the key messages into daily living throughout the span of life. However there is
evidence that age 50 marks the beginning of a period in the life during which the
benefits of physical activity programmes are most relevant. Evidence shows that
regular physical exercise helps regulate blood glucose levels, improves sleep,
improves cardiovascular functioning, helps maintain independence in old age,
enhances motor control and performance, reduces the risk of falls and enhances
cognitive function and mental health. The impact on society is seen by keeping the
elderly population active and therefore productive for longer, reducing health and
social care costs. Policies should ensure that elderly people can stay active, that
those who want to continue to contribute to society can do so, and that a positive
and active image of ageing is created and then maintained.
4 An ageing population which is not healthy will be a massive drain on resources.
The evidence shows that maintaining healthy lifestyles in old age is directly
associated with health gain. There is also clear evidence that there is considerable
10
Taking the Health Promotion Pulse
5
6
7
8
scope for ameliorating the experience of poor health and disability in old age by
appropriate health and social policies.
Ageing people need the opportunity for real choice to enable healthy living which
in turn will reduce disability costs. For this, adequate pensions provisions must be
made. There is also evidence that community health and social services provisions
improve the quality of life of this group, alleviate handicap and reduce the need
for institutional living. A minimum core set of services needs specifying and
policies are needed to deliver them.
Healthy eating in this age group also provides major health gains.
However, people on low incomes, the very old, chronically ill and
elderly males are at particular risk from nutritional deficiencies. This
is a priority for intervention.
Breast-cancer screening has been demonstrated as cost-effective in
women up to age 74.
Targets for dietary habits, activity levels and disability levels of
elderly people should be set and monitored through lifestyle surveys.
Political Challenges 2: Removing the Shadows of Mental Illness
Many of the most important causes of morbidity in Europe, and the world, are
associated with poor mental health. These range from mild forms of depression
through to complex psychiatric disorders. Evidence shows that between 15% and
20% of adults suffer some form of mental disorder. Between 17% and 22% of
teenagers under 18 suffer from developmental, emotional or behavioural
problems, and fewer than one in five of these young people are currently receiving
appropriate treatment.
2 The consequences of poor mental health can be seen in alcohol and drug misuse,
interpersonal violence, and self-harm, including suicide. The shadows across the
face of society cast by mental illness and its consequences are now better
understood and recognised. Managing this issue will require greatly improved
detection and treatment of the more serious problems, but mental health
promotion has proven that it can play a major role in reducing the personal, social
and economic costs of poor mental health, ft should be assisted to play that role
more widely.
3 There is significant evidence to show that mental health promotion
strategies have reduced depression, reduced suicide rates, and reduced 5^*
behavioural problems. Interventions targeted towards help in the family have
resulted in less domestic aggression, fewer learning problems with small children,
and generally more positive environments in which they can grow and take up
active and responsible citizenship. There is evidence of significant reductions in
child abuse (up to 50%) and in reductions in cases on the child protection registers
(41%).
4 Other mental health promotion programmes have furthermore shown
complementary social and health benefits, including decreases in teenage
pregnancies, reductions in HIV and AIDS and other sexually transmitted diseases.
There have been clinical impacts too. Pre-natal projects have resulted in up to
1
Taking the Health Promotion Pulse
11
5
6
7
8
75% reductions in pre-term delivery, reductions in babies born with low birth
weight (eliminating consequent health problems in later life), and fewer babies
born with brain damage.
Suicide is a common outcome from mental illness. It is a catalogue of despair for
families, associates and colleagues of the sufferer, and a tragic waste of human
potential. Health promotion strategies have been found to be effective. The
Swedish Educational Programme (Nordic countries have a very positive and
progressive record of successful health promotion in many areas) decreased
suicide rates from 19.7 cases per 100,000 population, to 7.1 cases after just three
years. An important economic side-effect was that the programme reduced the
number of in-patient days to treat sufferers by 70%, and other programmes have
reduced the numbers of tranquillisers and anti-depressant drugs prescribed.
Policy makers will be aware of the high costs of treatment of mental illness. They
are rising, and are expected to continue to rise sharply, as countries come to see
that many of their policies of the past decade, including community care, have not
been holistic enough for patients or safe enough for the rest of the community. The
social dynamic involved in mental health should also not be under-estimated, and
there is evidence to indicate the effectiveness of programmes targeted at specific
community groups.
Schools-based programmes in promoting better mental health show clear evidence of achieving higher literacy levels and reductions in 0+0
drop out rates; there are additional health benefits measured with success in
smoking cessation, reductions in substance abuse, reductions in the social
consequences of teenage pregnancy and unsafe sex. Work-based mental health
programmes also have measurable success. Reviews have shown not only
advances in ‘soft’ measures, such as better job satisfaction and reductions in stress
levels, but also there is clear evidence that a number of programmes have helped
unemployed people return to work quicker, and reduced the amount of sick leave
in workforces.
Effective mental health promotion programmes must be disseminated across
Europe, and guidelines for their effective management must be established.
Political Challenges 3: Reaching the Disenfranchised
1
Out of school youth represent a tremendous challenge to policy makers. They are
often vulnerable to disease and high risk behaviours and are notoriously hard to
reach through conventional educational media. They are often turned off or tuned
out to traditional health messages, especially if presented by ‘authority’ figures.
2 Smoking, alcohol and drug abuse, sexually transmitted diseases, suicide, eating
disorders and violence are among the many health risks faced by a group which
often regards itself as forgotten or disenfranchised by the rest of society.
Tx
3 There is evidence that peer education training programmes, targeted
mass media campaigns and targeted distribution of information,
products and services (often controversial items such as male and female \//\\)
condoms, clean needles and methadone) have all assisted in providing
<—>
adolescents with improved choices and access to new health options.
12
Taking the Health Promotion Pulse
4
Engaging this group in the development of health promotion programmes has
been key to success. There is evidence of increased condom use, and decreases in
drug use. There is less risky sexual behaviour. Socially, there is evidence of
dialogue restarting between the generations, with the young people feeling they
are valued. Some of the programmes in themselves actually provide a source of
income, and cost savings to other health services can be identified. Perhaps above
all, the health promotion work in this area has helped put this important social
group back on the agenda.
Health Challenges 1: The Lifestyle Killer - Heart Disease
1
2
3
4
5
6
Cardiovascular disease (CVD) is the number one killer and the major cause of
disability in Europe. Half the deaths in the industrialised world are the result of
CVD. Contrary to widespread mythology, CVD is not something which attacks
only elderly people. Much of the burden concerns the middle aged, women and
people in lower socio-economic groups. It is a major contributor to inequality
in health.
The problems facing decision makers in a Europe which is already
—A
witnessing a reduction (by demographic causes) of its available
working population are first, the early elimination from the workforce of human
talent and much needed resource and second, the cost of treatment when CVD
disables, but does not kill. The costs to health services are enormous.
The major causes of CVD are well known and have been well documented:
smoking, poor dietary habits, lack of exercise, high cholesterol. The effects of
these are very heavily influenced by the capacity of people to discriminate and
make positive health choices. Health promotion strategies over the past 20 years
have been shown, without doubt, to make a major difference in tackling those
diseases and illnesses which are most significantly affected by the way people
choose to live.
