Health Promotion in schools, the workplace and the community

Health Promotion in schools, the workplace and the community
Health Psychology

Schools

Walter et al., 1985 Some school programs have been effective. An experiment in 22 elementary schools introduced a carefully designed curriculum with emphasis on nutrition and physical fitness (Walter et al., 1985). The schools were randomly assigned so that their students either participated in the program or served as a control group.

Walter et al., 1985 The researchers compared the two groups after a year. Relative to the control subjects, the children who participated in the program showed improvements in their blood pressure and cholesterol levels.

Edwards and Hartwell (2002)
Edwards and Hartwell (2002) investigated whether children, aged 8-11 years could correctly identify commonly available fruit and vegetables; to assess the acceptability of these; and to gain a broad understanding of children's perceptions of 'healthy eating'. Fruit and vegetables used were those readily available in retail outlets in the UK.

Data were collected from 221 children using a questionnaire supported by semistructured interviews and discussions. Overall, fruit was more popular than vegetables and recognition of fruit better; melons being the least well identified.

Recognition of vegetables increased with age; the least well identified being cabbage which was confused with lettuce by 32, 16 and 17% of pupils in their respective age groups. Most children (75%) were familiar with the term healthy eating, citing school (46%) as the most common source of information.

Pupils showed an awareness and understanding of current recommendations for a balanced diet, although the message has become confused. If fresh fruit and vegetables are to form part of a balanced diet, the 'health message' needs to be clear.

Fruit is well liked; vegetables are less acceptable with many being poorly recognized, factors which need to be addressed.

Parcel, Bruhn, & Cerreto, 1986 Another study found that more children practiced safety behaviour if they were taught about health and safety in a 4- year program than if they were not (Parcel, Bruhn, & Cerreto, 1986).

Kolbe & Iverson, 1984 But many schools do not provide health education at all, or their programs are under funded, poorly designed, and taught by teachers whose interests and training are in other areas (Kolbe & Iverson, 1984).

Coates et al. (1985) Coates et al. (1985) examined the effectiveness of a 4-week school-based intervention for decreasing consumption of salty snack foods and increasing consumption of “heart healthy” snacks among African American adolescents.

Coates et al. (1985) One hundred fifty-four students from one high school received the treatment program, whereas 130 students from another high school served as the no- treatment control group. The program incorporated parental involvement, a school wide media program, and a classroom instruction program.

Coates et al. (1985) The classroom instruction program included setting written goals for substituting heart-healthy snacks for salty snacks. The treatment program was effective in producing reductions in salty snack foods, however, long-term changes were only significant for students who participated in the classroom instruction program that incorporated written objectives.

Bush et al. (1989) Relatedly, Bush et al. (1989) examined the effects of a 4-year program for reducing coronary heart disease risk factors among 1,041 African American adolescents. Participants were randomly assigned to either a treatment program or a control program (no treatment).

Bush et al. (1989) The treatment program involved goal setting, modelling, rehearsal, feedback of screening results, and reinforcement of healthful eating behaviours. Treatment participants showed significant decreases in cholesterol and blood pressure, which were maintained over a 2-year follow-up.

Perry et al. (1989) In Perry et al’s (1989) study, younger children (ages 8—9 years) participated in either a treatment or control school- based program designed to increase healthy eating habits. The intervention program included modelling through stories and role-playing, self-monitoring of behaviours, behavioural contracting, and material rewards.

Perry et al. (1989) Treatment participants showed significant reductions in the use of salt. Together, these studies reviewed above provide evidence that incorporating directly observable behavioural objectives—such as setting written goals, modelling behaviours, and providing feedback—can successfully result in long-term dietary change.

Staff support Another important aspect of school- based interventions has been obtaining support from school staff (e.g., teachers) and school cafeteria providers.

Staff support Bush et al. (1989) reported that young African American adolescents who were part of a coronary heart disease prevention program and were judged to have the best teachers showed significant decreases in total serum cholesterol at a 2-year follow-up.

Staff support Resnicow, Cross, and Wynder (1991) also examined the effects of a comprehensive school health education program designed to decrease total cholesterol in young adolescents. They conducted three studies with a combined sample of Whites, African Americans, and Hispanics.

