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Organizing the fight againstcardiovascular disease in Tangshan
and in the Netherlands: the role of health promotion
By Corinne Hinlopen, M.Sc., MPHNetherlands Heart Foundation
10 March 2008
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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.
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Short history of health education and health promotion (past 40-50 years)
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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
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Short history of health education and health promotion (past 40-50 years)
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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)
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Short history of health education and health promotion (past 40-50 years)
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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.
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Behavioral determinants (examples) 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”
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Environmental determinants (examples)
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
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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)
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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
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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)
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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
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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
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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
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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
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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
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Example of nutrition message: “EAT HEALTHY”
1. Variation 2. Not too much 3. Less saturated fat 4. Lots of vegetables,
fruit & bread 5. Safe
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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.
Planning health promotion interventions:
common features (6)
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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
Planning health promotion interventions:
common features (7)
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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
Planning health promotion interventions:
partners & strategic alliances
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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
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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.
