Modern methods of prevention and health promotion - working with people and their organisations

1. Modern methods of prevention and health promotion - working with people and their organisations Stefan Thorpenberg Associate professor Nordic School of Public Health (NHV) Gothenburg, Sweden

2. The ideals of Health Promotion in the Ottawa Charter 1986, according to Rothman et al: • Empowerment.Individuals and local society should have more power over factors having impact on health • Participatory. People should be involved in planning and evaluation • Holistic. health should be seen in all its aspects, physical, mental, social, etc. • Intersectoral. relevant social sectors should collaborate • Equity. Social equality and justice should be an aim • Sustainable.Changes should last and still function on its own when support is ended • Multistrategy. Different strategies should be used, like policy development, organisational changes, education and communication with different social actor • Rootman I, Goodstadt M, Hyndman B et al. Red. Evaluation in health promotion. Principles and perspectives. WHO Regional Publications European Series No 92, 2001

3. A change since the Bangkok conference 2005? • Christine Porter: • Ottawa Charter: social justice • Bangkok Charter: improve on health opportunities • Ottawa Charter: educated people should be able to strengthening public participation in and direction of health matters • Bangkok Charter: a demand for proven policy, a focus on strong intergovernmental agreements and government incentives and regulations. • Therefore, the general perspective on health promotion can be summarized as a change: • from bottom-up to top-down? • Porter, C. “Ottawa to Bangkok: changing health promotion discourse”. Health Promotion International, Vol 22, No 1, 2006, s. 72-79

4. Empowerment still depends on participation – individual and collective • Some studies show that many people learn better if they are involved and the teacher is an equal – a ”peer”. • This has been considered in a study on risks with HIV. Teens had their information from young people they knew; the vast majority of respondents in the study knew at least one person living with AIDS. (1) • This view on the importance of peers has also been tried in teaching about alcohol in the US. (2) • It has also been tried in a Danish study on young teenagers drinking, which introduced the term ”never leave a friend” to minimize the dangers of alcohol use at young age. • (!) Bay E, Godfrey C; Teens tell teens - adolescents survey HIV-related risk and health issues of peers. International Conference on AIDS. Int Conf AIDS. 1996 Jul 7-12; 11: 395 • Franco, D. Teens tell teens to stay away from alcohol, The Gazette, (Colorado Springs), Mar 16, 2000 • Jorgensen, M. H., Curtis, T., Christensen, P.,H., Gronbaek, M. Harm minimization among teenage drinkers: findings from an ethnographic study on teenage alcohol use in a rural Danish community. Addiction, 2007, 102, 4; 554-559

5. But this bottom-up strategy in health promotion has not the same value in all Nordic countries The picture of a unified Nordic welfare policy has recently been questioned by Signild Vallgårda who has pointed to the differences between the countries in an article based on policy documents from Sweden, Norway and Denmark. Danish public health programs often have a more liberal view on health, where the individual is responsible for his/her own health. Norwegian programs have a slightly different social liberal perspective and emphasize the need for the individual to strengthen his/her position in health issues. Swedish programs, on the other hand, focuses on inequality issues and its importance for the public health. The state and politicians are given an important role, which according to Vallgårda resembles a social democratic welfare ideal. Vallgårda, S. (2007). Public Health Policies: a Scandinavian Model? Scandinavian Journal of Public Health, 35, 205-211.

6. But that was a study of policy documents. Will these differences also be found in peer reviewed research material? • Traditional research ethics says that researchers should present their results in an objective, neutral and disinterested way, and to be autonomous o their own culture, social interests and political circumstances.

7. The observed association between risk of developing postmenopausal estrogen receptor+ (ER) breast cancer and alcohol drinking, especially among those women who use postmenopausal hormones, may be important, because the majority of breast tumours among postmenopausal women over-express ER. Suzuki R, Ye W, Rylander-Rudqvist T, Saji S, Colditz G A, Wolk A. Alcohol and postmenopausal breast cancer risk defined by estrogen and progesterone receptor status: a prospective cohort study. Journal of the National Cancer Institute 2005;42:97:1601-1608 The differences in interpretations of research results sometimes sticks out: Sweden

8. Compared to a Danish abstract: • There was no association between beer or spirits drinking and gastric cancer. In conclusion, the present study suggests that a daily intake of wine may prevent development of gastric cancer. • Barstad B, Sorensen T I A, Tjonneland A, Johansen D, Becker U, Andersen I B, Gronbaek M. Intake of wine, beer and spirits and risk of gastric cancer. European Journal of Cancer Prevention 2005;25:14:239-243.