Staff support The program incorporated a teacher component, a health-screening component, and extracurricular activities. The teacher component advocated decision-making, goal setting, and communication skills. The extracurricular activities included modifying the school cafeteria, developing recipe books, and holding heart-healthy bake sales.

Staff support The intervention schools reported significantly less consumption of high- fat foods in comparison with no- treatment schools. The intervention participants also showed 4%—7% decreases in total cholesterol level across all ethnic groups.

Staff support Although Bush et al. and Resnicow et al. did not specifically determine which components of their programs were most effective in creating dietary change, their findings do provide evidence for the importance of obtaining support from school staff and cafeteria providers when designing dietary interventions for adolescents.

Healthier food options
Other investigators have more specifically modified school cafeteria programs to provide healthier food options. Parcel, Simons-Morton, O’Hara, Baranowski, and Wilson (1989) worked with the food service personnel to institute specific goals for dietary change in several school cafeterias in Houston, Texas.

Their study sample was 62% White, 2I% Mexican, 15% African American, and 2% Asian American and Native American. Participants ranged in age from 5 to 10 years.

School lunches were modified to decrease the sodium content to less than 600 mg per average school lunch and to decrease the total fat to 30% and saturated fat to 100% or less of the total calories per day. New recipes were tested for taste, texture, appearance, and appeal. The results demonstrated significant decreases in the use of salt.

Similarly, in a recent review by Stevens and Davis (1988) it was found that effective dietary programs modified the offerings of school cafeterias to include salad bars, fresh fruit, and whole grain breads. Continued research is needed to better understand how programs such as these might affect specific adolescent minority groups.

French et al (2001) examined the effects of pricing and promotion strategies on purchases of low- fat snacks from vending machines. Low-fat snacks were added to 55 vending machines in a convenience sample of 12 secondary schools and 12 worksites. Pricing

Pricing Four pricing levels (equal price, 10% reduction, 25% reduction, 50% reduction) and 3 promotional conditions (none, low-fat label, low-fat label plus promotional sign) were crossed in a Latin square design. Sales of low-fat vending snacks were measured continuously for the 12-month intervention.

Pricing Results show that price reductions of 10%, 25%, and 50% on low-fat snacks were associated with significant increases in low-fat snack sales; percentages of low-fat snack sales increased by 9%, 39%, and 93%, respectively. Promotional signage was independently but weakly associated with increases in low-fat snack sales.

Pricing Average profits per machine were not affected by the vending interventions. It is concluded that reducing relative prices on low-fat snacks was effective in promoting lower-fat snack purchases from vending machines used by both adult and adolescent populations.

Culturally relevant information
More recently, investigators have integrated culturally relevant information into their school-based dietary interventions. For example, Schinke, Moncher, and Singer (1994) developed a cancer risk-reduction program that included a nutrition focus on reducing fat intake and increasing such nutrients as fibre and carotene.

The study included 368 Native American adolescents whose schools participated in either an intervention or a control program.

The intervention involved using an interactive computer program to present information in the context of a Native American story. The story emphasised the culturally relevant traditional advantages of sound nutrition (e.g., natural and whole foods).

A second aspect of the computer program focused on problem solving and helping adolescents to offset negative pressures within the context of the story. ‘The students received positive feedback on what they had learned through a computerised post- test.

Students in the intervention program showed a greater increase in knowledge regarding positive dietary changes than students from schools who did not receive the intervention. This study did not include behavioural measures to determine if this acquired knowledge would generalise to adolescents’ behaviour.

Nevertheless, this type of program may be especially effective with minority adolescents because it is culturally and developmentally appropriate and has a game like quality.

Aerobic exercise Ewart, Loftus and Hagberg (1995) evaluated the efficacy of school-based aerobic exercise program for lowering blood pressure in a high-risk urban sample of ninth-grade African American girls. Girls in the intervention group received a one-term aerobics class of fitness instruction and training designed to be enjoyable and engaging for high- risk girls.

