The past as present in health promotion: the case for a 'public health humanities'.

Health promotion is conceived as a unifying concept for improving the health of populations. This means addressing the socio-cultural, economic and commercial causes of ill-health, which are necessarily informed by past policies and socio-cultural contexts. However, historical scholarship has rarely figured in health promotion practice or scholarship. This gap resides in the determinants of health, and notably in the analyses of tobacco control and skin cancer prevention, two long-running campaigns that have shaped modern health promotion in Australia. Both highlight a need for understanding the profound impact of history on the present and the value of learning from past successes and failures. Doing so requires integrating historical analyses into existing health promotion scholarship. To achieve this aim, we present a new 'public health humanities' methodology. This novel interdisciplinary framework is conceived as a spectrum in which historical studies integrate with existing health promotion disciplines to solve complex health problems. We draw on the many calls for more interdisciplinarity in health promotion and derive this methodology from proposals in the medical humanities and cognate fields that have wrestled with combining history and present-focused disciplines. Using tobacco control and skin cancer prevention as case studies, we demonstrate how public health humanities uses interdisciplinary teams and shared research questions to generate valuable new knowledge unavailable with traditional methods. Furthermore, we show how it creates evaluation criteria to consider the powerful impact of issues like colonialism on current inequities that hinder health promotion strategies, and from which lessons may be derived for the future.

Strengthening cancer control in the South Pacific through coalition-building: a co-design framework.

Background: Cancer is a significant problem for the South Pacific region due to a range of complex health challenges. Currently gaps in diagnosis, treatment and palliative care are significant, and while governmental commitment is strong, economic constrains limit health system strengthening. Alliances have been successful in strengthening non-communicable disease and cancer control policy and services in resource constrained settings. A regional coalition approach has therefore been recommended as an effective solution to addressing many of the challenges for cancer control in the South Pacific. However, evidence regarding the effective mechanisms for development of alliances or coalitions is scarce. This study aimed to 1) create a Coalition Development Framework; 2) assess the use of the Framework in practice to co-design a South Pacific Coalition. Methods: Creation of the Coalition Development Framework commenced with a scoping review and content analysis of existing literature. Synthesis of key elements formed an evidence-informed step-by-step guide for coalition-building. Application of the Framework comprised consultation and iterative discussions with key South Pacific cancer control stakeholders in Fiji, New Caledonia, Papua New Guinea, Samoa and Tonga. Concurrent evaluation of the Framework utilising Theory of Change (ToC) and qualitative analysis of stakeholder consultations was undertaken. Findings: The finalised Coalition Development Framework comprised four phases with associated actions and deliverables: engagement, discovery, unification, action and monitoring. Application of the Framework in the South Pacific identified overwhelming support for a Cancer Control Coalition through 35 stakeholder consultations. Framework phases enabled stakeholders to confirm coalition design and purpose, strategic imperatives, structure, local foundations, barriers and facilitators, and priorities for action. ToC and thematic consultation analysis confirmed the Framework to be an effective mechanism to drive engagement, unification and action in alliance-building. Interpretation: A Coalition to drive cancer control has significant support among key Pacific stakeholders, and establishment can now be commenced. Importantly results confirm the effective application of the Coalition Development Framework in an applied setting. If momentum is continued, and a regional South Pacific Coalition established, the benefits in reducing the burden of cancer within the region will be substantial. Funding: This work was completed for a Masters of Public Health project. Cancer Council Australia provided project funding.

Conceptualising commercial entities in public health: beyond unhealthy commodities and transnational corporations.

Most public health research on the commercial determinants of health (CDOH) to date has focused on a narrow segment of commercial actors. These actors are generally the transnational corporations producing so-called unhealthy commodities such as tobacco, alcohol, and ultra-processed foods. Furthermore, as public health researchers, we often discuss the CDOH using sweeping terms such as private sector, industry, or business that lump together diverse entities whose only shared characteristic is their engagement in commerce. The absence of clear frameworks for differentiating among commercial entities, and for understanding how they might promote or harm health, hinders the governance of commercial interests in public health. Moving forward, it is necessary to develop a nuanced understanding of commercial entities that goes beyond this narrow focus, enabling the consideration of a fuller range of commercial entities and the features that characterise and distinguish them. In this paper, which is the second of three papers in a Series on commercial determinants of health, we develop a framework that enables meaningful distinctions among diverse commercial entities through consideration of their practices, portfolios, resources, organisation, and transparency. The framework that we develop permits fuller consideration of whether, how, and to what extent a commercial actor might influence health outcomes. We discuss possible applications for decision making about engagement; managing and mitigating conflicts of interest; investment and divestment; monitoring; and further research on the CDOH. Improved differentiation among commercial actors strengthens the capacity of practitioners, advocates, academics, regulators, and policy makers to make decisions about, to better understand, and to respond to the CDOH through research, engagement, disengagement, regulation, and strategic opposition.

