Self-reflections on health promotion in the UK and the USA.

OBJECTIVES: To compare and contrast the past 30-40 years of health promotion in the UK and the USA, and to identify two critical issues that relate to health promotion research and practice in both countries. METHODS: Historiography and self-reflection. CONCLUSIONS: Although the USA and the UK share different histories of health promotion development, many of the critical issues that characterize the field are similar. Two issues are particularly notable: the concern with evidence; and the problem of translation of the science of health promotion to practice.

Enhancing global capacity in the surveillance, prevention, and control of chronic diseases: seven themes to consider and build upon.

BACKGROUND: Chronic diseases are now a major health problem in developing countries as well as in the developed world. Although chronic diseases cannot be communicated from person to person, their risk factors (for example, smoking, inactivity, dietary habits) are readily transferred around the world. With increasing human progress and technological advance, the pandemic of chronic diseases will become an even bigger threat to global health. METHODS: Based on our experiences and publications as well as review of the literature, we contribute ideas and working examples that might help enhance global capacity in the surveillance of chronic diseases and their prevention and control. Innovative ideas and solutions were actively sought. RESULTS: Ideas and working examples to help enhance global capacity were grouped under seven themes, concisely summarised by the acronym "SCIENCE": Strategy, Collaboration, Information, Education, Novelty, Communication and Evaluation. CONCLUSION: Building a basis for action using the seven themes articulated, especially by incorporating innovative ideas, we presented here, can help enhance global capacity in chronic disease surveillance, prevention and control. Informed initiatives can help achieve the new World Health Organization global goal of reducing chronic disease death rates by 2% annually, generate new ideas for effective interventions and ultimately bring global chronic diseases under greater control.

Strengthening the evidence base for health promotion.

This paper describes the evidence debate from the many players currently attempting to define best practices in health promotion. Expert opinions on the purpose of collecting evidence range from those who view evidence as a western notion of little use in the developing world to those who choose to focus on opportunities to demonstrate the effectiveness of health promotion. There is also much disagreement on what constitutes evidence. Some view evidence as strict outcomes of randomized clinical trials (RCT) and others place greater value on other unpublished sources, not traditionally viewed as valuable information. A challenge for health promotion in the new century is to foster and develop high quality, widely recognized and acceptable standards for evidence-based evaluation.

Subgroup-specific effects of questionnaire wording on population-based estimates of mammography prevalence.

OBJECTIVES: This study investigated whether an apparent downturn in prevalence rates of mammography use reported in the 1992 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire resulted from a change in questionnaire wording. METHODS: In a pretest-posttest design (1990-1991 vs 1992), piecewise linear regression analyses were based on monthly prevalence estimates of mammography use among female BRFSS respondents 40 years or older. RESULTS: Self-reported mammography use was lower by 3.5 percentage points (95% confidence interval [CI] = 1.5, 5.5) overall--and lower by 13.6 percentage points (95% CI = 2.6, 24.6) among Black women with less than a high school education--when predicted from 1992 data than when predicted from 1990-1991 data. CONCLUSIONS: A change in questionnaire wording in the BRFSS caused demographic-specific effects in population-based estimates of mammography use.

Developing an evidence-based Guide to Community Preventive Services--methods. The Task Force on Community Preventive Services.

Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systematically review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.

State- and sex-specific prevalence of selected characteristics--Behavioral Risk Factor Surveillance System, 1992 and 1993.