Aerobic exercise Eighteen 50-min class periods involved lecture and discussion and 60 class periods were spent performing aerobic exercise. Girls assigned randomly to the control group just received the regular PE curriculum. After completing the course 81% wished to continue for another term, demonstrating their enjoyment and a developing commitment to regular exercise.

Peer-based programmes
We prefer to take advice from people like ourselves or from people who we respect. It seems reasonable to suggest, then, that health education programmes led by your peers will be more successful than programmes led by adult strangers or by teachers.

Bachman et al. (1988) looked at a health promotion programme where students were asked to talk about drugs to each other, to state their disapproval of drugs and to say that they didn’t take drugs. The idea was to create a social norm that was against drug taking and also give people practice in saying ‘no’.

It was claimed that the programme changed attitudes towards drugs and led to a reduction in cannabis use. A similar programme was reported by Sussman et al. (1995) who compared the effectiveness of teacher-led lessons with lessons that required student participation. The study looked at around 1000 students from schools in the US.

Results suggested that there were significant changes in attitudes to drugs and intentions to use drugs in the active participation lessons, but not in the teacher-led lessons.

WORKSITE WELLNESS PROGRAMS

Health hazard appraisal
An example of a work-based health programme was introduced at a glass product company in Santa Rosa, California (Rodnick, 1982, cited in Feuerstein, 1986, p. 271). A ‘health hazard appraisal’ counselling session was carried out with nearly employees at the company.

As part of the programme, full-time staff were offered a comprehensive health examination which included: • health history • weight and height measurement • blood pressure measurement • range of blood tests including: cholesterol, liver enzyme level, calcium, protein etc. • TB skin test • stool test • physical examination.

This information was used to provide feedback on the risks of contracting various diseases including specific cancers and cardiovascular disease. About two weeks after the tests, the workers attended a group session where they received feedback about their health-risk profiles. They were also given information about hypertension, heart disease and cancer.

One year later the workers were tested again and the following improvements in their general health were observed: • decrease in blood pressure (particularly in individuals with mild hypertension) • reduction in cholesterol levels in men • decrease in cigarette smoking • increase in exercise • increase in breast self-examination (BSE) • decrease in alcohol consumption in men • increase in seat-belt use by men.

A survey of over 1,300 worksites with 50 or more employees found that nearly two-thirds offered some form of health promotion activity, such as for fitness and weight control (Fielding & Piserchia, 1989). Some programs award prizes for losing weight, or pay employees for stopping smoking, or give bonuses for staying well.

By doing this, employers are helping their workers and saving a great deal of money. Workers with poor health habits cost employers substantially more in health benefits and other costs of absenteeism than those with good habits. These savings offset and often exceed the expense of running a wellness program (Winett, King, & Altman, 1989).

Worksite wellness programs vary in their aims, but they usually address some or all of the following risk factors: hypertension, cigarette smoking, unhealthy diets and overweight, poor physical fitness, alcohol abuse, and high levels of stress. Housing these programs in workplaces has several advantages:

· (a) Most employees go to the workplace on a regular schedule, facilitating regular participation in the programs; · (b) contact with co-workers can provide reinforcing social support

· (c) the workplace offers many opportunities for environmental supports, such as healthy food in the cafeteria and office policies regarding smoking; · (d) opportunities abound for positive reinforcement for individuals participating in the programs;

· (e) programs in the workplace are generally less expensive for the employee · (f) programs in the workplace are convenient. (Cohen, 1985, p. 215). Unfortunately, the employees who do not participate are often the ones who need it most - those who report having poor health and fitness (Alexy, 1991).

Johnson & Johnson's "Live for Life" Program
Johnson & Johnson is America's largest producer of health care products. They began the Live for Life program in 1978, and it is one of the largest, best funded, and most effective worksite programs yet developed (Fielding, 1990; Nathan, 1984). The number of employees covered by the program has grown over the years and now exceeds 31,000.

The health goal of the program is to help as many employees as possible live healthier lives by making improvements in their health knowledge, stress management, and efforts to exercise, stop smoking, and control their weight.

For each participating employee, Live for Life begins with a health screen - a detailed assessment of the person's current health and health-related behaviour, which is shared with the individual later. After taking part in a lifestyle seminar, the employee joins action groups for specific areas of improvement, such as quitting smoking or controlling weight. Professionals lead sessions of these action groups, focusing on how the employees can alter their lifestyles and maintain these improvements permanently.

