P&E by VION - Issuu

Volume XIII Number 1 2006

QUARTERLY TRIMESTRIEL TRIMESTRAL INTERNATIONAL JOURNAL OF HEALTH PROMOTION AND EDUCATION

REVUE INTERNATIONALE DE PROMOTION DE LA SANTÉ ET D’ÉDUCATION POUR LA SANTÉ

REVISTA INTERNACIONAL DE PROMOCIÓN DE LA SALUD Y EDUCACIÓN PARA LA SALUD

Advancing knowledge • Preffi 2.0- a quality assessment tool • Cultural and Western influences on the nutrition transition in Thailand • Health promotion policies in the Republic of Korea and Japan: a comparative study

Advocacy • Background information for adopting a policy encouraging earmarked tobacco and alcohol taxes for the creation of health promotion foundations • ‘We don’t want to manage poverty’: community groups politicise food insecurity and charitable food donations

Networking

ISSN 1025 - 3823

• Women’s Health Resources: facilitating a community of care for midlife women

Promotion & Education: français page 50 español página 68 Published by the International Union for Health Promotion and Education.

Promotion & Education, the International Journal of Health Promotion & Education, is an official publication of the International Union for Health Promotion & Education (IUHPE). It is a multilingual journal, which publishes authoritative peer-reviewed articles and practical information for a world-wide audience of professionals interested in health promotion and health education. The content of the journal reflects three strategic priorities of the IUHPE, namely, advancing knowledge, advocacy and networking.

Promotion & Education, la Revue internationale de Promotion de la Santé et d’Éducation pour la Santé, est une publication officielle de l’Union internationale de Promotion de la Santé et d’Éducation pour la Santé (UIPES). Il s’agit d’une revue multilingue, contenant des articles de référence sur tous les aspects théoriques et pratiques de la promotion de la santé et de l’éducation pour la santé. Elle s’adresse à un public de professionnels de toutes les régions du monde. Le contenu de la revue reflète trois des priorités stratégiques de l’UIPES, à savoir, développement des connaissances et compétences, plaidoyer pour la santé, et communication et travail en réseau.

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4 7

Editorial Health promoting settings: future directions M. Dooris

The statement of the Global Consortium on Community Health Promotion S. Nishtar et al.

Advancing Knowledge Prefﬁ 2.0- a quality assessment tool G. R. M. Molleman et al.

Cultural and Western inﬂuences on the nutrition transition in Thailand K. L. Craven and S. R. Hawks

Health promotion policies in the Republic of Korea and Japan: a comparative study E. W. Nam et al.

Dossier Français

Advocacy Background information for adopting a policy encouraging earmarked tobacco and alcohol taxes for the creation of health promotion foundations K. Slama ‘We don’t want to manage poverty’: community groups politicise food insecurity and charitable food donations M. Rock Networking Women’s Health Resources: facilitating a community of care for midlife women L. M. Meadows, et al.

Éditorial Milieux de vie et promotion de la santé : orientations futures M. Dooris Communiqué concernant le Consortium mondial sur la Promotion de la Santé communautaire S. Nishtar et al. Plaidoyer Informations de référence pour l’adoption d’une politique en faveur de taxes sur le tabac et l’alcool qui soient affectées a la création de fondation de promotion de la sante K. Slama

Résumés

Info de l’UIPES

Cuaderno Español 68

IUHPE Info

Editorial Entornos de promoción de la salud: orientaciones de futuro M. Dooris Declaración del Consorcio Mundial para la Promoción de la Salud Comunitaria S. Nishtar et al. Abogacía Información preparatoria para la adopción de una política que fomente la preasignación de los ingresos derivados de los impuestos sobre el tabaco y el alcohol a la creación de fundaciones de promoción de la salud K. Slama

Resúmenes

Info de la UIPES

Contents Sommaire Índice

English Section

Volume XIII Number 1 2006

Mark Dooris

Health promoting settings: future directions Looking back: reflections In 1986, the Ottawa Charter (WHO, 1986) declared that «Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.» The charter is widely acknowledged to have been the catalyst to the health promoting settings movement – resulting in the settings approach becoming the starting point for WHO’s health promotion programmes, with a commitment to «…shifting the focus from the deficit model of disease to the health potentials inherent in the social and institutional settings of everyday life» (Kickbusch 1996: 5). Two decades later, it is clear that the settings approach has captured the imagination of organisations, communities and policy-makers across the world. Since the Ottawa Charter, a plethora of international and national programmes and networks have emerged, covering settings as diverse as regions, districts, cities, islands, schools, hospitals, workplaces, prisons, universities and marketplaces. Accompanying this, the concept of health promoting settings has become firmly integrated within international health promotion policy. For example, the Jakarta Declaration strongly endorsed the approach within the context of Investment for Health (WHO, 1997); WHO included the term ‘settings for health’ within its Health Promotion Glossary, defining it as «the place or social context in which people engage in daily activities in which environmental, organisational and personal factors interact to affect health and wellbeing» (WHO, 1998a: 19); the new European Health for All Policy Framework, Health 21 included a target focused on settings (WHO, 1998b: 100); and most recently, the Bangkok Charter (WHO, 2005) highlights the role of

Mark Dooris Director Healthy Settings Development Unit Lancashire School of Health and Postgraduate Medicine Faculty of Health University of Central Lancashire, UK Email: mtdooris@uclan.ac.uk

settings in developing strategies for health promotion and the need for an integrated policy approach and commitment to working across settings. However, despite this popularity and championing, the approach has, arguably, not gained as much influence as it might have – in terms of either guiding wider international policy or driving national-level public health strategy. In seeking to understand this, it is useful to reflect on the views of Ilona Kickbusch, an early advocate. She has suggested that because the logic of the settings approach is a non-medical one, it is more easily understood by community members and political decision makers than by ‘health’ professionals (Kickbusch, 1996) and has commented that what settings initiatives achieve “does not fit easily into an epidemiological framework of ‘evidence’ but needs to be analysed in terms of social and political processes” (Kickbusch, 2003: 386).

Looking to the future: challenges In looking to the future and seeking to increase the inﬂuence of the settings approach, we therefore face a number of inter-linked challenges. Clarifying the theoretical base for health promoting settings work Firstly, a range of terminology has been used and a diversity of understandings and practice has been brought together under the health promoting settings ‘banner’. Whilst terms such as ‘health promoting settings’ and ‘healthy settings’ have increasingly been used interchangeably, with a dual focus on context and methods, it is important to acknowledge the semantic differences between them and the possible inﬂuences on understanding and practice – the former more clearly suggesting a focus on people and a commitment to ensuring that the setting takes account of its external health impacts. This echoes early work by Baric (1993), who suggested that standards should include three key dimensions – a healthy working and living environment, integration of health promotion into the

daily activities of the setting, and reaching out into the community. At a conceptual level, Wenzel (1997) has highlighted the tendency to conflate ‘health promotion in settings’ with ‘health promoting settings’, suggesting that the settings approach has been used to perpetuate traditional individuallyfocused intervention programmes. Whitelaw et al (2001) have discussed the variance in understanding and practice, emphasising the difficulties of translating philosophy into action and presenting a typology of settings practice. And Poland et al (2000) have focused on the differences within and across categories of settings – for example, workplaces differ in size, structure and culture; and a ‘total institution’ such as a hospital or school is very different to a less formal setting such as a home or neighbourhood. These differences become even more apparent when settings are viewed globally, and the influences of different cultural, economic and political factors are taken into account. All these issues point to the importance of balancing an acceptance of heterogeneity and difference with a complementary focus on building a shared conceptual understanding of the settings approach. Whilst there can indeed be a “tyranny…in the assertion or creation of consensus” (Green et al, 2000: 26), the articulation of theory can be constructive in guiding future practice. To this end, Dooris (2005) has drawn on the literature to suggest that the approach is characterised by three key characteristics: an ecological model of health, a systems perspective and a whole system organisation development and change focus. Staying with the bigger picture The second challenge, closely related to the conceptualisation of settings, is to stay with the bigger picture. Although people’s lives straddle different settings

Keywords • settings • evidence-base

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editorial

(either concurrently or consecutively), there is a continuing danger that the settings approach may encourage insularity and fragmentation, and unwittingly divert attention from the overarching social, economic and environmental inﬂuences on health. It is important, therefore, to make connections both outwards and upwards. Settings operate at different levels and, like ‘russian dolls’, may be located within the context of another. Galea et al (2000) discuss this, suggesting that a distinction should be made between different levels of ‘elemental’ and ‘contextual’ settings. For example, a hospital or school will be within a particular neighbourhood, within a larger town or city, within a district, region or island. Echoing Bronfenbrenner’s work on social ecology (Bronfenbrenner, 1994), we need to view individual settings as part of a bigger whole – and work to enhance the synergy between them and to maximise their contribution to the well-being of communities and cities. We need to lift our focus and consider what makes places liveable and vibrant, then take this diagnosis and apply it to the settings with which we work. Maybe we have to risk letting go of the explicit language of health, but in doing so release the energy to facilitate the innovative and creative change that can lead to more sustainable system-level well-being. As highlighted in the Bangkok Charter (WHO, 2005), it is also necessary to use advocacy and policy development to encourage action to address the determinants of health in the context of our globalised world. This will mean ensuring an integrated approach within settings, whereby the connections between health and other policy arenas are acknowledged and understood; developing wider corporate social responsibility as an integral dimension of the settings approach, thus highlighting external as well as internal institutional impacts (Dooris, 2004); and joining up settings in partnerships to speak with a single voice that can maximise their collective ability to inﬂuence regional, national and international policy.

Developing the evidence-base The third challenge concerns evidence. Whilst the settings approach is widely perceived to have a range of benefits, and evidence and evaluation reviews have included a focus on settings (International Union for Health Promotion and Education, 2000; Rootman et al, 2001), it remains true that: The settings approach has been legitimated more through an act of faith than through rigorous research and evaluation studies…much more attention needs to be given to building the evidence and learning from it. (St Leger, 1997: 100) There are a number of specific issues that make it difficult to build a convincing evidence base (Dooris, 2005). Firstly, the ways in which evaluation is funded and the evidence base for public health and health promotion is constructed reflect a continuing focus on specific diseases and single risk factor interventions. Secondly, the diversity of understandings and practice referred to above creates obvious problems in generating a substantive body of research that allows comparability and transferability. Thirdly, it is complex to evaluate the settings approach as defined in terms of an ecological approach and systems thinking – which, as Senge (1990) has argued, is a framework for seeing interrelationships and patterns of change rather than static ‘snapshots’. This requires a non-linear approach that recognises the interrelationships, interactions and synergies within and between settings. Researchers also need to recognise the synergistic effects of combining different methods to answer different research and evaluation questions (Baum, 1995, Steckler et al, 1992) and to combine specific ‘health’ measures with measures that focus on the core business of the setting (Lee et al, 2005). The result has been a tendency to evaluate discrete projects in settings rather than initiatives as a whole, mitigating against the generation of credible evidence of effectiveness for the

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

settings approach in terms of ‘added value’ and synergy. A possible way forward is to draw on the experience of ‘theory-based evaluation’, but to do this will require us to clarify the theoretical base, engage with policy makers to ensure that the evidence is being generated for a purpose (de Leeuw and Skovgaard, 2005) and secure adequate long term funding.

Conclusion Ziglio et al (2000) have argued that, despite an apparent widespread acceptance of a socio-ecological model of health, health promotion has continued to focus on single issues, achieving little impact on the determinants of health or policy development. They go on to suggest that these impacts will not occur “until the starting point for action is the creation of health…[and] it is accepted that social systems are complex and interwoven, and their interconnections are crucial to the creation of health.” The settings approach can make a valuable contribution to planning and delivering health and well-being in ways that takes account of this complexity, within the places that people live their lives. To do so, it needs to address the challenges outlined above, clarifying theory, staying with the bigger picture and generating evidence of effectiveness. IUHPE is committed to this process and to a vision of ‘joined-up’ health promoting settings. It will be looking to gather evidence of effectiveness and to encourage dialogue and debate at its forthcoming conferences – including the Nordic Health Promotion Research Conference in June 2006, the World Conferences in Vancouver and Hong Kong in 2007 and 2010. We invite you to contribute and get involved!

Acknowledgements Many thanks to Christiane Stock, Jürgen Pelikan, Albert Lee and Catherine Jones for their helpful comments and suggestions in preparing this editorial.

References Baríc, L. (1993) The settings approach – implications for policy and strategy. Journal of the Institute of Health Education, 31, 17-24. Bronfenbrenner, U. (1994). Ecological models of human development. In Husen, T. & Postlethwaite, T. (eds.), International Encyclopedia of Education, Vol. 3, 2nd ed., 1643-1647. Pergamon Press/Elseiver Science, Oxford. Baum, F. (1995) Researching public health: beyond the qualitative and quantitative method debate. Social Science and Medicine, 55, 459-468. Dooris, M. (2004) Joining up settings for health: a valuable investment for strategic partnerships? Critical Public Health, 14, 3749. Dooris, M. (2006) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International, 21, 55-65. Galea, G., Powis, B. and Tamplin, S. (2000) Healthy islands in the Western Pacific – international settings development. Health Promotion International, 15, 169-178. Green, L., Poland, B. & Rootman, I. (2001) The setting approach to health promotion. In Green, L., Poland, B. & Rootman, I. (eds) Settings for Health Promotion: Linking Theory and Practice. Sage, London. International Union for Health Promotion and Education (2000) The Evidence of Health Promotion Effectiveness. Shaping Public

Health in a New Europe. Part Two: Evidence Book. Paris: Jouve Composition & Impression.

St Leger, L. (1997) Health promoting settings: from Ottawa to Jakarta. Health Promotion International, 12, 99-101.

Kickbusch, I. (1996) Tribute to Aaron Antonovsky – ‘what creates health’. Health Promotion International, 11, 5-6.

Wenzel, E. (1997) A comment on settings in health promotion. Internet Journal of Health Promotion. http://elecpress.monash.edu.au/IJHP/1997/ 1/index.htm (date last accessed 26 January 2006).

Kickbusch, I. (2003) The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93, 383-388. Lee, A., Cheng, F., St Leger, L (2005). Evaluating health promoting schools in Hong Kong: the development of a framework. Health Promotion International, 20(2): 177186. de Leeuw, E. and Skovgaard, T. (2005) Utility-driven evidence for healthy cities: problems with evidence generation and application. Social Science and Medicine, 61, 1331–1341. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D., Potvin, L., Springett, J. and Ziglio, E. (eds) (2001) Evaluation in Health Promotion: Principles and Perspectives. World Health Organization Regional Office for Europe, Copenhagen. Senge P. (1990) The Fifth Discipline: The Art and Practice of the Learning Organization. Random House, London. Steckler, A., McLeray, K. and Goodman R. (1992) Towards integrating qualitative and quantitative methods: an introduction (Éditorial). Health Education Quarterly, 19, 1-8.

Whitelaw, S., Baxendale, A., Bryce, C., Machardy, L., Young, I. & Witney, E. (2001) Settings based health promotion: a review. Health Promotion International, 16, 339353. Ziglio, E., Hagard, S. and Griffiths, J. (2000) Health promotion development in Europe: achievements and challenges. Health Promotion International, 15, 143-153. World Health Organization (WHO) (1986) Ottawa Charter for Health Promotion. WHO, Geneva. World Health Organization (WHO) (1997) Jakarta Declaration on Health Promotion into the 21st Century. WHO, Geneva. World Health Organization (WHO) (1998a) Health Promotion Glossary. WHO, Geneva. World Health Organization (WHO) (1998b) Health21 – The Health for All Policy for the WHO European Region – 21 Targets for the 21st Century. WHO Regional Office for Europe, Copenhagen. World Health Organization (WHO) (2005). Bangkok Charter for Health Promotion in a Globalised World. WHO, Geneva.

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statement Sania Nishtar, Marco Akerman, Mary Amuyunzu-Nyamongo, Daniel Becker, Simon Carroll, Eberhard Goepel, Marcia Hills, Marie-Claude Lamarre, Alok Mukopadhyay, Martha Perry and Jan Ritchie

The statement of the Global Consortium on Community Health Promotion Sania Nishtar Heartfile Islamabad, Pakistan Email: Sania@heartfile.org Marco Akerman Facultade do ABC Sao Paolo, Brazil Mary Amuyunzu-Nyamongo African Institute for Health and Development Nairobi, Kenya Daniel Becker Centre for Health Promotion- CEDAPS Rio de Janeiro, Brazil Simon Carroll Centre for Community Health Promotion Research University of Victoria Victoria, Canada Eberhard Goepel University of Magdeburg Magdeburg, Germany Marcia Hills Centre for Community Health Promotion Research University of Victoria Victoria, Canada Marie-Claude Lamarre Internation Union for Heath Promotion and Education Alok Mukopadhyay Voluntary Health Association of India New Delhi, India Martha Perry Internation Union for Heath Promotion and Education Jan Ritchie University of New South Wales Sydney, Australia

Keyword • community health promotion

z The Global Consortium on Community Health Promotion – a collaborative initiative of the IUHPE - has been established to foster and strengthen effective community health promotion efforts at international, regional, national and local levels to enable people within communities to increase control over and improve their health. Encompassing diverse and complementary actions directed towards determinants of health, community health promotion focuses on communities as a whole in the context of their everyday lives. The concept of ‘community health promotion’ builds on the Ottawa Charter (WHO, 1986) emphasising that health promotion must be a value-based, empowering process, enabling people, in their communities, to take control over the determinants of their health. It is this participatory, empowering and equity-focused process that forms the fundamental bedrock of community health promotion. The concept also envisages strengthening linkages between health professionals that serve within community settings and people within communities to broaden the base of health systems from ones orientated to ‘healthcare’to ones focused on improving health. Within this context a set of strategic and operational parameters are outlined. These form the cornerstones of the Community Health Promotion initiative.

Strategic parameters The Global Consortium on Community Health Promotion has set out a vision for the future in which all populations have an equal opportunity to attain the highest possible level of health and well-being; where the right to health for all people is upheld and acted upon as a fundamental principle of social justice; where health inequities are eliminated and where community assets for health are fully actualized. This initiative is grounded in the realization that health promotion is essential to advancing health equity and social justice across the life course and is critical to well being and quality of life.

