Health Promotion in schools, the workplace and the community

Summary

Doctors warn of teen health 'timebomb'

David Batty and agencies
Monday December 8, 2003

Teenagers risk destroying their health in later life as a result of their obesity, drug taking and unsafe sex, doctors' leaders warned today.

The British Medical Association (BMA) called for urgent action to address the worsening trend in adolescent health, which it described as a "potential public health timebomb".

A report by the BMA's board of science, published today, recommends the creation of healthcare services specifically for teenagers, because their needs are often not addressed by services designed for younger children or adults.

The report, Adolescent Health, paints a bleak picture of the problems facing young people in the UK.

The number of overweight children has doubled in the last 20 years, with one in five 13 to 16-year-olds now classed as obese.

Rates of sexually transmitted infections (STIs) are soaring among 16 to 24-year-olds, with 60% admitting they do not use condoms. And as many as 10% of women aged 16 to 19 may be infected with chlamydia, which can make sufferers infertile if untreated.

Alcohol consumption is also on the rise, with some under-16s admitting drinking an average of 10 units of alcohol per week, equivalent to five pints of beer or 10 standard glasses of wines.

A quarter of 15 and 16-year-olds throughout the UK are regular smokers, while 11% of 11 to 15-year-olds in England have used drugs at least once in the past year.

In addition, one in five teenagers may experience mental health problems, such as depression and self-harm.

The report recommended improving access to contraceptive services, banning alcohol advertising, reducing the availability of cigarettes and increasing their price. It also called for social skills training and anti-bulling policies to improve teenagers' mental health.

The BMA's report follows a stark warning from by England's chief medical officer, Professor Liam Donaldson, that the health of some children is so poor they could die before their parents.

The government is already considering moves to limit junk food advertising to children amid warnings of a looming child obesity "epidemic". Doctors are seeing cases of diabetes in children aged just 13 due to poor diet and sedentary lifestyle.

British researchers subjected children aged seven to 11 to a school-based educational programme that encouraged them to consume fewer fizzy drinks.

This led to an average reduction of soft drink consumption of 50ml a day (compared to other children who went on to consume an average of 15ml more of soft drink per day). Over the course of one year, the incidence of obesity in children not subjected to the programme increased by 7.5 per cent, while those who tempered their soft-drink consumption saw a slight decrease in levels of obesity.

 

Ministers have launched several initiatives to tackle unhealthy lifestyles in recent years, including the "five a day" scheme to encourage people to eat more fruit and vegetables, smoking cessation projects, a sexual health strategy and a teenage pregnancy strategy. But, as yet, these have had little impact on adolescent health. (Guardian 8-12-03)

 

Fullan (1985) identifies three main phases of the change process in schools that could aid research.

1.        Firstly the initiation phase which includes the mobilisation of staff and resources, adoption of decision-making processes, and early development of materials.

2.        Secondly, the implementation phase, which involves putting the change into practice.

3.        And thirdly the institutionalising phase, which broadly means maintaining the change by building it into the system.

 

Fullan (1985) points out that based on a number of studies guidelines emerge on the best way to implement change. These can be summarised into three main categories:

 

1.   Good planning by school staff and outside advisers is indispensable as a first step. Mechanisms for testing and getting feedback, and then altering the plan (if necessary) are important, particularly if the school is unused to innovation.

2.   Role clarification of staff within schools and outside advisory staff. Teaching staff need to be involved in all three phases (outlined above) if the innovation is to be successfully adopted and institutionalised. This second category should include support in terms of training and resources and critically psychological support for teaching staff expected to carry through the change.

3.   Planning for continuation and dissemination. This should involve plans to introduce new staff to the change or innovation: identifying

resources each year for the new ‘product’. The change should gradually involve all staff in the school and in time the innovation could be disseminated to other schools in the region. This may need outside help.