Follow-up contacts are made with each participant during the subsequent year. The company also provides a work environment that supports and encourages healthful behaviour: it has designated no-smoking areas, established exercise facilities, and made nutritious foods available in the cafeteria, for example.

All the employees studied completed a health screen in the initial year and then again in later years. Compared with the employees at the companies where Live for Life was not offered, those where it was have shown greater improvements in their physical activity, weight, smoking behaviour, ability to handle job stress, absenteeism, and hospital medical claims.

Control Data's "StayWell" Program
Each StayWell participant completes a health screening, receives a resulting confidential health risk profile, and attends a workshop that focuses on interpreting the profile. The person can then join courses taught by professionals that provide information about lifestyle and health and teach the skills needed to change unhealthful behaviors. There are courses in physical fitness, nutrition, weight control, stopping smoking, and stress management.

Control Data's "StayWell" Program
The individual can also join action teams that focus on two things: (1) making the work environment more healthful, (2) forming support groups whereby members help one another in changing their behaviour. Evaluation of the StayWell program uses two approaches. Some sites did not offer the Staywell program, and therefore could be used as controls. Employess exhibited varying degrees of participation in the Staywell program so comparisons could be made.

Smoking reduction An attempt to encourage people to quit smoking was carried out at five worksites. All the sites received a six-week programme in cognitive behaviour therapy which focused on the skills of giving up. The workers who enrolled in the programmes in four of the sites were put into competing teams, with the workers at the fifth site acting as a control. At the end of the programme 31 per cent of the people in the programme at the control site and 22 per cent at the competition sites had stopped smoking.

Smoking reduction A follow-up study after six months found that 18 per cent of the control group and 14 per cent of the competition groups had stayed off the cigarettes. This appears to suggest that the control group were doing better than the competition groups, but this was not the case. At the competition sites 88 per cent of the smokers joined the programme, but only 54 per cent did so at the control site, suggesting that the incentive of competition encouraged more people to attempt to give up.

Smoking reduction When the data was compared for the total number of smokers at each site to give up, there was an overall reduction of 16 per cent at the competition sites and only 7 per cent at the control site (Klesger et al. 1986).

Smoking reduction A worksite intervention that has grown in popularity is to ban smoking at work. One of the questions to consider about this policy is whether smokers reduce their consumption because of the ban, or whether they simply adjust their behaviour and smoke at different times.

Smoking reduction A smoking ban in Australian ambulance crews was monitored by self-report measures, and also by physiological measures such as blood and exhaled carbon dioxide. The measures were taken just before the ban, just after it, and again six weeks later.

Smoking reduction The self-report results showed that the ambulance crews reported less smoking both at the start of the ban and after six weeks. The physiological measures, however, returned to the baseline measures after six weeks, suggesting that the smokers were finding other times to smoke, or were maybe finding secret places to smoke while at work (Gomel et al., 1993).

Smoking reduction This suggests that worksite smoking bans might well be useful in changing behaviour at work, and also improving the quality of life for non-smokers, but their overall effectiveness in reducing smoking is far less clear.

Smoking reduction The problem of measuring the effectiveness of worksite health promotion is a general one that goes beyond ‘quit smoking’ programmes. A review of over 100 programmes of worksite health promotion found that only a quarter of them were initiated in response to the needs or views of the workers, and very few involved partnerships between workers and employers.

Smoking reduction Most of the programmes were aimed at changing individual behaviour and did not include any changes in the working environment or working practices to encourage these behaviours. The review also noticed a gap between what was regarded as ‘good practice’ and what has been found to be effective in research studies (Harden, et al., 1999).

Smoking reduction I guess this means that, as with many other health interventions, people do what they believe to be the right thing, rather than what research has told us is the best thing.

Smoking reduction However, health promotion at the workplace has been successful in reducing absenteeism, health insurance claims and in improving health behaviours in weight control, exercise, smoking, nutrition, and stress management (Jose & Anderson, 1990; Naditch, 1984).