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The Consortium recognises that community participation is essential and must drive every stage of health promoting actions – setting priorities, making decisions, planning strategies and conducting evaluation. The Consortium also recognises that communities have assets and local knowledge that must be acknowledged and taken into account and that they also need support and encouragement to create the necessary conditions for health. The Consortium maintains that developing and implementing participatory healthy public policies is fundamental for ensuring the right to healthy environments for all people and that this is a prerequisite to move beyond approaches focused primarily on individual behaviour change. The Consortium’s strategies underscore the need for complementary and integrated approaches directed towards determinants of health. The Consortium believes that these approaches are critical to impact global agreed health and development targets as embodied within the Millennium Development Goals. Mainstreaming health promotion into global, national, regional and local health policies and integrating health outcomes into a broader policy context is critical to improving health outcomes. This stems from the Consortium’s belief that factors, which impact health status are much broader than those that are within the realm of the health sector and that these encompass social welfare, economic development, social justice, politics, trade, environment and national security. The Consortium believes objectives and targets within the health sector must take into account the aforementioned societal factors and that these need to be set within a more explicit policy framework in order to foster inter-sectoral collaboration between stakeholders both within and outside of the traditional health sector. The Consortium underscores the need for adequate resources to ensure the effective implementation of these policies and the

setting up of approaches to health that are based on inter-sectoral action linking people with their environments. The Consortium is committed to encouraging to international agencies, governments and other stakeholders to mainstream community health promotion as part of global and country development agendas and to lobby for appropriate resources in line with this approach. Based on these values and principles, the primary purpose of the Consortium is to promote the use of sustainable participatory methodologies to improve community health. Within this context, we will identify, review and analyse practices and policies from different parts of the world that are relevant to developing and disseminate policy recommendations for strengthening effective community health promotion programmes. The Consortium will provide technical assistance – as appropriate – to promote the use of evidence of effective community health promotion interventions particularly to specialty networks; it is envisaged that this will contribute to the development of strategic plans, which increase international impact of research in effective community health programmes. Other objectives focus on providing networking opportunities between policy makers and practitioners to raise awareness about the range and variability of community health

practices, training opportunities, and infrastructures around the world; catalyzing sharing of experiences; and developing and strengthening collaborative efforts to promote community health promotion.

Operational parameters Given its strategic parameters, the Consortium has outlined a number of initial steps towards operationalising its vision into concerted action. The creation of an institutional mechanism as an entity coordinated by the IUHPE and consisting of a network of experts in community health promotion is the ﬁrst step in this direction. As a next step, a consensus has been achieved to develop a “Community Health Promotion Dossier”. This Dossier aims to improve understanding about community health promotion; present an analysis of the current community health promotion practices and describes evidence upon which policy recommendations for community health promotion can be issued. The Consortium will also use the process of developing the Community Health Promotion Dossier as a tool to establish global partnerships for community health promotion including mainstreaming community health promotion on the global health and sustainable development agenda. Additional activities of the Consortium include overseeing a forthcoming issue

of the IUHPE ofﬁcial Journal Promotion & Education dedicated to community health promotion a one day symposium preceding the upcoming 19th IUHPE World Conference on Health Promotion and Health Education in 2007 in Vancouver, Canada. With these modest beginnings, the Consortium is contributing to existing efforts to place community health promotion prominently on the global and country health and development agendas – a place it rightly deserves.

Acknowledgements The Global Consortium on Community Health Promotion is supported, in part, by funding from the Centers for Disease Control and Prevention (CDC) through Cooperative Agreement Number U50 CCU021856-05 on “Global Health Promotion and Health Education Initiatives Related to Chronic Disease.” The authors wish to acknowledge the technical assistance provided by Marilyn Metzler, RN, of McKing Consulting Corporation and assigned to the National Center for Chronic Disease Prevention and Health Promotion, CDC.

Reference WHO (1986) Ottawa Charter. Proceedings of the First International Conference on Health Promotion. Ottawa, Canada, 21 November 1986. www.who.int/hpr/NPH/docs/ottawa_charter _hp.pdf [accessed 06, 05]

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Advancing knowledge Gerard R.M. Molleman, Machteld A. Ploeg, Clemens M.H. Hosman and Louk H. M. Peters

Preffi 2.0- a quality assessment tool Abstract: The findings of many metastudies into the effects of health promotion programmes indicate that there is still much room for improvement in the quality of these programmes. Insights gained from research are rarely applied in practice. Practitioners and policymakers often find it hard to assess the value of the many and sometimes contradictory research findings, partly because the necessary contextual information is usually lacking. Practical considerations force them to respond to specific problems at short notice in the form of programmes that are as effective as possible. Hence, effective health promotion requires not only the dissemination of effective programmes but also insights into principles of effectiveness and the way professionals use these insights. It is against this background that the Netherlands Institute for Health

Promotion and Disease Prevention (NIGZ) has developed and implemented the Preffi instrument. Preffi consists of a set of guidelines with items relevant to the effectiveness of health promotion and prevention projects, reflecting scientific and practical knowledge about effect predictors. This article describes the systematic, seven-step development process of the second version of the instrument, Preffi 2.0, a process in which scientists and practitioners were closely involved throughout. The article also describes the Preffi model and its scoring method. The draft version of Preffi 2.0 was tested for usefulness among 35 experienced practitioners from a range of health promotion institutes. They were asked to use the draft version to assess two project descriptions and to comment on their experiences using Preffi 2.0. They gave the instrument an average overall

mark of 7.7 on a scale of 10, and the large majority of them evaluated the instrument as valuable, complete, clear, well-organised and innovative. The findings of this trial implementation were used to construct the definitive version of Preffi 2.0. To an experienced user, applying Preffi to assess a project takes less than an hour. Preffi is used as a diagnostic quality assurance instrument at various stages of a project, either to critically evaluate one’s own project or to comment on projects proposed by others. Assessing other people’s projects may be difficult if the necessary information is lacking or unclear. A supplementary discussion with the project manager is always required. Users have commented that applying Preffi to a project yields a balanced and useful assessment, as well as a clear overview of points in the project that could be improved.

This manuscript was submitted on June 10, 2004. It received blind peer review and was accepted for publication on September 26, 2005.

What makes health promotion programmes effective? How can projects be designed and implemented so as to maximise the chances of it being effective?

studies into the effects of health promotion programmes have yielded many new insights, their findings are rarely applied in practical health promotion. Practitioners find it hard to assess the value of the many and sometimes contradictory research findings. In addition, researchers often fail to supply details about the contextual conditions (in terms of available time, funding and support) and circumstances (local context, social, cultural and economic influences, timing) in which the reported effects were achieved, whereas such details are required to decide whether and how the intervention needs to be adjusted to allow its successful repetition or implementation in a different situation. Researchers and practitioners often work to different time-scales. Attempts to improve effectiveness through controlled studies require long-term investments and involve long periods between programme development and the provision of feedback on effects. This is an important but extremely slow process. Policy-makers and practitioners, however, often need faster feedback as well, since they are asked to respond to specific problems at short notice, in the form of preventive programmes and interventions that yield the maximum

Keywords • quality • effectiveness • health promotion

Gerard R.M. Molleman, PhD NIGZ Centre for Knowledge and Quality P.O.Box 500 NL-3440 AM Woerden The Netherlands Phone: +31 348 437621 E-mail: gmolleman@nigz.nl Machteld A. Ploeg, MA NIGZ Finance department Woerden, The Netherlands Clemens M.H. Hosman PhD Prevention Research Centre, Dept. of Health Education and Promotion University of Maastricht, and Dept. of Clinical Psychology University of Nijmegen The Netherlands Louk H. M. Peters, MA NIGZ Woerden, The Netherlands

Over the past 20 years, many researchers have tried to answer these questions in studies focusing on meta-analysis of the effectiveness of programmes, and preferably assessing effectiveness by means of randomised controlled trials (RCTs). These studies have found great variation in the extent to which health promotion programmes are evidencebased (Durlak and Welsh, 1997; Kok et al., 1997; Boddy, 1999) . Although signiﬁcant effects of many programmes have been proven in various countries, the average size of such effects has so far been moderate. And whereas many programmes were found to be effective or moderately effective, many others were poorly effective or even ineffective. In addition, many of the effective programmes have proved to be effective only for part of the target group, only for a limited number of objectives or only in the short or medium term, or to lose some or all of their effectiveness in a different setting. This means that there is much room for improvement in the quality and effectiveness of programmes. Although the various studies and meta-

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effect. In short, what they need is to have insights gained from research translated into practical guidelines, which fit in with the context in which they have to work. This means that stimulating effective health promotion requires a combination of: 1. developing and disseminating programmes that have proven to be effective; and 2. insights into principles of effectiveness that influence the effectiveness of health promotion programmes in practice, and the way professionals use such insights. It was against this background that the Netherlands Institute for Health Promotion and Disease Prevention (NIGZ) initiated the Preffi project in the mid-1990s. The project consists of a longterm process attempting to improve the effectiveness of health promotion efforts by stimulating systematic and critical reflection on programmes and projects. The core element of this project is the Preffi instrument, a set of guidelines on items that help determine the effectiveness of health promotion and prevention projects. These items reflect the available scientific knowledge on effect predictors, as well as insights derived from a critical debate with practitioners about such effect predictors (practical expertise). This article describes the development and content of the second version of this instrument, Preffi 2.0. It is based on data relating to the development process, experiences and implementation which were systematically gathered among users of the instrument at various stages of the process (Molleman and Hosman, 2003; Molleman et al., 2004; Molleman, 2005).

experience gained with Preffi 1.0 since its introduction. The team tried to improve four aspects: content, norms, format and positioning. As regards content, the aim was to incorporate into the second version all recent insights provided by health promotion research and practice. In addition, the Preffi criteria had to be operationalised in such a way as to allow users to compare their own projects against a normative standard and to allow third parties to assess a project. The format developed for the new Preffi version intended to do justice to the cyclical and iterative nature of many health promotion projects. Finally, it was deemed necessary to clarify Preffi’s position as a quality assurance instrument aimed at identifying and improving conditions for the effectiveness of a project. Therefore, it was decided to change the name to Health Promotion Effect Management Instrument. In developing Preffi 2.0, much effort was invested in developing a solid scientific basis and in operationalising all Preffi criteria. To achieve these aims, we collaborated closely with a Scientific Advisory Committee, representing the various bodies engaged in health promotion research in the Netherlands. In addition, a Practitioners’ Advisory Committee, composed of 53 Dutch health promotion professionals, ensured that the users’ perspective would not be neglected.

The systematic development of the Preffi guidelines started in 1994, on the basis of a survey of research findings, an exploration of methods for guideline development and an extensive round of interviews with practitioners. This process resulted in the introduction of the Health Promotion Effectiveness Fostering Instrument, Preffi 1.0, in 1995 (Molleman, 1999).

The development process of Prefﬁ 2.0 was based on a model consisting of a number of systematic steps, and used various methods of formative evaluation, viz., product-oriented, expert-oriented and target-group-oriented methods (Jong and Schellens, 2000). In product-oriented methods, it is the designers themselves who indicate the aspects of the draft design on which they base their evaluation, while in the other two methods, the design is submitted to external experts and to members of the target group, respectively. The Prefﬁ 2.0 design process started with productoriented methods (steps 1-5), followed by expert-oriented methods (steps 4-6) and target-group-oriented methods (steps 6-7).

In 2000, a joint task force of NIGZ and the Prevention Research Centre at Nijmegen University started work to develop a second version of Prefﬁ, building on the

Step 1. The Preffi task force first tried to define the instrument’s position within the general context of quality management. It decided that, as regards

Developing Preffi

output, Preffi should focus on the effectiveness, relevance and coverage of programmes, rather than on other output characteristics such as cost-effectiveness or client satisfaction, at least at this stage of its development. On the input side, Preffi’s focus was to be on the actual operational processes involved in the design and implementation of programmes. Major contextual variables such as structural aspects of organisations (infrastructure, institutional policies, staffing, collaborative relations, etc.) were to be included in Preffi as contextual conditions for the actual operational processes. Step 2. It was decided that the general structuring principle for the operational processes would be that of a systematic approach, since there is broad consensus that a systematic approach improves the effectiveness of prevention programmes (Bartholomew et al., 2001; Glanz et al., 2002) . Together with the contextual conditions dimension, the four stages in a systematic approach (analysis, development, implementation and evaluation) were seen as individual dimensions, and the main effect predictors of each of these five dimensions were identified and explicated. Step 3. Originally, five criteria were defined for the selection of effect predictors, viz., relevance, scientific evidence, generalisability, modifiability and measurability. In the process of applying these criteria, we found that virtually all effect predictors in Preffi 1.0 met the criteria of ‘generalisability’ and ‘modifiability’, which meant that these criteria had hardly any discriminatory value for the selection of the effect predictors. Nor did ‘measurability’ discriminate, since any effect predictor can in principle be made as clear and measurable as possible for the target group of practitioners. This left the criteria of ‘relevance’ and ‘evidence’. The task force decided that the relevance of an effect predictor for the effectiveness of a programme was the most important criterion. Relevance refers to the proven or assumed impact of a particular characteristic or condition of a project on its effectiveness. Each effect predictor was given a score for scientific evidence, to assess the ‘evidence-based’ character of Preffi (Peters et al., 2003). A broad definition of

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Figure 1

Preffi 2.0

the concept of ‘evidence’ was used, for one thing because the predictive value of some effect predictors that are deemed important is hard to prove in controlled quantitative research (which is usually regarded as the highest form of evidence) . The principles of a systematic approach, for instance, are usually based on logical argument, consensus and the findings of multiple case studies. There is still no such thing as an internationally accepted specific ranking of types of evidence, and support is growing for the view that other methods of verification than controlled experimental research are also legitimate (Koelen et al., 2001; McQueen and Anderson, 2002). Step 4. The results of the application of these selection criteria to Preffi 1.0 were first discussed within the task force, then with the individual members of the Scientific Advisory Committee and then in a plenary meeting with the entire committee. The outcome of these consultations was used to define a number of Preffi 1.0 criteria more precisely, though no criteria were removed. The consultations also covered ideas for the addition of new effect predictors. These ideas were based on new insights derived from health promotion research and practice, as well as on the experience gained with Preffi 1.0. Step 5. The selection of effect predictors thus obtained was discussed in detail in an explanatory document that described the nature of each predictor, its relation with effectiveness (relevance) and the

available evidence for this relation. A second document provided a further operationalisation of each predictor in terms of specific questions, as well as the corresponding norms, based on argued consensus between the task force and the scientific advisory committee. This should help the intended users, that is, the practitioners, decide to what extent their projects pay adequate attention to each predictor, while also proposing specific aspects that need to be improved. Step 6. In addition to the Scientific Advisory Committee, the Practitioners’ Advisory Committee was also involved in the various consultations and asked to give its opinion on the explanatory and operationalisation documents for Preffi 2.0. Their feedback was used to introduce various adjustments, such as subdividing effect predictors, clarifying explanations and adjusting the operationalisation and norms. Step 7. A draft version of Preffi 2.0 (consisting of a scoring form, the explanatory document, the operationalisation document and a user manual) was tested for practicability among 35 experienced practitioners from a range of institutes. They were asked to use the draft version of Preffi 2.0 to assess two project descriptions, and then to complete a questionnaire (including both open and closed questions) about their experiences in applying the instrument and their opinions about the various elements of the draft version. Supplementary interviews were held with 10 of the practitioners. The findings of this study were then used to adjust certain aspects of the content and layout of the draft version in the definitive version of Preffi 2.0. In addition, they were used to adjust ideas on the use of the instrument.

Content of Preffi 2.0 Prefﬁ 2.0 consists of an Assessment Package (Molleman et al., 2003), which includes: • the Scoring form, which allows users to allocate scores on a list of quality criteria (= effect predictors), as well as providing room to identify points to be improved and showing a visual representation of the Prefﬁ 2.0 model; • a document called Operationalisation and Norms, which provides operationalisations for each of the

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quality criteria using one or more yes/no-type questions and norms (categories of scores) based on the answers to the operationalisation questions; • a User Manual, which explains Prefﬁ 2.0 and provides instructions for the use of the instrument and each of its components. This is supplemented by an extensive document called Explanatory Guide, which provides further details on the quality criteria (effect predictors) and discusses their importance for the assessment of effectiveness and the available evidence for their impact on effectiveness (including literature references) (Peters et al., 2003) .

The Preffi 2.0 model The main conceptual elements are represented in the Preffi 2.0 model (see Figure 1), which emphasises the dynamic nature of health promotion projects, the permanent interaction between content and contextual conditions and the cyclical nature of the process of health promotion. The central part of the model shows the steps involved in the systematic design and implementation of a project, that is, the actual process of health promotion: analysing the problem, choosing and designing the right intervention, implementing it and evaluating it. These process steps are shown in lozenge shapes because each step first involves looking at a wide range of options (divergence) and then choosing from among these options on the basis of content aspects and contextual conditions (convergence). To give an example: the analysis of the problem ideally involves identifying all potential causes/determinants, after which a choice is made of determinants to be addressed in the intervention, based on substantive arguments, relevance, modifiability and practicability. The lozenges overlap because the selection process should always take the consequences and options in the next stage into consideration. For instance, in choosing a particular intervention, designers should already take account of the opportunities for implementation. The evaluation relates to all moments in the process where choices have to be made, which is why arrows point to all these moments.

changes reﬂect the new scientiﬁc and practical developments and insights that have arisen since 1995.

