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.
Edwards and Hartwell (2002)
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.
Edwards and Hartwell (2002)
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.
Edwards and Hartwell (2002)
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.
Edwards and Hartwell (2002)
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.
Healthier food options
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.
Healthier food options
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.
Healthier food options
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
Pricing 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
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.
Culturally relevant information
The study included 368 Native
American adolescents whose schools
participated in either an intervention or
a control program.
Culturally relevant information
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).
Culturally relevant information
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.
Culturally relevant information
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.
Culturally relevant information
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.
Peer-based programmes
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‘.
Peer-based programmes
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.
Peer-based programmes
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 300
employees at the company.
Health hazard appraisal
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.
Health hazard appraisal
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.
Health hazard appraisal
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.
Health hazard appraisal
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.
Health hazard appraisal
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).
Health hazard appraisal
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:
Health hazard appraisal
· (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
Health hazard appraisal
· (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;
Health hazard appraisal
· (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.
Johnson & Johnson's "Live
for Life" Program
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.
Johnson & Johnson's "Live
for Life" Program
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.
Johnson & Johnson's "Live
for Life" Program
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.
Johnson & Johnson's "Live
for Life" Program
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.
1. Some sites did not offer the Staywell program,
and therefore could be used as controls.
2. 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.
Coronary heart Disease
and mass media appeals
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.
Coronary heart Disease
and mass media appeals
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.
Coronary heart Disease
and mass media appeals
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.
Coronary heart Disease
and mass media appeals
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.
Coronary heart Disease
and mass media appeals
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
Reducing skin cancer risk
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.
Reducing skin cancer risk
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).
Reducing skin cancer risk
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.
Reducing skin cancer risk
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.
Reducing skin cancer risk
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.
Reducing skin cancer risk
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.
Reducing skin cancer risk
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,
1996). 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