One of the most carefully documented interventions has taken place in North
Karelia, Finland, where cardiovascular mortality has been reduced by 73% since
1972, and all-cause mortality has been reduced by 50% in the working age
population over the same period.
As so often happens, lifestyle changes introduced to deal with
cardiovascular disease threats have a positive benefit in other health
areas too. The North Karelia experience recorded reductions in lung cancer
mortality of 71%, and cancer (other causes) mortality by 44%.
The example in Finland, while spectacular in its success, is not alone. Other
studies show that programmes aimed at changing lifestyle habits bring very
positive health benefits. In Belgium, a WHO collaborative worksite project for
CVD prevention resulted in a 25% reduction in CVD mortality. Programmes
aimed at lowering serum cholesterol through healthy diets in schools produced an
average reduction in levels of 15%, with huge positive health implications.
Taking the Health Promotion Pulse
13
Health Challenges 2: The ‘Smoking Gun’ —
Tobacco, Alcohol and Illicit Drugs
1
2
3
4
5
6
7
Among the greatest risk factors in CVD and other diseases, such as respiratory
illness, lung cancer and some other cancers, is smoking. Tackling the issue can also
be seen as a particular case study of the effectiveness of the comprehensive
approach of multiple-strands of health promotion and disease prevention. When
a smoker quits, is it because the price went up, he was banned from smoking at
work, he read an article in a newspaper or his doctor told him the consequences
of not stopping? In reality, it was probably all of these things. The best health
promotion is where various strands delivering a single message come together.
The World Bank estimates that the economic burden from smoking, including
health costs and loss of productive capacity by disability or death, is around $200
billion annually. The WHO indicates that 3 million people die annually from
smoking. Fifty percent of all people who smoke regularly will die from cigarettes,
half in middle age, with an average loss of 20 years of life expectancy. Smokers are
making their own coffins, and furthermore, are contributing to disease among
their close families by polluting the atmosphere in their own homes and public
places.
There is evidence that a 10% increase in the price of cigarettes
(through taxation) leads on average to a 5% decrease in the quantity
smoked across the whole population, and up to a 15% decrease in the
quantity smoked by the young people.
Legislative restrictions in worksite smoking in Finland led to 2.4% of
smokers quitting, 2.6% stopping smoking while at work, and 14.3%
reducing their cigarette consumption.
Since the 1970s, smoking cessation programmes have been conducted
in schools. Some programmes, particularly those involving peer groups, indicate
30-50% fewer smokers in programme groups compared with controls. However,
there is also evidence to show that without determined follow-up with multiple
strands of action, these rates do not hold.
Health professionals are effective in smoking cessation programmes. Over a 20
year period, there is evidence that, of those people offered smoking cessation advice
by doctors, 13% were less likely to die from coronary heart disease, and 11% less
likely to die from lung cancer, as a consequence of quitting smoking. With pregnant
women, 11 trials showed increased rates of smoking cessation (up to 50%),
lowering the risk of low birth weight and reducing adverse obstetric outcomes.
Smoking cessation programmes appear as part of virtually every
health promotion or disease prevention initiative - in the workplace,
in the out-of-school youth sector, with elderly people. In Spain last
year a comparison of a range of interventions designed to reduce cardiovascular
disease was undertaken. Smoking cessation was the most cost effective. The cost
per life year gained from these programmes ranged from $2600 to $5700, whereas
the costs per life year gained from treatment for mild hypertension was up to
$86,000. The costs of extensive drug treatment per life year gained was more than
double that.
14
Taking the Health Promotion Pulse
Social Challenges 1: Feeding our Families - the Impact of Nutrition
1
2
3
4
5
6
The impact of proper dietary controls on the health of people - particularly heart
health - has been proven to be immense. Such an issue is of course regarded with
high political sensitivity: can we live in a democracy and be directed or even
advised what to eat? A key role in health promotion is to increase through
literature and other means the comprehension of health issues, and to provide
every assistance for people to make positive health choices. Nutrition is one such
example.
In recent years, diets in most European countries have become richer in animal
protein and saturated fats, whereas the consumption of vegetable protein,
complex carbohydrates and dietary fibre has decreased. There is clear evidence to
link increased incidence of coronary heart disease, type2 diabetes and some types
of cancer to these dietary changes. There is also a causal link between diet and
obesity and impaired bone development.
An expert panel of the World Cancer Research Fund has concluded
that eating the recommended five servings of fruits and vegetables
each day could reduce cancer rates by more than 20%. They further report that
adhering to dietary recommendations and physical activity, plus maintaining a
healthy body weight, could reduce cancer risk by 30-40%. There is a consistent
body of evidence which supports the beneficial effects of diets rich in plant-based
foods, and relatively poor in alcohol and foods from animal origin.
Time and again, reviews of effective health promotion show clearly the inequity
existing in the provision of health services. The poor are always worst off. It is
statistically proven that they face higher mortality rates and more disability than
individuals with a higher socio-economic status.
On the issue of diet, for example, poorer families take more cheap energy from
foods such as meat, fats, sugars, preserves and potatoes, but have relatively little
intake of vegetables , fruit and whole-wheat bread. The link between this and the
prevalence of CVD amongst the lower income groups is direct.
In the Netherlands, a ‘Fat Watch’ campaign, run in partnerships with
supermarkets and other private sector allies, brought favourable changes to
consumption of saturated fats (from 16.4% to 14.1% of energy intake over a five
year period). Mainly due to such changes in fat intake, the prevalence of
hypercholesrerolaemia dropped by 6%. A 1% reduction in serum cholesterol
achieved through dietary knowledge would bring a 2-3% reduction in coronary
heart disease. The example shows, amongst other things, the importance of
involving new partners in health promotion, a theme now actively supported by
the WHO, and embraced in the Jakarta Declaration on health promotion.
Social Challenges 2: Keeping Safe
1. Injuries are an increasing health threat - and they attack at any age. At present,
one in seven premature deaths is injury related ; this is predicted to rise to one in
five by 2020. Health promotion strategies aimed at injury prevention are being
Taking the Health Promotion Pulse
15
under-utilised.
2 There are many strands to successful health and safety promotion, but researchers
report the best effects when legislative developments are coupled with welltargeted information campaigns.
3 In Victoria, Australia, campaigns to improve the use of cycle helmets
increased wearing from 5% before to 83% after, corresponding to a
decrease of head injuries by 70%. In the United States, campaigns
promoting the use of child safety seats in vehicles reduced the
likelihood of fatal injury by 69% for infants and 47% for toddlers. What are
described as ‘comprehensive’ SAFE community programmes in Nordic countries
produced decreases of up to 30% in the number of injuries.
4 Legislation in this field can be a key strategy. In Washington State,
USA, a law on tap water heat decreased the number of hospital
admissions for burns from that source by 50%. A Poison Prevention
Packaging Act, designed to reduce the incidence of aspirin poisoning,
*—
did so by 45-55%. Policy makers should note carefully the positive beneficial
effect of strategically placed health promotion-related legislation, and the added
impact it brings when related to well formulated education programmes.