Figure 2 Health Promotion Effectmanagement Instrument version 2.0 (PREFFI 2.0): Quality Criteria Contextual conditions 1 Contextual conditions and feasibility 1.1 Support/commitment 1.2 Capacity 1.3 Leadership 1.3a Expertise and characteristics of project manager 1.3b Focal points for leadership Analysis 2 Problem analysis 2a Nature, severity, scale of problem 2b Distribution of problem 2c Problem perception by stakeholders 3 3a 3b 3c 3d

Determinants of (psychological) problem, behaviour and environment Theoretical model Contributions of determinants to problem, behaviour or environmental factor Amenability of determinants to change Priorities and selection

Selection and development of intervention(s) 4 Target group 4a General and demographic characteristics of target group 4b Motivation and possibilities of target group 4c Accessibility of target group 5 Objectives 5a Objectives fit in with analysis 5b Objectives are specific, specified in time and measurable 5c Objectives are acceptable 5d Objectives are feasible 6 Intervention development 6.1 Rationale of the intervention strategy 6.1a Fitting strategies and methods to objectives and target groups 6.1b Previous experiences with intervention(s) 6.2 Duration, intensity and timing 6.2a Duration and intensity of intervention

The effectiveness of interventions and the choices that can be made within those interventions are partly determined by contextual conditions like the support for the project, the capacity available for its implementation and the quality of the leadership provided by the project manager. The arrows pointing inwards indicate the moments when choices have to be made. The arrow pointing at the choice of an intervention is larger, to indicate that this is the point where the inﬂuence of contextual conditions is often particularly strong. The 39 quality criteria (effect predictors) included in Prefﬁ 2.0 have been

6.2b 6.3 6.3a 6.3b 6.4 6.4a 6.4b 6.4c 6.4d 6.4e 6.4f 6.4g 6.4h 6.4i 6.5 6.5a 6.5b 6.6 6.7

Timing of intervention Fitting to target group Participation of target group Fitting to 'culture' Effective techniques (recommended) Room for personalised approach Feedback on effects Use of reward strategies Removing barriers to preferred behaviour Mobilising social support/commitment Training skills Arranging follow-up Goal-setting en implementationintentions Interactive approach Feasibility in existing practice Fitting to intermediary target groups Characteristics of implementability of intervention(s) Coherence of interventions/activities Pretest

Implementation 7 Implementation 7.1 Choice of implementation strategy fitted to intermediaries 7.1a Mode of implementation: top-down and/or bottom-up 7.1b Fitting implementation interventions to intermediaries 7.1c Appropriateness of supplier to intermediaries 7.2 Monitoring and generating feedback 7.3 Incorporation in existing structure Evaluation 8 Evaluation 8.1 Clarity and agreement on principles of evaluation 8.2 Process evaluation 8.3 Effect evaluation 8.3a Has a change been measured? 8.3b Was a change caused by the intervention? 8.4 Feedback to stakeholders

subdivided into eight clusters (see Figure 2). The clusters 2-6 relate mostly to the systematic development of interventions, while the clusters 1, 7 and 8 relate particularly to aspects of implementation. The basic structure is the same as that of Preffi 1.0, although certain clusters have been redefined with respect to one another. At criterion level, Preffi 2.0 has been thoroughly revised compared to the first version. The nature and designation of a number of criteria have been changed, criteria and clusters have been made more rational and contentbased, and the number of criteria has been reduced from 49 to 39. These

Scoring method Each of the Preffi quality criteria has been operationalised in one or more specific yes/no questions. The answers to these questions allow users to rate the degree to which an intervention meets a particular criterion as ‘weak’, ‘moderate’ or ‘strong’ (see the example in Box 1). This operationalisation aims to provide Preffi users with an instrument that allows them to assess a programme as objectively as possible. Nevertheless, the nature of a particular criterion or of the questions operationalising the criterion may not always allow an objective assessment. A rough distinction can be made into three types of criteria. The first type is that of criteria for which the questions can be unequivocally answered, such as ‘Is it known to what extent the target group does indeed perceive the problem as a problem?’ (2.3). The second category is that of criteria for which the questions cannot be so straightforwardly answered because they require an assessment of certain aspects, such as that about the expertise of the project manager (1.3.a) or the question whether the target group perceives the intervention as compatible with their culture (6.3.b). In such cases, users are advised to seek peer consensus on the answer. Finally, there are a number of criteria which basically require an expert opinion. An example is the operationalisation of ‘theoretical model’ (3.1), which includes not only the question whether a theoretical model is being used but also asks whether it has been made plausible that the model chosen is suitable for application in a particular situation. A number of Preffi criteria offer the opportunity to choose the option ‘not assessable’; these are particularly those criteria that are difficult to assess by third parties on the basis of documentary evidence provided, such as the expertise and characteristics of the project manager (1.3.a). In the other criteria, a lack of information is assessed as ‘weak’. The scoring form allows each cluster to be given an overall mark between 1 and 10, which is to be composed from the individual criterion

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marks within the cluster. This can ultimately result in an overall mark for the project as a whole, based on the assessments for the individual clusters. The overall mark need not be a simple average, as different weights can be allocated to certain criteria or clusters. The back of the scoring form provides room to enter the cluster scores in graphic format, and to indicate points to be improved and actions required to achieve this improvement.

Experiences with Preffi 2.0 The trial run among 35 practitioners (step 7), which can be regarded as a pretest for Preffi 2.0, yielded a favourable assessment of the draft version (Meurs, 2002; Molleman, 2005) . Of the 28 respondents who had worked with Preffi 1.0 before, 25 regarded Preffi 2.0 as an improvement, particularly because of its improved underpinning and the operationalisation of the quality criteria. The instrument was given an average overall mark of 7.7 out of 10, and was evaluated by the large majority as valuable, complete, clear, well-organised and innovative. Most respondents reported Preffi 2.0 to be useful for themselves (83%) and for colleagues (89%), both for project development (79%) and for project evaluation (85%). They regarded Preffi 2.0 as difficult and long, rather than as easy and short. They also reported that the time they had to invest to apply it decreased with successive applications: the first project required an average of 113 minutes to asses, the second 85 minutes. Practice has since shown that an experienced Preffi 2.0 user can assess a project fully within one hour. It has become clear that people use Preffi in various stages of projects, both to scrutinise their own projects and as a basis to discuss those of colleagues. Assessing other people’s projects can be difficult if information is lacking or unclear. In addition to an assessment of the documentary evidence provided, it

has been found to always require a supplementary discussion with the project manager. Users feel that this then yields a balanced and useful overview of points in the project that need to be improved. Some practitioners involved in community development projects first considered the draft Preffi 2.0 as too linear, top-down and expert-driven to be very useful for their work. However, in interactions with the task force their opinion changed. The cyclical form of Preffi 2.0, and the emphasis on the importance of a broad analysis of the problem and of participation of the target group in several items of the Preffi convinced them of the usefulness of Preffi 2.0 for community projects. In addition, in the user manual extra attention is paid to community projects. In that manual it is stated that this type of project requires intensive collaboration with and support from the members of the community, with special emphasis on their preferences and needs. The opinions expressed in the trial study have been confirmed by the experiences with our Preffi 2.0 implementation programme, in which more than 400 health promotion specialists have already attended courses.

Conclusions Effective health promotion requires the development and dissemination of programmes whose effectiveness has been proven, as well as knowledge about principles of effectiveness that influence the effectiveness of health promotion programmes in practice. Preffi is a dynamic learning system that could assist this process in various ways. The instrument combines scientific and practical knowledge on principles of effectiveness in health promotion. Preffi’s primary function is that of a diagnostic quality assurance instrument that helps users to identify possible improvements to their projects, and Preffi is above all suitable for this function. In addition, it

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Box 1 An example of the operationalisation and norms for a Preffi criterion

6.3.a. Participation of the target group Operationalisation: 1. In the case of interventions developed elsewhere (e.g. at national level): has the general target group at least been consulted while the intervention was being developed? 2. For any project: has the specific target group for the present project (e.g., residents of the target district) been at least consulted while the intervention was being developed or before the model intervention was selected? 3. For any project: in view of the nature of the project, has the target group participated sufficiently in the development or selection of the intervention? Norms: • Weak: question 1 = no or not applicable and question 2 = no (making question 3 irrelevant) • Moderate: question 1 and/or 2 = yes and question 3 = no • Strong: question 1 and/or 2 = yes and question 3 = yes

could be used as an instrument for the selection of projects, though this function needs further research and development. A study has been conducted to examine how many assessors would be needed to obtain reliable conclusions (Molleman, 2005). The Prefﬁ instrument is still being developed further, in that new versions are regularly produced and its practicability, reliability and validity are continuously being improved. Dutch practitioners have expressed the opinion that the use of Prefﬁ to assess their own and each other’s projects actually results in improved project quality. We are currently trying to corroborate this opinion by means of research.

References Bartholemew, L. K., Parcel, G. S., Kok, G. & Gottlieb, N. H. (2001). Intervention mapping: designing theory- and evidencebased health promotion programs. Mountain View: Mayfield. Durlak, J. A. & Welsh, A. M. (1997). Primary prevention mental health programs for children and adolescents: A meta-analytic review. Am J Commun Psychology, 25, 115-152. Glanz, K., Lewis, F. M. & Rimer, B. K. (Eds.) (2002) Health behavior and health education: theory, research and practice. San Francisco: Jossey-Bass. IUHPE (1999). The evidence of health promotion effectiveness: shaping public health in New Europe. Paris: Jouve Composition & Impression. Jong, M. D. T. d. & Schellens, P. J. (2000) Formatieve evaluatie. In Schellens, P. J., Klaassen, R. and Vries, S. d. (eds), Communicatief ontwerpen. Methoden, perspectieven en toepassingen. Assen: Van Gorcum. Koelen, M. A., Vaandrager, L. & ColomĂ¨r, C. (2001) Health promotion research: dilemmas

and challenges Journal of Epidemiology and Community Health, 55, 257-262.

Helsinki/Talinn: Finnish Centre for Health Promotion.

Kok, G. J., Borne, B. v. d. & Mullen, P. D. (1997) Effectiveness of health education and health promotion: meta-analyses of effect studies and determinants of effectiveness. Patient Education and Counseling, 30, 1927.

Molleman, G. R. M., Peters, L. H. M., Hommels, L. H. & Ploeg, M. A. (2003) Assessment Package; Health Promotion Effect Management Instrument Preffi 2.0. Woerden: NIGZ. Available: http://www.nigz.nl/english/index.cfm?code= 904

McQueen, D. V. & Anderson, L. M. (2002) What counts as evidence: issues and debates on evidence relevant to the evaluation of community health programs. In Rootman, I., Goodstadt, M., McQueen, D., Potvin, L., Springett, J. and Ziglio, E. (eds), Evaluation in Health Promotion: principles and perspectives. Copenhagen: WHO/EURO.

Molleman, G. R. M., Peters, L. W. H., Hosman, C. M. H. and Kok, G. J. (2004) Implementation of a quality assurance instrument (Preffi 1.0) to improve the effectiveness of health promotion in The Netherlands Health Educ. Res., 20(4): 410-422.

Meurs, L. H. v. (2002) Concept Preffi 2.0; reliability and usefulness, research-paper (in Dutch). Woerden: NIGZ.

Molleman, G. R. M. (2005) Preffi 2.0: Health Promotion Effect Management Instrument; Development, validity, reliability and usability. NIGZ, Woerden, Netherlands.

Molleman, G. R. M. (1999) Implementing the Preffi: the use of guidelines for practitioners in the Netherlands in Best Practices, a selection of papers on Quality and Effectiveness in Health Promotion.

Peters, L. H. M., Molleman, G. R. M., Hommels, L. H., Ploeg, M. A., Hosman, C. M. H. & Llopis, E. (2003) Expanatory Guide Preffi 2.0. Woerden: NIGZ. Available: http://www.nigz.nl

Katherine L. Craven and Steven R. Hawks

Cultural and Western influences on the nutrition transition in Thailand Abstract: The impact of economic development and urbanisation on nutrition and dietary changes in transitional countries has been well researched. It generally has been found that there is a positive correlation between economic development, urbanization, and negative nutrition transitions with the result of growing levels of obesity and diet related noncommunicable diseases. However, the impact of Western influences and culture on specific eating styles associated with the nutrition transition has been less studied. There is limited information about cultural and Western influences on eating styles in Thailand. Recent findings suggest that Thailand may have progressed further along the nutrition transition model, in terms of unhealthy eating styles, than would be expected based on economic development. This study was designed to determine the prevalence of current eating styles and eating motivations

among Thai university students. University students were chosen for evaluation as they are thought to represent the forefront of dietary trends and nutrition changes in a population. Convenience samples from four different universities in south-central and northern Thailand were selected. The following scales were used to assess eating and dieting styles and attitudes among 662 Thai undergraduate and graduate students: Motivation For Eating Scale (MFES), Eating Attitudes Test-26 (EAT-26), and Cognitive Dieting Behavior Scale (CBDS). All scales have been shown to be reliable and valid in previous research. For this study, scales were translated into Thai, reverse translated, and pilot tested to ensure cultural relevancy and the conveyance of intended meanings. Basic demographic information was also obtained, including age, gender, year in school, marital status, height and weight, and income. Results indicated

that Thai students exhibit significant levels of dieting behaviour and extrinsic eating based on CBDS and MFES scores (with the exception of environmental eating). For most negative eating styles, females scored higher than males. It was also found that high levels of dieting and extrinsic eating were positively correlated with body mass index, suggesting the possible risk of future weight gain and obesity. While the occurrence of eating disordered attitudes based on EAT-26 scores was low (13%), analysis of EAT26 scores indicated that the occurrence of eating disordered attitudes was strongly correlated with dieting behaviour among this population. The results support the need for a programme to educate Thai students, especially females, regarding healthy patterns of dieting and eating attitudes in order to prevent future weight gains and eating disorders predicted by the nutrition transition model.

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This manuscript was submitted on November 8, 2004. It received blind peer review and was accepted for publication on September 23, 2005.

The nutrition transition in Thailand Over the past 30 years, economic development and demographic changes in Thailand have led to signiﬁcant changes in nutrition and eating styles (Kosulwat, 2002). As the economy has moved from agriculture to the industrial sector, demographics have also changed resulting in a greater urban population. Increased urbanisation and an increase in income per capita have led to the availability of more expensive, Westerntype foods. Greater availability of inexpensive fats and oils has contributed to a change in dietary intake from traditional meals of fruits, vegetables, and grains to foods containing fats and animal products for middle and lower income families (Kosulwat, 2002). A more hectic urban lifestyle has led to a decreased consumption of home-prepared meals and an increased consumption of readymade foods, which tend to be high in fat and carbohydrates. The transition from labor-intensive agricultural lifestyles to more sedentary manufacturing occupations has resulted in lower energy expenditure (Kosulwat, 2002). As a result of this nutrition transition, adulthood obesity has increased markedly in recent years, particularly in urban areas where one-third of middle class women are overweight or obese (Aekplakorn et al., 2004). The impact of the nutrition transition may be compounded for Thai adults by the fetal origin hypothesis. This theory suggests that a history of childhood

Katherine L. Craven, BS Department of Physical Education Brigham Young University Provo, UT 84602 Steven R. Hawks, EdD, MBA, CHES Professor of Health Science College of Health and Human Performance Brigham Young University 229L-Richards Building Provo, UT 84602, USA Tel: (801)422-1706 Fax: (801)422-0273fax Email: steve_hawks@byu.edu

Figure 1

malnutrition and underdevelopment, a legacy shared by many Thai adults, may alter metabolism in a way that promotes obesity among those who later become over nourished (Binns, Lee, & Scott, 2001). In Thailand, obesity among children and adolescents has also greatly increased from 5% during 1986-1995 to 17.9% during 1996-1999 (Likitmaskul et al., 2003). While childhood obesity may be linked to genetic factors, the rapid increase seen in Thailand is primarily the result of the socioeconomic and demographic changes associated with the nutrition transition (Mo-suwan & Geater, 1996; Sakamoto, Wansorn, Tontisirin, & Marui, 2001). Increased obesity has led to a growing prevalence of diet-related noncommunicable diseases (DR-NCDs) in Thailand such as diabetes, cardiovascular disease, stroke, cancer and hypertension among adults and children who become over nourished (Chaisiri et al., 1998; InterASIA, 2003; Likitmaskul et al., 2003). An increase in DR-NCDs has become a burden on the health care system and thus on the economy, and has decreased the quality of life for persons affected (Ke-You & DaWei, 2001; Popkin, 1994, 2001). Eating styles and the nutrition transition In a previous study conducted by Hawks and colleagues, samples from the US and four Asian countries (China, Japan, the Philippines, and Thailand) were analysed to determine to what extent each of the countries had progressed within the nutrition transition model based on

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economic development and Western influences (see Figure 1). The general hypothesis of Hawks’ research was that the progression of certain types of eating styles associated with the nutrition transition relate directly to economic development. He found that an increase of urbanisation and income correlated with a trend towards adopting a diet of readymade foods, a more sedentary lifestyle and the adoption of negative eating styles and dieting habits. However, the results from the Thailand portion of the study showed that Thailand had moved further along in the nutrition transition, in terms of eating styles, than would be predicted by economic development (Hawks et al., 2004). This suggests that understanding the nutrition transition in Thailand may require the additional consideration of Western influences. Traditionally, the preferred body type in Thailand was a large and robust figure as it signified wealth and prosperity. However, most of the population had slim and lean figures because of the lack of excess food and the physically-demanding nature of a traditional, agricultural lifestyle. As Thailand has undergone economic transition and been increasingly exposed to Western influences, the

Keywords • Thailand • dieting behaviour • eating disorders • nutrition transition • eating attitudes

preferred body type has changed according to Western ideals now favoring thinness (Sharps, Price-Sharps, & Hanson, 2001). At the same time, the actual body type also changed, becoming larger, because of the changing diet and lifestyle (Aekplakorn et al., 2004). The contrast between the actual body type (heavier) and the preferred body type (thin) has prompted high levels of dieting behaviour, social and emotional eating styles, and even eating disorders (Hawks et al., 2004). While the occurrence of eating disorders in Asia is generally lower than in the west, Thai women have been shown to prefer an even smaller body type than their western counterparts (Lucero, Hicks, Bramlette, Brassington, & Welter, 1992; Sharps et al., 2001; Tsai, 2000). This trend may contribute to a growing prevalence of dysfunctional eating styles and eating disordered attitudes in Thailand which further complicate our understanding of the nutrition transition. Purpose and objectives In order to understand Thailand’s unpredicted advancement in negative eating styles within the nutrition transition model, it is necessary to further explore eating styles and eating motivations among the Thai people. The purpose of this study was to determine current prevailing motivations for eating and to identify eating styles. It was hypothesized that despite the lower level of economic development when compared to the US, Thailand would demonstrate high levels of extrinsic eating and dieting behaviour. Extrinsic eating is characterised by food consumption motivated by factors other than the physical satisfaction of hunger. These factors include eating for emotional satisfaction, environmental influences, and social influences (Hawks, Madanat, Merrill, Goudy, & Miyagawa, 2003; Hawks et al., 2004). Dieting behaviour is defined as restricting food intake to control weight gain. Confirmation of the hypothesis would support the need for educational programmes in Thailand that might help prevent the unhealthy progression of a nutrition transition based on negative eating styles associated with Western influences that promote a culture of thinness and excessive dieting.