 

Several innovatory programmes in health education and health promotion particularly in the United States have tried to implement these stages and categories to try and overcome traditional problems associated with adoption of new curriculum materials. A school-based tobacco-use prevention programme developed some of Fullan’s ideas and built on various smaller scale studies (Parcel et al., 1989). The study identified four phases — Dissemination, Adoption, Implementation and Maintenance — and aimed to involve head teachers and teaching staff in all four phases. The theoretical basis for smoking prevention, which included social learning theory, modelling and the health belief model formed part of the teacher training on the innovation. The researchers were also acutely aware that the teachers needed incentives to accept and adopt the intervention. These were offered in the form of a demonstration on how the programme would benefit the users and the professional benefit to teachers in using the material.

The dissemination phases provided school staff with information on the prevalence of tobacco use, but more importantly described the prevention education programme and ways in which to increase motivation of potential users to adopt the programme. These phases involved a great deal of outside agency help including the recruitment of local opinion leaders, network development and the involvement of the local media. These outside agencies involved education advisers and, in US terms, regional health education specialists promoting the innovation.

The adoption phase was characterised by a direct mailing of a newsletter to the target schools with details of how to enrol for the programme and savings to be made for early registration. This charging for curriculum development and advice pre-dated the radical changes now taking place within the school system in England and Wales following the 1988 Education Act.

The implementation phase in the Parcel study in Texas involved testing two methodologies for tobacco-use prevention in schools, a teacher-based workshop and a self-instructional video.

The maintenance phase must be seen as crucial and in the Texas study both the teachers and the students were included. Teachers joined focus groups to help determine maintenance strategies and learning outcomes were monitored.

Parcel concluded that whilst the receptivity of schools to a new tobacco-­use prevention programme is high, the actual use of curriculum materials is relatively low. Parcel argues that the challenge is not in the development of educational interventions but in their comprehensive dissemination. The opposite may be the case in the United Kingdom. Schools are perhaps suffering from innovation fatigue although good dissemination of materials and projects usually means use and adoption.

The Parcel study and others (Basch, 1984; Gottleib, et al., 1987) all emphasise the need to win school support for the innovation in the first place. This may increasingly involve incentives to increase recruitment. This is particularly the case in the United Kingdom with what is now commonly referred to as ‘innovation overload’ amongst teaching staff and within schools generally. Much of the work on curriculum development in the United Kingdom and United States have similar characteristics that tend, at least historically, not to allow for teacher value systems or behavioural traits. The reasons for this are twofold. National or local governments fund most research, or other tax funded agencies, in order to find the most efficient cost-effective way of ensuring the successful dissemination and implementation of their ‘products’. The implicit assumption is that all innovations are ‘good’ and therefore worth adopting and implementing.

 

 

Teacher attributes

 

The perspective adopted in most studies tends to be a top down one and most researchers adopt the so-called ‘fidelity approach’ (Bollam, 1982) in that they look for implementation that is true to the original innovation. The underlying assumption appears to be that men and women are rational creatures and will respond to rationally presented innovations. Subsequently they will behave rationally and systematically during the adoption, implementation and maintenance phases of the diffusion process. This ignores the increasing evidence (Parcel, et al., 1988; Smith, et al., 1992) that teachers, like many other professionals, tend not to use systematic planning techniques and methods, do not read research reports as a matter of course and tend to behave more intuitively.

There are, of course, signs that this is changing especially in the United Kingdom with the recent overhaul of state education. Nevertheless most research into innovation diffusion in schools assumes that teachers are able to act and respond in a planned and organised way when in fact they are under increasing pressure to take on an ever-increasing workload associated with the national curriculum, key stage assessment and performance indicators.

The standard approach ignores that fact that teachers operate within a complex organisation that allows very little time to plan, organise and reflect and that in many cases the teacher and the school could be dealing with more than one innovation at any one time. Innovation diffusion also has to take cognisance of the ever-changing staffing levels and memberships in schools. In the 1990s staff turnover in many schools has approached 20 per cent. From the dissemination or initiation stage through the adoption, implementation and maintenance stages, the staffing levels and membership in schools could change dramatically. This is bound to have very important implications for the understanding and usage of the innovation.