5 Article 152 of the Amsterdam Treaty probably provides more
opportunity for action than at any time in the last 20 years. For
example, in the field of transport policy, there is clear evidence that speed
restriction policies and road-calming initiatives - all of which could viably be
called health promotion - have produced the most cost-effective health promoting
environmental change in traffic areas. Furthermore, legislation and community
information campaigns on safety devices - smoke detectors, fireguards, stairgates,
child restraint container closures, thermostat control of tap water - have been
shown to be extremely effective and cost efficient. Evaluation of a three year,
Swedish based Accident Prevention Programme across the community reduced
accidents in the home by 27%, in the workplace by 28%, and traffic-related
accidents by 28%. In Norway, a similar traffic-related programme reduced injury
to cyclists by 37% and pedestrians by 54%, while accident rates in a reference
community hundreds of kilometres away actually went up over the same period.
Settings 1: Effective Health Promotion in the Workplace
1 The ‘Productive Capacity Gap’ - i.e. the gap between the available
working population and the numbers of people it has to support - is
predicted to grow significantly over the next decades. In the United Kingdom, the
gap will grow by 40% between now and 2025.
2 A key issue facing all European governments and political institutions is to ensure
that Europe’s workforce remains healthy and productive, and that the ‘dependant’
population of elderly people remains fit, active and healthy for longer,
»
available to contribute to society and not be considered as a burden.
3 Over recent years, many European countries have embraced an increasing number
of Workplace Health Promotion (WHP) programmes. There is evidence that such
programmes, combined with occupational health and safety practices, improves
16
Taking the Health Promotion Pulse
productivity, product and process quality, and keeps labour costs controlled,
thereby improving competitiveness.
4 Ten major reviews between 1968 and 1995 produced a weight of evidence
indicating the positive effect of WHP programmes on industrial health awareness
and behaviour. This is significant in that recent EU surveys have shown that up to
42 million employees throughout Europe believe that their health and safety in the
workplace is at risk. That risk stems from heavy physical work (25%), pressure of
time (20%), small decision latitude (35%) and monotony (60%).
5 The costs of work related illnesses are high. The German Federal Institute for
Occupational Safety & Health calculated costs of DM89 Billion solely due to
people’s inability to work. The work related proportion of widespread common
illnesses is estimated at 33% for musculo-skeletal disorders, 20% for
cardiovascular disease, and 45% for skin diseases. Evidence shows major cost
savings for hypertension control, back injury prevention and pre-natal care
programmes. Building on experience and evidence, occupational health and safety
practices are now based on well-substantiated ergonomic knowledge of workplace
design. Some of this has been included in national and European standards and
directives. The results have been positive. In the area of musculo-skeletal
problems, for example, most studies report between 20% and 50% reduction in
disorders.
Settings 2: Effective Health Promotion in Schools.
There is a substantial body of evidence which shows that poor health >+<
inhibits learning. In addition, studies have found a strong relationship
between health behaviour and educational outcomes (e.g. grades and classroom
performance), educational behaviours (school attendance, disciplinary issues) and
student attitudes.
2 School health promotion interventions can be effective in transmitting knowledge,
developing skills, and supporting positive health choices. But evidence indicates
greatest effectiveness where programmes are comprehensive and ‘holistic’, linking
the school with agencies and sectors dealing with health, and where it lasts several
years. Adequate attention needs to be given to teacher training for health
promotion.
3 The ‘health promoting school’ concept has emerged in the last decade in Europe
and has spread in the world as a mechanism to combine a variety of elements to
achieve maximum success in pursuing educational and health outcomes. It is clear
that the school, in conjunction with the family, is one of the key sites where
individual and social development occurs.
4 Schools have been shown to be cost effective sites for health promotion
interventions. The effectiveness and sustainability of school health interventions is
governed by how closely the health promotion interventions are linked to the
primary business of schools in developing the educational skills and knowledge
base of young people. Evidence shows that programmes should focus primarily on
cognitive and social outcomes, rather than concentrate on achieving specific
behavioural outcomes.
1
Taking the Health Promotion Pulse
17
5
The European Network of Health Promoting Schools is operational in 38
countries. Whilst its potential is great as a model for development of programmes,
the evidence is clear that schools cannot be looked upon to solve health and social
problems in isolation from other forms of public health action.
Settings 3: Effective Health Promotion in the Health Care Sector
1
2
3
4
5
What part in health promotion can the health care sector play? Is it an effective
health promoting ambassador? Should governments divert resources towards the
health care sector and hope that the professionals there can do the health
promoters job?
Evidence indicates success by members of the health sector through interventions
to promote smoking cessation and to deal with problems of alcohol abuse. Other
evidence is inconclusive about the effectiveness of the health care team in
delivering health promotion programmes and messages. What is plain, however,
as recognised by the WHO and its Jakarta Declaration, is that the health care
sector is an essential partner in creating the right conditions for health in society.
It has an important leadership role in society.
This leadership role can either be exercised by providing examples of what can be
done to achieve a healthy environment, or as an advocate for healthy public
policies, or as a source of advice to individuals on healthy behaviours.
It is widely recognised that the health sector alone cannot deliver major changes
in health behaviours and depends on co-ordinated action across a range of sectors.
This means that a health promotion policy that depends on reform of
V'x'V
the health care sector to achieve its goals will not work. If health care
professionals can be re-oriented to become advocates for health,
rather than simply part of the repair service, they can become
V
powerful allies for those seeking to promote health. But interventions to stop
smoking are an example of the challenges faced. Despite its undoubted
effectiveness, advice by doctors to quit is given rarely, and in some countries is
undermined by the high frequency of smoking by doctors.
Oral Health: A Case Study in Effectiveness
Oral diseases are an often neglected, but nonetheless, important aspect of the
public health problem. Prevalence is high, treatment costs can be high, and there
is often a trauma involved for individuals. Dental disorders rank as the third most
expensive to treat among all diseases, exceeded only by costs related to
cardiovascular diseases and mental disorders.
2 Water fluoridation is the most cost-effective method of prevention. But it is a
controversial issue and requires political commitment. Evidence shows that since
the 1970s there have been dramatic declines, from mean levels of 5 and 10, to
lower than 1 decayed, missing or filled permanent teeth in children.
3 The generally held reason for the decline is the impact of widespread use of
fluoridated toothpastes. This is an example of how industry and public health can
1
18
Taking the Health Promotion Pulse
work together to promote health.
Studies show that the current traditional curatively-oriented strategies for
improving ora! health are relatively ineffective and very expensive. Oral health
promotion should be aimed at achieving rational use of sugar products,
fluoridation of the mouth, effective oral hygiene, reductions in smoking and
drinking, prevention of trauma and appropriate use of dental care.
5 What is very clear is that a number of chronic diseases, such as heart
disease, cancer, strokes, accidents and oral diseases, have some
important risk factors in common. Health promotion strategies are therefore
relevant to more than one disease area or issue. Strategies oriented towards risk
factors, as distinct from specific diseases, are likely to be more inclusive and
therefore more cost-effective.
