Health-promotion research over three decades: The social-ecological model and challenges in implementation of interventions.

AIMS: This debate paper traces the development of innovative methods for undertaking health promotion research with a socialecological orientation, with a few examples drawn from 30 years of research on adolescent health promotion research at the University of Bergen. CONCLUSION: We aim to show how the social-ecological model is becoming more evident as a guide to research, using three cases that illustrate progress and potential. The first case is the Norwegian part of the European Network of Health Promoting Schools. The second case is a project just underway, The COMPLETE study, which is a community-led effort to promote students' mental health and create a good psychosocial learning environment. The third case is a developing idea for the next generation of social-ecological research on adolescent well-being, using an asset approach to foster social inclusion and sense of community in multiple settings.

Aspirations and realities in a North-South partnership for health promotion: lessons from a program to promote safe male circumcision in Botswana.

BACKGROUND: International donors support the partnership between the Government of Botswana and two international organisations: U.S. Centers for Disease Control and Prevention and Africa Comprehensive HIV/AIDS Partnership to implement Voluntary Medical Male Circumcision with the target of circumcising 80 % of HIV negative men in 5 years. Botswana Government had started integration of the program into its health system when international partners brought in the Models for Optimizing Volume and Efficiency to strengthen delivery of the service and push the target. The objective of this paper is to use a systems model to establish how the functioning of the partnership on Safe Male Circumcision in Botswana contributed to the outcome. METHODS: Data were collected using observations, focus group discussions and interviews. Thirty participants representing all three partners were observed in a 3-day meeting; followed by three rounds of in-depth interviews with five selected leading officers over 2 years and three focus group discussions. RESULTS: Financial resources, "ownership" and the target influence the success or failure of partnerships. A combination of inputs by partners brought progress towards achieving set program goals. Although there were tensions between partners, they were working together in strategising to address some challenges of the partnership and implementation. Pressure to meet the expectations of the international donors caused tension and challenges between the in-country partners to the extent of Development Partners retreating and not pursuing the mission further. CONCLUSION: Target achievement, the link between financial contribution and ownership expectations caused antagonistic outcome. The paper contributes enlightenment that the functioning of the visible in-country partnership is significantly influenced by the less visible global context such as the target setters and donors.

Associations between intimate partner violence, childcare practices and infant health: findings from Demographic and Health Surveys in Bolivia, Colombia and Peru.

BACKGROUND: Child health is significantly poorer in homes with intimate partner violence (IPV). However, a possible link to parental provision of childcare has been neglected. METHODS: Utilizing data from Demographic and Health Surveys, this study examined the association between IPV and illness signs in children 0-59 months in Bolivia (n = 3586), Colombia (n = 9955) and Peru (n = 6260), taking into account socio-demographic factors, childcare and severe child physical punishment. Data were collected in the years 2008, 2010 and 2012 for Bolivia, Colombia and Peru respectively. RESULTS: The study found weak but persistent effects of IPV on illness signs in Bolivia (OR 1.37, 95% CI 1.14-1.63) and Peru (OR 1.49, 95% CI 1.26-1.77), after adjusting for the effects of childcare. These effects were not observed in Colombia. CONCLUSIONS: The results call for a mix of qualitative and quantitative research that can map direct, mediating and moderating patterns of relationships between IPV, childcare practices and child health. Can good childcare mitigate the negative effects of IPV? Can poor childcare exacerbate the negative effects of IPV? Such interactions were not observed in the present study, but should be the focus of much more intensive investigation, to help inform child health promotion. Answers could lead to better interventions to improve child health, and perhaps to tackle IPV.

Trends in stunting and overweight in Peruvian pre-schoolers from 1991 to 2011: findings from the Demographic and Health Surveys.