Methods A cross-sectional research design was used to analyse the prevalence of

different eating styles among college students in two regions of Thailand. Population and sample The target population for this study was students attending four universities in two regions of Thailand. College students were chosen as they are most susceptible to the nutrition transition because they reside in urban centers and are exposed to Western media inﬂuences and current eating fads and fashions. They are also more likely to embrace change and experiment with food and image fashions in order to enhance their personal image or experience crosscultural vogues. Although Thai students may not be representative of the Thai population as a whole, or of young Thai people in particular, they are nevertheless harbingers of future trends in middle-class fashion and lifestyle, including those that impact eating styles and obesity. Non-random, convenience samples were taken from general education courses at four different universities in Thailand. Ramkamhaeng University is an openadmission, low-cost university in Bangkok. Julalongkorn University, also in Bangkok, is a closed-admission university and the most competitive in the country. The University of Chiang Mai and Payap University are both closed-admission universities in Chiang Mai, a northern province of Thailand. The four universities enroll students that represent college students throughout the country, both geographically and economically. Instrumentation Data was collected using the 26-item version of the Eating Attitudes Test (EAT26), the Cognitive Behavioral Dieting Scale (CBDS), and the Motivation for Eating Scale (MFES). The EAT-26 was designed to evaluate the presence of eating disorders through three subscales that measure: bulimic tendencies and preoccupation with food, excessive preoccupation with dieting and dietary restraint, and preoccupation with anorexic tendencies and oral control (Garner, Olmsted, Bohr, & Garﬁnkel, 1982). The CDBS is designed to evaluate current dieting behaviour and how it relates to eating disorders, dietary restraint, and obesity (Martz, Sturgis, & Gustafson, 1996). The MFES has four subscales: emotional eating (eating motivated by the emotional state of the

eater—loneliness, boredom, anxiety, etc.), environmental eating (food consumption motivated by environmental surroundings—advertisements, presence of palatable food, eating during meal preparation, etc.), social eating (food consumption influenced by social situations or pressure—family celebration, eating out with friends, etc.), and physical eating (eating motivated by hunger or physical need—growling stomach, fatigue, etc.). Based on relative scores on the four subscales, the MFES evaluates the dominant motivation for eating (Hawks et al., 2003; Hawks, Merrill, Gast, & Hawks, 2004). Based on previous studies performed in the US, the EAT-26 yielded three factor groupings that correspond to the following three subscales: bulimia, with a possible score from 0 to 18; dieting, with a possible score from 0 to 39; and oral control, with a possible score from 0 to 21. A cut-off score of 20 or higher for the Total EAT-26 signifies the potential presence of an eating disorder and indicates a need for further diagnostic follow-up (Garner et al., 1982; Koslowsky et al., 1992). Similar analysis of the CBDS yielded a single factor grouping related to current dieting behavior with possible scores ranging from 14 to 70 (Martz et al., 1996). Analysis of the MFES yielded four factor groupings that correspond to four subscale constructions, including: emotional eating (scored between 19 and 95), environmental eating (scored between 11 and 55), physical eating (scored between 7 and 35), and social eating (scored between 5 and 25) (Hawks et al., 2004). For this study, the EAT-26, CBDS, and MFES were translated into Thai. Reverse translation was used to further refine the translations. Surveys were administered to a small group of Thai students prior to data collection to ensure that understanding in Thai matched the original meaning and that each item was culturally meaningful. In addition to each of these scales, demographic and personal data was also collected including gender, age, year in school, residence, height, weight, health and weight of parents, and parent’s income. Height and weight values collected from the demographic questionnaire were used to calculate body mass index (BMI). BMI (weight in kilograms divided by height in meters squared) is generally thought to correlate with percent body

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Table 1

Descriptive statics for study variables

Age BMI EAT-26 Diet Bulimia Oral Total EAT-26 CBDS MFES Emotional Environmental Social Physical Income (in Baht)

n 659 655

Minimum 17 13.17

Maximum 44 33.20

Mean 21.83 20.23

Median 21 19.7

Std. Deviation 3.645 2.994

655 654 655 655 656

0 0 0 0 14

32 17 15 55 67

4.95 1.88 3.31 10.23 38.90

2 1 2 8 39

6.320 2.413 3.214 9.088 10.500

613 625 628 628 557

19 11 5 7 1500

87 48 25 35 10000000

38.29 29.00 14.45 21.58 290048

36 29 14 19 120000

12.874 6.967 2.474 5.777 653334

fat and the risk of obesity related illness. It is acknowledged that BMI categories for Asians should probably differ from Caucasians as Asian populations tend to experience higher levels of body fat at lower BMI values (Kanazawa et al., 2002). For this study, BMI was not used to categorise overweight or obesity, but rather as a correlate of eating styles and as a basis of comparison among demographic variables. Data collection EAT-26, CBDS, MFES, and demographic data were collected using paper and pencil questionnaires. Questionnaires were given to undergraduate and graduate students on college campuses by general education course instructors and research assistants who were trained in data collection methodologies. It was explained to the students that participation was voluntary and that there was no penalty for not participating. Ten to ﬁfteen minutes were required to complete the questionnaires. Institutional Review Board (IRB) approval for human subjects was obtained prior to data collection. Data analysis Pearson’s correlations were obtained for a 2-tailed, bivariate analysis of each subscale in relation to other eating scales, to BMI, and to other continuous

Table 2

demographic variables. The correlations were used to indicate the strength of linear correlation between each variable. Independent T-tests were performed to compare mean BMI values and eating style scores with various demographic variables (gender, year in school, and marital status). Frequencies were also obtained for each of the above demographic factors. Statistical analysis was completed using the SPSS Graduate Pack 12.0 for Windows.

Results The sampling strategy resulted in a total of 662 participants: 191 from Ramkamhaeng University, 199 from Julalongkorn University, 173 from Payap University, and 99 from Chiang Mai University. Response rates on each campus exceeded 90%. Frequencies showed that the population included 395 (59.7%) females and 267 (40.3%) males. Participants had a mean age of 22 years (3.64 standard deviation) and included both graduate students (6.5%) and undergraduate students (93.5%). Ninetyﬁve percent of the participants were single (See Table 1). Approximately 45% of respondents scored higher than 40 on the CBDS indicating high levels of purposeful dieting behaviour among this sample. Similarly, the dieting

subscale of the EAT-26 accounted for nearly half of the total EAT score, further suggesting the presence of problematic dieting attitudes and behaviors. An unexpected 13% of respondents scored 20 or higher on the EAT-26 indicating the possibility of an eating disorder. Females scored significantly higher than males (p < .001) on the dieting and bulimia subscales of the EAT-26, as well as the total EAT-26 and the CBDS. On the MFES, females also scored higher than males on emotional eating (p < .001), environmental eating (p = .005), and social eating (p = .001). There were no differences between male and female scores on the physical subscale of the MFES, or the oral subscale of the EAT-26. Results of Pearson’s correlations showed that BMI was positively correlated with age, the dieting subscale of the EAT-26 and the CBDS. (Age, however, did not significantly correlate with any of the other subscales of the EAT-26, the CBDS, or the MFES, indicating that age has no significant relationship with various eating styles.) BMI correlated negatively with the oral subscale of the EAT-26, the environmental subscale of the MFES, and the physical eating subscale of the MFES (see Table 2). Both the dieting subscale of the EAT-26 and the CBDS had significant positive correlations with the bulimia subscale of

Significant correlations with body mass index (BMI)

BMI Pearson Correlation Sig.(2-tailed) n

Age .222 .000 652

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Diet .141 .000 649

Oral -.309 .000 649

CBDS .254 .000 649

Environmental -.109 .006 619

Physical -.105 .009 623

Table 3

Significant correlations with cognitive behavioural dieting scores (CBDS)

CBDS Pearson Correlation Sig.(2-tailed) n

BMI .254 .000 649

Diet .628 .000 650

the EAT-26, the total EAT-26 score, the emotional eating subscale and the social eating subscale of the MFES. Interestingly, the CBDS also demonstrated a significant negative correlation with the oral subscale of the EAT-26 (see Table 3). The oral subscale of the EAT-26 also had an unexpected significant positive correlation with the physical eating subscale of the MFES and a significant positive correlation at the 0.05 level with the environmental eating subscale of the MFES. The results of an independent samples ttest showed that BMI did not differ significantly with grade level, although there were significant differences in BMI between males and females and between married and single participants (see Table 4).

Discussion Thailand has a lower risk of occurrence of eating disorders based on EAT-26 scores (>20) when compared to results of a similar study conducted among US college students (Anstine & Grinenko, 2000). However, Thailand had an unexpectedly high frequency of dieting among undergraduate and graduate students, indicated by the mean CBDS

Table 4 Freshmen Graduate Male Female Single Married

Table 5

Bulimia .304 .000 649

Total EAT-26 .453 .000 650

score which is higher than the mean CBDS score of a similar US population of university students (Psujek, Martz, Curtin, Michael, & Aeschleman, 2004). In addition, those who scored higher in both the dieting subscale of the EAT-26 and the CBDS tend to have a larger BMI, indicating a positive association between larger body mass index and excessive dieting behavior. It is also clear from the correlation between the dieting subscale and the CBDS that while the occurrence of eating disorders was not excessive, a significant occurrence of dieting behavior occurred in cases where the presence of an eating disorder would be predicted by the EAT-26, suggesting that dieting behavior in Thai students is associated with an increase in eating disordered attitudes (see Table 5). The results also showed that in Thai culture dieting behaviour is strongly correlated with emotionally and sociallymotivated eating. Because emotionally and socially-motivated eating define extrinsic eating, these results confirm previous findings that Thai students who tend to diet are extrinsic eaters—a significant risk factor for future weight gain and obesity (Hawks et al., 2004). The participants who tended to engage in dieting behaviour also engaged in

Comparisons of mean BMI by demographic variables n 114 43 265 388 623 20

Mean BMI 19.39 20.13 21.50 19.36 20.15 23.34

Std. Deviation 2.85 2.95 2.97 2.69 2.95 3.16

t -1.409

Sig.(2-tailed) .163

9.536

.000

-4.452

.000

Cross-cultural comparison of EAT-26 and CBDS scores EAT-26

US Thailand

Oral -.195 .000 650

n 402 655

CBDS %>20 17% 13%

n 461 656

Mean 32.10 38.90

Emotional .199 .000 608

Social .158 .000 623

emotional and social eating. Emotional and social eating are also unhealthy eating styles that frequently lead to weight gain and eating disorders. Although it was expected that those physically-motivated eaters would have a lower BMI as found in this study, the negative correlation between BMI and environmental eating was unexpected. Environmental eating, a characteristic of extrinsic eating, should correlate positively with an increasing BMI. The expected negative correlation between BMI and oral control (high dietary restraint, anorexic tendencies) was also supported in this study. The primary purpose of this research was to identify the current status of Thai college students in the nutrition transition as measured by eating styles. Based on past research, it was hypothesized that Thailand had progressed further than economic development would predict, especially in terms of dieting and extrinsic eating styles. The hypothesis was supported by this data as BMI was most positively correlated to dieting behaviour and did not have signiﬁcant positive correlations with any other particular eating style or motivation. The hypothesis was also supported by the high CBDS scores, indicating that dieting behaviour may be more prevalent among Thai students than among their American peers. Excessive extrinsic eating would be indicated by a strong positive correlation between dieting and each of the subscales of the MFES excluding physical eating. This hypothesis was generally supported with a notable exception of the environmental subscale, which had no correlation with dieting. The unexpected negative correlation of the environmental eating subscale of the MFES with BMI did not support the research hypothesis. Environmental eating, a characteristic of extrinsic eating, was predicted to correlate positively with CBDS and EAT-26 dieting scores. This

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anomaly may be the result of unique Thai cultural inﬂuences. Environmental eating in the United States is generally characterised by eating while watching television or other such things associated with weight gain. In Thailand, however, environmental eating may be associated with less negative habits and attitudes that do not lead to weight gain. This unexpected result opens an avenue for exploring the Thai culture and motivation for eating. Limitations The ﬁndings of this study are limited by the use of convenience samples which may not be representative of all university students in Thailand. A further limitation is that no test/retest correlations are available to verify the reliability of the instruments in the study population (although all instruments have been shown to be valid and reliable in similar populations). The design used in this study is capable of identifying associations between variables of interest, but is not able to establish cause and effect relationships.

Conclusion To understand the irregularity of Thailand in the relationship between economic development and the nutrition transition (speciﬁcally extrinsic eating habits and dieting behavior) it is

necessary to explore in depth Thai students eating styles and motivations for eating (Hawks et al., 2004). Without a more complete understanding of the current eating styles and attitudes of Thai students, it is impossible to establish an accurate educational program to correct unhealthy eating styles and attitudes to prevent further deterioration of healthy eating styles among the Thai people. The general hypothesis of this study was supported by the data. While Thailand does not exhibit a more frequent occurrence of eating disorders than other Asian countries or the United States, there is a significantly larger occurrence of dieting behavior among Thai university students which in turn is positively correlated with eating disordered attitudes and higher BMI. This could be the result of western influence on body image as well as a growing Thai tendency to control food intake and body size (Sharps et al., 2001). The hypothesis that Thai students tend to be extrinsic eaters (eating motivated by emotion, environment, or social influences) is supported by the strong correlation between dieting behaviour and extrinsic eating characteristics (with the exception of environmental motivation). This tentatively indicates that extrinsic eating is accompanied by high levels of dieting behavior among

Thai students. This is of concern as dieting behaviour tends to be associated with higher BMI as well as the risk for eating disorders. While environmental eating did not support the hypothesis, it does present the opportunity for further exploration into Thai culture in relation to eating styles and attitudes. The results of this study indicate that Thai students, especially females, should be discouraged from participating in dieting behaviour as it is associated with eating disordered attitudes and an increase in BMI. The progression toward dieting behaviour and disordered eating is not unique to Thailand. There is a global preference for a thin, lean ﬁgure which motivates the adoption of dieting behaviour and propels progression within the nutrition transition model toward disordered eating. As in Thailand, this negative progression may be prevented by the implementation of educational programmes to introduce healthy eating styles among the affected population.

Acknowledgements This research was generously supported by the David M. Kennedy Center for International and Area Studies, the Office of Research and Creative Activities, the Honors Program, and the College of Health and Human Performance—all at Brigham Young University.

References Aekplakorn, W., Chaiyapong, Y., Neal, B., Chariyalertsak, S., Kunanusont, C., Phoolcharoen, W., et al. (2004). Prevalence and determinants of overweight and obesity in Thai adults: results of the Second National Health Examination Survey. Journal of the Medical Association of Thailand, 87(6), 685-693. Anstine, D., & Grinenko, D. (2000). Rapid screening for disordered eating in collegeaged females in the primary care setting. Journal of Adolescent Health, 26(5), 338342. Binns, C. W., Lee, M., & Scott, J. A. (2001). The fetal origins of disease hypothesis: public health implications for the Asia-Pacific region. Asia Pacific Journal of Public Health, 13(2), 68-73. Chaisiri, K., Pongpaew, P., Tungtrongchitr, R., Phonrat, B., Kulleap, S., Sutthiwong, P., et al. (1998). Nutritional status and serum lipids of a rural population in Northeast Thailand—an example of health transition. International

Journal for Vitamin and Nutrition Research, 68(3), 196-202. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes test: psychometric features and clinical correlates. Psychological Medicine, 12(4), 871-878. Hawks, S. R., Madanat, H. N., Merrill, R. M., Goudy, M. B., & Miyagawa, T. (2003). A cross-cultural analysis of ‘motivation for eating’as a potential factor in the emergence of global obesity: Japan and the United States. Health Promotion International, 18(2), 153-162. Hawks, S. R., Merrill, C. G., Gast, J. A., & Hawks, J. F. (2004). Validation of the Motivation for Eating Scale. Ecology of Food and Nutrition, 43(4), 307-326. Hawks, S. R., Merrill, R. M., Madanat, H. N., Miyagawa, T., Suwanteerangkul, J., Guarin, C. M., et al. (2004). Intuitive eating and the nutrition transition in Asia. Asia Pacific Journal of Clinical Nutrition, 13(2), 194-203.

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InterASIA. (2003). Cardiovascular risk factor levels in urban and rural Thailand—The International Collaborative Study of Cardiovascular Disease in Asia (InterASIA). European Journal of Cardiovascular Prevention and Rehabilitation, 10(4), 249257. Kanazawa, M., Yoshiike, N., Osaka, T., Numba, Y., Zimmet, P., & Inoue, S. (2002). Criteria and classification of obesity in Japan and Asia-Oceania. Asia Pacific Journal of Clinical Nutrition, 11 Suppl 8, S732-S737. Ke-You, G., & Da-Wei, F. (2001). The magnitude and trends of under- and overnutrition in Asian countries. Biomededical and Environmental Sciences, 14(1-2), 5360. Koslowsky, M., Scheinberg, Z., Bleich, A., Mark, M., Apter, A., Danon, Y., et al. (1992). The factor structure and criterion validity of the short form of the Eating Attitudes Test. Journal of Personality Assessment, 58(1), 27-35.

References (contd.) nicotine dependence, body image, depression, and anxiety within a college population. Addictive Behaviors, 29(2), 375-380.

Kosulwat, V. (2002). The nutrition and health transition in Thailand. Public Health Nutrition, 5(1A), 183-189.

validation of the cognitive behavioral dieting scale. International Journal of Eating Disorders, 19(3), 297-309.

Likitmaskul, S., Kiattisathavee, P., Chaichanwatanakul, K., Punnakanta, L., Angsusingha, K., & Tuchinda, C. (2003). Increasing prevalence of type 2 diabetes mellitus in Thai children and adolescents associated with increasing prevalence of obesity. Journal of Pediatric Endocrinology and Metabolism, 16(1), 71-77.

Mo-suwan, L., & Geater, A. F. (1996). Risk factors for childhood obesity in a transitional society in Thailand. International Journal of Obesity and Related Metabolic Disorders, 20(8), 697-703.