4
Health Equity: A Fundamental Human Right
1
2
3
4
5
6
Equity in health is at the heart of nearly every health promotion strategy. The term
Equity, as described by the WHO, focuses on the ideal of providing a fair
opportunity for all people to enjoy health to their fullest potential. It does NOT
mean equal health status for everyone; but as the well-known Black report on
Inequalities in Health (1982) points out, a realistic goal should be the reduction
of differences between people’s health as much as possible through equal
opportunity for health.
There is very substantial evidence that socio-economic conditions (
related to income, education and employment are at the root of much
of ill health. In 1993 it was estimated that more than 57 million people in Europe
lived in almost 23 million poor households. Even in the richest countries in
Europe, people with the best resources live several years longer and have fewer
illnesses and disabilities than poorer people.
Evidence indicates that ‘relative deprivation’ rather than absolute poverty is the
crucial element in understanding health inequalities in a Europe that is far from
the crushing poverty of some other regions of the world. Relative deprivation can
have many faces : poorer education, higher unemployment, lower capacity to deal
with information, lack of material resources, among others. Evidence is strong
that relative deprivation in these areas is closely linked to poorer health.
The fundamental understanding of this evidence is that health promotion to
improve equity in health must be conducted within the context of economic, social
and human development.
Many ‘equity interventions’ for health have their most important impact at
community level. Evidence shows that people gain increased ability' to define and
solve local problems, and at every stage participation or involvement of the local
community is a key factor in success.
Healthy Cities, a component of WHO’s Health for All strategy, with hundreds of
participating communities, provides a strong multi-agency framework and
philosophical model for the support of community development and health
approaches in Europe. Programmes have shown evidence of effectiveness
including generating increased income through work opportunities, improved
Taking the Health Promotion Pulse
.19
community support with counselling services, better community involvement,
closer links with professional services and improved inter-agency collaboration.
7 Data also shows that health and education are among the most
V'w'V
powerful forces for economic health. In poorer countries basic
y,
investments in health and education can leverage positive economic
outcomes. Outside of Europe, in countries such as Trinidad, Cuba,
V
Chile, and Costa Rica, this form of investment has high priority, and poverty has
been reduced to affect less than 10% of people. Yet in Europe there remains great
disparity, both in the levels of health investment, and in economic vitality. This
disparity could increase still further with the imminent refugee problem arising
from the Balkans crisis.
8 Most European countries are signatories to WHO’s Health for All programme,
recently updated as Health for All in the Twenty-first Century. With equity for
health at its heart, this sets global priorities for the first two decades of the new
millennium, and 10 targets to create the highest attainable levels of health. This
has led to the formation of frameworks for action at the national level, with many
European countries having health policies that aim at reaching the Health for All
targets.
9 There remains a long way to go before Europe enjoys a degree of equity in health
that would signal success, despite the progress recently made. There are sound
health, economic and political reasons for reductions in inequity in health.
10 All of these reasons, however, are underpinned by the fact that good health is a
fundamental human right.
20
Taking the Health Promotion Pulse
Chapter Three
Bridging the Gap
When the health promoters met with representatives of the political community
over a total of four days in Brussels and Paris as part of the innovative development
process leading to this report, several things became clear.
First, the language spoken by each side was different. A health promoter would be
more likely to advocate a health solution first and worry about the cost later; the
politician would understandably view it the other way round.
Next, as the dialogue unfolded, different sets of priorities became clearer on both
sides, until finally, and most importantly, common ground began to emerge. There
was recognition from the health promotion community that the need was to
demonstrate to audiences unfamiliar with the health promotion ‘jargon’ or
terminology the clear relevance in health, social, economic and political terms of what
they actually do. Each section in the Evidence Book spells out how, in the opinion of
its author, a particular health promotion discipline has been politically, socially and
economically relevant.
The dialogue has begun. A bridge is being built to remove the gaps in
understanding. From both sides.
This chapter summarises some of the key points made during the dialogue
between the health promoters and the political audience. The next chapter offers
some opening recommendations for political action.
Health Impacts
i Europe is facing greater health challenges than at any time since the end of the
Second World War. The emphasis needed to meet these challenges must be on
health, not sickness. The need is for effective health services, not just effective
repair services.
2 The evidence shows health promotion as an essential element in the provision of
health services. Significant experience, supported by a sound and supportive
governmental framework at all levels, enables health promotion to deliver
measurable results.
3 In tackling the issue of the rising ageing population in Europe, it is
clear that health promotion interventions can sustain a more active
and significantly enhanced quality of life for millions of people. It is equally clear
that health promotion is a life-cycle issue - work done with and for children, in
homes and schools, can show a short-term impact, but if sustained through the
working life and into old age, the health benefits can be enormous.
4 In meeting the epidemic of mental health problems, it is clear that interventions
tackle depression, suicide, stress and anxiety. The evidence shows reductions in
Bridging the Gap
child abuse, child neglect, learning difficulties and other behavioural problems.
Programmes demonstrate possibilities for greater life satisfaction, increased sexual
satisfaction and optimal functioning in the psychological domain. Some
projects help people back to work more quickly after suffering the trauma of
unemployment; others can show benefits with fewer teenage pregnancies and
on the other hand, major reductions in pre-term deliveries.
5 Health promotion programmes can reach disenfranchised groups, helping to
increase their perception of risk-taking behaviour, and in some cases decrease the
use of illicit drugs. Work in schools can produce health gains in nutrition, safersex, reductions in tobacco usage, and the evidence points to other gains such as
enhanced academic performance as a consequence of regular physical activity.
6 Other health impacts are detailed in the Evidence Book. What is clear, however,
and was widely agreed upon at the joint meetings, is the need for sustainability.
Health gains do not come quickly, whereas attempting to repair health damage
nearly always has to.
7 The debate acknowledged that fundamentally, health promotion is clinically safe
and ethically friendly.
8 It was also acknowledged that effective health promotion works on the
determinants of health i.e. the causes, and not just the effects. It is an interweave
of actions and reactions, but all focused on providing enhanced quality of life, and
the sustaining of human well-being as productive and contributive members of
society. People have a responsibility to choose better health options, but society
has a responsibility to help them do so with the provision of proper, timely and
well-targeted resources through well funded health promotion.
9 Evidence from around the world is mounting, and will continue to do
VXZ'y
so, that health promotion needs to play an increasing part in the
public health policy mix. The health promoters were keen to point
\/
out that not too much should be claimed; the health promotion
v
strategy was not the sole answer to major issues. Equally, however, after 20 years
experience, it deserved a higher priority than it has at present with governments
and decision makers.
_
10 Both sides recognised that regular monitoring of best-practice around /^jlx
the world would be very helpful. It was widely encouraged.
—
i
Social Impacts
1 Health promoters have always strongly linked social inequalities with health
inequalities. Health is a fundamental human right and that concept is held onto
with firm determination. The evidence is available to indicate that poverty,
homelessness, joblessness, poor sanitation, and various social breakdowns,
including the family unit, are significant contributory factors to poor health. These
are all issues of political and social importance.
2 It was recognised that health promotion can play a part in tackling some of the
social crises in our societies. It has the potential to contribute to the reduction of
these inequalities, and amongst its many methods is the empowerment of people
and community groups. Health promotion is very supportive of local democracy
22
Bridging the Gap
3
4
5
6
7
and is a means of helping to develop strong and united communities.