OBJECTIVE: To examine trends in stunting and overweight in Peruvian children, using 2006 WHO Multicentre Growth Reference Study criteria. DESIGN: Trend analyses using nationally representative cross-sectional surveys from Demographic and Health Surveys (1991-2011). We performed logistic regression analyses of stunting and overweight trends in sociodemographic groups (sex, age, urban-rural residence, region, maternal education and household wealth), adjusted for sampling design effects (strata, clusters and sampling weights). SETTING: Peru. SUBJECTS: Children aged 0-59 months surveyed in 1991-92 (n 7999), 1996 (n 14 877), 2000 (n 11 754), 2007-08 (n 8232) and 2011 (n 8186). RESULTS: Child stunting declined (F(1, 5149) = 174·8, P ≤ 0·00) and child overweight was stable in the period 1991-2011 (F(1, 5147) = 0·4, P ≤ 0·54). Over the study period, levels of stunting were highest in rural compared with urban areas, the Andean and Amazon regions compared with the Coast, among children of low-educated mothers and among children living in households in the poorest wealth quintile. The trend in overweight rose among males in coastal areas (F(1, 2250) = 4·779, P ≤ 0·029) and among males in the richest wealth quintile (F(1, 1730) = 5·458, P ≤ 0·020). CONCLUSIONS: The 2011 levels of stunting and overweight were eight times and three and a half times higher, respectively, than the expected levels from the 2006 WHO growth standards. The trend over the study period in stunting declined in most sociodemographic subgroups. The trend in overweight was stable in most sociodemographic subgroups.

Unintended effects in settings-based health promotion.

The settings-based approach to health promotion (HP) employs a social ecological (SE) framework to integrate HP into the usual activities of the setting and to increase the setting's support for healthy choices. The SE approach calls for systems thinking to account for the inextricable relationship between people, their behaviour and their environment. Knowledge about a setting can be used to mobilise people to participate in HP, to optimise success by taking into account the local context, and to anticipate and avoid barriers to success. In other words, the SE approach aims to help HP reach its goals for better health, established in concert with community needs and wishes. Yet, the focus on HP goals may detract attention from how intervention may have unanticipated, and even untoward effects on the setting. There is much evidence from classical ecological research that well-meaning interventions have unintended effects. Biology is so tuned to the possibility that the study of unintended effects is integral to the field. There is some evidence--but much less--that HP also has unexpected, deleterious effects. The evidence is limited because of neglect; the subject of unintended effects is only of peripheral interest in HP. This is a call for a more robust SE approach, in which frameworks used to guide settings-based HP are augmented so as to be concerned with planned effects, and also unplanned effects. What can be done to more responsibly monitor, document and report the full panoply of our effects, including detecting and preventing untoward effects?

Child undernutrition in Kenya: trend analyses from 1993 to 2008-09.

BACKGROUND: Research on trends in child undernutrition in Kenya has been hindered by the challenges of changing criteria for classifying undernutrition, and an emphasis in the literature on international comparisons of countries' situations. There has been little attention to within-country trend analyses. This paper presents child undernutrition trend analyses from 1993 to 2008-09, using the 2006 WHO criteria for undernutrition. The analyses are decomposed by child's sex and age, and by maternal education level, household Wealth Index, and province, to reveal any departures from the overall national trends. METHODS: The study uses the Kenya Demographic and Health Survey data collected from women aged 15-49 years and children aged 0-35 months in 1993, 1998, 2003 and 2008-09. Logistic regression was used to test trends. RESULTS: The prevalence of wasting for boys and girls combined remained stable at the national level but declined significantly among girls aged 0-35 months (p < 0.05). While stunting prevalence remained stagnant generally, the trend for boys aged 0-35 months significantly decreased and that for girls aged 12-23 months significantly increased (p < 0.05). The pattern for underweight in most socio-demographic groups showed a decline. CONCLUSION: The national trends in childhood undernutrition in Kenya showed significant declines in underweight while trends in wasting and stunting were stagnant. Analyses disaggregated by demographic and socio-economic segments revealed some significant departures from these overall trends, some improving and some worsening. These findings support the importance of conducting trend analyses at detailed levels within countries, to inform the development of better-targeted childcare and feeding interventions.

An analysis of socio-demographic patterns in child malnutrition trends using Ghana demographic and health survey data in the period 1993-2008.

