Organizing the fight against cardiovascular disease in Tangshan and in the Netherlands : the role of health promotion

1. Organizing the fight againstcardiovascular disease in Tangshan and in the Netherlands: the role of health promotion By Corinne Hinlopen, M.Sc., MPH Netherlands Heart Foundation 10 March 2008

2. Question: how healthy are we? How come we are (un-)healthy? • Determinants of health (Lalonde, 1981): • Health & well-being are influenced by: • Human biology: genes, age, congenital malformations • Environment: external factors in the social, natural, economic, political, cultural environment • Lifestyle: smoking, nutrition, physical activity, etc. • Health care organisation: availability of & accessibility to doctors, hospitals, insurance schemes, etc.

3. Short history of health education and health promotion (past 40-50 years)1 • The ultimate goal of health education is behavior change. • “transfer of knowledge leads to behavior change” • > false assumption • “awareness in the target group, together with knowledge transfer, leads to behavior change” • > false assumption • “influencing attitudes towards the desired behavior change plus awareness raising and transfer of knowledge leads to behavior change” • > false assumption

4. Short history of health education and health promotion (past 40-50 years)2 • More behavioral research was done. • More, and more complex, models for explaining behavior were developed, such as: • Theory of Planned Behavior(e.g. Ajzen & Fishbein, 1980) • Social learning (Bandura, 1986) • Health Belief Model(e.g. in Glanz, 1997) • Stages of change model (Prochaska & DiClemente, 1984) • ASE-model(De Vries et al., 1987)

5. Short history of health education and health promotion (past 40-50 years)3 Two most important lessons: • 1) Health education alone seldom leads to behavior change: there are other behavioral determinants to consider. • 2) Behavior of individuals does not develop in a vacuum, there are always environmental factors to consider.

6. Awareness Knowledge Personal relevance Skills Self-efficacy Beliefs & values Social norms Social support Role models “A healthy lifestyle has nothing to do with heart disease” “A 10-minute bicycle ride every day is enough” “I don’t need to change my lifestyle, but my neighbor does!” “I don’t know how to ride a bike” “I don’t have time, so I won’t even try” “My family will think I’m a fool” “Sweat is dirty” “Nobody rides a bike to work, so I won’t, either” “My doctor smokes - if he can’t quit, I certainly can’t” Behavioral determinants (examples)

7. Price, income level Availabilityof “healthy choices” Insurance schemes or subsidies Health care organisation Availability of trained doctors & nurses Rules & regulations Fruit, vegetables, fish are too expensive;sports facilities are too expensive; Fruits, vegetables, fish are not availablethere are no safe roads or hiking trails Health insurance does not pay for lifestyle counseling/support There is no agreement on ‘who does what’ in health care, esp. regarding lifestyle counseling There are no trained ‘lifestyle advisors’ to support smoking cessation Prohibition of smoking; of selling sodas in schools; of starting a fastfoodshop within 500 meters of a school Environmental determinants (examples)

8. From health education to health promotion • With the realisation that health-related behavior is not just a matter of education or re-education, the concept of health education was replaced by the concept of health promotion. • Health promotion is defined as: • "any combination of educational, organizational, economic and environmental supports for behavior and conditions of living conducive to health." (Green, Prevention and Health Education, 1992)

9. Health promotion interventions • In order to change behavior, interventions are developed & tested that address one or (usually: more) determinants of behavior • Since behavior is complex and has several determinants, we need to: • Define, through research, which determinants are obstructing behavior change • Establish which determinants can be changed • Make choices regarding the determinants to tackle in an intervention

10. Planning health promotion interventions • Several methodologies have been developed to facilitate the intervention planning process and to support decision making • Examples: • Intervention Mapping (Bartholomew et al., 2006) • PRECEDE/PROCEED (in: Green & Kreuter, 2005)