Debate also indicated the need to be watchful that health promotion did not
increase inequality of health opportunity, and there was some support for
interventions to be subject to an equity-impact analysis. The evidence is clear that
people from lower socio-economic groups face relatively higher mortality rates
and more disability than those with a higher socio-economic status.
Health promotion programmes have helped claimants on benefits programmes to
take up their dues, and to reschedule debts; others have helped vulnerable and
socially isolated clusters or individuals to re-connect, improving self-esteem,
motivation and life-skills; for the most part, the programmes have improved the
quality of life.
The evidence is equally clear that poor housing, low income, lone
/x. z*—
parenthood, unemployment and homelessness are associated with
high rates of smoking and low rates of quitting. Policies that regulate the
availability of, and demand for, tobacco and alcohol will not succeed in the long
term if the social factors that determine their use are not tackled. The broad
framework of social and economic policy must therefore support effective
substance-use policy.
Partnerships across society are a dynamic growth point in health
promotion. Health promotion is a contributory factor in helping
tackle social issues; often, however, other partners will need to take the lead. In
areas like nutrition, for example, private and public sector co-operation can bring
about health and social gains.
However, as work in the nutrition field has clearly shown, disadvantaged groups
are often those suffering from poor literacy and poor cognitive and
communication skills. There is a need, therefore, to support health promotion
programmes with the right infrastructure and framework. The experience of the
Canadian government, which has led the way through the 1970s, is worthy of
examination in this respect.
Economic Impacts
Health promoters are suspicious when politicians look to them for cost-cutting
solutions to over-spent health budgets; and the political audience is suspicious of
the health promoters if it is suggested that major additional spending is needed to
maximise the impact of interventions. The debate on this issue needed to reach
consensus.
2 It became clear that health promotion is not a cheap fix to the
problem of over-extended health budgets; the most effective
programmes require proper funding, over sustained periods. Equally,
however, the debate clearly indicated that the right level of resourcing
could produce significant economic gains, for governments, societies and
individuals, as well as health gains.
3 While recognising that there was a lack of traditional cost-benefit
analysis work available to support many of the health promotion
arguments (an area that both politicians and health promoters
1
Bridging the Gap
23
recognise needs rectifying), it could nonetheless be argued that evidence was
available to indicate clearly that investment in health does pay dividends.
4 The ageing issue has already been well addressed; but alongside that
is the issue of the ‘productive capacity gap’. The demographics are
clear. Over the next 30 years, Europe’s working population will have
"A /
to support more dependants than at any time ever before. Therefore,
V
to lose one in two smokers in middle age, cutting 20 years off their productive life
cycle, is economically ridiculous. Equally, to have men and women in middle age
crippled by cardiovascular diseases, causing not only the loss of productive output
but creating a burden of expensive care for many years, is a sheer waste. And
particularly so when there is clear evidence that effective health promotion can
make a huge difference.
5 The productive capacity in Europe is also threatened by accidents, and safety is a
rising health issue. If the prediction that one in five premature deaths by the year
2020 will be caused by injury holds true, again that is a phenomenon which health
promotion strategies can address directly.
6 There was wide agreement that the economic impact of health promotion was not
just the obvious ‘cost-saving’ side; there is a significant positive economic benefit
to be experienced by increasing health promotion investment.
7 Controversy inevitably surrounded the issue of ‘public-services versus
personal responsibility’. Should smokers, for example, be able to
claim by right continued medical care when the disease they suffer is
self-inflicted? And on the other hand, if nutritional benefits can be
V
clearly demonstrated as being positive for health, should governments take a
firmer line in legislating the content of school meals, hospital diets, and the rest?
This debate merely started and needs to continue.
8 Where measures of agreement, however, did emerge was a growing understanding
that even limited amounts of health promotion investment could show a positive
gain - in economic, as well as health terms. Instead of analysing interventions on
the traditional cost-effectiveness or cost-benefit analysis, some interest was shown
in developing a cost-utility methodology ► See : Effective Health Promotion in the
Workplace, Evidence Book, Ch 9.
There were calls for more attention to be paid to eliminating those risk factors to
health which also have a severe cost to society, such as smoking. Often,
governments can make big health and economic gains through advancing health
promotion by the legislative process, for example, banning smoking in public
places or ending tobacco advertising and promotion.
10 Throughout the new Europe there was great disparity between developed and
developing economies. To gain the maximum economic outcomes from health
promotion, there was a clear need for a supportive infrastructure which would
allow best-practice to flow across borders.
9
Political Impacts
1 Examining the political impacts of health promotion practices was a novel
experience for many health promoters. Yet lack of familiarity in framing political
24
Bridging the Gap
arguments could be overcome with open dialogue on all sides.
2 Providing the right level of resources for health promotion is ‘politically safe’. The
major ethical dilemmas facing governments over issues such as cloning and genetic
engineering, are not part of the core health promotion argument.
3 Health promotion, properly resourced and sustained, is also |^x^|
inherently accepted by a wide variety of population groups, who ”
simply regard it as ‘common sense’. It provides governments with an effective and
practical approach to dealing with important social issues.
4 The Canadian experience demonstrates how the health promotion concepts can
translate into effective political action plans. Health promotion can demonstrate
that governments are ‘doing’ something.
5 Health promotion is capable of affecting the largest and one of the
most influential population groupings - elderly people. They are an
important political constituency.
6 Health promotion can also provide practical responses and play a part in dealing
with other major political problems. Interventions can help the unemployed find
self-esteem and regain the energy to look for work; programmes can reduce the
psychological impacts of stress, and reduce anxiety and depression; strategies can
ensure greater academic excellence from schooling and greater productivity in the
workplace.
The dialogue between the political representatives and the health
promoters agreed that as Europe faces a new millennium, decision
takers in the European Union and in member state governments \/7\V
should be urged to re-examine the health promotion case, and devote
<_3
appropriate and sustainable resources towards those initiatives which are backed
by evidence that they work.
Bridging the Gap
25
Chapter Four
Making the Journey
Recommendations for Political Action
The process of analytical study of health promotion effectiveness, and public
dialogue between representatives of the political and health promotion communities,
has allowed for a creative and dynamic ‘brains trust’ response to a variety of
important public health issues.
None of the ideas presented below has been fully developed or costed; nor do they
necessarily represent the views of all the participants in the process. They are not
designed as a ‘manifesto’ from IUHPE. They have emerged in the process of preparing
this report, and they provide a catalyst for those decision makers who would wish to
lift up the health promotion profile on the new public health agenda.
Some of these ideas are initiatives where European competence already exists.
Others are where health value can be added by adoption of policies or practices
across the Community. Still others would require concerted action by all member
states of the Union, and all prospective member states. Most of the issue-specific
recommendations are covered in greater detail in the Evidence Book.
General Recommendations
As with the Canadian government experience, the Commission is
urged to consider the appropriate framework and infrastructure for
development of successful health promotion programmes in
identified areas. In particular, the Commission is urged to look at the
levels of funding and practical support for its own health promotion directorate,
and its profile within DGV. (IUHPE has already worked hard on the infrastructure
issue, with a global seminar and development of a set of recommendations
and findings.)