BACKGROUND: A small but growing body of research indicates that progress in reducing child malnutrition is substantially uneven from place to place, even down to the district level within countries. Yet child malnutrition prevalence and trend estimates available for public health planning are mostly available only at the level of global regions and/or at country level. To support carefully targeted intervention to reduce child malnutrition, public health planners and policy-makers require access to more refined prevalence data and trend analyses than are presently available. Responding to this need in Ghana, this report presents trends in child malnutrition prevalence in socio-demographic groups within the country's geographic regions. METHODS: The study uses the Ghana Demographic and Health Surveys (GDHS) data. The GDHS are nationally representative cross-sectional surveys that have been carried out in many developing countries. These surveys constitute one of the richest sources of information currently available to examine time trends in child malnutrition. Data from four surveys were used for the analysis: 1993, 1998, 2003 and 2008. RESULTS: The results show statistically significant declining trends at the national level for stunting (F (1, 7204) = 7.89, p ≤ .005), underweight (F (1, 7441) = 44.87, p ≤ .001) and wasting (F (1, 7130) = 6.19, p ≤ .013). However, analyses of the sex-specific trends revealed that the declining trends in stunting and wasting were significant among males but not among females. In contrast to the national trend, there were significantly increasing trends in stunting for males (F (1, 2004) = 3.92, p ≤ .048) and females (F (1, 2004) = 4.34, p ≤ .037) whose mothers had higher than primary education, while the trends decreased significantly for males and females whose mothers had no education. CONCLUSIONS: At the national level in Ghana, child malnutrition is significantly declining. However, the aggregate national trend masks important deviations in certain socio-demographic segments, including worsening levels of malnutrition. This paper shows the importance of disaggregated analyses of national child malnutrition data, to unmask underlying geographic and socio-demographic differences.

Mapping synergy and antagony in North-South partnerships for health: a case study of the Tanzanian women's NGO KIWAKKUKI.

North-South partnerships for health aim to link resources, expertise and local knowledge to create synergy. The literature on such partnerships presents an optimistic view of the promise of partnership on one hand, contrasted by pessimistic depictions of practice on the other. Case studies are called for to provide a more intricate understanding of partnership functioning, especially viewed from the Southern perspective. This case study examined the experience of the Tanzanian women's NGO, KIWAKKUKI, based on its long history of partnerships with Northern organizations, all addressing HIV/AIDS in the Kilimanjaro region. KIWAKKUKI has provided education and other services since its inception in 1990 and has grown to include a grassroots network of >6000 local members. Using the Bergen Model of Collaborative Functioning, the experience of KIWAKKUKI's partnership successes and failures was mapped. The findings demonstrate that even in effective partnerships, both positive and negative processes are evident. It was also observed that KIWAKKUKI's partnership breakdowns were not strictly negative, as they provided lessons which the organization took into account when entering subsequent partnerships. The study highlights the importance of acknowledging and reporting on both positive and negative processes to maximize learning in North-South partnerships.

Does loneliness mediate the stress-sleep quality relation? The Hordaland Health Study.

BACKGROUND: Sleep problems are common in the general population. A strong association between stress due to inadequate social relationships or loneliness and sleep problems has been found. This paper aims to investigate stress in close social relationships in relation to disrupted sleep patterns in middle-aged and older adults. In addition, in exploring the underlying processes involved in poor social interactions, loneliness is assumed to be a mediator in the stress-sleep quality relation. METHODS: Data from a community sample of 7074 Norwegian middle-aged and older adults in the Hordaland Health Study (HUSK) were used to examine the mediating role of loneliness. RESULTS: A significant association between interpersonal stress and both nocturnal sleep problems and daytime sleepiness was found in both age groups. This relation was mediated by loneliness (indirect path) as well as effected by a direct path (RMSEA = 0.051; CFI = 0.93). The size of the indirect effect varied with age. Nocturnal sleep problems were fully mediated by loneliness in the older group, while 74% of the total effect was mediated through loneliness in the middle-aged group. For daytime sleepiness, a partial mediation of 36% and 40% was observed for the two groups respectively. CONCLUSIONS: The mediation effects found in this study indicate that the wider social aspects of an individual's life should be taken into account when planning interventions for improving sleep quality in the elderly.

Social determinants of rest deprivation amongst Ghanaian women: national and urban-rural comparisons with data from a cross-sectional nationally representative survey.

