Public Health Getting back to basics Education for Health is an independent education and research charity for health professionals. Educational programmes are run nationally and internationally and are accredited by the Open University. This workshop presentation has been adapted from the Improving Health diploma level module designed by Education For Health. (Find out more about Improving Health at: http://www.educationforhealth.org/courses/44 ) It explores some of the theories and tools which can applied in order to set up an effective public health improvement initiative. Notes have been included to assist the facilitator with presentation.

The process of enabling people to increase control over the determinants of health and thereby improve their health This is the WHO definition of improving health and health promotion. You may want to explore the thoughts of your group to understand their perceptions of health improvement. WHO 1986

Tannahill’s model Health education protection Prevention Downie 1990 Tannahill’s model describes the different aspects of health promotion. Health promotion is pictured as three overlapping circles of activity. These circles identify the major functions of Public Health. Health Education is communication aimed at preventing ill health and enhancing well-being. Knowledge is increased, and beliefs and attitudes influenced in favour of healthy behaviour. Health Protection includes policies, codes of practice and laws aimed at preventing ill health. It can be undertaken at various levels (national, legislative, fiscal, local / community, individual). Prevention involves specific interventions aimed at avoiding contact with disease producing risk factors, or reducing the harmful consequences of the disease process.

Cervical cancer Use of condoms Cervical HPV Vaccination screening This Cervical Cancer slide demonstrates how Tannahill’s model can be implemented to address a Public Health issue.

Cardiovascular disease Change 4 Life Smoking Ban Fruit in schools This slide gives a further demonstration of applying Tannahill’s Model. This time towards addressing Cardiovascular Disease.

Beattie’s model (1991) Health persuasion Legislative action Authoritative Health persuasion Individual Legislative action Collective Personal counselling Negotiated Community development The Beattie Model allows us to map and evaluate different approaches to health promotion. It is divided into two dimensions (top and bottom) with two boxes (paradigms) in each dimension. Each paradigm contains a description of different approaches that are delivered in an authoritarian ‘top down’ fashion: health persuasion and legislative action. The two paradigms in the bottom dimension describe ‘bottom up’ approaches: personal counselling and community development. The ‘top down’ approaches aim to inform about unhealthy behaviours and risk, or to impose change at national level. The aim of the ‘bottom up’ approaches is to empower individuals and / or communities to make healthier choices. Beattie’s model fits well with the current political climate; increasingly active communities bring about sustainable changes to reduce health inequalities. Real improvements are likely to occur with a ‘bottom up’ approach.

What happens in your workplace? What opportunities does your group have within their workplace to promote health and well being? You may find it useful to discuss and share this, either as a whole group, or smaller groups of perhaps two or three.

How do we make health choices? What influences those ‘choices’? Health choices will be influenced by perceptions / beliefs / cues to action / self efficacy. The next slide goes on to develop this

Health belief model Janz and Becker 1984 To act, we need to believe We are at risk The problem can be serious We can reduce the risk The costs of action are outweighed by the benefits We also need to be prompted, and be confident in our ability The Health Belief Model was one of the first theories about health behaviour. It was proposed in 1966 and has been further developed and adapted over the years, Its basis is that in order to act to prevent or control an illness we need to believe the following: We are at risk (perceived susceptibility) That the problem has serious consequences (perceived severity) We can reduce the risk, or reduce the severity of the illness by taking action (perceived benefits) The costs of the action (perceived barriers) are outweighed by the benefits; i.e. the action needed to control or prevent illness is not worse that the disease. In addition we need to be: Exposed to something that prompts us to take action (e.g. something in the media, a reminder from the doctor or nurse) (cue to action) Confident in our ability to act (self- efficacy)

Can you think of examples? HPV vaccination? NHS Health Checks? Excessive alcohol? Lack of exercise? Explore this with a group discussion

Theory of reasoned action and theory of planned behaviour Costs/benefit calculation Normative beliefs Motivation to comply Beliefs about control Perceived power behaviour Attitude toward behaviour Subjective norm Perceived behavioural control Behavioural intention Behaviour (Fishbein and Ajzen, 1975; Ajzen, 1985) The theory of reasoned action rests on the idea that personal attitudes and social pressures shape an individual’s behaviour and intention to change (or not). It examines the relationships between behaviour (demonstrated on the slide in the green boxes) and beliefs (demonstrated on the slide in the pink boxes), and attitudes and intentions. Behavioural Intention: This is the person’s perception of how likely they are to perform a behaviour. Attitude: This refers to that individual’s personal evaluation of the behaviour; whether they see it as good, bad or neutral. Subjective Norm: These are the beliefs about attitudes of key people in their lives and whether they would approve or disapprove. Most people are motivated to behave in a way that gains approval, so motivation to comply comes from a subjective norm. The theory of planned behaviour is an extension of the theory of reasoned action and they are usually looked at in combination. It includes a further dimension: Perceived Behavioural Control: This has to do with the person’s beliefs that they can control a particular behaviour or change; whether they feel that their behaviour is up to them or not.