2 There is now an impressive body of evidence on best-practice in
health promotion. This needs to be made available, and to be
regularly updated, in a systematic and authoritative way to all
member state governments. The Commission is urged to examine
which of the existing European-wide bodies would be best placed to undertake
this role, or whether a specific and independent health promotion monitoring
authority should be created.
3 The Commission is urged to consider developing and supporting a
‘European league table’ as a tool for measuring and managing
community wide progress on adopting effective health promotion practices.
Again, there is already some preliminary work in place, particularly the WHO
Verona Benchmark Initiative for investment in health. Health promotion ‘Audits’
i
26
Making the Journey
could provide significant political and health advantages.
This twin-track approach of capturing and encouraging best-practice, and the
‘stick’ of league table performance measures, would be a low-cost but effective
means of improving the health status of Europeans.
5 The Commission should seek to use its considerable influence with > + <
other international organisations, as well as with member and
applicant state governments, to take a leading advocacy role in developing health
promotion. Article 152 of the Amsterdam Treaty, which provides a ‘health test’
across all policy areas, is a platform from which to build. The Commission might
set an example by creating systems which allow public monitoring of its own
health promotion performance.
4
Issue Specific Recommendations
There is considerably further to go with action against the use of 4TA /
tobacco, and other forms of substance abuse. Further action is needed p1
to promote a total ban on tobacco advertising and sponsorship of Vy
public events, services and products, especially those marketing
initiatives aimed at young people. There is also clear evidence that increasing
prices on tobacco products does reduce demand and use; a 10% rise in price will
bring up to a 15% reduction in the quantity of tobacco smoked by young people.
Member and applicant state governments are urged to adopt further aggressive
hikes in excise duties on tobacco products, especially cigarettes.
Member state governments, and the Commission, are also urged to eliminate
the inconsistencies in policies which often show as sympathy for health promotion
on the one hand, but as active support for the tobacco growing or manufacturing
industry on the other.
2 A key to healthy ageing is the adequate provision of pensions to
ensure healthy living environments, lifestyle choices and access to
health and social care. This is a much wider issue than health
promotion, but the health dimension needs to be fully embraced in
the debate.
3 Governments are encouraged to work with the food industry towards
improving the diet of elderly people, for example from better labelling
and packaging, reduction of salt content (especially of convenience
foods), provision of small food portions, development and promotion
of low fat products.
As the evidence shows that health promotion in nutrition leads to health gains
at a much lower cost than medical treatment of either high risk groups or patients,
this is recommended as an arena for political attention. Governments are urged to
develop intersectoral alliances between their own departments (especially
agriculture, health, finance and social affairs), local government, food producers,
distributors and retailers.
4 Transport policies impact on health in a variety of ways - especially
on elderly and poor people - by affecting opportunities for exercise,
access to social facilities, shops and health care. Lack of affordable public
i
Making the Journey
27
transport is a distinct disadvantage, and has a health impact on the elderly, the
poor, and those in rural areas. Close examination of the health dimension of
transport policies, either under Article 152, or independently by member state
governments, could have a positive impact on overcoming health inequalities.
5 Governments are also urged to give greater attention to safety. Many
of the predicted deaths, and loss of productive capacity as a
consequence, are preventable. Again, inter-sectoral collaboration is
needed between and within governments.
6 In the workplace, the European Union needs to be encouraged to
proceed with implementation of key health promotion
recommendations in its Green Paper, Partnership for a New
Organisation of Work. Special emphasis should be given to ensuring
health promoting working conditions, especially in those industry
sectors which depend on motivated and highly qualified employees.
7 Schools are also cost-effective sites for health promotion action, and
frequently attract political support. But the effectiveness of these
interventions is closely linked with the development of educational
skills and the general knowledge base of young people. Schools should not be
looked on by politicians to solve health and social problems in isolation from
other forms of public health action. Support, however, should be given to the joint
WHO-EU-Council of Europe Health Promoting Schools Programme.
8 Political awareness of the Out-of-School youth problem is also called
for. To get this group on political agendas as an audience, and not a
problem, is a key target. Pragmatic recognition of the needs of this
largely disenfranchised group is needed. This would include opening
debate on training, housing, welfare, the provision of sexual health products and
services, safe injecting equipment or abusive-substance alternatives, such as
methadone.
9 With one in five adults already suffering some form of mental disorder, and with
one in five of those young people with mental illness not getting proper treatment,
the whole issue of well-being in this area needs to come out of the political
shadows. Health promotion in this area evidently works.
Effective model programmes need to be disseminated across
Europe and analysis undertaken as to the likely outcomes following
their large scale implementation. Guidelines for effect management
and quality indicators also need to be established, and the
Commission could take a lead in this work.
Perhaps above all, a properly resourced policy platform, providing
a co-ordinated response to this enormous health and social problem
needs to be created.
10 Governments in Europe, and those joining the Union, need to act on
their commitment to Article 25 of the Universal Declaration of
Human Rights, that health is a fundamental human right. With that
commitment comes responsibility to work with determination to
tackle the determinants of health, and to enable health equity to prevail. This
means adopting a high profile political response to tackling poverty, homelessness,
28
Making the Journey
sanitation, and the clutch of social issues which create poor health.
Governments need to acknowledge that investments in health are a positive
contributor to social and economic development.
► Readers wishing to pursue these arguments are referred to The Evidence Book,
which forms Part 2 of this report.