BACKGROUND: Rest deprivation (rest/napping/sleep 6 or less hours daily) is a clinically recognised risk factor for poor health, but its epidemiology is little studied. This study reports prevalence's and social correlates of rest deprivation in Ghana. METHODS: Data are from the 2008 Ghana Demographic and Health Survey. Women ages 15-49 were recruited in a national sampling design. Respondents were 4,916 women in the national sample, a sub-sample of 530 women in the three northernmost rural regions and a sub-sample of 853 women in urban Greater Accra. RESULTS: Prevalence's of rest deprivation were 0.13% nationally, 14.5% in Greater Accra and 16.8% in the North. The significant correlates nationally were age, education, wealth index, Christian religion and literacy. In Accra, they were age, wealth index, having household electricity, and possession of a refrigerator, a stove and a mobile phone. In the North, they were education, occupation, drinking water source, possession of motorcycle/scooter, Christian religion, literacy, and possession of a clock and a cupboard. In logistic regression analyses controlling for age in the national sample, the significant odds ratios were 1.40 for no education compared to secondary and higher education, 0.78-0.43 for the four poorer wealth quintiles compared to the richest wealth index quintile, and 0.55 for Christian religion compared to all others.Also controlling for age, the significant odds ratios in Accra were 2.15 for the second richest wealth quintile compared to the richest quintile and 0.16 for possession of a mobile phone. In the North they were 0.49 for Christian religion compared to all others, 1.87 for having a protected compared to an unprotected water source, and 0.41 for having a cupboard in the home. CONCLUSIONS: Education, wealth and religion were related to rest deprivation nationally but not in the urban and rural regions (except for religion in the North). This suggests caution in generalising about the social correlates of rest deprivation at a regional level, based on national-level data. Qualitative research in local contexts is needed in order to illuminate the social determinants of rest pattern, and to provide guidance about better ways to measure such determinants in future survey research.

Intervention to enhance empowerment in breast cancer self-help groups.

As arduous psychological reactions and loss of control almost inevitably represent a challenge for women diagnosed and treated for breast cancer, a participatory intervention study was initiated that aimed to enhance empowerment in breast cancer self-help groups. Women newly diagnosed with breast cancer were invited to participate. The intervention encompassed three professionally led self-help groups running sequentially, each group for approximately 4 months. Each group of five to seven participants met weekly. Several empowerment strategies were initiated by two professional facilitators, aiming to promote empowerment processes and to manage stress. The participants experienced group participation as both empowering and as a valuable source of support, and although the group processes developed very differently, a strong sense of fellowship developed in all three groups. The discussion highlights the findings in relation to several theoretical perspectives including social capital, social cohesion, risky agreements, helper-therapy and power/empowerment. We conclude that empowerment strategies that are implemented in professionally led breast cancer self-help groups can contribute to participant empowerment and function as an important source of re-discovery and confirmation of the participants' strengths and abilities.

Domains of core competency, standards, and quality assurance for building global capacity in health promotion: the galway consensus conference statement.

This paper reports the outcome of the Galway Consensus Conference, an effort undertaken as a first step toward international collaboration on credentialing in health promotion and health education. Twenty-nine leading authorities in health promotion, health education, and public health convened a 2-day meeting in Galway, Ireland, during which the available evidence on credentialing in health promotion was reviewed and discussed. Conference participants reached agreement on core values and principles, a common definition, and eight domains of core competency required to engage in effective health promotion practice. The domains of competency are catalyzing change, leadership, assessment, planning, implementation, evaluation, advocacy, and partnerships. The long-term aim of this work is to stimulate a global dialogue that will lead to the development and widespread adoption of standards and quality assurance systems in all countries to strengthen capacity in health promotion, a critical element in achieving goals for the improvement of global population health.

Learning as an empowerment process in breast cancer self-help groups.