9. Low dose alcohol to pregnant women: does it harm the child? • Children exposed to prenatal alcohol experience significantly more mental health problems that include hyperactivity/inattention, conduct problems, emotional problems and peer relationship problems as well as being less attentive and experiencing shorter “longest attention episodes”. Such impact was only found in 2 of 5 analyses of schoolchildren 6–16 years of age. From a children’s perspective, it is safest if the mother abstains from social drinking during pregnancy or when planning a pregnancy, since even small to moderate doses of alcohol consumption may have an impact on fetal neurobehavioral development. • Holmgren S. Low dose alcohol exposure during pregnancy – does it harm? The Swedish National Institute of Public Health, Östersund 2009;R 2009:14

10. But an English study have total opposite results: • Children born to light drinkers were less likely to score above the cut-offs compared with children of abstinent mothers. • Children born to heavy drinkers were more likely to score above the cut-offs compared with children of abstinent mothers. • Boys born to mothers who had up to 1–2 drinks per week or per occasion were less likely to have conduct problems and hyperactivity. These effects remained in fully adjusted models. • Girls were less likely to have emotional symptoms and peer problems compared with those born to abstainers. These effects were attenuated in fully adjusted models. • Boys born to light drinkers had higher cognitive ability test scores compared with boys born to abstainers. The difference for BAS was attenuated on adjustment for socio-economic factors, whilst the difference for BSRA remained statistically significant. • Kelly Y, Sacker A, Gray R, Kelly J, Wolke D, Quigley M A. Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age? International Journal of Epidemiology 2008;1–12

11. Alcohol is a health risk in the Swedish cultureHolder, H. D., Agardh, E., Hogberg, P., Miller, T., Norstrom, T., Osterberg,. E., Ramstedt, M., Rossow., I., Stockwell, T. (2007). If Retail Alcohol Sales in Sweden were Privatized, What Would be the Potential Consequences? Stockholm, Swedish Institute of Public Health.

12. Compared to Denmark where a modest intake of alcohol is healthy • Alcohol intake at least 3 to 4 days per week is associated with a lower risk of myocardial infarction among women and men, an association apparently attributable to the relationship of alcohol with HDL cholesterol, fibrinogen, and hemoglobin A1c. Because the effects of alcohol on HDL cholesterol, fibrinogen, and insulin sensitivity have been confirmed in randomized trials, our findings support the hypothesis that the inverse relation of alcohol use and myocardial infarction is causal [5]. • Mukamal K J, Jensen M K, Gronbaek M, Stampfer M J et al. Drinking frequency, mediating biomarkers, and risk of myocardial infarction in women and men. Circulation 2005;51:112:1406-1413.

13. Also Denmark: • This study indicates that the apparent lower risk of stroke associated with moderate alcohol consumption is confined to a group of highly stressed persons. It is suggested that alcohol consumption may play a role in reducing the risk of stroke by modifying the physiological or psychological stress response [6]. • Nielsen N R, Truelsen T, Barefoot J C, Johnsen S P, Overvad K, Boysen G, Schnohr P, Gronbaek M. Is the effect of alcohol on risk of stroke confined to highly stressed persons? Neuroepidemiology 2005;29:25:105-113.

14. A study of Nordic alcohol health promotion research. Method: • The first two figures below comes from a coding of 258 abstracts with “health promotion” as a keyword, and address in one of the five Nordic countries, combined with common terms in health promotion like intersectoral, multi-disciplinary, participation and sustainable somewhere in the abstract. • The two last figures below comes from a search with “health promotion” as a keyword, and “alcohol” somewhere in the abstract, and address in 1 of the 5 Nordic countries. 164 articles were found. Those abstracts with alcohol merely as one of many health issues were sorted out. Only the “pure” alcohol articles were used for this study, the reason being that the aim was to find the different discourses specifically in Nordic alcohol research, and 36 were found. • The coding was searching for top-down or bottom-up perspectives and levels – how to attack the problem. The last study also was looking for different relevance perspectives. These could be: • 1) descriptive – no relevance was mentioned, 2) science – relevance for other researchers, 3) individual(s), 4) organisations, 5) sectors – county councils or communes, 6) Government policy, and 7) judicial – the project had relevance for coming changes of laws and authority rules