A major study undertaken in the United Kingdom in the early 1980s (Schools Council, 1980) highlights a number of issues that constrain the dissemination and impact of an innovation. The study was designed to determine how best to disseminate Schools Council material to effect maximum impact and take up. The Council led the way in the production and dissemination of teacher materials and programmes in the 1970s, but it was concerned that some materials was used more than others and some not at all.

The study found that when teachers were asked what factors hindered the introduction of new ideas, methods or teaching materials in schools, 20 per cent mentioned cost, 18 per cent mentioned time, and 14 per cent identified staff attitudes. Other comments included external examination requirements, school structures and the lack of applicability of the innovation to their particular school. To some extent these findings are replicated in later work carried out in Wales (Smith et al., 1992). Both mirror the concerns outlined above that innovation in schools has to acknowledge the organisational structure of the school, the processes that hinder or help adoption, the ability of the teacher to devote time to the programme and, importantly, the psychological map of the teacher. This means paying greater attention to the value system operating within the school and to the teacher’s own beliefs, attitudes and behaviour.

Innovators would do well to gain an understanding of the relationship between these three psychosocial attributes, and apply them to teachers. It might be that only then will a real understanding emerge on the best methods for the diffusion of innovations to schools.

 

(Acknowledgment - Gordon Macdonald Innovation diffusion and health education in schools in Moyra Sidell et al (Eds.) 1997, Debates and Dilemmas in Promoting Health, Open University, 0-333-69417-1)

 


Some school programs have been effective. An experiment in 22 elementary schools introduced a carefully designed curriculum with emphasis on nutrition and physical fitness (Walter et al., 1985). The schools were randomly assigned so that their students either participated in the program or served as a control group. The researchers compared the two groups after a year. Relative to the control subjects, the Text Box: Edwards and Hartwell (2002) investigated whether children, aged 8-11 years could correctly identify commonly available fruit and vegetables; to assess the acceptability of these; and to gain a broad understanding of children's perceptions of 'healthy eating'. Fruit and vegetables used were those readily available in retail outlets in the UK. Data were collected from 221 children using a questionnaire supported by semistructured interviews and discussions. Overall, fruit was more popular than vegetables and recognition of fruit better; melons being the least well identified. Recognition of vegetables increased with age; the least well identified being cabbage which was confused with lettuce by 32, 16 and 17% of pupils in their respective age groups. Most children (75%) were familiar with the term healthy eating, citing school (46%) as the most common source of information. Pupils showed an awareness and understanding of current recommendations for a balanced diet, although the message has become confused. If fresh fruit and vegetables are to form part of a balanced diet, the 'health message' needs to be clear. Fruit is well liked; vegetables are less acceptable with many being poorly recognized, factors which need to be addressed. children who participated in the program showed improvements in their blood pressure and cholesterol levels.

Another study found that more children practiced safety behaviour if they were taught about health and safety in a 4-year program than if they were not (Parcel, Bruhn, & Cerreto, 1986). But many schools do not provide health education at all, or their programs are under funded, poorly designed, and taught by teachers whose interests and training are in other areas (Kolbe & Iverson, 1984).

School-based programs that have incorporated behavioural objectives that are directly observable have been effective in promoting and maintaining healthy dietary change. Coates et al. (1985) examined the effectiveness of a 4-week school-based intervention for decreasing con­sumption of salty snack foods and increasing consumption of “heart healthy” snacks among African American adolescents. One hundred fifty-four students from one high school received the treatment pro­gram, whereas 130 students from another high school served as the no-treatment control group. The program incorporated parental in­volvement, a school wide media program, and a classroom instruction program. The classroom instruction program included setting written goals for substituting heart-healthy snacks for salty snacks. The treat­ment program was effective in producing reductions in salty snack foods, however, long-term changes were only significant for students who participated in the classroom instruction program that incorpo­rated written objectives. Relatedly, Bush et al. (1989) examined the effects of a 4-year program for reducing coronary heart disease risk factors among 1,041 African American adolescents. Participants were randomly assigned to either a treatment program or a control program (no treatment). The treatment program involved goal setting, modelling, rehearsal, feedback of screening results, and reinforcement of healthful eating behaviours. Treatment participants showed significant decreases in cholesterol and blood pressure, which were maintained over a 2-year follow-up.