Gambling-related harms attributable to lotteries products.

Lotteries products (lottery tickets and scratch tickets) are the most popular forms of gambling worldwide, however little research has investigated whether these products are associated with gambling-related harm. The limited available research suggests these products are linked to problematic gambling behaviors and a range of resulting negative outcomes, with certain sub-groups appearing to be more vulnerable to experiencing harms. The present study examined risk of gambling-related harm (measured by the Problem Gambling Severity Index) from lotteries products use in an Australian sample of lotteries-only gamblers (n = 540). Additionally, the study investigated whether risk varied according to a range of sociodemographic and behavioral characteristics (age, gender, household income, location (rural vs. metropolitan), employment status, alcohol consumption, smoking status, frequency of e-cigarette use, frequency of scratch ticket use, frequency of lottery ticket use, expenditure on scratch tickets, and expenditure on lottery tickets). Almost one-third of the sample was found to be at some level of gambling-related risk due to their use of lotteries products. Younger respondents, males, current smokers, e-cigarette users, and those who purchase scratch tickets more frequently were more likely to report problematic use of lotteries products. Policy makers should enact strategies to prevent and reduce harms resulting from lotteries products, especially among the identified at-risk groups.

Exploring Perception of Indians about Plain Packaging of Tobacco Products: A Mixed Method Research.

This study assessed perceptions and support among the Indian populace about plain packaging for all tobacco products. Twelve focus group discussions (n = 124), stakeholder analysis with 24 officials and an opinion poll with 346 participants were conducted between December 2011 and May 2012, Delhi. Plain packages for tobacco products were favored by majority of participants (69%) and key stakeholders (92%). The majority of participants perceived that plain packaging would reduce the appeal and promotional value of the tobacco pack (>80%), prevent initiation of tobacco use among children and youth (>60%), motivate tobacco users to quit (>80%), increase notice ability, and effectiveness of pictorial health warnings on tobacco packs (>90%), reduce tobacco usage (75% of key stakeholders). Majority of participants favored light gray color for plain packaging. This study provides key evidence to advocate with Indian Government and other countries in South Asia region to introduce plain packaging legislation for all tobacco products.

Eat, drink and gamble: marketing messages about 'risky' products in an Australian major sporting series.

BACKGROUND: To investigate the alcohol, gambling, and unhealthy food marketing strategies during a nationally televised, free to air, sporting series in Australia. METHODS/APPROACH: Using the Australian National Rugby League 2012 State of Origin three-game series, we conducted a mixed methods content analysis of the frequency, duration, placement and content of advertising strategies, comparing these strategies both within and across the three games. RESULTS: There were a total of 4445 episodes (mean = 1481.67, SD = 336.58), and 233.23 minutes (mean = 77.74, SD = 7.31) of marketing for alcoholic beverages, gambling products and unhealthy foods and non-alcoholic beverages during the 360 minutes of televised coverage of the three State of Origin 2012 games. This included an average per game of 1354 episodes (SD = 368.79) and 66.29 minutes (SD = 7.62) of alcohol marketing; 110.67 episodes (SD = 43.89), and 8.72 minutes (SD = 1.29) of gambling marketing; and 17 episodes (SD = 7.55), and 2.74 minutes (SD = 0.78) of unhealthy food and beverage marketing. Content analysis revealed that there was a considerable embedding of product marketing within the match play, including within match commentary, sporting equipment, and special replays. CONCLUSIONS: Sport is increasingly used as a vehicle for the promotion of range of 'risky consumption' products. This study raises important ethical and health policy questions about the extent and impact of saturation and incidental marketing strategies on health and wellbeing, the transparency of embedded marketing strategies, and how these strategies may influence product consumption.

Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries.

The 2011 UN high-level meeting on non-communicable diseases (NCDs) called for multisectoral action including with the private sector and industry. However, through the sale and promotion of tobacco, alcohol, and ultra-processed food and drink (unhealthy commodities), transnational corporations are major drivers of global epidemics of NCDs. What role then should these industries have in NCD prevention and control? We emphasise the rise in sales of these unhealthy commodities in low-income and middle-income countries, and consider the common strategies that the transnational corporations use to undermine NCD prevention and control. We assess the effectiveness of self-regulation, public-private partnerships, and public regulation models of interaction with these industries and conclude that unhealthy commodity industries should have no role in the formation of national or international NCD policy. Despite the common reliance on industry self-regulation and public-private partnerships, there is no evidence of their effectiveness or safety. Public regulation and market intervention are the only evidence-based mechanisms to prevent harm caused by the unhealthy commodity industries.