Lucero, K., Hicks, R. A., Bramlette, J., Brassington, G. S., & Welter, M. G. (1992). Frequency of eating problems among Asian and Caucasian college women. Psychological Reports, 71(1), 255-258.

Popkin, B. M. (2001). Nutrition in transition: the changing global nutrition challenge. Asia Pacific Journal of Clinical Nutrition, 10 Suppl, S13-18.

Sharps, M. J., Price-Sharps, J. L., & Hanson, J. (2001). Body image preference in the United States and rural Thailand: an exploratory study. Journal of Psychology, 135(5), 518-526.

Psujek, J. K., Martz, D. M., Curtin, L., Michael, K. D., & Aeschleman, S. R. (2004). Gender differences in the association among

Tsai, G. (2000). Eating disorders in the Far East. Eating and Weight Disorders, 5(4), 183-197.

Martz, D. M., Sturgis, E. T., & Gustafson, S. B. (1996). Development and preliminary

Popkin, B. M. (1994). The nutrition transition in low-income countries: an emerging crisis. Nutrition Reviews, 52(9), 285-298.

Sakamoto, N., Wansorn, S., Tontisirin, K., & Marui, E. (2001). A social epidemiologic study of obesity among preschool children in Thailand. International Journal of Obesity and Related Metabolic Disorders, 25(3), 389-394.

Eun Woo Nam, Toshihiko Hasegawa, John Kenneth Davies and Nayu Ikeda

Health promotion policies in the Republic of Korea and Japan: a comparative study Abstract: Health promotion strategies have been developed and implemented in some Asian countries, particularly in the Republic of Korea (Korea) and Japan. It would help to understand features of health promotion in each country to compare health promotion strategies between them. In this study, using categories developed by HPSource.net, we conducted a comparative analysis of health promotion strategies between Korea and Japan to understand features of health promotion in each country and contribute to the improvement of population health. One of the goals of Health Plan 2010 is to assess its achievements with

numerical targets, which is also the case in Japan. One of the important discussion points involves a decision on the optimal number of targets for evaluation. There is a major difference in the funding of health promotion activities between Korea and Japan. They are financed through the general account in Japan, while in Korea a foundation for health promotion has been established and the income from tobacco tax is ringfenced for this fund. The database and methodology of HPSource needs adaptation for global use. We encountered some disadvantages in

Background and purpose of study This manuscript was submitted on December 21, 2004. It received blind peer review and was accepted for publication on September 29, 2005. The authors gratefully acknowledge the support of Jackie Green received through the peer plus system, as part of the Health Promotion Journals’ Equity Project (HPJEP).

Over the last few decades industrialised nations have placed renewed emphasis upon strategies to maintain and promote health and prevent illness in line with the philosophy of New Public Health (NPH) (Ashton and Seymour, 1998; Goraya and Scambler, 1998). The World Health Organization (WHO) has been proactive in stimulating health promotion

using its current framework for comparing and analysing information on health promotion in Korea and Japan. It has been recognised that HP-Source could influence the development and implementation of health promotion strategies in other parts of the world. Health promotion tools can help decision makers, planners and researchers to formulate and enhance comprehensive plans. In this study we learned many lessons in expanding policy tools outside of one region to aid the global development of effective health promotion policy and practice.

and encouraging its member states to embrace NPH since the declaration of ‘Health for All by the Year 2000’ at the Alma-Ata Conference on primary health care in 1978 (WHO, 1978). This has been maintained in its more recent Health 21 strategy (WHO 1999). The Ottawa Charter for Health Promotion was presented at the First WHO International Conference on Health Promotion held in Ottawa on November 21, 1986 for actions to achieve ‘Health for

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Table 1

Socio-economic status and health insurance

Population (thousand, 2003)* GDP per capita (Intl $, 2002)* Life expectancy at birth (male/female, years, 2003)* Total health expenditure per capita (Intl $, 2002)* Total health expenditure as % of GDP (2002)* Type of health insurance Coverage of health insurance (%)

Korea 47,700 19,523 73.0/80.0 982 5.0 NHI1 100

Japan 127,654 26,860 78.0/85.0 2,133 7.9 NHI1 100

Source: World Health Organization (2005) 1

In the study reported here, the authors conducted a comparative analysis of health promotion strategies between Korea and Japan which included the categories of data collection developed by HP-Source.net. The paper seeks to make a contribution to the improvement of population health through systematic investigation of various dimensions of health promotion strategies in these two countries.

NHI denotes National Health Insurance.

All by the Year 2000 and Beyond’.1 This conference was primarily a response to growing expectations for a new public health movement around the world. Discussions focused on the needs in industrialised countries, but took into account similar concerns in all other regions. It built on the progress made through the Declaration on Primary Health Care at Alma-Ata, the World Health Organization’s Targets for Health for All document, and the recent debate at the World Health Assembly on intersector action for health. Health promotion strategies have been developed in some Asian countries. In particular, in the Republic of Korea (Korea) and Japan, national health promotion initiatives are currently in their implementation phases. These two neighbouring countries share some

Eun Woo Nam Professor Department of Health Administration College of Health Sciences Yonsei University Wonju, Republic of Korea Email: koreahealth@hotmail.com Toshihiko Hasegawa Director Department of Policy Sciences National Institute of Public Health Wako, Japan John Kenneth Davies Director International Health Development Research Centre Faculty of Health University of Brighton Brighton, United Kingdom Nayu Ikeda Research Resident Japan Foundation for Aging and Health Chita, Aichi Prefecture, Japan

commonalities in culture and values with each other, and comparisons of health promotion strategies between them would help to understand features of health promotion in each country, identify similarities and differences and to derive strategies for further improvement. However agreed criteria are needed to sort out such complex contextual factors surrounding health promotion in each country. HP-Source.net is a pioneering initiative in this context. It is an attempt to establish a dynamic Internet-based data base for capacity mapping of health promotion at the national level in Europe.2 Aiming at the maximization of efﬁciency and effectiveness of health promotion policies, infrastructures and practices, HPSource.net collects qualitative and quantitative data through a international voluntary collaboration of researchers, practitioners and policy makers. It is developing a structurally uniform system for collecting information, creating a database and communication strategies for easy access to information for a wide range of stakeholders in health promotion, analysing this database to generate models, actively imparting this information and knowledge, and advocating the adoption of models of proven effectiveness and efﬁciency throughout Europe. The construction of this database was funded by the European Commission and initially coordinated at the London School of Hygiene and Tropical Medicine. The second (current) phase of the project began in 2004 and is coordinated at the University of Bergen in Norway. Data on political, economic and practical aspects of health promotion were provided by relevant correspondents from all 15 member states of the European Union before 1 May 2004, plus Norway, Iceland, Latvia, Switzerland, and the Czech Republic.

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Methods 1. Subjects This study compares health promotion policies between Korea and Japan. Their basic indicators are as shown in Table 1. There are three administrative tiers in Korea. The highest tier includes seven metropolitan cities and nine provinces. Designated metropolitan cities are those urban areas with a population of over one million inhabitants. At the second level, provinces are subdivided into cities and counties, and metropolitan cities are subdivided into districts. The lowest units are dong in cities and ri in counties.. Provincial governments, although they have to some extent their own functions, basically serve as an intermediary between the central and municipal governments. Highly centralised governments have been a strong tradition in Korea, extending back more than six hundred years to the establishment of the Joseon Dynasty (1392-1910). Thus, even with the advent of decentralisation and popularly-elected local governments, there is a long way before local autonomy is achieved to the extent that is practiced today in advanced countries. The affairs of local government are conducted at two levels in Japan (i.e. prefectures and municipalities). As of April 1, 2004, there are 47 prefectures, which consits of 3123 municipalities, including 23 wards within Tokyo. Since the Comprehensive Decentralization Law came into force in April 2000, the consolidation of municipalities has been promoted to strengthen their

Keywords • health promotion • HP-Source • Korea • Japan

administrative foundations. Local government has established an equal and cooperative relationship with the national government, and is expected to carry out their administration independently in accordance with individual local circumstances. 2. Data and analysis Following the structure of the database of HP-Source.net, data was collected for health promotion capacity mapping in Korea and Japan. HP-Source.net includes data in 9 areas in each country – overview of health promotion, formulation of policy, evaluation of policy, monitoring and research, implementation, professional workforce development, professional associations, and funding. Data in eight of these areas were reviewed, excluding professional associations due to insufﬁciency of data. Qualitative and quantitative data from published and unpublished literature and from the internet websites of relevant ofﬁcial agencies, were collected and inserted into comparative tables. The data from each country is then described item by item for comparison.

Results 1. Overview of health promotion Although health promotion strategies in Korea originally adopted deﬁnitions proposed in the Ottawa Charter, they did not establish long-range policies (see Table 2). The Health Promotion Act of 1995 embodied tobacco control strategies, including the imposition and collection of tobacco taxes, limitations on the advertisement and sponsorship of tobacco companies, the designation of smoking areas in public places, and other regulations. The Korea Health Promotion Fund (KHPF) was established in 1996 as a source of funding support for national health promotion programmes. Clause 22 of the 1995 Health Promotion Act is the legal basis of its provision of funding. The Ministry of Health and Welfare (MHW) launched its Health Plan 2010 strategy for the improvement of population health. In 2004 the healthy city movement started in Korea when four healthy cities joined the WHO Healthy City Alliance (http://www.alliancehealthycities.com,2005.7.18). A Field Management Training Programme (FMTP) began in sixteen local

2Table 2 Background

Current initiatives

Overview of health promotion Korea Ottawa Charter Health Promotion Act 1995 KHPF* in 1996

Health Plan 2010 Healthy Cities Project FMTP (Field Management Training Program)

Japan National measures in 1978 & 1988 • Infrastructure developement • Lack of numerical standards Decentralization Healthy Japan 21 Health Promotion Act 2002 Healthy City Project

*Abbreviation for Korea Health Promotion Fund.

government areas for officers responsible for health promotion. In addition, the Korean government posted young physicians from the army to serve as health promotion practitioners for a mandatory period of 2.25 years. National health promotion policies in Japan have already been operating for 30 years. The Japanese government advocated the development of an infrastructure for health promotion through the First-Phase Measures for National Health Promotion in 1978, and the Second-Phase Measures for National Health Promotion in 1988. These two initiatives developed infrastructures for for example health checkup systems, facilities, human resources and fitness guidelines. Despite their successful contribution to health promotion, the evaluation of outcomes was difficult because numerical standards had not been set in advance. In addition, due to further decentralisation encouraged by the Decentralization Promotion Act of 1995, prefectures and municipalities became responsible for the development of health promotion strategies in their local areas. The central government then launched in 2000 the third initiative for health promotion called the National Health Promotion Movement in the 21st Century (Healthy Japan 21). Based on concepts of health promotion advocated in the Ottawa Charter, Healthy Japan 21 emphasises the importance of societywide support, as well as individual efforts, for people to become proactively involved in health promotion activities. Moreover, specifying the roles of stakeholders at national and local levels, Healthy Japan 21 pursued promotion of healthy lifestyles, mandatory segregation of smoking, and coordination of health screening conducted under different schemes. In addition, the initiative adopted the management with numerical goals and targets, which was in line with

Healthy People 2000 of the United States (U.S. Department of Health and Human Services Public Health Services,2005). The Health Promotion Act came into force in 2002 as a legal basis for the initiative (Japan Public Health Association, 2005). The Healthy City movement started in the mid 1990’s, and eleven healthy cities enrolled in the WHO Healthy City Alliance.3 Thus health promotion initiatives have been developed in Japan for a longer time than in Korea. Based on the Ottawa Charter, current health promotion initiatives were launched in 2000 and will be implemented until 2010 in both countries. Health promotion initiatives have a legal basis in Japan and financing of health promotion initiatives has a legal basis in Korea. Decentralisation is a key theme for health promotion initiatives in Japan, while in Korea the administrative system is still centralised. Healthy People 2010 emphasises that prevention saves lives, improves the quality of life and can be cost effective in the long run. It has 28 focus areas, 467 specific objectives and 10 leading health indicators. The first focus area includes access to quality services, the second includes arthritis, osteoporosis and chronic back conditions, and the third includes cancer.4 2. Formulation of Health Promotion Policy 1) National level (a) Publication and actions (Table 3) In 2003, the MHW published a report entitled Health Plan 2010 in Korea (KIHASA and MHW, 2000), which is electronically available on their website.5 Key policy recommendations for the initiative have been highlighted by KIHASA. The initiative in practice seeks to create public awareness of

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2Table 3 Contents Publication Title of document Status of document Key policy recommendations/ statements Practice recommendations/ statements

Levels and sectors of actions

National health promotion policies Korea Published by MHW Health Plan 2010 Report • extending life expectancy • Reducing cancer • Reducing tobacco smoking • Reducing alcohol consumption • Creating public awareness of responsibility in health • Strengthening public sense of value in health

National • Bureau of Health Promotion, MHW Sub-national • Metropolitan cities, provinces, cities, and counties • Public health centres • Other relevant organizations

Japan Published by JHPFF* Healthy Japan 21 Report • Reducing premature death • Extending healthy life expectancy • Improving QOL • Emphasis on primary prevention • General improvement to support health promotion • Goal settings & evaluation • Effective implementation through inter-organizational cooperation National: • Health Service Bureau, MHLW Sub-national: • Prefectures and municipalities • Public health centres • Other relevant organizations

*Abbreviation for Japan Health Promotion and Fitness Foundation.

responsibilities for health and to strengthen the public’s sense of value in health. The initiative proposes that actions should be taken by the Bureau of Health Promotion of MHW at the national level, and by metropolitan cities, provinces, cities, counties, public health centres, and other relevant organisations at the sub-national level. A report entitled “Healthy Japan 21: National Health Promotion in the 21st Century” was published in 2000 by the Japan Health Promotion and Fitness Foundation (JHPFF). This document was written in Japanese only and a brief introduction in English is available at the website of the Ministry of Health, Labour

2Table 4

and Welfare (MHLW).6 JHPFF is a foundation, ﬁnanced through subsidies and private donations, working in close coordination with the central government for diffusion of information and education on health promotion, fostering leadership, and carrying out surveys and research on relevant aspects of health sciences. The basic premise of Healthy Japan 21 is to create a vibrant society in which the whole nation is healthy and spiritually rich through the reduction of premature deaths, the extension of healthy life expectancy, and the improvement of quality of life. The initiative therefore emphasises primary prevention through making general

Goals and targets of national health promotion policies

Goals Life expectancy Anti-tobacco (smoking) Alcohol consumption Exercise Nutrition Mental health Dental health Reproductive health Arthritis Cancer Diabetes mellitus Cardiovascular diseases Hypertension Cerebrovascular diseases Total

Number of objectives Korea Japan* 2 NA 4 4 2 3 1 6 2 14 4 4 3 13 4 NA 1 NA 11 7 1 8 1 11† 1 NA 1 NA 14 goals & 38 objectives 9 goals & 70 objectives

NA denotes «Not Applicable». * Source: http://ml-www.kenkounippon21.gr.jp/kenkounippon21/ugoki/houkoku/pdf/0410mokuhyou_zanteiti.pdf (in Japanese) † Including targets on hypertension and stroke.

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improvements to support health promotion, setting numerical goals for evaluation, and initiating cooperation and partnerships working among relevant organizations, such as the mass media, health insurers, healthcare providers, and volunteers. Actions are proposed at both national and sub-national levels: Health Service Bureau of MHLW at the national level; and prefectures, municipalities, public health centres, and other relevant organisations at the subnational level. The Korean Health Plan 2010 established fourteen goals which related to health expectancy, smoking, drinking, exercise, nutrition, mental health, dental health, reproductive health, hypertension, cerebrovascular disease, arthritis, diabetes mellitus, cardiovascular disease, and cancer. Thirty-eight objectives were specified: one objective each on exercise, hypertension, cerebrovascular diseases, arthritis, diabetes mellitus, and cardiovascular diseases, two each on health expectancy, drinking and nutrition, three objectives on dental health, four each on smoking, mental health and reproductive health, and eleven on cancer. Healthy Japan 21 established nine goals, i.e. smoking, drinking, exercise, nutrition, rest and mental health, dental health, diabetes mellitus, cardiovascular diseases, and cancer. Then seventy objectives were specified in total: four objectives on smoking; three on drinking; six on exercise (three each on adults and the elderly); fourteen on nutrition (five on nutritional status and intake, six on knowledge, attitude and behavior, and three on environment); four on rest and mental health (one each on stress and suicide, and two on sleep); thirteen on dental health (three each on infants, school children, and the elderly, and four on adults); eight on diabetes mellitus; eleven on cardiovascular diseases, including those on health checkup, hypertension and stroke; and seven on cancer. Twice as many objectives have been set up in Japan as those in Korea (see Table 4). Lifestyle modification is common to both countries. Health expectancy and reproductive health are still important goals in Korea. Curative service and management of arthritis is peculiar to Korea. Many targets have been set on cancer in Korea.