In Perry et al’s (1989) study, younger children (ages 8—9 years) participated in either a treatment or control school-based program designed to increase healthy eating habits. The intervention program included modelling through stories and role-playing, self-monitoring of behaviours, behavioural contracting, and ma­terial rewards. Treatment participants showed significant reductions in the use of salt (it was not stated whether minorities were included). Together, these studies reviewed above provide evidence that incor­porating directly observable behavioural objectives—such as setting written goals, modelling behaviors, and providing feedback—can suc­cessfully result in long-term dietary change.

Another important aspect of school-based interventions has been obtaining support from school staff (e.g., teachers) and school cafeteria providers. Bush et al. (1989) reported that young African American adolescents who were part of a coronary heart disease prevention pro­gram and were judged to have the best teachers showed significant decreases in total serum cholesterol at a 2-year follow-up. Resnicow, Cross, and Wynder (1991) also examined the effects of a comprehen­sive school health education program designed to decrease total cho­lesterol in young adolescents. They conducted three studies with a combined sample of Whites, African Americans, and Hispanics. The program incorporated a teacher component, a health-screening com­ponent, and extracurricular activities. The teacher component advo­cated decision-making, goal setting, and communication skills. The extracurricular activities included modifying the school cafeteria, de­veloping recipe books, and holding heart-healthy bake sales. The in­tervention schools reported significantly less consumption of high-fat foods in comparison with no-treatment schools. The intervention participants also showed 4%—7% decreases in total cholesterol level across all ethnic groups. Although Bush et al. and Resnicow et al. did not specifically determine which components of their programs were most effective in creating dietary change, their findings do provide evidence for the importance of obtaining support from school staff and cafeteria providers when designing dietary interventions for ad­olescents.

Other investigators have more specifically modified school cafeteria programs to provide healthier food options. Parcel, Simons-Morton, O’Hara, Baranowski, and Wilson (1989) worked with the food service personnel to institute specific goals for dietary change in several school cafeterias in Houston, Texas. Their study sample was 62% White, 2I% Mexican, 15% African American, and 2% Asian American and Native American. Participants ranged in age from 5 to 10 years.  School lunches were modified to decrease the sodium content to less than 600 mg per average school lunch and to decrease the total fat to 30% and saturated fat to 100/o or less of the total calories per day. New recipes were tested for taste, texture, appearance, and appeal. The results demonstrated significant decreases in the use of salt. Similarly, in a recent review by Stevens and Davis (1988) it was found that ef­fective dietary programs modified the offerings of school cafeterias to include salad bars, fresh fruit, and whole grain breads. Continued research is needed to better understand how programs such as these might affect specific adolescent minority groups.

French et al (2001) examined the effects of pricing and promotion strategies on purchases of low-fat snacks from vending machines. Low-fat snacks were added to 55 vending machines in a convenience sample of 12 secondary schools and 12 worksites. Four pricing levels (equal price, 10% reduction, 25% reduction, 50% reduction) and 3 promotional conditions (none, low-fat label, low-fat label plus promotional sign) were crossed in a Latin square design. Sales of low-fat vending snacks were measured continuously for the 12-mo intervention. Results show that price reductions of 10%, 25%, and 50% on low-fat snacks were associated with significant increases in low-fat snack sales; percentages of low-fat snack sales increased by 9%, 39%, and 93%, respectively. Promotional signage was independently but weakly associated with increases in low-fat snack sales. Average profits per machine were not affected by the vending interventions. It is concluded that reducing relative prices on low-fat snacks was effective in promoting lower-fat snack purchases from vending machines used by both adult and adolescent populations.

