Health Promotion Interventions for beginners… and for those who’ve been there and got the T-Shirt

1. Health Promotion Interventionsfor beginners… and for those who’ve been there and got the T-Shirt Kathy Cobain, Amanda Drakeley & Beck Taylor 4th July 2012

2. Agenda for today: 0930 Introduction & overview 0950 PART 1: What is health promotion? 1020 Break 1030 PART 2: The role of theory and evidence in health promotion 1100 PART 3: Approaches to health promotion 1200 Lunch 1245 PART 4: Implementing a health promotion intervention in the real world: a practical exercise and post-mortem (coffee to be taken during this time) 1430 PART 5: Reflective practice 1500 Close

3. Introduction and overview

4. Aim of today: To deliver a session on health promotion to allow novices to the areas to learn the fundamentals but for experienced practitioners in this area to be able to discuss, reflect and evaluate their current practice.

5. Learning outcomes: By the end of this masterclass the practitioner should be able to: • Understand key points in history • Understand key terms • Discuss of the role of, and how to find and use health promotion theories/models • Understand importance of evidence and policy • Describe the different approaches to health promotion • Consider design, planning, barriers, monitoring and evaluation • Understand realities of implementing health promotion

6. The pre-masterclass survey • We decided to send out the pre-masterclass survey to gain an understanding of who we would have in attendance, particularly: • Knowledge about health promotion • Qualifications in health promotion • Experience in delivering health promotion • Current job role in relation to health promotion • Sent to 39 proposed attendees. • Response of n = 22 (56% response rate) The results are as follows…

7. Knowledge:

8. Qualifications:

9. Experience:

10. Current job role:

11. Tobacco Control Co-ordinator Senior Health Improvement Specialist Health Development Officer Environmental Health Officer Public Health Epidemiologist Health Intelligence Analyst Health Check Co-ordinator Health Improvement Practitioner Specialist Health Trainer Health & Wellbeing Strategy Officer Falls Management Lead Health Information & Social Marketing Officer Specialist Stop Smoking Advisor in Pregnancy Breastfeeding Support Coordinator Public Health Adviser Health Improvement Worker – Smoking Cessation Lifestyle risk implementation Manager A range of roles…

12. So that’s all of you…. But what about us?

13. Kathy • Specialty Registrar in Public Health, Year 2 based at Worcester PCT. • Previous experience: • Clinical Nurse Specialist Drug and Alcohol • PhD "Alcohol Treatment in the NHS: Challenging the Paradigm” • involved in a national alcohol needs assessment for the DH • Research Fellow Public Health and Primary Care (NHS and University) • BSc Psychology & MSc Health Psychology

14. Amanda • Specialty Registrar in Public Health, Year 4 based at Staffordshire Public Health. • Previous experience in planning, developing and implementing health promotion initiatives: • Walking for Health Scheme • Exercise on referral programme • “Sport Relief” events • “Fruity Friday” campaigns • No smoking day events • Community health fairs, etc.

15. Beck • Clinical Research Fellow in Public Health, based at Birmingham University (having completed the public health training scheme). • Current experience: • Working on a PhD (lay health worker interventions). • Research interests include health inequalities, lay worker interventions, policy evaluation and the role of theory in public health. • The use of realisticevaluation and its application in complex interventions (Health Trainers).

16. So, in summary… This health promotion masterclass is about: Understanding the fundamentals Exploring further Sharing, reflecting on and evaluating your own practice And why is this relevant to you? In public health roles, you may need to: Develop your own idea Project manage local implementation Advise on how to develop/implement Assess the evidence for an ‘evidence based’ intervention Decide whether or not to fund an intervention

17. PART 1 - Agenda Learning Outcome 1: Understand the key points in the history and evolution of health promotion (including the relationship between health education and health improvement). Learning Outcome 2: Understand the key terms around health promotion What is health promotion? • A brief history & the Ottawa Charter • Understanding health • Factors that influence health • Inequalities in health • Group work task

18. The “old” public health • In the 19th century: • Most histories of public health begin with this “sanitation phase” • a period characterised by environmental issues such as housing, working conditions, supply of clean water and safe disposal of waste. Reduction in infectious diseases

19. The rise of health education • In the early 20th century: a second phase known as the “Personal hygiene era”. • Prevention is better than cure! • Local authorities extended services beyond preventing disease to improving health through health education. • Examples: • School children were taught hygiene principles (i.e. teeth brushing) • Parents (mothers) were taught hygiene, nutrition and childcare in the home (through home visiting). • Central Council for Health Education was first established in 1927 – financed by local authority public health departments. • Health Education Council created in England 1968 as an Non Government Organisation. • Create a climate of opinion generally favourable to health educ. • Develop blanket programmes of education and (target) selected priority subjects.