2) Sub-national level Some health promotion policy documents at the provincial level in Korea were published in 2000, such as those in Kyungnam Province 2001, Ulsan City 2001 and Changwon City 21. These documents refer to the five priority areas identified by the Ottawa Charter, i.e. building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. The Department of Health of each provincial government is generally responsible for the formulation of these documents. It is discretionary on local government whether or not to develop and publish local health promotion policies in Japan. All prefectures completed the formulation of health promotion policies by March 2002, and 40% of municipal governments (1222/3123) did so as of July 2004. Health promotion strategies of the 627 municipal governments are under development and are due to be completed by March 2006.7 References to some local policy documents on health promotion are electronically accessible at the official website of Healthy Japan 21.8 3. Monitoring, survey and research on health promotion and public health (Table 5) The Korean Institute of Health and Social Affairs (KIHASA) is responsible for the development of theory and research in health promotion. They also conduct and report every 3 years systematic monitoring of health promotion policies by the Health and Nutrition Survey. The Korean Centre for Disease Control and Prevention (KCDC) has recently been established to review the development and practice of health promotion programmes. The Korean Health Industry Development Institute (KHIDI) is responsible for carrying out a nutritional survey. In Japan, surveys and research on health promotion and the development of relevant databases are conducted by JHPFF, the National Institute of Health and Nutrition (NIHN) and the National Institute of Public Health (NIPH). JHPFF not only conducts but commisions research to academic researchers at universities and other relevant institutions. NIHN is an independent policy corporation responsible for

2Table 5

Monitoring, survey and research Responsible bodies

Responsibilities Theory & research

Korea KIHASA 1)

Systematic monitoring Health and Nutritional survey & reporting of public health by KIHASA, KCDC 2) and KHIDI 3)

Japan • JHPFF, NIHN, HIHN† • Universities • National: NNS, Vital Statistics, Patient Survey, etc. by MHLW • Local: Nutrition surveys by prefectures

1) KIHASA denotes Korean Institute of Health and Social Affairs. 2) KCDC denotes Korean Center for Disease Control and Prevention 3) KHIDI denotes Korean Health Industry Development Institute † Abbreviations for Japanese Health Promotion and Fitness Foundation, National Institute of Health and Nutrition, and National Institute of Public Health, respectively.

implementing National Nutrition Survey (NNS) and research on the maintenance and promotion of health, nutrition, diet and lifestyle. NIPH was established in April 2002 through the merger of the former National Institute of Public Health and the National Institute of Health Service Management, and focuses on the training of experts and research on public health, healthcare, and social welfare. National data on public health such as Vital Statistics, Patient Survey, NNS, National Livelihood Survey, Health and Welfare Survey have been regularly collected for the monitoring of public health. NNS is the most useful in the context of Healthy Japan 21, because it emphasizes the prevention of lifestylerelated diseases (Kawaminami, 2001). The survey involves approximately 15,000 people from 5000 households in randomly selected 300 local units in Japan. The data consists of food and nutritional intake, diet, and physical status such as height and weight, blood pressure, blood biomarkers, exercise, and medication to control blood pressure, cholesterol and blood sugar. The 2002 Health Promotion Act stipulates NIHN as a responsible body for compiling NNS. Prefectures conduct surveys on health, nutrition and diet concurrent with NNS. They are similar to NNS in the questionnaire formats and methods of compilation and analysis.

implementation of Health Plan 2010 (Health Korea 2010). They are involved in planning health promotion and supporting national and local bodies in carrying out health promotion programmes. It is unclear which bodies are responsible for the implementation of health promotion at regional and local levels. (2) Facilitation of Better Quality Health Promotion Practices The bodies in charge of facilitation of better health promotion practices are the following: KIHASA and KCDC in the health sector; Korean National Health Insurance Cooperation in other public sectors; Korean Anti-Smoking Association, Korean Association of Public Health Administration, Korean Association of Family Health, and Korean Association of Health Promotion; graduate schools of public health, faculties of public health and preventive medicine, medical schools, and nursing schools of universities; and Korean Health Industry Development Institute as a research centre. (3) Creation of Health Promotion Materials Materials on health promotion are produced through various sources, including the Health Promotion Development Centre (HPDC) of KIHASA and health centres in the health sector, and NGOs such as the Korean AntiSmoking Association. Universities prepare study materials for students.

1) Korea

(4) Health Promotion Networking The implementation of health promotion programmes require close collaboration between the Health Promotion Development Centre (HPDC) of KIHASA, health centres, and NGOs.

(1) Implementation of National Health Promotion Policy MHW is responsible for the

(5) Planning and Implementing Health Promotion Programmes KIHASA and MHW are planning and

4. Implementation at national and subnational levels (Table 6)

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implementing health promotion programmes at the national level; also, KCDC and Korea Food and Drug Agency (KFDA) together with the Regional Health Promotion Fund, which has been supporting programmes from 2005. Public health centres are responsible for health promotion at the local level and sub-health centres also implement the programme. NGOs including the mass media, have supported these efforts on a more local level. (6) Implementation at the Local Level Korea is a centralised country and the implementation at the local level depends on local capacity. It depends on speciﬁc resources and politics, how much freedom local bodies have in setting priorities for local implementation of the national health promotion policy. 2) Japan (1) Implementation of National Health Promotion Policy MHLW is responsible for the implementation of Healthy Japan 21 at the national level. The central health authority is responsible for facilitating the nationwide implementation of the initiative, the dissemination of information and education through diverse channels, the provision of technical support for the development of local plans, the implementation of surveys and research, securing of adequate human resources, and the coordination of health programmes. (2) Facilitation of Better Quality Health Promotion Practices Three organisations were established for the effective implementation of the health promotion initiatives at the national level. Firstly, the Headquarters for the Promotion of Healthy Japan 21 was established in MHLW to facilitate the inter-departmental implementation of measures for the initiative. Secondly, the National Council for Promotion of Healthy Japan 21 was launched as a central organisation for the efﬁcient and continuous implementation of Healthy Japan 21. Representatives from national and local levels meet and exchange opinions and information four times a year. Thirdly, organisations approving the initiative created the National Liaison Council for Promotion of Healthy Japan 21 as the core for dissemination of information to the public and

Table 6

Implementation at the national and sub-national levels

Responsibility Implementation of national HP policy Facilitation of better HP practices Creation of HP materials

Networking

Planning and running programmes and campaigns

Responsible bodies Korea MHW MCHP of KIHASA • National: KIHASA*, other public sectors • Universities and colleges • NGOs • National: HPDC†, KHPF, KCDC • Local: MCHP††, public health centres • NGOs • Universities and colleges • National: MCHP, HPDC, KIHASA • Local: MCHP, public health centres, healthy city networks, healthy lifestyle advisory groups • NGOs • National: KIHASA, MoHW • Local: MCHP, city governments (e.g. Seoul, Wonju and other ‘healthy cities’, public health centres • NGOs

Japan MHLW National: HPHJ21, NCPHF21, NLCPHF21‡ • National: MHLW • Local: prefectures, public health centres, municipalities, JHPFF¶ Local: prefectures, public health centres, municipalities, JHPFF

• National: MHLW • Local: prefectures, public health centres, municipalities

* MCHP denotes Management Centre for Health Promotion under the Korean Institute for Health and Social Affairs(KIHASA). † HPDC denotes Health Promotion Development Center under KIHASA. ÅıÅı RMCHP denotes Regional Management Center for Health Promotion under MCHP ‡ HPHJ21, NCPHF21, and NLCPHF21denote Headquarters for Promotion of Healthy Japan 21, the National Council for Promotion of Healthy Japan 21, and the National Liaison Council for Promotion of Healthy Japan 21, respectively. ¶ Abbreviation for Japanese Health Promotion and Fitness Foundation

strengthening of mutual collaboration through the exchange of information. Academic bodies contribute to the facilitation of better quality health promotion practices; for example NIPH, medical and nursing schools, and academic societies in health promotion such as the Japanese Public Health Association,9 the Japanese Society of Health Education and Promotion,10 and the Japanese Society for Health Promotion and Welfare Policy.11 (3) Health Promotion Networking Prefectures play a central role in networking of municipalities, health insurers, school health workers and occupational health nurses. Moreover, prefectures and municipalities are required to formulate local health promotion plans in harmonisation with other existing local health plans and in turn, integrate local plans within the existing comprehensive plan. Public health centres function as the base for health promotion activities in their jurisdiction. Their responsibilities not only include networking between relevant organisations, but include the collection and analysis of health data, and the provision of technical support for municipalities.

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(4) Planning and Running Health Promotion Programmes and Creation of Materials MHLW is responsible for the development of a strategic master plan for Healthy Japan 21 at the national level. The plan formulates overall philosophy and goals to provide the long-term direction of efforts in health promotion for local governments. MHLW facilitates and supports the development of local plans by holding seminars and distributing information to stakeholders. They further implement national health promotion programmes by encouraging the nation through the mass media, developing support systems, and establishing a health information system. Prefectures formulate more concrete strategic plans and action plans aligned with the national master plan and focus on the choice of measures and resource allocation for the efﬁcient and effective implementation of strategies. Prefectures also develop health promotion plans for secondary health areas, which are geographical units stipulated by Medical Service Law for the provision of comprehensive health and medical services ranging from health promotion

2Table 7

Evaluation of health promotion policy, programmes, campaigns and projects

Single responsible body National level Development of tools

2Table 8

Korea • National: MHW • Local: RHPF To be conducted in 2005 & 2010 KIHASA and MHW

Japan • National: MHLW • Local: Local governments To be conducted in 2005 & 2010 Panel set up by MHLW

Degree programmes in health promotion

Courses Bachelor Master Doctorate Postgraduate non-degree Non-academic

Korea NA Yonsei University NA KHEA* KIHASA†,MCHP, KHRDL

Japan NA NA NA NA Health fitness instructors/

* KHEA denotes Korean Health Education Association. † KIHASA denotes Korean Institute of Health and Social Affairs. . MCHP denotes Management Center for Health Promotion under the MoHW KHRDI denotes Human Research Development Institute under the MoHW

2Table 9 Level/Nation National Local

7. Funding (Table 9)

Financial source of health promotion programmes Financial source Korea Tobacco Tax Tobacco Tax

to treatment and rehabilitation. Public health centres play a central role in collecting and analyzing health data at this level. Moreover, prefectures support municipalities in developing and implementing their plans through the dissemination of prefecture plans and the provision of health statistics data. Healthy Japan 21 recommends that municipalities proactively formulate and implement health promotion plans and programmes, because they directly provide local residents with services in maternal and child health and in geriatric health. They are expected to disseminate health promotion, network relevant organisations, support voluntary community participation, and evaluate municipal plans through community involvement. 5. Evaluation of health promotion policy, programmes, campaigns and projects (Table 7) MoHW in Korea will evaluate Health Plan 2010 in 2005 and 2010. The midterm evaluation (2005) is currently underway and will most likely result in redeﬁning the national objectives by the Management Centre for Health Promotion (MCHP) under the KIHASA, and in formulating more concrete strategies to support the implementation process at the provincial and local level

the local level from 2005. Korea has 17 academic courses in health sciences at the undergraduate level and more than 28 MA or MPH courses. Furthermore, more than 10 Ph.D. courses in health sciences fields are offered by universities. Although there is no academic institution in Japan which offers a degree specifically in health promotion, many degree programmess in relevant fields such as those in public heath and nutrition include lectures on health promotion as a part of their courses. Training courses for instructors and programmers of health fitness are also available at universities, colleges, and at the Japanese Health Promotion and Fitness Foundation.

Japan General taxation General taxation

by the Regional Management for Health Promotion (RMCHP). The tools for the evaluation of health promotion programmes are being developed under initiatives from the MCHP. Pilot projects for demonstration and research are evaluated every year by the MCHP. The MHLW and local governments are responsible for the evaluation of Healthy Japan 21 at national and local levels. Healthy Japan 21 will be evaluated in 2005 and 2010 with evaluation tools developed by a panel which MHLW formed in 2002. Their interim report is electronically available on the website of MHLW. Some of health promotion interventions at the local level started later and will be evaluated later. 6. Professional education in health promotion (Table 8) Academic qualiﬁcations in health promotion are available only at Master’s level in Korea. There is a Master’s course in health promotion at the Department of Health Promotion, Graduate School of Public Health, Yonsei University in Seoul. Postgraduate non-degree courses are offered by the Korean Health Education Association and non-academic courses are available at KIHASA and KCDC. The MHW has launched a FMTP for staffs in public health and health promotion at

Financial sources for health promotion programmes are divided into two types; Korea has a health promotion fund from the tobacco tax and general taxes are used in Japan. In Korea, the KHPF is the primary source of finance for health promotion programmes at national and local levels. Table 10 shows recent changes in the health promotion fund. The fund is financed through income from tobacco tax collected from tobacco companies and importers. The tax rate was 150 Won per pack of cigarettes in 2000 and rose to 354 won per pack of cigarettes in February 2005. Three percent of collected tobacco tax is earmarked for the fund and the remainder goes into National Health Insurance in 2000. This rate recently was increased to 17.7 percent to the health promotion fund. Healthy Japan21 is financed by national, prefecture, and municipal budgets through a specified fund. Table 11 shows the transition of national budgets for health promotion from 2001 to 2004. The exact budget for Healthy Japan21 is however unknown because the initiative is implemented with other programmes such as those for elderly health (MHLW, personal communication, 2004). Kawahara (2001) described that in 2001 most of the budget of 1,069 million yen for health promotion had been allocated for the comprehensive implementation of Health Japan21 within existing programmes in addition to other health programmes, while projects for the diffusion of specific initiatives had accounted for 0.6% of the budget.

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2Table 10

Source HP Fund Ratio

Change in the Health Promotion Fund by Tobacco Tax in Korea (Unit: hundred million won) Year 2000 30,539 1.63

1997 18,688 1.0

2004 91,349 4.89

MoHW, National Health Promotion Budget, each year. The base year 1997.

2Table 11 Year Budget

National budget of policies relevant to health promotion in Japan (Unit: million yen) 2001* 106,925

2002* 92,623

2003† 92,919

2004‡ 93,406

* Source: http://mhlw.go.jp/topics/2002/bukyoku/kenkou/2.html † Source: http://mhlw.go.jp/topics/2003/bukyoku/kenkou/2.html ‡ Source: http://mhlw.go.jp/topics/2004/bukyoku/kenkou/2.html

Most of the programmes in health education and health promotion in Japan are organised under the framework of health services for the elderly ﬁnanced by sickness funds, and maternity and child health services delivered by local governments. Although sickness funds can denote the amount of funds to be put into health services for the elderly, decisions on resource allocation largely depend on political circumstances. Moreover, programmes by local governments have experienced substantial changes. Administrative tasks in programmes of maternity and child health have been decentralised to local governments from prefectures municipalities and their local branches.

Discussion Having applied the European HP-Source tool for the analysis of health promotion policies, the first comparative study between Korea and Japan identified a number of issues that reflected similarities and differences in health promotion policies between these two countries. Current political interests in health promotion in Korea and Japan At present in many countries particularly in Europe, there is a major focus on providing ‘evidence’ of successful interventions and programmes in public health and health promotion and relating this to good practice. The European Commission has provided financial support to a Multi-Network Project entitled ‘Getting Evidence into Practice’ (GEP) and the 6th IUHPE European Conference on Quality and Effectiveness of Health Promotion, which was held in June 2005,

continues the theme, “Evidence for Practice: Best Practice for Better Health”. One of the goals of Healthy Japan 21 is to use evidence-based numerical targets as indicators for evaluating the status of public health. The same trend can be observed in Korea. An important discussion point involves deciding on the optimal number of targets for evaluation. Healthy Japan 21 has twice as many targets as those of Health Plan 2010. Is it too many or too few? Should the Korean list of objectives be reduced to the equivalent of those of the Japanese, particularly by merging hypertension, cardiovascular diseases and cerebrovascular diseases into one category? There is a major difference in the funding of health promotion activities between Korea and Japan. Japanese health promotion policies and programmes are financed through the general account, while in Korea a foundation for health promotion has been established and the income from tobacco tax is ring-fenced for this fund. This Korean system follows those in some other countries such as Australia and Finland. One of interesting issues arising from the growth of health promotion foundations with ring-fenced funding is the shift in the perception of health promotion from just health (services) to include cultural and sports sponsorship. However it cannot be said that this is the main-stream method for health promotion financing yet, and there still remains much room for discussions on the efficiency of earmarked funds from taxes. For instance, successive British governments have refused to ear-mark or ring-fence income in the public sector as

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expenditure. This means that the financing of health promotion or public health depends on the National Health Service, whose political priorities are reducing hospital waiting lists and meeting the demands for treatment from patients. How can health promotion move forward within a global environment? The HP-Source data base and methodology need to be adapted for global use. Some disadvantages arose for comparing and analysing information on health promotion in Korea and Japan using the database’s current framework. Firstly, administrative units of ‘regional’, ‘provincial’, and ‘local’ are not applicable to all countries. For example, the Japanese system consists of local prefectures and municipalities under the national government, while in Korea there are only the provincial level of municipalities and wards under the national level. Terminology and definitions of administrative units are thus diverse among nations and cannot be straightforwardly interpreted. Secondly, evaluation questions could not be compared because Korea and Japan are at the early stage of the development of health promotion initiatives and their evaluation tools are still under discussion. Questions should therefore be created in the data base to account for health promotion policies that are under development. Thirdly, some questions in the database overlap, causing some confusion to respondents. Terminology regarding the stages of health promotion such as policy, programmes, projects and interventions should be determined and clearly defined, so that each question clearly reflects the appropriate meaning in that stage of implementation and evaluation. The benefits resulting from HP-Source pioneering efforts in Europe are recognised as potentially influencing the development and implementation of health promotion strategies in other parts of the world. Health promotion tools, such as those in the HP-Source can help decision makers, planners and researchers to formulate comprehensive plans and identify deficits. Limitations This study compared health promotion policies in Korea and Japan using the health promotion tool HP-Source.net. The

HP Source instrument was developed and to date has been applied by using country-based named researchers to ascertain and enter information into the database from a variety of country sources in Europe. But, in this study subjects of comparison were used for the ďŹ rst time in Asia and limited to Japan and Korea, rather than drawing on the full current HP-Source database for 25 European countries. There are nevertheless many lessons to be learnt from expanding policy tools such as HPSource outside of one region to aid the global development of effective health promotion policy and practice.

http://www.who.int.org (accessed on July 18, 2005) * Corresponding author: Eun Woo Nam Tel 82-33-760-2413 Fax 82-33-762-9562 e-mail ewnam@dragon.yonsei.ac.kr #234-1 Maejiri Heungup-myun Wonju-city Korea. 2. http://www.hp-source.net 3. http://www.alliance-healthycities.com, accessed on 2006.1.30. 4. http://www.healthypeople.gov/healthfinder, accessed on 2005.7.18. 5. http://www.mohw.go.kr (accessed on March 20, 2004) 6. http://www.mhlw.go.jp/english/wp/wphw/vol1/p2c6s4.html (accessed on April 17, 2004) 7. http://www.kenkounippon21.gr.jp/kenkounippon21/ chihou_keikaku/sakutei/index.html (in Japanese) 8. http://www.kenkounippon21.gr.jp/kenkounippon21/ chihou_keikaku/jireisyu/index.html (in Japanese) 9. http://www.jpha.or.jp/jpha/english/index.html 10. ttp://www.onyx.dti.ne.jp/~health (in Japanese) 11. http://gakkai.umin.ac.jp/gakkai/gakkai/2003/A01560.htm (in Japanese)