What are the pressures? Confidence Family Peers Work Media Use this slide to open up a group discussion to share examples of pressures.

Stages of Change Model Stages of Change Model (Prochaska and DiClimente, 1983) The basis of this model is that change is a cyclical process, not an event. Individuals who are making a change, e.g. stopping smoking, losing weight, taking up exercise etc. move through five stages before the behaviour change becomes fixed and established. People do not progress systematically through all these stages, and the speed at which they move around the cycle is individual. The only stage that is not re-visited is pre-contemplation. Contemplation can last for many years. For example, the majority of smokers say they would like to stop (contemplation) but fewer are actually making concrete plans or have seriously thought about stopping in the next six months (preparation). People may go through this process repeatedly. Understanding the stage that people are at can help you tailor the kind of help and information you offer to the most appropriate time, when it is likely to be of the most use. education for health

Working in communities What works? Community development works at different levels.; on individuals, in communities and on organisations and the structure of society.

Community development Disempowered community Needs assessment and problem recognition Establishment of tenants/residents associations Regeneration of community spirit/social capital Multi-agency awareness raising meeting Identify and recruit key community members Inform community (newsletter, local media, personal contact, door to door) Community engagement Health improvement Community identifies problem (with key agencies) Community forums (listening meetings in local, inviting venue) Contact Strategy Intervention Outcome The most important feature of any community development project is that it is a ‘bottom up’ approach (refer back to the Beattie model described earlier). Involving the community and implementing this ‘bottom-up’ approach can be difficult and time consuming, but is essential if a project is to work. For example, a community development project is NOT the local authority sending council workers into an area to paint a community centre and plant some flowers. A community development project is when the residents get together, decide that a coat of paint and some flowers are a priority, and then organise how this is to be achieved (lobbying the local authority to do it, or getting a group of residents together to tackle the job themselves). The model demonstrated here looks at the process of project development as a flow diagram.

Health improvement planning Identify problem Identify needs – health needs assessment Aims Goals Objectives Evidence base Plan content and methods of programme Action – carry out programme Evaluate Identify resources Identify Problem: Problems may be identified by professionals working with a target population, or in a particular area. Problems can also be highlighted by comparing local and national statistics Identify Needs / Health Needs Assessment: This is an essential first step in order to identify the target group, clarify the problem and recognise the current assets available to deal with it. Aims are statements of intent; what you want to do Goals: Once you have stated your aim, you then need to think about the goals of the project. Objectives are the specific activities you will undertake to achieve your aims and reach your stated targets; what you are actually going to do. Evidence Base: There are many bases to source evidence for the effectiveness of public health interventions. Two examples are NICE (http://www,nice.org.uk) and the Department of Health (http://www.dh.gov.uk/en/Publichealth/index.htm) Plan: When planning the project the first task is to identify the need that the programme will address. Then you will need to think about which individuals and organisations will have an interest in what you propose to do; who are the stakeholders? You will then need to consider what they can contribute and how you can engage them and motivate them to become actively involved. A collaborative project team needs to be built up. The team needs to develop a shared understanding of what the programme is aiming to achieve. The programme’s activities and ‘milestones’ then need to be planned. Responsibilities for various tasks needs to be assigned, and planning in place for monitoring and evaluation. Identify Resources: Even the smallest project requires resources and will need identification around the following: Money, Space, Paper, Printing / Design, Media / Advertising, Partners, Time. Action / Implementation: The activities identified in the planning stage can now begin. It is very important to monitor how each activity is progressing. Evaluation is vital. The evidence base for many public health interventions is small. The only way that this will improve is if people planning and undertaking health improvement programmes discover what worked, evaluate how well and make their results available to others. Call to Action: ‘Effective universal and targeted preventive interventions can bring important benefits.’ Fair Society, Healthy Lives The Marmot Review 2010 Discuss with your group how, with the application of the tools covered in this presentation, they may assist with addressing this important strategy.