More recently, investigators have integrated culturally relevant in­formation into their school-based dietary interventions. For example, Schinke, Moncher, and Singer (1994) developed a cancer risk-reduction program that included a nutrition focus on reducing fat in­take and increasing such nutrients as fibre and carotene. The study included 368 Native American adolescents whose schools participated in either an intervention or a control program. The intervention in­volved using an interactive computer program to present information in the context of a Native American story. The story emphasized the culturally relevant traditional advantages of sound nutrition (e.g., nat­ural and whole foods). A second aspect of the computer program fo­cused on problem solving and helping adolescents to offset negative pressures within the context of the story. ‘The students received posi­tive feedback on what they had learned through a computerized post-test. Students in the intervention program showed a greater increase in knowledge regarding positive dietary changes than students from schools who did not receive the intervention. This study did not in­clude behavioural measures to determine if this acquired knowledge would generalize to adolescents’ behaviour. Nevertheless, this type of program may be especially effective with minority adolescents be­cause it is culturally and developmentally appropriate and has a game like quality.

 

Ewart, Loftus and Hagberg (1995) evaluated the efficacy of school-based aerobic exercise program for lowering blood pressure in a high-risk urban sample of ninth-grade African American girls.  Girls in the intervention group received a one-term aerobics class of fitness instruction and training designed to be enjoyable and engaging for high-risk girls.  Eighteen 50-min class periods involved lecture and discussion and 60 class periods were spent performing aerobic exercise.  Girls assigned randomly to the control group just received the regular PE curriculum.  After completing the course 81% wished to continue for another term, demonstrating their enjoyment and a developing commitment to regular exercise.

 

Peer-based programmes

 

We prefer to take advice from people like ourselves or from people who we respect. It seems reasonable to suggest, then, that health education programmes led by your peers will be more successful than programmes led by adult strangers or by teachers. Bachman et al. (1988) looked at a health promotion programme where students were asked to talk about drugs to each other, to state their disapproval of drugs and to say that they didn’t take drugs. The idea was to create a social norm that was against drug taking and also give people practice in saying ‘no’. It was claimed that the programme changed attitudes towards drugs and led to a reduction in cannabis use. A similar programme was reported by Sussman et al. (1995) who compared the effectiveness of teacher-led lessons with lessons that required student participation. The study looked at around 1000 students from schools in the US. Results suggested that there were significant changes in attitudes to drugs and intentions to use drugs in the active participation lessons, but not in the teacher-led lessons.

Two of the criticisms of the peer-led health education programmes are that they are not based on sound theory and do not have much evidence of their effectiveness. There are, however, a number of studies that have compared the effectiveness of peer-led health education in schools with adult-led programmes delivering the same material (Mellanby et al., 2000). It appears that peer-led programmes were at least as effective as the adult-led programmes and sometimes more effective. One of the reasons for this might be that information, particularly of a sensitive kind, is more easily shared between people of a similar age

Promoting healthy school meals for Norwegian children

Anti-smoking promotions in schools

WORKSITE WELLNESS PROGRAMS

Health hazard appraisal

 

An example of a work-based health programme was introduced at a glass product company in Santa Rosa, California (Rodnick, 1982, cited in Feuerstein, 1986, p. 271). A ‘health hazard appraisal’ counselling session was carried out with nearly 300 employees at the company. As part of the programme, full-time staff were offered a comprehensive health examination which included:

 

•       health history

•       weight and height measurement

•       blood pressure measurement

•       range of blood tests including: cholesterol, liver enzyme level, calcium, protein etc.

•       TB skin test

•       stool test

•       physical examination.

 

This information was used to provide feedback on the risks of contracting various diseases including specific cancers and cardiovascular disease. About two weeks after the tests, the workers attended a group session where they received feedback about their health-risk profiles. They were also given information about hypertension, heart disease and cancer.

One year later the workers were tested again and the following improvements in their general health were observed:

•       decrease in blood pressure (particularly in individuals with mild hypertension)

•       reduction in cholesterol levels in men

•       decrease in cigarette smoking

•       increase in exercise

•       increase in breast self-examination (BSE)

•       decrease in alcohol consumption in men

•       increase in seat-belt use by men.