Factors influencing receipt of iron supplementation by young children and their mothers in rural India: local and national cross-sectional studies.

BACKGROUND: In India, 55% of women and 69.5% of preschool children are anaemic despite national policies recommending routine iron supplementation. Understanding factors associated with receipt of iron in the field could help optimise implementation of anaemia control policies. Thus, we undertook 1) a cross-sectional study to evaluate iron supplementation to children (and mothers) in rural Karnataka, India, and 2) an analysis of all-India rural data from the National Family Health Study 2005-6 (NFHS-3). METHODS: All children aged 12-23 months and their mothers served by 6 of 8 randomly selected sub-centres managed by 2 rural Primary Health Centres of rural Karnataka were eligible for the Karnataka Study, conducted between August and October 2008. Socioeconomic and demographic data, access to health services and iron receipt were recorded. Secondly, NFHS-3 rural data were analysed. For both studies, logistic regression was used to evaluate factors associated with receipt of iron. RESULTS: The Karnataka Study recruited 405 children and 377 of their mothers. 41.5% of children had received iron, and 11.5% received iron through the public system. By multiple logistic regression, factors associated with children's receipt of iron included: wealth (Odds Ratio (OR) 2.63 [95% CI 1.11, 6.24] for top vs bottom wealth quintile), male sex (OR 2.45 [1.47, 4.10]), mother receiving postnatal iron (OR 2.31 [1.25, 4.28]), mother having undergone antenatal blood test (OR 2.10 [1.09, 4.03]); Muslim religion (OR 0.02 [0.00, 0.27]), attendance at Anganwadi centre (OR 0.23 [0.11, 0.49]), fully vaccinated (OR 0.33 [0.15, 0.75]), or children of mothers with more antenatal health visits (8-9 visits OR 0.25 [0.11, 0.55]) were less likely to receive iron. Nationally, 3.7% of rural children were receiving iron; this was associated with wealth (OR 1.12 [1.02, 1.23] per quintile), maternal education (compared with no education: completed secondary education OR 2.15 [1.17, 3.97], maternal antenatal iron (2.24 [1.56, 3.22]), and child attending an Anganwadi (OR 1.47 [1.20, 1.80]). CONCLUSION: In rural India, public distribution of iron to children is inadequate and disparities exist. Measures to optimize receipt of government supplied iron to all children regardless of wealth and ethnic background could help alleviate anaemia in this population.

UN High-Level Meeting on Non-Communicable Diseases: addressing four questions.

Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes, and chronic respiratory diseases, are a global crisis and require a global response. Despite the threat to human development, and the availability of affordable, cost-effective, and feasible interventions, most countries, development agencies, and foundations neglect the crisis. The UN High-Level Meeting (UN HLM) on NCDs in September, 2011, is an opportunity to stimulate a coordinated global response to NCDs that is commensurate with their health and economic burdens. To achieve the promise of the UN HLM, several questions must be addressed. In this report, we present the realities of the situation by answering four questions: is there really a global crisis of NCDs; how is NCD a development issue; are affordable and cost-effective interventions available; and do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities. A successful outcome of the UN HLM depends on the heads of states and governments attending the meeting, and endorsing and implementing the commitments to action. Long-term success requires inspired and committed national and international leadership.

Priority actions for the non-communicable disease crisis.

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Childhood obesity--a sign of commercial success, but a market failure.

'Obesogenic' products, such as energy dense foods, passive entertainment products, cars, and labour-saving devices, are widely available and heavily promoted. Because they are highly consumed and very profitable, obesity becomes the inevitable consequence of their commercial successes. Contemporary market forces heavily favour behaviours for short-term preferences (i.e. over-consumption and underactivity) over long-term preferences (i.e. healthy weight) and this is especially true for children. Hence, if the market, as the main mechanism for determining choices, results in outcomes, which make our children worse off, as is occurring with childhood obesity, then the market has failed to sustain and promote social and individual goals. This is a serious market failure. In the current obesogenic environment, expecting adults, let alone children, to make food and activity choices in their own best long-term interests is, therefore, demonstrably flawed. We argue that significant government intervention is needed to correct this market failure, as has been done for other major health problems.

[Measuring the effectiveness of health promotion policy: what can be learnt from Australian success stories?]. / Mesurer l'efficacité des politiques de promotion de la santé: quelles leçons tirer des succès australiens?

In 1987, the Australian state of Victoria has created VicHealth, the Victorian Health Promotion Foundation, which has since been quite successful in implementing effective health promotion policies. This paper, after presenting briefly three of these success stories (tobacco control, road trauma decrease and skin cancer prevention), goes on to derive from them the essential steps of successful health promotion interventions. It concludes by reflecting on the nature of the intelligence gathering systems required to anchor good health promotion in good science, and on the barriers to proper measurement that are still pervasive.