15. Perspectives in Nordic HP research (Thorpenberg, S. “Alcohol health promotion research and policy in the Nordic countries – a literature review 1986-2008”, Science Studies, vol 23, No 1, 2010)

16. Also different levels; ”how to attack the problems”

17. Small differences becomes larger when more controversial issues are studied:

18. The relevance for this research is described differently in the Nordic countries:

19. Examples: Swedish top-down • There has been a significant improvement in the rate of refusal of alcohol service at licensed premises in Stockholm during the project period. The reason for this is probably a combination of the intervention efforts: community mobilization, RBS training and a more efficient monitoring of alcohol service by authorities. • Wallin E, Gripenberg J, Andreasson S, Overserving at licensed premises in Stockholm: Effects of a community action program. Journal of Studies on Alcohol 2005;36:66:806-814

20. Danish bottom-up: • The informants monitored their own level of intoxication, but in order to reduce alcohol consumption they depended upon support from their peers. The informants preferred drinking in the company of well known and trusted peers, and during drinking episodes they supervised and intervened in each others’ drinking to the extent that they deemed it necessary and possible. In regulating the social context of drinking they relied more on their personal experiences than on formalized knowledge about alcohol and harm, which they had learned from prevention campaigns and educational programmes. Conclusions: In this study we found that teenagers may help each other to minimize alcohol related harm, and teenage peer groups should thus be considered a resource for health promotion. • Jorgensen M H, Curtis T, Christensen PH, Gronbaek M. Harm minimization among teenage drinkers: findings from an ethnographic study on teenage alcohol use in a rural Danish community. Addiction, 2007;102:4:554-559.

21. Danish policy is perhaps not as effective? • RESULTS from a Danish study: A little over 5% of the population are abstainers. Fourteen per cent of men and 9% of women are heavy drinkers; 38% of men and 18% of women are heavy episodic drinkers. Youth of both sexes drink heavily, and especially in a binge drinking style. Regular, more temperate drinking is associated with increasing age. Multivariate analyses suggest that other than age and sex, classical socioeconomic factors do not play a great a role in determining drinking patterns. Social integrative factors in particular influence women's drinking. • CONCLUSIONS: With respect to the rest of Europe and North America, Danes consume high levels of alcohol with a large percentage of youth drinking in a binge pattern. Classical socioeconomic factors play a lesser role in determining drinking patterns compared to other Western countries. Longitudinal studies and studies of alcohol-related consequences in the Danish general population should be conducted to better formulate alcohol and public health policy. • Bloomfield K, Grittner U, Rasmussen HB, Petersen HC. Socio-demographic correlates of alcohol consumption in the Danish generalpopulation. Scand J Public Health. 2008 Aug;36(6):580-8.

22. Neither is the Swedish? • The current Swedish national plan for preventing alcohol consumption-related problems puts greater emphasis on community-level prevention measures. • Findings indicated that community alcohol consumption prevention has been strengthened and that the activity level is high in all municipalities, especially in relation to youth. • However, problematic alcoholic beverage consumption by adults was rarely targeted; the limited resources were dispersed over too many projects; there was too little collaboration between stakeholding authorities and adherence to evidence-based practice still is lacking. • Spak F, Blanck P. Implementing a national alcohol consumption prevention program at the locallevel: what does early evaluation tell us? Subst Use Misuse. 2007;42(12-13):2063-72

23. Policy differences not only in the Nordic countries: UK • ”General price increases on alcohol were effective for reduction of consumption, health-care costs, and health-related quality of life losses in all population subgroups. Minimum pricing policies can maintain this level of effectiveness for harmful drinkers while reducing effects on consumer spending for moderate drinkers. Total bans of supermarket and off-license discounting are effective but banning only large discounts has little effect. Young adult drinkers aged 18-24 years are especially affected by policies that raise prices in pubs and bars.” (1) • (1) Purshouse RC, Meier PS, Brennan A, Taylor KB, Rafia R. ”Estimated effect of alcohol pricing policies on health and health economicoutcomes in England: an epidemiological model”. Lancet. 2010 Apr 17;375(9723):1355-64