A survey of over 1,300 worksites with 50 or more employees found that nearly two-thirds offered some form of health promotion activity, such as for fitness and weight control (Fielding & Piserchia, 1989). Some programs award prizes for losing weight, or pay employees for stopping smoking, or give bonuses for staying well. By doing this, employers are helping their workers and saving a great deal of money. Workers with poor health habits cost employers substantially more in health benefits and other costs of absenteeism than those with good habits. These savings offset and often exceed the expense of running a wellness program (Winett, King, & Altman, 1989).

Worksite wellness programs vary in their aims, but they usually address some or all of the following risk factors: hypertension, cigarette smoking, unhealthy diets and overweight, poor physical fitness, alcohol abuse, and high levels of stress. Housing these programs in workplaces has several advantages:

·  (a) Most employees go to the workplace on a regular schedule, facilitating regular participation in the programs;

·  (b) contact with co-workers can provide reinforcing social support

·  (c) the workplace offers many opportunities for environmental supports, such as healthy food in the cafeteria and office policies regarding smoking;

·  (d) opportunities abound for positive reinforcement for individuals participating in the programs;

·  (e) programs in the workplace are generally less expensive for the employee

·  (f) programs in the workplace are convenient. (Cohen, 1985, p. 215).

Unfortunately, the employees who do not participate are often the ones who need it most-those who report having poor health and fitness (Alexy, 1991).

Johnson & Johnson's "Live for Life" Program

Johnson & Johnson is America's largest producer of health care products. They began the Live for Life program in 1978, and it is one of the largest, best funded, and most effective worksite programs yet developed (Fielding, 1990; Nathan, 1984). The number of employees covered by the program has grown over the years and now exceeds 3 1,000. The health goal of the program is to help as many employees as possible live healthier lives by making improvements in their health knowledge, stress management, and efforts to exercise, stop smoking, and control their weight.

For each participating employee, Live for Life begins with a health screen-a detailed assessment of the person's current health and health-related behavior, which is shared with the individual later. After taking part in a lifestyle seminar, the employee joins action groups for specific areas of improvement, such as quitting smoking or controlling weight. Professionals lead sessions of these action groups, focusing on how the employees can alter their lifestyles and maintain these improvements permanently. Follow-up contacts are made with each participant during the subsequent year. The company also provides a work environment that supports and encourages healthful behaviour: it has designated no-smoking areas, established exercise facilities, and made nutritious foods available in the cafeteria, for example.

All the employees studied completed a health screen in the initial year and then again in later years. Compared with the employees at the companies where Live for Life was not offered, those where it was have shown greater improvements in their physical activity, weight, smoking behaviour, ability to handle job stress, absenteeism, and hospital medical claims.

Control Data's "StayWell" Program

Each StayWell participant completes a health screening, receives a resulting confidential health risk profile, and attends a workshop that focuses on interpreting the profile. The person can then join courses taught by professionals that provide information about lifestyle and health and teach the skills needed to change unhealthful behaviors. There are courses in physical fitness, nutrition, weight control, stopping smoking, and stress management. The individual can also join action teams that focus on two things:

Evaluation of the StayWell program uses two approaches.

  1. Some sites did not offer the Staywell program, and therefore could be used as controls.
  2. Employess exhibited varying degrees of participation in the Staywell program so comparisons could be made.

Smoking reduction

 

An attempt to encourage people to quit smoking was carried out at five worksites. All the sites received a six-week programme in cognitive behaviour therapy which focused on the skills of giving up. The workers who enrolled in the programmes in four of the sites were put into competing teams, with the workers at the fifth site acting as a control. At the end of the programme 31 per cent of the people in the programme at the control site and 22 per cent the competition sites had stopped smoking. A follow-up study after six months found that 18 per cent of the control group and 14 per cent of the competition groups had stayed off the cigarettes. This appears to suggest that the control group were doing better than the competition groups, but this was not the case. At the competition sites 88 per cent of the smokers joined the programme, but only 54 per cent did so at the control site, suggesting that the incentive of competition encouraged more people to attempt to give up. When the data was compared for the total number of smokers at each site to give up, there was an overall reduction of 16 per cent at the competition sites and only 7 per cent at the control site (Klesger et al. 1986).