PROBLEM/CONDITION: Much chronic disease and injury morbidity and mortality is associated with high-risk behaviors (e.g., cigarette smoking, excessive alcohol consumption, and physical inactivity) and with lack of preventive health care (e.g., screening for cancer). States use the Behavioral Risk Factor Surveillance System (BRFSS) to collect data about these modifiable health behaviors and to monitor trends and significant changes in their populations over time. REPORTING PERIOD: 1992 and 1993. DESCRIPTION OF SYSTEM: The BRFSS is a state-based telephone survey of the civilian, noninstitutionalized, adult (persons > or = 18 years of age) population. In 1992, 48 states and the District of Columbia participated in the BRFSS; in 1993, 49 states and the District of Columbia participated. Several questions were added to the BRFSS in 1993. RESULTS: As in previous years, state-specific variations occurred in the prevalence of high-risk behaviors, awareness of certain medical conditions, use of preventive health services, and health-care coverage. In 1993, 4.0% (range: 1.4% - 6.4%) of adults reported riding with a driver who had had too much alcohol to drink. The percentage of persons > or = 50 years of age who had ever had a proctoscopic examination ranged from 25.6% to 51.5% (median: 36.8%). Among adults > or = 65 years of age, 27.4% (range: 18.5 % - 40.0%) had ever had a pneumococcal vaccination, and 49.9% (range: 28.7% - 66.2%) had had an influenza vaccination within the past 1 year. INTERPRETATION: The variations in prevalence across states likely reflect socioeconomic differences, differences in state laws enacted to discourage risky behaviors, different levels of effort to screen for certain types of cancer or risk factors for other diseases, and other factors. ACTION TAKEN: States will continue to use the BRFSS to collect data about health behaviors. Analysis of these data will enable states to monitor factors that may affect the rate of chronic disease and injury mortality and morbidity and to develop public health policies to address these problems.

Perceived risk of becoming infected with HIV by donating blood and changes in reported blood donation practice among the Scottish general public 1989-1992.

A total of 17,537 respondents aged 18-60 and resident in Edinburgh and Glasgow were interviewed between January 1989 and May 1992 as part of a large scale continuous monitoring survey of lifestyles and health. A computer assisted telephone interview (CATI) system was used. Respondents were chosen randomly from households with telephones. The objective was to see whether concern about the risks of becoming infected with HIV by donating blood led to a change in the blood donating habits of existing blood donors. Results showed no change in the percentage of donors, ex-donors and non-donors between 1989 and 1992, but a recent decrease in the percentage of respondents who thought that you could become infected with HIV by donating blood was observed. The percentage of new donors and ex-donors balanced each other out, but in all years respondents reporting a decreased frequency of donation outweighed those reporting an increased frequency. The belief that you can become infected with HIV by donating blood was most prevalent among non-donors followed by ex-, current and new-donors in that order. There was some evidence that the belief that you can become infected with HIV by donating blood was adversely affecting blood donation habits.

Conceptions and misconceptions about transmission of HIV/AIDS among the Scottish general public, 1988-1992.

Knowledge levels among the Scottish general public about so called 'casual' transmission of the AIDS virus were analysed using data collected by our Unit's survey using computer-assisted telephone interviewing methods. Five cross-sections of data from the period March to May of each year were analysed and compared to provide overall estimates of knowledge on four items relating to casual transmission between respondent groups and to provide an estimate of changes over time in knowledge levels from 1988 to 1992. The data show that significant differences in knowledge exist, with the lowest levels of knowledge found among the older and among the less educated respondents. There is evidence for a continuing increase in knowledge for all items studied and for most respondent groups, but little evidence that disparities in knowledge between respondent groups are lessening over time. Misconceptions about potential risks from donating blood and kissing persist at quite high levels.

Sexual behavior and exposure to HIV infection: estimates from a general-population risk index.

OBJECTIVES: The spread of the human immunodeficiency virus (HIV) in the general population has been a much debated topic in the mass media. The aim of this study was to create an approach to estimating the risk of exposure to HIV resulting from sexual behaviors. METHODS: A theoretical estimate was applied to data obtained from a large-scale risk factor survey carried out in Britain. An HIV infection-exposure risk index was constructed by ranking different sex-related categorizations derived from variables in the survey. RESULTS: The risk index involved a Delphi-based assessment of self-reported behavioral factors associated with HIV exposure and subsequent transmission. Roughly 85% of the adult population aged 18 to 50 were estimated to be at some risk for behavioral exposure to HIV virus with regard to reported sexual behavior. Over time, those who could be considered at no risk have declined as a proportion of the population. CONCLUSIONS: The estimates appear to refute commonplace assertions that exposure to HIV through sexual behavior is not a problem for general populations.