References Ashton, J, and H. Seymour. (1988) The New Public Health: The Liverpool experience. Milton Keynes: Open University Press. Busan Metropolitan City (2000) Busan Health Care Plan 2000. Busan, Korea. Goraya, A, and Scambler, G. (1998). From Old to New Public Health: Role Tensions and Contradictions. Critical Public Health; 14:144. Japan Health Promotion and Fitness Foundation.(2000) Healthy Japan 21: National Health Promotion in the 21st Century. Tokyo: Japan Health Promotion and Fitness Foundation. Japan Public Health Association.(2005) Public Health in Japan 2004. Available at:http://www.jpha.or.jp/jpha/english/apha/to p.html. Accessed July 3, 2005. Jeong, HS and Hurst, J. (2001) An Assessment of the Performance of the Japanese Health Care System. OECD Labour Market and Social Policy Occasional Papers, No. 56. 2001, 23-47. Kawahara, K.(2001) The Differences in Administrative Approach Between Medical Care Plan and Healthy Japan 21 Initiatives. J. Natl. Inst. Public Health 2001; 50: 216-219 (in Japanese). Kawaminami, K.(2001) The Problem and the Method of the Monitoring System that Follow Up Obtainable Information in Healthy Nippon 21. J. Natl. Inst. Public Health; 50: 241-246 (in Japanese). Korean Institute for Health and Social Affairs and UNDP, Korea. (1998) Human Development Report. Ministry of Health, Labour, and Welfare. Annual Reports on Health and Welfare: 1998-1999 Social Security and National Life. Available at: http://www.mhlw.go.jp/english/wp/wphw/index.html. Accessed April 17, 2004. Mittlemark, MB, Fosse, E, Jones, C, Davies, M and Davies, JK (2005) Mapping European Capacity to Engage in Health Promotion an National Level: HP-Source .net, Promotion & Education, International Journal of Health Promotion & Education, Paris, IUHPESupplement 1, 33-39. Mittlemark, MB, Wise, M, Nam,EW, Burgoa, CS, Fosse, E, Saan, H, Hagard, S, and Tang, KC. (2005) Mapping National Capacity to Engage in Health Promotion: Overview of Issues and Approaches, 6th WHO Global Conference on Health Promotion, Bangkok, Thailand, 7-11 August. Nam, EW.(2002) Health Education in the Republic of Korea, Health Promotion and Education, IUHPE-SEARB, Vol. XVII, No.4. October. Nam, EW. (2003) Health Promotion and Non Smoking Policies. International Journal of health Promotion & Education, Paris. IUHPE, Spring Vol X. 1.2003. 6-8

Nam EW and Sakamaki, H. (2004) Current Status and Issues on Diabetes Mellitus Management in Korea. Journal of National Institute of Public Health; 53:60-3 (in Japanese). Nam, EW, Davies, JK, Hasegawa, T. Nam, JJ, and Fujisawa, Y. (2005) Healthy Public Policy in the 21st Century: a Comparative Study of Health Promotion Development in Korea, United Kingdom & Japan. Available from: URL:http://www.health2004.com.au/program 2/friday/hp_op_01.asp. Nam EW, Park JS, Song AR et al, (2005) A Comparative Study on Healthy City Indicators in Wonju, Institute of Health and Welfare Yonsei University, Wonju, Korea. Nam, J J (2002) Health Promotion in Korea. Seoul: KIHASA. Nam, J J et al. (2003a) Health Plan 2010. Seoul: KIHASA, October. Nam, J J et al. (2003b) Overview of Health Promotion Programmes in Korea. Seoul: KIHASA, October (in Korean). Oh D K. Objectives and Strategies for National Health Promotion, (2001) Korean Society for Health Education and Promotion, Dec. p.40-5. Suwon City. (2000) Suwon Health Care Plan. Suwon, Korea. Thorogood, M. and Coombes, Y.(eds).(2000) Evaluating Health Promotion Practice and Methods. Oxford University Press. Ulsan City.(2000) Ulsan Health Plan. Korea U.S. Department of Health and Human Services Public Health Services, Healthy People 2010 (http://www.healthypeople.gov/Contact/2005 -10-12) Wonju City(2005) Wonju Health Promotion Plan. Wonju, Korea. WHO, (1978) Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September. Geneva: World Health Organization; 1978. World Health Organization.(1986) The Ottawa Charter for Health Promotion, Geneva: World Health Organization. World Health Organization. (2005) The World Health Report: 2005: Make Every Mother and Child Count. Geneva: World Health Organization. WWW.HP-source.net (accessed on 2005.7.15). http://www.healthypeople.gov/healthfinder (accessed on 2005.7.18). http://www.who.int/countries/en/ (accessed on 2005. 12.1). http://www.alliance-healthycities.com (accessed on 2006.1.30)

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Advocacy The use of “sin taxes” to fund heath promotion foundations: introducing the debate addressed in Karen Slama’s article Commentary by Michel O’Neill Finding ways to fund health promotion infrastructures and interventions is a constant and major problem, most countries devoting an extremely low percentage of their health budget to these endeavors. In order to alleviate this problem, a few innovative countries have decided to earmark certain tax monies for health promotion purposes, these monies being sometimes channeled into public Foundations totally or partially dedicated to health promotion interventions. The Australian state of Victoria led the way, followed by other Australian States and after that by several other countries as diverse as Switzerland, Thailand or Poland, to name but a few. These foundations are now organised in the International Network of Health Promotion Foundations <www.hpfoundations.net/>. These public foundations are quite different from private ones, like the Melinda and Bill Gates Foundation for instance <http://www.gatesfoundation.org/defaul t.htm>, which can work rather independently <http://www.gih.org/usr_doc/2003_Co nversion_Report.pdf> or in close partnership (see the Fondation Lucie et André Chagnon for instance <http://www.fondationchagnon.org>) with governments. In many instances, these public foundations get their funding through mechanisms involving the utilization of taxes levied on products potentially harmful to health like tobacco or alcohol, often labeled “sin taxes”. In order to reflect on this complex topic and eventually take a position on these issues, the Board of Trustees (BOT) of the International Union for Health Promotion and Health Education (IUHPE) has commissioned an important paper1 which has been presented to its executive in Paris in

December 2005. Looking at several countries, the paper first documents how the taxation of alcohol and tobacco can be utilized as a policy instrument to promote the health of populations, reviewing the potential harms and benefits of doing so and showing that the impact of taxing tobacco is quite different than taxing alcohol. The paper then goes on to discuss the issue of earmarking (i.e. specifically dedicate) taxes for health purposes and some of the ethical, social justice and economic dilemmas that this practice can raise. Finally, the question of channeling earmarked taxes into Health Promotion Foundations is treated and lessons learnt in doing so over the past decade are exposed. The paper has generated significant interest and debate at the IUHPE Executive Committee meeting of December 2005. Even if it is of common use in certain quarters, the expression “sin taxes” seemed very moralistic, culturally specific and inappropriate to many. The fact that the paper was commissioned to make the case that earmarking and health promotion foundations were appropriate mechanisms, rather than asking in a less committed way if we had sufficient evidence to actually make the case, was questioned by others. Finally, the fact that the utilisation of taxation as a policy instrument to promote health was covered in the same paper than earmarking taxes for health promotion foundations seemed a bit confusing to some. Consequently, it was decided that two sets of reactions would be sought on the paper in order to provide additional input to IUHPE Board of Trustees, for discussion and eventual adoption of a position. On the one hand, under the guidance of IUHPE Vice-President for

Websites of Health Promotion Foundations Austrian Health Promotion Foundation: www.fgoe.org BC Coalition for Health Promotion: www.vcn.bc.ca/bchpc/ Health 21 Foundation (Hungary): www.health21.hungary.globalink.org Health Promotion Switzerland: www.promotionsante.ch Health Promotion Foundation (Poland): www.promocjazdrowia.pl Healthway: www.healthway.wa.gov.au ThaiHealth: www.thaihealth.or.th VicHealth: www.vichealth.vic.gov.au/

Advocacy Marilyn Wise, a more internal discussion would be undertaken on the BOT electronic discussion list. On the other hand, and it is what we are doing here, a call would be made to the general membership of IUHPE to contribute its reflections and reactions through Reviews of Health Promotion & Education Online – RHP&EO (www.rhpeo.org). IUHPE members are thus invited to react, using the usual guidelines to do so that can be found in the RHP&EO website. Even if you do not want to react, reading this paper is surely a very useful endeavor for anybody concerned with funding health promotion infrastructures and interventions, because it raises quite successfully most of the issues and dilemmas involved in using tobacco and alcohol taxes (and eventually the taxation of other products with a high detrimental potential to health like fastfood, weapons, etc.) to do so.

Michel O’Neill Editor in Chief, RHP&EO Laval University Quebec, Canada Email: Michel.ONeill@fsi.ulaval.ca

1. Slama, K. (2006) “Background information for adopting a policy encouraging earmarked tobacco and alcohol taxes for the creation of health promotion foundations” Promotion & Education. XIII (1): 30-35.

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Karen Slama

Background information for adopting a policy encouraging earmarked tobacco and alcohol taxes for the creation of health promotion foundations z There are a number of ways to examine the issues involved in a) raising taxes on specific products to influence health and b) the dedication of a proportion of those taxes to specific purposes, in this case, earmarking taxes for the creation and maintenance of a health promotion foundation. This background paper will examine some of the common considerations of fiscal policy in relation to alcoholic beverages and tobacco products, look at the impact of raising prices on changes in consumption and the corresponding health and social consequences, examine more specifically the pros and cons of earmarking a portion of alcohol and tobacco taxes for health promotion, and look at some aspects of successful creation of health promotion foundations based on earmarked taxes.

Fiscal policy applied to alcoholic beverages and tobacco products A basic economic truth is that the price of a product is linked to the demand for that product, and an increase in price is expected to lower demand, other things being equal. Those other things can be legal, cultural, normative or related to characteristics of the product, such as its addictive potential (Cook & Moore, 2002). Price elasticity of demand is the percentage change in consumption resulting from a 1% increase in price. As long as the price elasticity of the demand is less than a value of -1, an increase in taxes will result in a net gain in total tax revenues. This is the case for tobacco. Taxes on tobacco products are important for generating revenue. The major criteria for choosing a revenue-generating tax are equity and efﬁciency. Equity in taxation means that there should be an equal tax burden among tax payers, either through taxes based on individual

Karen Slama, PhD. International Union Against Tuberculosis and Lung Disease Paris, France Email: kslama@iuatld.org

benefit received from services provided by the government or through taxes based on an individual’s ability to pay. So-called «sin» taxes apply the benefit principle; that individuals pay for the use of government-provided services in proportion to the benefits they derive from them. Alcohol abuse and tobacco consumption generate an economic burden that affects all individuals in the society and not just the users, so the total tax revenue collected should be equal to the total societal costs. Because consumption decreases even with inelastic products, policy can also have public health objectives. If a price policy has as its goal to reduce consumption of dangerous products such as alcoholic beverages or tobacco products, it is usually excise tax that is raised (Chaloupka et al, 2002); the cost is passed on to consumers in the form of higher retail prices. A 10% increase in tobacco prices reduces consumption by 4% on average in developed countries, and by 8% in low and middle-income countries (WHO, 2002). In Thailand for example, price elasticity for tobacco is estimated to be 0.7 (Siwraksa, no date). Raising alcohol taxes may not generate substantial revenue; there appears to be no consensus on the size of effect and there is disagreement as to the responsiveness to price of the heaviest drinkers. Nevertheless, economists agree that even small variations in price have an impact in reduced consumption (Cook & Moore, 2002). Tobacco can be taxed more heavily than products with elastic demands (Hu et al, 1998). But for both alcohol and tobacco, many countries have not raised taxes to keep up with inflation and thus do not benefit from either the revenuegeneration or public health benefits of raised taxes. In 11 out of 42 countries investigated in a recent study, tobacco prices in 2000 were more affordable than they had been in 1990, and in Iran, Egypt, and Viet Nam, prices had decreased by more than 50% (Guindon et al, 2002). In the US external costs for alcohol were over three times the tax rate in the 1980s

(Cook & Moore, 2002). With decreased taxation, consumption rises. For example, in 1999, Switzerland reformed its spirits markets in line with World Trade Organisation agreements, decreasing prices and encouraging market competition. Alcohol consumption increased signiﬁcantly, particularly among young people and there were corresponding increases in alcohol-related problems (Mohler-Kuo et al, 2004). When Canada reduced tobacco taxes in 1994 to counteract increased smuggling, consumption rose dramatically as did youth prevalence of smoking. With trade liberalisation, low income countries that previously had tobacco monopolies are subjected to competition and general price decreases. In the 1990s, opening their markets resulted in net increases in tobacco use in Japan, Korea and Taiwan. (Chaloupka & Corbett, 1998).

Benefits of price policy for tobacco and alcohol control Tobacco taxes protect health, deter uptake, promote quitting and reduce exposure to secondhand smoke pollution (Wilson & Thomson, 2005). Raising taxes on tobacco products is considered to be one of the most effective components of a comprehensive tobacco control policy. Even when prevalence rates have decreased signiﬁcantly, price increases remain a strong economic disincentive, as shown in a recent study of the effects of continued price rises in California (Sung et al, 2005). Indeed, cigarette prices are higher and have become less affordable over time in many countries with strong national tobacco control programmes. Appropriate tax levels for tobacco according to the World Bank are the equivalent of 2/3 to 4/5 of retail price. The potential impact of a 10% increase in price is 40 million people quitting (4% of all smokers) and 10 million deaths

Keywords • earthmarking taxes • ﬁscal policy • health promotion foundation

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Advocacy averted (3% of all expected deaths from tobacco). Of deaths averted, the greatest effect would be among younger smokers (Ranson et al, 2000). For alcohol, consumers drink less and have fewer problems if alcohol prices are raised. Beer is often found to be the least responsive, spirits the most (Chaloupka et al, 2002), but price elasticity for alcohol is highly inﬂuenced by social values about drinking. Unlike for tobacco, alcohol consumption is highly concentrated in the top 10% of users, who consume more than half of all alcohol consumed. According to the “Single Distribution Theory”, the whole population is associated with drinking patterns. To reduce consumption among heavy drinkers, the entire population needs to decrease consumption (Cook & Moore, 2002). An increase in price reduces alcohol morbidity, mortality and adverse social events among light, moderate and heavy drinkers, and consequently reduces the number of rapes, robberies, incidents of maternal child abuse, spouse abuse, episodes of sexual misconduct, property damage and involvement in violence. And these effects are largest for those under 21 years of age. (Chaloupka et al, 2002). Youth are disproportionately represented in alcohol-related problems; the major cause of death among those under 35 in rich countries is fatal vehicle accidents, about half of which involve alcohol. Alcohol abuse in adolescence is related to later abuse (Ludbrook et al, 2001). So policies to reduce drinking among youth probably are the most effective in reducing drinking in the entire population. Price measures have been shown to reduce the percentage of youths who drink heavily, and to reduce binge drinking (Cook & Moore, 2002).

Potential harms caused by raising tobacco or alcohol taxes There is no evidence that individuals or communities experience harmful health consequences from reduced consumption of tobacco products or alcoholic beverages. There may be a possible but unlikely reduction of the protective effect of very moderate alcohol consumption on cardiovascular disease risk. Increased taxes do, however, have the potential of causing harm in contributing to ﬁnancial hardship among individuals

who do not change their consumption. Low income populations spend a greater percentage of disposable income on tobacco products, so tobacco taxes are regressive. In many countries the tobacco use prevalence and consumption rates are higher in low income groups than other income groups, increasing the hardship. But some see a «self-control» value of taxes in the extent to which the higher taxes help people to quit at some time in the future. The self-control element is probably more useful to low income people, so tobacco taxes can be beneficial overall to them (Lav, 2002). In other words, even if taxes on tobacco are regressive, tax increases can be seen as progressive in that they have more effect on low income groups and lead to reduction in health inequalities. Studies have found that price responsiveness is inversely related to social class and education. Smokers from lower income groups are more likely to quit in response to price rises rather than reduce consumption (Guindon et al, 2002). In addition, there are a number of possible remedies for hardship exacerbated by consumption taxes, such as providing tax relief or using earmarked revenues for health promotion in these populations. Tax changes in Australia resulted in decreases in consumption in both blue and white collar groups and the proportion of heavier smokers has declined. There has been more of an effect among low income groups, who are targeted by quit campaigns and mass media campaigns (See:http://www.quit now.info.au/tobccamp3.html) Despite the clear advantage for public health of increased tobacco and alcohol taxes, structural barriers remain. In most countries, policy-makers are attuned to the short-term benefits and costs of policy. In countries with underdeveloped health sectors, most of the external costs of tobacco or alcohol are not assumed by governments so there is less of an impetus to recuperate costs. In both these situations, the short term perceived costs seem high in relation to tobacco or alcohol control policy: pressure from industry not to act, identifiable job losses if consumption drops regularly, (unfounded) fear of reduced tax revenues. (Chaloupka et al, 2000). Raising prices through taxation, however, can raise new revenue in the short-term, while enabling the full effect of taxes after

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many years as related disease incidence drops and higher prices reduce recruitment of new heavy drinkers or smokers. One of the best uses for a proportion of newly generated revenues from price policies to reduce consumption of unhealthy products is to legislate a funding mechanism for programmes through a health promotion foundation.

Earmarking Government policy-makers should consider using price policy to reduce the damage caused by tobacco and alcohol. Overall, tobacco and alcohol taxation is justified, and there are many steps that can be taken to reduce harms and injustices (Wilson & Thomson, 2005). More and more countries are using earmarking of tobacco taxes to do this, and some add alcohol taxes. Earmarking a part of tobacco and alcohol taxes to finance health promotion foundations would provide the means for greater benefit for health than occur by only raising taxes. And yet concerns remain. The process of advocating for the creation of health promotion foundations from earmarked funds includes understanding and countering the arguments against earmarking. In this section, the arguments put forward to reject earmarking are assembled and followed by the reasoning and justifications for using earmarking. Arguments concerning earmarked taxes can be grouped into the following categories, fiscal and governance issues, ethical issues, health and social consequences, justice and equity and economic issues. Arguments against earmarking are presented in italics, and are followed by possible rebuttals or evidence of advantages accruing to earmarking for health promotion.