11. Planning health promotion interventions:common features (1) • Defining the target group • In which (sub-)population(s) does the problem occur most? Where do we expect most health gain from our intervention? • Health inequalities are a powerful argument for choosing a certain target group • Most health gain to be expected • But: difficult to achieve • Example from the Netherlands Heart Foundation • First generation Turkish immigrants (especially men), in Rotterdam

12. Planning health promotion interventions:common features (2) • Defining the health-related problem • In terms of: mortality, morbidity, quality of life • Example from the Netherlands Heart Foundation • First generation Turkish immigrants (especially men), in Rotterdam • High prevalence of CVD

13. Planning health promotion interventions:common features (3) • Defining the causes of the problem • In terms of: behavior/lifestyle, prevalence of risk factors, health care organisation, social/cultural factors, economic factors • Example from the Netherlands Heart Foundation • First generation Turkish immigrants (especially men), in Rotterdam • High prevalence of CVD • High prevalence of smoking, hypertension • No habit of physical activity • Cultural mismatch between Dutch doctors & Turkish patients • Lower income levels, stress

14. Planning health promotion interventions:common features (4) • Defining the goal of the intervention • First question to ask: which of the causes can be influenced (by us)? • Other considerations: • Effectiveness (learn from others!) • Cost • Feasibility

15. Planning health promotion interventions:common features (5) • Defining the strategy of the intervention • 1: influencing behavior • Mass media campaign to raise awareness about a specific problem • Feedback instruments to increase personal relevance: tools that make people realise that they themselves are at risk • Organise courses or events that help people learn ‘how to’ (skills) (supermarket tours; wok demonstrations) • Find a role model to set the social norm (doctors, famous persons, sportsmen/-women) • Organise support for behavior change (patient groups, personal coaching) • Develop simple & effective messages (scientifically sound!) that improve knowledge level

16. Example of nutrition message: “EAT HEALTHY” • 1. Variation • 2. Not too much • 3. Less saturated fat • 4. Lots of vegetables, fruit & bread • 5. Safe

17. Planning health promotion interventions:common features (6) • Defining the strategy of the intervention • 2: influencing the (social, physical, economic) environment of individuals. Examples: • Pricing policy in workplace cafeterias • Subsidise ‘Schoolfruit’, ‘Workfruit’ • Raise price of tobacco • Ban tobacco in public places (work place, trains, restaurants) • Ban sodas (Coca Cola, etc.) in schools • Traffic safety • Physical activity for the underprivileged (“Prescription exercise”) in health insurance coverage • Insurance covers smoking cessation support • Fitness equipment in public places • Fat & salt content in ready-to-go meals & fast food • Etcetera, etcetera.

18. Planning health promotion interventions:common features (7) • Look for partners & strategic alliances… • …for money, co-operation • Family doctors, hospital staff (screening; lifestyle coaching; education) • Ministry (subsidies; endorsement) • Tv, radio, magazines • Public personalities (role models) • Retail industry (promotional activities) • Restaurants & fastfood companies (healthier menus) • Food industry (composition of foodstuffs: esp. fat & salt & fibre content) • Insurance companies • Welfare groups, ngo’s

19. Planning health promotion interventions:partners & strategic alliances • Appeal to a higher, shared goal • Make clear what the problem is • Explain what they could do to help solve the problem.. • …. And what they would gain by helping! Investing in partnerships requires a lot of lobby-work and a long breath

20. Health promotion interventions:important to remember Effective health promotion is: • Multifactorial: • There are usually multiple factors that contribute to health problems • Multi-strategy: • There is no single intervention to solve the problem: • an intervention mix is more effective than a one-dimensional approach • Multi-sectoral • Partners from various sectors are needed • Sustainable • Time and continuity is needed

21. Thank you! • The hosts of this conference • The organisers of this conference • The audience • Fellow health promotors in the Netherlands, from The Netherlands Heart Foundation, The Netherlands Insititute for Sport & Physical Activity, The Nutrition Centre, etc.