Anti-permissive attitudes to lifestyles associated with AIDS.

AIDS is in the tradition of diseases which have given moral interpretations. One way in which this moralistic perspective may express itself is by members of the public holding high risk groups responsible for their (AIDS related) lifestyles and their considering AIDS to be a self-inflicted disease. A unique data source of 7000 verbatim comments recorded in the course of 25,000 structured Computer Assisted Telephone Interviews on Lifestyle and Health which contain a substantial component on AIDS--knowledge, attitudes, beliefs and sexual behaviour, was used to document negative attitudes to 'AIDS related lifestyles'. These comments revealed that despite evidence of concern about drug use, many respondents consider AIDS to be irrelevant to the majority of the population. There is some evidence that AIDS has contributed to reinforcing negative attitudes towards homosexuality and drug use, especially among older respondents. Extreme punitive attitudes towards high risk groups were expressed by a small minority (predominantly males).

Trends in Scottish cigarette smoking by gender, age and occupational status, 1984-1991.

Data from the General Household Survey (GHS) for the period 1984-1988 and data from the RUHBC-CATI (Research Unit in Health and Behavioural Change - Computer Assisted Telephone Interview) survey for the period 1988 to 1991 are pooled to study changes in the cigarette smoking prevalence in Scotland. It is concluded that the Scottish smoking prevalence shows a slight downward trend for males and a slight upward trend for females. There is some evidence for an earlier decrease in smoking prevalence related to a lower smoking uptake among younger generations, however, the current pattern of smoking among the youngest age group shows an increase. The reported difference in smoking prevalence between those in manual and non-manual occupations seems to be increasing among females and decreasing among males.

Patterns of unhealthy eating behaviours in a middle aged Scottish population.

This paper examines unhealthy eating in a middle aged Scottish population. Data from a 1989 survey of 500 Scottish men and women aged 45 to 59 years are used to explore inter-relations among five items of unhealthy eating, smoking and alcohol consumption. The results show that unhealthy eating behaviours are highly correlated, indicating strong links among certain nutrition habits. The findings also reveal that such patterns of unhealthy eating vary considerably between males and females. Finally, unhealthy eating behaviours were also found to be significantly associated with smoking and alcohol consumption. Implications of these findings for future research in epidemiology and health promotion are considered.

Assessing the qualitative data component in large-scale quantitative surveys: computer aided qualitative survey data management, retrieval and analysis.

In a large-scale survey the qualitative component of the interview is often used either to refine the quantitative coding categories or to get a 'general feel' for the respondents' comments with no attempt at analysis. This article reports on an approach which has been developed for solving some of the problems of linkage of qualitative and quantitative components at the survey analysis stage. This approach is dependent on efficient methods of data management and text retrieval, and presupposes a system of data collection that produces computer-based text files to store the verbatim comments of study participants. The size of the data set necessitated using a mainframe computer for data management, text retrieval and analysis. The article provides illustrations of how the analysis of 11 000 files consisting of textual data was facilitated.

Changing patterns in reported sexual practices in the population: multiple partners and condom use.

OBJECTIVE: To determine whether the pattern of change with regard to condom use and multiple sexual partners is influenced by gender or educational level. DESIGN: Findings from data collected from 1987 to 1990 about changes in condom use and multiple-partner activities are presented, based on telephone interviews with 9416 participants aged 18 to 44 years resident in central Scotland, UK. METHODS: Change in patterns over time were modelled in a multivariate logistic regression using a linear interactive modelling program. RESULTS: Several models showing changes in the proportion of multiple-partner respondents and condom users yielded a complicated pattern of behavioural change in educational status and gender. CONCLUSIONS: There is a large difference in reported condom use and multiple sexual partners by gender, but the difference is decreasing over time. Better educated respondents increased their use of condoms while less educated respondents showed a decrease in the proportion of multiple partners.