A worksite intervention that has grown in popularity is to ban smoking at work. One of the questions to consider about this policy is whether smokers reduce their consumption because of the ban, or whether they simply adjust their behaviour and smoke at different times. A smoking ban in Australian ambulance crews was monitored by self-report measures, and also by physiological measures such as blood and exhaled carbon dioxide. The measures were taken just before the ban, just after it, and again six weeks later. The self-report results showed that the ambulance crews reported less smoking both at the start of the ban and after six weeks. The physiological measures, however, returned to the baseline measures after six weeks, suggesting that the smokers were finding other times to smoke, or were maybe finding secret places to smoke while at work (Gomel et al., 1993). This suggests that worksite smoking bans might well be useful in changing behaviour at work, and also improving the quality of life for non-smokers, but their overall effectiveness in reducing smoking is far less clear.

The problem of measuring the effectiveness of worksite health promotion is a general one that goes beyond ‘quit smoking’ programmes. A review of over 100 programmes of worksite health promotion found that only a quarter of them were initiated in response to the needs or views of the workers, and very few involved partnerships between workers and employers. Most of the programmes were aimed at changing individual behaviour and did not include any changes in the working environment or working practices to encourage these behaviours. The review also noticed a gap between what was regarded as ‘good practice’ and what has been found to be effective in research studies (Harden, et al., 1999). I guess this means that, as with many other health interventions, people do what they believe to be the right thing, rather than what research has told us is the best thing.  However, health promotion at the workplace has been successful in reducing absenteeism, health insurance claims and in improving health behaviours in weight control, exercise, smoking, nutrition, and stress management (Jose & Anderson, 1990; Naditch, 1984).

 

COMMUNITIES

 

Coronary heart Disease and mass media appeals

 

It is difficult to evaluate the effect of mass media appeals. In the case of product advertising the effect can be measured in sales. In the case of health behaviour it is difficult to come up with appropriate measures since there are so many influences on us every day. One of the most famous studies on the effectiveness of mass media messages was the Stanford Heart Disease Prevention Programme (see, for example Farquhar et al., 1977). This study looked at three similar small towns in the US. Two of the towns received a massive media campaign concerning smoking, diet and exercise over a two-year period. This campaign used television, radio, newspapers, posters and mailshots. The third town had no campaign and so acted as a control.

The researchers interviewed several hundred people in the three towns between the ages of 35 and 60. They were interviewed before the campaign began, after one year, and again after two years when the campaign ended. The interviews included questions about health behaviours, knowledge about the risks of heart disease, and physical measures such as blood pressure and cholesterol levels. In one of the two campaign towns, the researchers used the interview data to identify over one hundred people who were at high risk of heart disease and offered them one-to-one counselling.

The people in the control town showed a slight increase in risk factors for heart disease, and the people in the campaign towns showed a moderate decrease. The campaign produced increased awareness of the dangers of heart disease but produced relatively little change in behaviour. The exception to this was the people who had been offered one-to-one counselling — this group showed significant changes in behaviour. This study suggests that mass media campaigns by themselves produce only small changes in behaviour, but they can act as a cue to positive action if further encouragement is offered.

 

Reducing skin cancer risk

 

Over the past twenty years there has been a large growth in the incidence of skin cancers, which might be due to a combination of changes in the environment and changes in lifestyles. There are a number of health promotion campaigns to encourage safe behaviours in the sun. A study on the effectiveness of these programmes was carried out by McClendon and Prentice (2001). White students who chose to tan were given a health promotion intervention based on protection motivation theory (PMT). The intervention was made up of brief lectures, an essay, short discussions and a video about a young man who died of melanoma (a particularly dangerous form of skin cancer). There were two sessions, each just over one hour long and taking place two days apart.

The researchers used psychometric tests to estimate responses to a range of variables including:

•       vulnerability

•       severity of the threat

•       self-efficacy

•       costs and rewards

•       intentions.