COMMUNITIES Coronary heart Disease and mass media appeals
It is difficult to evaluate the effect of mass media appeals. In the case of product advertising the effect can be measured in sales. In the case of health behaviour it is difficult to come up with appropriate measures since there are so many influences on us every day.

Coronary heart Disease and mass media appeals
One of the most famous studies on the effectiveness of mass media messages was the Stanford Heart Disease Prevention Programme (see, for example Farquhar et al., 1977). This study looked at three similar small towns in the US.

Two of the towns received a massive media campaign concerning smoking, diet and exercise over a two-year period. This campaign used television, radio, newspapers, posters and mailshots. The third town had no campaign and so acted as a control.

The researchers interviewed several hundred people in the three towns between the ages of 35 and 60. They were interviewed before the campaign began, after one year, and again after two years when the campaign ended.

The interviews included questions about health behaviours, knowledge about the risks of heart disease, and physical measures such as blood pressure and cholesterol levels. In one of the two campaign towns, the researchers used the interview data to identify over one hundred people who were at high risk of heart disease and offered them one- to-one counselling.

The people in the control town showed a slight increase in risk factors for heart disease, and the people in the campaign towns showed a moderate decrease. The campaign produced increased awareness of the dangers of heart disease but produced relatively little change in behaviour.

The exception to this was the people who had been offered one-to-one counselling — this group showed significant changes in behaviour. This study suggests that mass media campaigns by themselves produce only small changes in behaviour, but they can act as a cue to positive action if further encouragement is offered.

Reducing skin cancer risk

Over the past twenty years there has been a large growth in the incidence of skin cancers, which might be due to a combination of changes in the environment and changes in lifestyles. There are a number of health promotion campaigns to encourage safe behaviours in the sun.

A study on the effectiveness of these programmes was carried out by McClendon and Prentice (2001). White students who chose to tan were given a health promotion intervention based on protection motivation theory (PMT).

The intervention was made up of brief lectures, an essay, short discussions and a video about a young man who died of melanoma (a particularly dangerous form of skin cancer). There were two sessions, each just over one hour long and taking place two days apart.

The researchers used psychometric tests to estimate responses to a range of variables including: • vulnerability • severity of the threat • self-efficacy • costs and rewards • intentions.

With the exception of self-efficacy, these variables all showed some significant change after the intervention and remained effective one month later. However, the issue is not whether people intend to change their behaviour, but whether they actually do change their behaviour. This is always more difficult to measure.

In this study, however, they took photographs of the participants at the start of the study and again after one month. These pairs of photographs were then judged by four blind-raters (judges who did not know whether the pictures were before or after) to see whether the students’ skin had tanned further or become lighter.

The students were not aware that this judgement would take place. Of the 32 individuals photographed, 23 (72 per cent) were judged to have lighter skin tone after one month, 4 (12.5 per cent) were rated as having no change and 5 (16 per cent) were judged to have darker skin.

Homelessness Not everybody has equal access to healthcare. Some members of our society are socially excluded from the wealth and health that most people enjoy. One group of people who fall into this category is the homeless, and one of the challenges for health promotion is to create initiatives that deal with their needs.

Homelessness The health status of homeless people is very poor compared to the general population (Plearce and Quilgares, ). This is true for diet, malnutrition, substance misuse, mental health problems, infectious diseases such as tuberculosis), cardiovascular disease, accidents and hypothermia.

Homelessness Homeless people commonly come to the attention of health workers only when they develop an illness rather than through screening procedures, and they often use accident and emergency departments to deal with their health problems (Power et al., 1999). As a result the regular health promotion programmes often miss them.

Homelessness There are a number of barriers to health promotion for homeless people including (Power et al., 1999): • workers with homeless people are often isolated and there is not very much collaboration between the various agencies that work with the homeless

Homelessness • health promotion units do not set up many initiatives aimed specifically at homelessness and housing • homeless people can feel alienated from health education messages as they often require a high level of literacy

Homelessness although homeless people are concerned about health problems, issues such as low self-esteem and low expectations can prevent them from taking part in heath promoting activities.

The end

Health Promotion in schools, the workplace and the community

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