24. But this policy has an ethical dilemma: UK • Walker (2010) has criticized the policy of putting a minimum price on alcohol, and pointed to the ethical problem that it means that the cheapest alcohol will be more expensive, i.e. that which is consumed by people with lower economical status. The policy will affect these people more than people from the middle classes, even if alcohol related problem can be found in all social classes. [1] • [1] Walker, T, “Why We Should Not Set a Minimum Price per Unit of Alcohol”, Public Health Ethics Vol 3, No 2, 2010, pp. 107–114

25. Is social marketing effective? USA • Evaluation of awareness (recall) of the National YouthAnti-Drug Media Campaign (NYADMC) benefited youth by attenuating their drug use: • ”Overall early levels of campaign awareness had a limited influence on rates of growth, and in a few cases higher levels were associated with quicker acquisition of drug use behaviors. When they were younger, these youth accelerated their drug use and reported increasing amounts of campaign awareness. • (BUT:) When they were older, increasing awareness was associated with declines in binge drinking and cigarette smoking. No effects for marijuana were significant but trended in the direction of increased awareness associated with declining drug use. The findings are discussed in terms of how they depart from previous reports of campaign efficacy and the potential efficacy of social marketing campaigns to reach a large and impressionable youthful audience with strategically placed advertisements. • Scheier LM, Grenard JL. Influence of a nationwide social marketing campaign on adolescent drug use. J Health Commun. 2010 Apr;15(3):240-71

26. Australian top-down To reach the ”goal of reshaping Australia's drinking culture to produce healthier and safer outcomes”: The optimal package of interventions identified in the study comprises, in order of cost effectiveness, • volumetric taxation, • advertising bans, • an increase in the minimum legal drinking age to 21 years, • brief intervention by primary care practitioners, licensing controls, a drink-driving mass media campaign, and • random breath testing. Australia has a window of opportunity to significantly expand activities to reduce alcohol-related harm. It is important that federal and state governments take this opportunity to reform alcohol policy in Australia. Doran CM, Hall WD, Shakeshaft AP, Vos T, Cobiac LJ. Alcohol policy reform in Australia: what can we learn from the evidence? Med J Aust. 2010 Apr 19;192(8):468-70

27. Can be compared to Australian social marketing:"Is Getting Pissed Getting Pathetic? (Just Ask Your Friends)" Six hundred and seventy one university students (51% females), who had seen the campaign posters, with the tagline "Is Getting Pissed Getting Pathetic? (Just Ask Your Friends)", were asked to comment on the messages that the campaign was communicating and how informative, relevant, and effective they perceived the campaign. Many students were positive in their evaluations and described the messages as "truth and realistic", "clear and to the point", and that the campaign made them think about their own drinking. However, other views were more negative and indicative of psychological reactance. These included concerns that students "won't listen" or "don't care" about media campaigns, and that "they don't what to be told what to do". The findings highlight how media campaigns can help an audience contemplate behavioral change, however, they can also alienate students and promote counterproductive attitudes. Ricciardelli LA, McCabe MP. University students' perceptions of the alcohol campaign: "Is Getting Pissed Getting Pathetic? (Just Ask Your Friends)". Addict Behav. 2008 Feb;33(2):366-72

28. Why the differences between the Nordic countries? • A stronger liberal tradition in Denmark • And more socialdemocratic tradition in Sweden • (that seems at least to be a quite popular interpretation among ordinary people?) • Vallgårda has spoken about some differences already seen in new policy documents, and perhaps things can change quite rapidly?

29. Problem for health promotion research: • The idea of empowerment and bottom-up seems to be difficult to introduce in a top-down culture • And a top-down perspective in a bottom-up culture have probably the same difficulties? • Will produce problems in research financing for controversial projects?

30. Still important to involve people in bottom-up oriented work: • Individuals and organisations can make a difference with peer-to-peer teaching • Important to have a realist view on the problem, young people will test alcohol, but they will not tell us – if it is forbidden • So it is important to teach HOW to drink and WHAT to drink, not only to generally prohibit it • A more cultural approach to alcohol: wine is better than vodka, and getting pissed should be pathetic.