With the exception of self-efficacy, these variables all showed some significant change after the intervention and remained effective one month later. However, the issue is not whether people intend to change their behaviour, but whether they actually do change their behaviour. This is always more difficult to measure. In this study, however, they took photographs of the participants at the start of the study and again after one month. These pairs of photographs were then judged by four blind-raters (judges who did not know whether the pictures were before or after) to see whether the students’ skin had tanned further or become lighter. The students were not aware that this judgement would take place. Of the 32 individuals photographed, 23 (72 per cent) were judged to have lighter skin tone after one month, 4 (12.5 per cent) were rated as having no change and 5 (16 per cent) were judged to have darker skin.

Skin cancer is increasing, and prevention programs are essential. Glanz et al (2002) evaluated the impact of a skin cancer prevention program on sun-protection habits and swimming pool environments. The intervention included staff training; sun-safety lessons; interactive activities; providing sunscreen, shade, and signage; and promoting sun-safe environments. A randomised trial at 28 swimming pools in Hawaii and Massachusetts tested the efficacy of this program (Pool Cool) compared with an attention-matched injury-prevention control program. Results showed significant positive changes in children's use of sunscreen and shade, overall sun-protection habits, and number of sunburns and improvements in parents' hat use, sun-protection habits, and reported sun-protection policies and environments. Observations corroborated the positive findings. Pool Cool had significant positive effects at swimming pools in diverse audiences.

Hillhouse and Turrisi (2002) designed and implemented an appearance-based skin cancer prevention intervention in college-aged females. 147 respondents (mean age 20.8 yrs) were randomly assigned to treatment or control groups. Treatment respondents received a short workbook describing the appearance damaging effects of indoor tanning. At short-term follow-up (2 weeks later) treatment respondents had significantly more negative attitudes toward indoor tanning, and reported fewer intentions to indoor tan. At 2-month follow-up, treatment respondents reported indoor tanning one-half as much as control respondents in the previous 2 months. This appearance-based intervention was able to produce clinically significant changes in indoor tanning use tendencies that could have a beneficial effect on the future development of skin cancer.

Campaigns using television, radio and print media were conducted over 3 summers in Australia, aiming to increase the use of sun protection measures among children under 12 years. Smith et al (2002) evaluated cross-sectional telephone surveys before and after each of the first 2 campaigns and following the third campaign. The study group were parents of children under 12 years. Measures addressed campaign recall and sun protection knowledge, attitudes, and behaviours. The surveys revealed significant levels of campaign recall. Knowledge about the protective benefits of sunscreens, hats and protective clothing was high at baseline and showed little improvement over time. Knowledge levels about the benefits of shade cover and of the risks of skin cancer from sun exposure were lower, and also did not show improvement. After the final campaign there were increases compared with baseline in children's use of sunscreen, protective clothing and shade, but it was notable that between campaigns levels of these behaviours were similar to or below those at baseline. Mass media campaigns may contribute to short-term increases in some sun protection behaviours; however, as their impact is not sustained they should be repeated and supplemented by educational, policy and environmental strategies.

 

Homelessness

 

Not everybody has equal access to healthcare. Some members of our society are socially excluded from the wealth and health that most people enjoy. One group of people who fall into this category is the homeless, and one of the challenges for health promotion is to create initiatives that deal with their needs. The health status of homeless people is very poor compared to the general population (Plearce and Quilgares, 1996). This is true for diet, malnutrition, substance misuse, mental health problems, infectious diseases such as tuberculosis), cardiovascular disease, accidents and hypothermia. Homeless people commonly come to the attention of health workers only when they develop an illness rather than through screening procedures, and they often use accident and emergency departments to deal with their health problems (Power et al., 1999). As a result the regular health promotion programmes often miss them.

There are a number of barriers to health promotion for homeless people including (Power et al., 1999):

•       workers with homeless people are often isolated and there is not very much collaboration between the various agencies that work with the homeless

•       health promotion units do not set up many initiatives aimed specifically at homelessness and housing

•       homeless people can feel alienated from health education messages as they often require a high level of literacy

•       although homeless people are concerned about health problems, issues such as low self-esteem and low expectations can prevent them from taking part in heath promoting activities.

 

Source

Philip Banyard, 2002, Psychology in practice – Health, Hodder & Stoughton, 0-340-84496-5