20. The health promotion movement By the mid-1980s: it became wider acknowledged that effective health education involved making healthier choices easier: • Proposing a wider agenda which involved modifying circumstances, environment and policy to become more “health promoting”. • So people had opportunities to choose a healthier lifestyle. • Recognised that people’s capacity to take action was limited by environmental / social circumstances. The first International Conference on Health Promotion was held in Ottawa on November 21, 1986. It was at this conference that The Ottawa Charter for Health Promotion was adopted.

21. The Ottawa Charter (WHO 1986) The Ottawa Charter for Health Promotion provided a further impetus to an emerging modern health promotion movement. Definition: “Health promotion is the process of enabling people to increase control over, and to improve their health”. Ottawa Charter for Health Promotion. WHO, Geneva,1986 Over the last 25 years, the Ottawa Charter has been highly influential, constant point of reference for those involved in promoting health: http://www.who.int/healthpromotion/en/

22. Health Promotion Emblem It identified: 3 basic strategies: "enabling, mediating, and advocacy” 5 key themes: • Build healthy public policy • Create supportive environments • Strengthen community action • Develop personal skills • Reorientation of health services Logo visualises the idea that health promotion is a comprehensive multi-strategy approach

23. Understanding health? In order to fully understand health we should consider the following two questions: • How should health be defined? • Why is defining it so important when promoting public health?

24. Definitions of health • Health as “absence of disease” • Medical model of health • Can be traced back as far as the ancient Greeks • Health as “well being” Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO 1948) • Health as “a resource” Health is a resource for everyday life, not the object of living. It is a positive concept emphasizing social and personal resources as well as physical capabilities (Ottawa Charter for Health Promotion. WHO, Geneva, 1986)

25. The WHO definition of health as “complete wellbeing” is no longer fit for purpose given the rise of chronic disease. Huber and colleaguespropose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges… BMJ 2011;343:d4163 doi: 10.1136/bmj.d4163 A new definition? (June 2011)

26. Why is defining health so important? The answer?: The way in which people think about health and well being influences their health behaviours. Hughner & Kleine (2004). Thus in order to effectively promote health, we need to interrogate its meaning (UKPHR indicator 5e)to: Individuals An individual’s perspective and expectation of health is highly fluid and interchangeable (depending on both their characteristics and experiences) • Lay concepts of health • Young Vs old • Women Vs men • Lower socioeconomic groups Societal / Cultural • Health & illness influenced by magic / witch craft, fatness seen as healthy, etc.

27. Factors that influence health The factors which influence health are: • multiple and interactive • both within and outside an individual’s control • modifiable or non-modifiable Health promotion is fundamentally concerned with action and advocacy to address the full range of potentially modifiable determinants of health: • not only those which are related to the actions of individuals (health behaviours and lifestyles) • but also factors such education, employment and working conditions and the physical environments. Non-modifiable determinants of health: • biology and genetics.

28. “Seeing the bigger picture” • Wider determinants of health: an influential framework by Dahlgren and Whitehead (1991) (UKPHR indicator 5b)

29. Dahlgren and Whitehead (1991) Illustration of the wider determinants of health, identifying layers which influence health from individual to societal to global. Used to flag inequalities in health, identifying socio-economic, cultural and environmental factors which affect health. Identifies the need for structural interventions to impact on the causes.

30. Social Determinants of Health • The social determinants of health “are the conditions in which people are born, grow, live, work and age, including the health system”. • These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. • Healthy public policy = “characterized by an explicit concern for health and equity in all areas of policy, and by an accountability for health impact. The main aim…to create a supportive environmentto enable people to lead healthy lives…makes healthy choices possible or easier. It makes social and physical environments health enhancing”. (WHO Health Promotion Glossary) • The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.

31. Inequalities in health • What are health inequalities? • Examples of ways of measuring inequalities: • Individual level • Area level • Explanations for inequalities? • UKPHR indicator 5d

32. What are health inequalities? • Inequality: unequal “differences in health status, or in the distribution of health determinants, between different population groups”. • Deprivation: a relative and broad concept, referring to not having something that others have. “a state of …observable and demonstrable disadvantage relative to the local community or the wider society or nation to which an individual, family or group belong.” (Townsend, 1987). • Inequality Vs Inequity

33. Measuring inequalities • Individual level: socio-economic position Education, occupation, social class, employment status, income, access to amenities, housing, etc. • Ecological/Area level: deprivation Townsend, Carstairs, Jarman, Indices of Deprivation 2010, etc.