Making the Journey
29
Index
Icon
r\
Book
Subject
Core
Ageing (2) ............................................................................................ 11
Page
Core
Disenfranchised/Out-of-School Youth
Core
General Recommendations (2)........................................................... 26
<—>
Core
Health Promo. Dialogue/Political Impact...........................................25
Action Points
Core
Health Promotion/Political Arena .........................................................6
Core
Issue Specific Recommendations (3) ............................................... 27
30
............................................... 12
Core
Issue Specific Recommendations (5) ............................................... 28
Core
Political Challenges.............................................................................. 11
Core
Safety/Social Challenges (2) ............................................................. 16
Core
Tobacco, Alcohol, and Illicit Drugs/Health Challenges..................... 14
Evidence
Ageing (5) ............................................................................................ 13
Evidence
Ageing/Poverty (2) .............................................................................. 15
Evidence
Case Study: Canada/lnfrastructure Development.......................... 138
Evidence
Elderly Care/Economic Impact (2)...................................................... 22
Evidence
Evalutating Health Promotion (2) ...................................................... 10
Evidence
Health Care Sector............................................................................ 124
Evidence
Health Care Sector............................................................................ 125
Evidence
Health Care Sector (2)....................................................................... 127
Evidence
Health Care Sector/Political Impact ............................................... 130
Evidence
Health Care Sector/Political Impact (2).......................................... 131
Evidence
Healthy Lifestyles/Ageing (2)..............................................................19
Evidence
Heart Disease ..................................................................................... 56
Evidence
Heart Disease ..................................................................................... 57
Evidence
Heart Disease/Economic Impact ...................................................... 62
Evidence
Heart Disease/Economic Impact (2)..................................................63
Evidence
Heart Disease/Research Indicates.................................................... 60
Evidence
Heart Disease/Research Indicates.................................................... 59
Evidence
Infrastructure Development/Assessing Impact...............................142
Evidence
Infrastructure Development/Assessing Impact (2) ........................ 143
Evidence
Keeping Safe/Home............................................................................ 92
Evidence
Keeping Safe/Road
Evidence
Keeping Safe/Road (3)....................................................................... 93
Evidence
Mental Health/Economic Impact
Evidence
Mental Health/Political Impact........................................................... 37
Evidence
Mental Health/Research..................................................................... 32
............................................................................ 94
.......................................................30
Evidence
Mental Health/Research..................................................................... 34
Evidence
Oral Health Promotion/Case Study.................................................. 146
Evidence
Oral Health Promotion/Economic Impact (2) ................................. 148
Evidence
Oral Health Promotion/Health Impact............................................. 147
Evidence
Oral Health Promotion/Political Impact ........................................... 150
Evidence
Oral Health Promotion/Political Impact ........................................... 151
Index
Action Points
Consider Carefully
Index
Evidence
Oral Health Promotion/Political Impact (2)...................................... 149
Evidence
Out-of-School Youth.............................................................................. 47
Evidence
Out-of-School Youth/Economic Impact............................................... 49
Evidence
Out-of-School Youth/Health Impact.................................................... 44
Evidence
Out-of-School Youth/Mass Media Effects...........................................49
Evidence
Out-of-School Youth/Political Impact .................................................. 51
Evidence
School Health Promotion/Context.................................................... Ill
Evidence
School Health Promotion/lmpact .................................................... 115
Evidence
School Health Promotion/lmpact .................................................... 116
Evidence
School Health Promotion/Social Impact ........................................ 118
Evidence
Tobacco, Alchohol, and Illicit Drugs.................................................... 82
Evidence
Tobacco. Alchohol, and Illicit Drugs (3) ............................................. 72
Evidence
Tobacco, Alchohol, and Illicit Drugs/Market Regulators (3) ............ 71
Evidence
Tobacco, Alchohol, and Illicit Drugs/Policy........................................ 70
Evidence
Tobacco, Alchohol, and Illicit Drugs/Policy........................................ 71
Evidence
Tobacco, Alchohol, and Illicit Drugs/Political Impact (2)................... 77
Evidence
Tobacco, Alchohol, and Illicit Drugs/Political Impact (3)................... 87
Evidence
Tobacco, Alchohol, and Illicit Drugs/Settings....................................84
Evidence
Tobacco, Alchohol, and Illicit Drugs/Settings (2)............................... 74
Evidence
Tobacco, Alchohol, and Illicit Drugs/Social Impact .......................... 86
Evidence
Workplace Health Promotion/Economic Impact ............................ 105
Core
Ageing/Political Challenges ................................................................ 10
Core
Bridging Gap (2)................................................................................... 25
Core
Framework for Health Promotion........................................................... 7
Core
General Health Promotion .....................................................................5
Core
General Recommendations ................................................................ 26
Core
Health Equity ........................................................................................19
Core
Heart Disease/Health Challen-ges .................................................... 13
Core
Issue-Specific Recommendations...................................................... 28
Core
Keeping Safe/Social Challenges
Core
Mental Illness/Political Challenges.................................................... 11
...................................................... 16
Core
Nutrition/Social Challenges................................................................ 15
Core
Oral Health
Core
Political Impacts................................................................................... 25
Core
Tobacco, Alcohol, and Illicit Drugs/Health Challenges......................14
Core
Workplace Health Promotion/Settings................................................ 16
Evidence
Ageing.................................................................................................... 12
Evidence
Ageing/Economic Impact..................................................................... 14
Evidence
Ageing/Economic Impact..................................................................... 17
Evidence
Agemg/Health Impact.......................................................................... 14
Evidence
Agemg/Health Impact.......................................................................... 16
Evidence
Ageing/Health Impact.......................................................................... 20
Evidence
Ageing/Health Impact.......................................................................... 22
Evidence
Ageing/Political Impact ........................................................................ 19
.......................................................................................... 19
■Hptv
u?u22 •j f
31
.
’
Consider Carefully
32
Evidence
Ageing/Social Impact ......................................................................... 15
Evidence
Assessing Health Promotion
Evidence
Assessing Health Promotion 1 Impact (2) ...................................... 140
Evidence
Assessing Outcome ..............................................................................9
........................................................... 144
Evidence
Base of Health Promotion Evidence .................................................... 2
Evidence
Case Study. Canada/lnfrastructure Development.......................... 134
Evidence
Case Study: Canada/lnfrastructure Development.......................... 138
Evidence
Case Study: Canada/lnfrastructure Development (2) ................... 136
Evidence
Equity in Health
Evidence
Equity in Health/Determinants......................................................... 158
Evidence
Equity in Health/Economic Impact ................................................. 162
Evidence
Equity in Health/Health Impact.........................................................159
Evidence
Equity in Health/Health Impact.........................................................160
Evidence
Equity in Health/Political Impact (2) ............................................... 162
Evidence
Equity in Health/Social Impact (2)
Evidence
Health Care Sector........................................................................... 125
Evidence
Health Care Sector............................................................................126
Evidence
Health Care Sector/Economic Impact............................................. 129
Evidence
Health Care Sector/Economic Impact............................................. 130
Evidence
Health Care Sector/Political Impact ............................................... 131
Evidence
Health Care Sector/Political Impact (2).......................................... 130
Evidence
Heart Disease ..................................................................................... 58
Evidence
Heart Disease (2)................................................................................ 58
Evidence
Heart Disease/Economic Impact ...................................................... 62
Evidence
Heart Disease/Political Impact (2).................................................... 64
Evidence
Heart Disease/Research Indicates.................................................... 61
Evidence
Heart Disease/Research Inidicates ..................................................59
Evidence
Heart Disease/Research Inidicates ..................................................60
Evidence
Infrastructure Development/External Factors................................. 139
Evidence
Keeping Safe/Economic Impact......................................................... 95
Evidence
Keeping Safe/Social Impact
..............................................................92
Evidence
Keeping Safe/Social Impact
..............................................................94
Evidence
Mental Health
Evidence
Mental Health/Economic Impact
Evidence
Mental Health/Research..................................................................... 33