AIM: This intervention study aimed to promote and examine empowerment processes in women recovering from breast cancer and participating in self-help groups. BACKGROUND: Feelings of powerlessness may follow from being diagnosed and treated for breast cancer. In theory, self-help groups may stimulate empowerment, which stands in contrast to powerlessness, by increasing the participants' sense of control. Professional assistance may contribute positively, by assuring that the issue of empowerment is addressed. DESIGN: The study had an intervention design based on the ideas of empowerment and self-help. Three professionally led self-help groups were established. The groups ran sequentially and met weekly for approximately four months. METHODS: Eighteen women in groups of 5-7 participated in self-help group discussions and also in focus group interviews, which provided the main study data. Each group was interviewed three times. Observation data provided a basis for comprehension of the groups' culture, relationships and processes. RESULTS: Learning appeared as one of three salient components in empowerment processes in the self-help groups. This learning component consists of four elements: consciousness-raising, acquisition of objective knowledge, learning from others' experiences and discovery of new perspectives in life and in oneself. CONCLUSIONS: The study shows that self-help groups focusing on empowerment issues made a valuable contribution to recovery and are strongly recommended by the participants. RELEVANCE TO CLINICAL PRACTICE: This study suggests that best practice, for those who manage self-help programmes of all types, may be to arrange for empowerment to be an explicit aspect of the intervention, guided by professionals with training in group facilitation and knowledgeable about the facilitation of empowerment in particular.

Setting an ethical agenda for health promotion.

The Bangkok Charter for Health Promotion in a Globalized World has sparked lively dialogue. Welcomed by some as a Charter current to the times, there are others who see it as an unneeded and therefore unwelcome challenger to the Ottawa Charter for Health Promotion. Intended or not, the Bangkok Charter seems to signal a shift in discourse, from a social-ecological approach and an emphasis on individual and community capacity-building and empowerment, to an investment approach and an emphasis on globalization, macro-level factors and policy. Positively, the Bangkok Charter proclaims to build on Ottawa, and no one suggests it is meant to replace the Ottawa Charter outright. In concert with that, the dialogue today is not so much about the ascendancy of the one Charter over the other, but about the degree to which the Bangkok Charter remains true to the ethic of the Ottawa Charter. It is welcome that the Ottawa and Bangkok Charters are the subject of brisk dialogue about strategy and tactics in a rapidly changing world, and about the foundational values of health promotion. Regarding the latter, we have unfinished work in constructing an ethic for health promotion, and the present dialogue may inspire us to progress. Though we have the cornerstone of an ethic for health promotion, in the Ottawa Charter and in other principled documents that have followed, we have yet to build sufficiently on the cornerstone; an ethic for practice has yet to be codified, and the same is true for research. Health promotion journals, conferences and organizations can and should do more to facilitate dialogue on ethics in health promotion, and the Internet provides the means for all to participate actively.

Partnership lessons from the Global Programme for Health Promotion Effectiveness: a case study.

It is an article of faith in health promotion that health challenges cannot be confronted successfully by actors working in isolation. The synergy produced through collaboration is seen as vital. Yet, collaboration is arduous and many collaborations fade before their goals are met. Research is needed to identify factors and processes that promote as well as inhibit the production of synergistic outcomes. To this end, a case study was undertaken of the Global Programme for Health Promotion Effectiveness (GPHPE). The GPHPE reviews and disseminates evidence for the effectiveness of health promotion. Interviews with 20 GPHPE participants were conducted, transcribed and analyzed, and GPHPE documentation provided additional data. The results were used to develop the Bergen Model of Collaborative Functioning. It is a systems model (input, throughput, output) building on earlier research, that adds three new elements suggested by the findings of this study. First, the partnership's mission--to disseminate evidence of effectiveness--was identified as a significant input (alongside the conventional inputs of partner resources and financing) that affected the GPHPE's functioning in fundamental ways. Second, positive and negative cycles of interaction were identified that simultaneously strengthened and weakened the GPHPE's ability to sustain itself and produce the desired outcomes. Third, the construct 'antagony' was introduced as a unique type of output, in addition to synergy and additive results, representing unwanted and disturbing outcomes. The Model is constructed to have wide applicability, and further research now underway tests its utility in the study of local and national collaborations.

Community nurses who thrive: the critical role of job engagement in the face of adversity.

Among community health nurses who thrive despite difficult working circumstances, habitual introspection and reflection about job engagement helped them make positive, adaptive adjustments in their working life. A practical implication is the need to educate nurses about the importance of reflection not only over nursing practice but also of habitual introspection and reflection about their job engagement. Nurses in staff development should teach and reinforce the needed skills and habits.