34. The Indices of Deprivation 2010 (ID2010) is the 3rd release in a series of statistics produced to measure multiple forms of deprivation at the small spatial scale. Updates the Indices of Deprivation 2007 and 2004 retaining broadly the same methodology, domains and indicators 145 pages later…. http://www.communities.gov.uk/pu blications/corporate/statistics/indic es2010technicalreport If you’re really keen…

35. Explanations for inequalities? Artefact • Artefact, biases and changes in the way the statistics are produced. Social factors • Social selection • Stressors & coping capacity Behaviour • Lifestyle factors Material circumstances • Poverty • Poor environments

36. TASK 1:Understand the key terms around health promotion Mapping of the World Health Organisation (WHO) Health Promotion Glossary of key terms. This Health Promotion Glossary was prepared on behalf of WHO by Don Nutbeam. Includes both basic and an extended list of 54 terms which are commonly used in health promotion. (UKPHR indicator 5c) FIND THIS GLOSSARY AT: http://www.who.int/healthpromotion/about/HPG/en/

37. Time for a short break…

38. PART 2 - Agenda Learning Outcome 3: Discuss the role of theories and models of health and health promotion, and understand how to find and use them. Learning Outcome 4: Understand the importance of evidence and policy and its impact of health promotion. The role of theory and evidence in health promotion • What is theory / different types • Theoretical perspectives / using theories in context • The role of evidence • Group work task

39. What is theory? The ‘journey’ from A to Z, or ‘present state to health improvement’ Not just one step or academic theory, e.g. “We used the transtheoretical model”. Purpose: so that everybody understands it You and your team, commissioner, client, wider PH etc. Success in implementation can be measured It can be replicated and adapted by you and others Ask yourself: What are you trying to do? How is it supposed to work? What needs to be in place for it to work?

40. Types of theory Management and business Psychology and behaviour Communications Community / social And many, many others… Several theories (or none?) can be used to build your own intervention’s theoretical pathway.

41. Today isn’t about us teaching you all the different health promotion theories or models… For further reading: this book is recommended. A very useful introduction to health promotion theory

42. Theoretical perspectives? • Is it possible to promote public health successfully without an understanding of some of the theoretical, conceptual or research issues than underpin public health practice? • The answer is probably yes. • However, to promote health effectively, practice should be underpinned by relevant knowledge (theoretical, conceptual, methodological) AND appropriate skills AND…

43. Depending on the context! • When promoting health, practitioners may draw from the many theories and models from different disciplines, depending on their focus. • Theories and models can be categorised in a variety of ways, but the key to ensure those chosen are appropriate to the task. • Therefore, match theory to the task and context.

44. Why re-invent the wheel? • Finding and using promising and evidence based practices, as well as models and tools developed by others, is an important way to learn from one another as we strive to deliver the most effective initiatives possible • Increasingly, we are able to base health promotion decisions and interventions on evidence. This involves using information derived from formal research, and program evaluation. • Thus our evidence base for health promotion could draw from theory / models, research and practice.

45. The role of evidence We live in an ‘evidence-based’ world. Several steps: Find it: know how to use resources (or who to ask) Appraise quality: is it any good? Appraise results: is it effective? Appraise relevance: is it important to me? Can it be applied locally? Problems with HP evidence: Often ‘grey’ – ask the experts Often pragmatic / ‘low quality’ Often complex and specific

46. Lessons learned from practice It isn’t ‘evidence based’ if your evidence only explains some of it. Understand context of intervention: will this work with my population/organisation? Some things with no evidence may still be worth doing – this is hard to explain to commissioners!

47. TASK 2:Matching evidence to the task and context • Working with your table as a group. • You will be given a health promotion topic / setting: • Alcohol abuse • Teenage Pregnancy • Breast screening (increasing uptake) • Workplace • Breastfeeding peer support service • Cardiac Rehabilitation

48. Task 2 (continued) In 15 minutes, discuss in your group how you would: • Define the intervention • Find evidence to design and implement it • Would you use research, best practice, real-world evaluations, theories/models, etc… • Use the evidence that you find • Identify any strengths and weaknesses. • Would the evidence actually be usefulin practice? • Prepare 1-2 minutes feedback for the whole group • Describe how you have gone about the task for your topic / setting.

49. PART 3 - Agenda Learning Outcome 5: Describe the different approaches to health promotion. Approaches to health promotion • Discussion: experiences in health promotion • National policy and its impact on heath promotion • Different health promotion approaches • Group work task

50. What kinds of experiences do you have of doing health promotion (or health education or health improvement) with citizens in local communities?