Evidence
Mental Health/Research..................................................................... 34
Evidence
Nutrition
............................................................................................... 81
Evidence
Nutrition
............................................................................................... 82
Evidence
Nutrrtion/Economic Impact
Evidence
Nutrition/Settings................................................................................. 84
Evidence
Nutrition/Settings................................................................................. 85
................................................................................ 157
................................................. 161
..................................................................................... 29
...................................................... 30
................................................................ 86
Evidence
Nutrition/Social Impact (2).................................................................. 85
Evidence
Oral Health Promotion (2) ................................................................ 146
Evidence
Oral Health Promotion/Economic Impact........................................ I48
Evidence
Oral Health Promotion/Health Impact............................................. 147
Evidence
Oral Health Promotion/Political Impact
Index
Consider Carefully
More Research
Open Detbate
Index
Evidence
Out-of-School Youth............................................................................. 42
Evidence
Out-of-School Youth............................................................................. 45
Evidence
Out-of-School Youth............................................................................. 52
Evidence
Out-of School Youth/Commumty and Individual Impact ................... 50
Evidence
Out-of-School Youth/Cultural Norms ................................................. 48
Evidence
Out-of-School Youth/Successful Projects.......................................... 43
Evidence
Out-of-School Youth/Successful Projects.......................................... 44
Evidence
Programs Worth Evaluating ............................................................... 10
Evidence
Research Methods................................................................................8
Evidence
School Health Promotion/Context.................................................... Ill
Evidence
School Health Promotion/lmpact (2)............................................... 116
Evidence
School Health Promotion/Political Impact ...................................... 119
Evidence
School Health Promotion/Research Indicates ............................... 112
Evidence
School Health Promotion/Research Indicates ...............................114
Evidence
School Health Promotion/Social Impact ........................................ 118
Evidence
School Health Promotion/Substance Use ...................................... 117
Evidence
Tobacco, Alcohol, and Illicit Drugs/Economic Impact........................76
Evidence
Tobacco, Alcohol, and Illicit Drugs/Health Impact............................ 71
Evidence
Tobacco, Alcohol, and Illicit Drugs/Policy.......................................... 70
Evidence
Tobacco, Alcohol, and Illicit Drugs/Policy (2) ....................................70
Evidence
Tobacco, Alcohol, and Illicit Drugs/Provider...................................... 73
Evidence
Tobacco, Alcohol, and Illicit Drugs/Social Impact............................ 75
Evidence
What is Health Promotion Effectiveness? (2)...................................... 4
Evidence
Workplace Health Promotion ............................................................. 99
Evidence
Workplace Health Promotion/Economic Impact ............................ 106
Evidence
Workplace Health Promotion/Economic Impact (2)........................ 105
Evidence
Workplace Health Promotion/Research Indicates.......................... 102
Evidence
Workplace Health Promotion/Research Indicates.......................... 103
Evidence
Workplace Health Promotion/Social Impact (2) ............................ 104
Core
Bridging Gap/Economic Impact
........................................................ 23
Core
Bridging Gap/Economic Impact
........................................................ 25
Core
Bridging Gap/Health Impact................................................................22
Evidence
Assessing Effectiveness .......................................................................7
Evidence
Healthy Lifestyles/Ageing
Evidence
Heart Disease .....................................................................................61
Evidence
Mental Health/Economic Impact
Evidence
Mental Health/Research.................................................................... 36
Evidence
Nutrition/Economic Impact ................................................................ 86
Evidence
School Health Promotion/Economic Impact..............
.................................................................. 19
...................................................... 36
................. 118
Core
Bridging the Gap/Economic Impact.................................................... 23
Core
Bridging the Gap/Economic Impact (2) ............................................. 24
Core
Bridging the Gap/Health impact......................................................... 22
Core
Health Care Sector/Settings (3)......................................................... 18
33
Open Detbate
Concerted Action
>+<
Health Added
Value
34
Core
Health Equity....................................................................................... 20
Core
Introduction to Health Promotion ........................................................ 4
Core
Introduction to Health Promotion ........................................................ 5
Core
Introduction to Health Promotion ........................................................ 7
Core
Issue-Specific Recommendations...................................................... 28
Evidence
Heart Disease .................................................................................... 59
Evidence
Tobacco. Alcohol, and Illicit Drugs...................................................... 73
Evidence
Tobacco, Alcohol, and Illicit Drugs/Economic Impact........................76
Evidence
Tobacco. Alcohol, and Illicit Drugs/Priorities for Action ...................77
Evidence
Tobacco, Alcohol, and Illicit Drugs/Social Impact ............................ 75
Core
Bridging the Gap/Social Impacts (2)................................................. 23
Core
Workplace Health Promotion/Settings............................................... 16
Evidence
Ageing/Economic Impact.................................................................... 17
Evidence
Assessing Effectiveness ...................................................................... 7
Evidence
Assessing Health Promotion Impacts (2)........................................ 141
Evidence
Assessing Health Promotion Impacts (2)........................................ 144
Evidence
Equity in Health/Health Impact........................................................ 160
Evidence
Heart Disease .....................................................................................58
Evidence
Mental Health/Research.................................................................... 36
Evidence
Nutrition/Effective Intervention........................................................... 83
Evidence
Oral Health/Political Impact............................................................. 149
Evidence
Oral Health/Political Impact............................................................. 152
Evidence
Oral Health/Political Impact (2) ...................................................... 151
Evidence
School Health Promotion/Policies .................................................... 114
Evidence
Tobacco, Alcohol, and Illicit Drugs...................................................... 74
Evidence
What is Health Promotion Effectiveness? .......................................... 4
Evidence
Workplace Health Promotion/Political Impact................................. 106
Core
Bridging the Gap/Health Impacts ...................................................... 21
Core
General Recommendations ............................................................... 27
Core
Health Promotion leader.......................................................................8
Core
Heart Disease/Health Challenges .................................................... 13
Core
Issue Specific Research .................................................................... 27
Core
Mental Illness/Political Challenges.................................................... 12
Core
School Health Promotion/Settings (2)............................................... 17
Evidence
Ageing/Social Impact ......................................................................... 21
Evidence
Assessing Health Promotion Impact ............................................... 141
Evidence
Equity in Health/Health Impact.........................................................159
Evidence
Equity in Health/Health Impact.........................................................160
Evidence
Heart Disease ..................................................................................... 67
Evidence
Heart Disease/Research Indicates.................................................... 60
Evidence
Heart Disease/Social Impact..............................................................62
Index
>+<
Health Added
Value
Index
Evidence
Mental Health
Evidence
Mental Health/Political Impact........................................................... 37
Evidence
Mental Health/Research.................................................................... 33
Evidence
Out-of-School Youth/Effective Practice............................................... 47
Evidence
Out-of-School Youth/Social Impact .................................................... 46
.................................................................................... 35
Evidence
Out-of-School Youth/Successfull Projects.......................................... 44
Evidence
What is Health Promotion Effectiveness? .......................................... 4
35
s we face the new millennium, many
of the ,,.ajor political, social and
A
economic challenges facing policy
makers and their advisers focus on issues
of public health.
Europe faces particular challenges. It’s
population will be the oldest in the world for
the next 30 years. Not only are theremew
diseases to be met, but the region I. facing
the re-emergence of disease threats many'
of which it was believed had been defeated
in the last decades. Pressures on budgets
are enormous. And as the final year of the
old millennium fades, a refugee crisis of
immense proportion adds to the politick
and budgetary pressures.
As new public health policy emerges to
cope with these dynamics, what part can
health promotion and disease prevention
play in improving the quality of life for all?
Does health promotion work? Does it
deserve additional resources or a higher
role on political agendas?
This two-part report identifies the
effectiveness of health promotion over the
past 20 years, and seeks to assess the
political, social, economic and health
impacts of interventions across the world.
INTERNATIONAL U NION
Fort 1IEAMII PROMOTION
AND EDUCAT ION
European Commission
. .
This project has received financial support from the European Commissi
Position: 313 (10 views)