Commentary: improving the quality and effectiveness of IUHPE communications: work plan 2007--2010.

The article presents the work plan of the IUHPE Communications portfolio during the present term of the Vice-President for communications in the IUHPE Board of Trustees (2007-10). The plan has been put together after a comprehensive review of the existing IUHPE communications areas. The result is a plan that aims to provide overarching support for the development of the organisation. In the plan, existing IUHPE communication tools are strengthened to respond better to today's communications' aims and objectives; while new tools are designed to make an impact through all communications' channels. The quality and effectiveness of these tools will contribute to shape a sustainable communications strategy and priorities.

Higher education in health promotion in Europe: a comparative analysis of master's level training programmes using HP-Source.net.

This report summarises opportunities in Europe for master's degree level training in health promotion. Using data available at www.HP-Source.net, 105 study programmes at 71 institutions, spread over 20 European countries, were identified that include health promotion as a main subject. The programmes were analysed along a number of dimensions, including title, learning objectives, curricula, learning and teaching methods, entry requirements, duration, accreditation, language(s) of instruction and participation in European educational structures. The present analysis reveals great diversity along all these dimensions, but also several clusters of programmes that offer quite similar education in health promotion. Of special interest is the range of options available in Europe for length of study, ranging from one to two years, with part-time as well as full-time options.

Enhancing the effectiveness of the International Union for Health Promotion and Education to move health promotion forward.

The success in recent years of many IUHPE initiatives provides cause for celebration, but also reminds us of the challenges that lie ahead. The Global Programme for Health Promotion Effectiveness provides a blueprint for how the IUHPE can effectively participate in, and lead, global networks for health. Health promotion research is well organized and productive in most of the Northern hemisphere, but important wells of health promotion knowledge in the Southern hemisphere are not widely-enough disseminated. The IUHPE needs to help liberate knowledge producers everywhere from unnecessary structures, and find innovative ways to illuminate knowledge for all to see. We have developed and proven the effectiveness of a range of technologies such as settings-based health promotion. However, the vast majority of communities are untouched, and the IUHPE needs to be a leader in finding ways to better disseminate effective health promotion practice. The IUHPE is a vigorous and effective advocate for health promotion training, practice and research. Now we need to expand our advocacy for equity in health, building on our effective work on social clauses in trade agreements and on tobacco control.

Household food security and adequacy of child diet in the food insecure region north in Ghana.

BACKGROUND AND OBJECTIVES: Adequate diet is of crucial importance for healthy child development. In food insecure areas of the world, the provision of adequate child diet is threatened in the many households that sometimes experience having no food at all to eat (household food insecurity). In the context of food insecure northern Ghana, this study investigated the relationship between level of household food security and achievement of recommended child diet as measured by WHO Infant and Young Child Feeding Indicators. METHODS: Using data from households and 6-23 month old children in the 2012 Feed the Future baseline survey (n = 871), descriptive analyses assessed the prevalence of minimum meal frequency; minimum dietary diversity, and minimum acceptable diet. Logistic regression analysis was used to examine the association of minimum acceptable diet with household food security, while accounting for the effects of child sex and age, maternal -age, -dietary diversity, -literacy and -education, household size, region, and urban-rural setting. Household food security was assessed with the Household Hunger Scale developed by USAID's Food and Nutrition Technical Assistance Project. RESULTS: Forty-nine percent of children received minimum recommended meal frequency, 31% received minimum dietary diversity, and 17% of the children received minimum acceptable diet. Sixty-four percent of the children lived in food secure households, and they were significantly more likely than children in food insecure households to receive recommended minimum acceptable diet [O.R = 0.53; 95% CI: 0.35, 0.82]. However, in 80% of food secure households, children did not receive a minimal acceptable diet by WHO standards. CONCLUSIONS: Children living in food secure households were more likely than others to receive a minimum acceptable diet. Yet living in a food secure household was no guarantee of child dietary adequacy, since eight of 10 children in food secure households received less than a minimum acceptable diet. The results call for research into factors besides household food security in the search for determinants of child diet adequacy. In this study at least, household food security was a very weak marker of child diet adequacy. This finding is of significance to public health practice, since it calls into question any assumption that having enough food in a household necessarily results in adequately fed children.