Fiscal and governance issues • Not all fiscal specialists are convinced about the equity and efficiency justifications made for tobacco taxation and earmarking. Instead of looking at the benefits, some look at the loss of consumer surplus, the loss of producer surplus, and dead-weight loss (the excess burden) on society. Some may object to transferring the costs of people smoking in past generations to younger current smokers. And depending on the methods

Figure 1

the beginning of a slippery slope of other special-interest programmes funded by earmarked taxes.

Taxes and revenues in Zimbabwe

of establishing cost, some see possible medical and retirement cost savings due to tobacco-related early death. The public generally supports special taxes on dangerous products for revenue needs and social goals. Because consumption of tobacco and alcohol impose public costs across communities, citizens accept that excise taxes do not broadly distribute the tax burden for public services (Hu & Mao, 2002). A major public relations flop occurred when the public rejected the conclusions of the Philip Morris International study funded for the Czech government which found the government would save on pensions because of deaths at younger ages among smokers. Once potent, this accounting procedure is no longer acceptable. • There is greater flexibility for finance if all revenues are in a single pile. Earmarking means that appropriation choices are removed from the legislature or the government ministry; this is generally contrary to government fiscal practices of allocation. Some feel that earmarking undermines financial discipline and introduces budgetary

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• On the other side of the issue, some fear that earmarking carries the possibility of instability of revenues over time. That is, as consumption declines, revenues in the long term also decline and the functioning of a health promotion foundation would be disrupted

rigidity in face of competing needs. Earmarking eases pressure on general revenue finance for particular public goods or services when users or beneficiaries of these sources can be easily identified. (Earmarking serves as a sort of replacement for direct charges for services). The reality of funding in competitive allocation is that prevention and promotion are discounted in light of needs for hospital and treatment services. If taxes are raised for earmarking, this creates additional funds, so regular tax revenues are not disrupted. With earmarked taxes, the income stream is separated from the main budget. Resources are generated to reach those not reached by the tax itself through media or special programmes. This is an appealing policy instrument for tobacco control or health promotion policy makers. • Accepting the concept of earmarking taxes for health foundations may be blocked by the fear that if there is one extra-budgetary programme, that may be

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Revenues from tobacco taxation, Australia, 1995-2004

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Earmarking allotted for a health promotion foundation is clearly in the public’s best interests. Experience shows that this does not lead inexorably to copycat proposals for earmarking (eg., fears at the creation of ThaiHealth have since been allayed.).

There is no documented loss of government revenues upon raising tobacco taxes anywhere in the world. Examples of this are presented in the ﬁgures.

Ethical issues • The major ethical issue is found in receiving funds directly from the industry involved and the conflict of interest that can be created. In the United States, the Master Settlement Agreement between 46 states and major tobacco companies specified that up to $206 billion would be allocated over 25 years to the states, depending on future sales to compensate for health costs due to smoking-related diseases. Conflict of interest arises when the fiscal health of the source of the money, the tobacco companies, influences decisions about the uses of that funding (Sindelar & Falba, 2004). Declines in tobacco consumption have already reduced payments to states by 10% (-$1.6 billion) from what was initially projected, and the shortfall is estimated to rise to 20%. (Lav, 2002). Many states have invested little or none of this money into tobacco control. More generally, conflict of interest arises when funders can censor the content of health promotion programmes. The source of funding for health promotion from government allocation through earmarking or any other fiscal measure removes conflict of interest, for the revenue is what is paid by consumers, it is not taken from the profits of the producers; there is no impetus to help these industries to retain

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Advocacy their proﬁt margins. Health promotion in general and tobacco control in particular are chronically under-funded. The tobacco industry works against the public good, and tobacco and other industries (alcohol, food etc) can use their money to distort public health priorities, far outspending anything that health promotion can fund. Resources are required to initiate alcohol and tobacco control programmes; price policy alone is not sufﬁcient (Hu et al, 1998). By earmarking a portion of taxes for health promotion funding, all additional strategies will mutually increase the total impact for the public good and health promotion can make up for the shortfalls of price effects.

Health and social consequences • Higher prices could enhance smuggling which would add additional costs and impede revenue generation. The expected beneﬁcial effect on consumption and health may not occur if consumers have access to lower cost products, thereby subverting the purposes of the tax (Hyland et al, 2004). Smuggling is more related to the degree of corruption in a country than the price of the product. Control of tobacco smuggling with internationally coordinated and unambiguous technical solutions is currently on the international agenda, through work with the Framework Convention on Tobacco Control. Earmarked funds could be used for this as well.

Justice and equity • Taxes are a blunt policy tool that reduces the welfare of tobacco users who choose to use these products with a clear understanding of the consequences of their addiction. Even though the risks of tobacco use are generally understood in some populations, tobacco users are consistently shown to underestimate the extent of risk, which indicates that prevalence is higher than it would be if users were well informed about the risks. Raising and earmarking taxes helps to make risk information more resonant to users, with beneﬁts to youth that are considerably larger than losses to adults. Health promotion foundations would

Figure 3

per head tobacco consumption vs smoking prevalence

ensure that earmarked taxes are used for health promotion programmes to reduce health inequalities. Earmarking can be consistent with an overall system of taxes and transfers that promotes equity as many of the activities funded by earmarked tobacco taxes signiﬁcantly reduce the welfare losses resulting from tobacco tax increases (Hu et al, 1998). Smoking is harmful to health, leading to increased health care costs, placing a burden on all, including non-smokers. • Governments may be reticent to increase taxes on alcohol because they fall not only on abusers but light drinkers who do not abuse alcohol and do not need to be discouraged from drinking. Alcohol price increases reduce alcohol morbidity, mortality among drinkers, even light drinkers, and reduce adverse social events related to abuse that are a burden on all of society. Raising alcohol taxes produces beneﬁts that are much superior to the costs.

Economic issues • If tax increases for earmarking reduce consumption of tobacco, this would bring about job losses creating an extra burden on society. While jobs directly related to tobacco growing and manufacturing would decline, the impact on employment in other sectors would increase, as exsmokers spend their money on other goods and services, with the net macroeconomic impact of higher tobacco taxes being negligible or positive. • The amount of funding provided by

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earmarking could be inappropriate in relation to changing social environments or economic conditions and distort government spending Even if there is earmarking, politicians can intervene. In Australia and California, large tax increases led to capping of funds available for health promotion from earmarking (but this did create some budgetary instability). Overall, earmarking reduces budgetary ﬂuctuations in the long term. In Australia, the current system of annual review with indexation at around yearly cost of living increases means that continuous and substantial funding is available from consolidated funds for health promotion. In California in the early 1990s, the budget for health promotion was the equivalent of 25% of tobacco industry spending. After government intervention capping revenues attributed to tobacco control, the equivalence dropped to 12% (Sung et al, 2005). This is nevertheless a considerable amount of money that would not have otherwise been available for tobacco control.

Creating and running health promotion foundations: best practices and lessons learned Health promotion foundations do not have to be funded by earmarked taxes. But, where these do not exist, there is usually little impetus to create and assure funding for them despite universal agreement “in principle” with the concept. But if policy-makers can be persuaded by the arguments for raising taxes for earmarked funds, this is probably the best guarantee that a health promotion foundation will be funded.

This section will look at some of the important issues relating to the creation and funding of health promotion foundations.

Finances In Australia, tobacco tax collections have continued to increase over time, despite prevalence decreasing and prices increasing. However it is important that the price of tobacco is indexed and adjusted to the consumer price index. Health promotion foundations in Australia are now funded by direct allocation from consolidated revenue, at rates similar to capped hypothecated funding indexed to inflation. A fixed rate from taxes for funding is better than a ceiling: VicHealth’s budget dropped as ceilings on funds from earmarking were changed. There is always the potential for politician interference, but whatever the conditions of earmarked funds, they tend to be better than general government allotments. Allocations can be earmarked. At VicHealth, 30% of funds are used for sports promotion, 30% for health promotion. Priority is given to fight health inequalities for indigenous people, rural communities, the impoverished and the disabled, through cultural activities as well as health promotion. According to the International Network of Health Promotion Foundations, Health Promotion Foundations must be created through specific legislation that specifies the long-term recurrent funding mechanism and administration of funds. They should be set up to distribute funds for health promotion. They should be overseen by an independent Board that represents all stakeholders; but the organisation should be able to exercise a high level of autonomous decision making. The Health Promotion Foundation would have an obligation to be non-partisan and to work with other sectors and organisations at all levels of society (Phipps R, 2003).

Goals Health promotion foundations generally allocate funding for health promotion programmes, tobacco prevention programs, health promotion and prevention research, replacement of tobacco and alcohol sponsorship, and services for smokers and problem

drinkers. Earmarking makes sustained, sophisticated, public and school health promotion and education campaigns feasible. In Australia, the Health Promotion Foundation model was developed to replace tobacco sponsorship in light of new bans on tobacco advertising, and support for tobacco control strategies also in light of new legislation; secondary to this, additional funding was secured for health promotion and research. Health Promotion Foundations would be the most apt source of programmes to reduce health inequalities.

Lessons learned The experiences of VicHealth (Carol A, 2004; Sheehan C & Martin J. private communication) and Healthway (Cordova S. 2003) in Australia, ThaiHealth (Siwraksa P) in Thailand and the Korean Health Promotion Fund (Nam EW, private communication) show that earmarking of health promotion foundations or funds can greatly improve the health promotion activities in a country. They were created after intense and long-term effort from health promotion advocates. Here are some of the lessons learned in advocating for earmarking tobacco (and alcohol) taxes for health promotion funds or the creation of a health promotion foundation. • The Finance Ministry, in particular, needs cogent logic on the economic benefits and public health good of raising and earmarking taxation. • An extensive community support network should be created, with high profile, articulate spokespersons, probably already part of bureaucracy. All actors should have agreed and common goals. • Evidence should be available of the expected positive effect on health and the cost-benefit effectiveness of those effects in the local context. All expert information should be readily available. The main message is always that the extra tax will protect the community and strengthen public health. • Surveys should be undertaken to show public support for the initiative. • Draft legislation should be prepared, including the exact mechanism for collecting the levy and for managing it. • Lobbying should involve arguments to

convince the government that it must act, that such action is a bi-partisan, visionary step that will mark history. • It is important to find common ground with those who might have economic losses, e.g., those who would lose tobacco sponsorship. Proponents of VicHealth stressed its goal of using funds to replace tobacco advertising and were thus able to win over potential adversaries. • Lobbying activity should keep the time period short, for the tobacco industry has money and will use it to subvert support if given the time. • ThaiHealth followed the model of VicHealth, feeling it was a more flexible and adaptable structure with legislative backing and a guaranteed source of income so as not to have to fight for its budget each year. • From the experience of lobbying for ThaiHealth, it is suggested that a twostep process may be useful: first get cigarette tax increases, then go for earmarking for a health promotion foundation. • The basic context of the creation of a Health Promotion Foundation has been seen to be strong leadership, stable government and a commitment to health. Evaluation once in place is essential for continued support • There is a danger in the Master Settlement Agreement approach: direct agreement with the tobacco industry meant that there was no restriction on the tobacco industry’s ability to promote tobacco products; in 2001 in the US, the tobacco industry spent $11.2 billion on advertising, the effect of which partially offset the effects of the higher prices. • Alcohol taxation issues appear more complex than those for tobacco. While reducing consumption, they may not generate excess revenue. If large alcohol tax increases are politically unacceptable, one approach could be a progressive application of tax according to the amount of alcohol in the purchased item. (Ford, 2004) • Other information concerning creation and administration issues is available from the Health Promotion Foundations Network (http://www.hpfoundations.net).

Conclusions Price policy can be an important part of tobacco and alcohol control. The

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Advocacy evidence is strong that the use of tax for health promotion and disease prevention produces public good. Effects on health promotion from earmarked taxation are higher than for taxes alone and are an important tool to promote public health. This could be even more widespread and equitable if used in the context of a health promotion

foundation. Earmarking additional tax revenues for the creation and funding of a health promotion foundation will create the means to implement a full arsenal of programmes for the public good and to ﬁght health inequalities. The various experiences of creating health promotion foundations from earmarked taxes

converge on these points. It takes solid data, perseverance and long-term planning. There will be set-backs and opposition from not only the tobacco (and alcohol) industry, but other sectors of society. Misperceptions will need to be dispelled regularly. But the potential health beneﬁts for society are enormous and make the endeavour well worth the effort.

References Carol A. The Establishment and Use of Dedicated Taxes for Health. WHO Western Pacific Region. 2004. Chaloupka FJ, Grossman M, Saffer H. The effects of price on alcohol consumption and alcohol-related problems. Alcohol Res Health 2002; 26:22-34. http://www.niaaa.nih.gov/publications/arh261/22-34.htm Chaloupka FJ, Hu T, Warner KE, Jacobs R, Yurekli A. The taxation of tobacco products. In Jha P, Chaloupka F (eds). Tobacco Control in Developing Countries. Oxford: Oxford University Press. 2000; pp237-272. Chaloupka F, Corbett M. Trade policy and tobacco: Towards an optimal policy mix. In Abedian I, van der Merwe R, Wilkins N, Jha P. (eds). The Economics of Tobacco Control. Towards an optimal policy mix. Capetown: Applied Fiscal Research Centre, University of Capetown. 1998; pp129-145. Cook PJ, Moore MJ. The economics of alcohol abuse and alcohol-control policies. Health Affairs 2002; 21:120-133. Cordova S. Best practices in tobacco control earmarked tobacco taxes and the role of the Western Australia Health Promotion Foundation (Healthway). WHO Tobacco Control Papers. 2003. http://repositories.cdlib.org/tc/whotcp/WAustr alia2003 European Report on Tobacco control policy (WHO regional office) WHO European Ministerial Conference for a Tobacco-free Europe 2002.

Ford S. letter. Alcohol evidence and policy. BMJ 2004; 328:1202-1203. Guindon GE, Tobin S, Yach D. Trends and affordability of cigarette prices: ample room for tax increases and related health gains. Tob Control 2002; 11/35-43. Hyland A, Higbee C, Bauer JE, Giovino GA, Cummings KM. Cigarette purchasing behaviours when prices are high. J Public Health Manag Pract 2004; 10:497-500. Hu TW, Mao Z. Effects of cigarette tax on cigarette consumption and the Chinese economy. Tob Control 2002; 11:105-108. Hu T. Xu X. Keeler T; Earmarked tobacco taxes: Lessons learned. In Abedian I, van der Merwe R, Wilkins N, Jha P. (eds). The Economics of Tobacco Control. Towards an optimal policy mix. Capetown: Applied Fiscal Research Centre, University of Capetown. 1998; pp102-118. International Network of Health Promotion Foundations website accessed 10/10/2005 http://www.hp-foundations.net/new/ehpf_ earmarking_taxes.html Lav IJ. Cigarette tax increases: cautions and considerations. Revised 2002 Center on Budget and Policy Priorities. http://www.Cbpp1\data\media\michelle\postin gs\7-3-02sfp-rev.doc Ludbrook A, Godfrey C, Wyness L, Parrott S, Haw S, Napper M, van Teijlingen E. Effective and cost-effective measures to reduce alcohol misuse in Scotland: A literature review. Scottish Executive, 2001. For the final report: http://www.alcoholinformation.isdscotland.org/

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alcohol_misuse/files/MeasureReduce_Full.pdf Mohler-Kuo M, Rehm J, Heeb JL, Gmel G. Decreased taxation, spirits consumption and alcohol-related problems in Switzerland. J Stud Alcohol 2004; 65:266-73. Phipps R. Report on the 3rd Meeting of the International Network of Health Promotion Foundations, Budapest, April, 2003. Ranson K, Jha P, Chaloupka FJ, Nguyen S. The effectiveness and cost-effectiveness of price increases and other tobacco-control policies. In Jha P, Chaloupka F (eds). Tobacco Control in Developing Countries. Oxford: Oxford University Press. 2000; pp427—447. Sindelar J, Falba T. Securitization of tobacco settlement payments to reduce states’ conflict of interest. Health Affairs 2004; 23:188-193. Siwraksa P. English version translated by V. Isarabhakdi. The Birth of the ThaiHealth Fund (published by ThaiHealth) http://www.thaihealth.or.th/en/download/TheBi rthOfTheThaiHealthFund.pdf Sung H-Y, Hu T-W, Ong M, Keeler TE, Sheu M-L. A major state tobacco tax increase, the Master Settlement Agreement and cigarette consumption: the California experience. AJPH 2005 95:1030-1035. Wilson N, Thomson G. Tobacco taxation and public health: ethical problems, policy responses. Soc Sci Med 2005; 61:649-59. Wilson N, Thomson G. Tobacco tax as a health protecting policy: a brief review of the New Zealand evidence. NZ Med J 2005 118:U1403.

Melanie Rock

‘We don’t want to manage poverty’: community groups politicise food insecurity and charitable food donations Abstract: Charitable assistance is a common response to food insecurity in many affluent countries. The coalition featured in this case study is explicitly concerned with social justice, mitigating the potential for charitable assistance to mask the extent of food insecurity, its root causes and its long-term consequences. The coalition structure

This manuscript was submitted on August 26, 2004. It received blind peer review and was accepted for publication on September 26, 2005.

In afﬂuent countries, social inequalities persist and frequently affect health status (Macintyre 1997; Ross, Wolfson et al. 2000; Potvin, Lessard et al. 2002). In the United States (Poppendieck 1998) and Canada (Jacobs Starkey, Kuhnlein et al. 1998; Jacobs Starkey, Gray-Donald et al. 1999; Tarusuk & Beaton 1999; Jacobs Starkey & Kuhnlein 2000; McIntyre, Raine et al. 2001; Hamelin, Beaudry et al. 2002), charitable food assistance has become an institutionalised response to social inequality. Since the early 1980s, food banks have become the main way of distributing emergency food assistance in Canada. Some of the supply distributed through food banks comes through individual donations, and some comes from corporate donations (Tarasuk and Eakin 2003 for further discussion). Besides food banks, ‘collective kitchens’ have also been established in many parts of Canada; many collective kitchens rely on donated ingredients and supplies (Tarasuk and Reynolds 1999; Racine and St-Onge 2000; Sabourin, Hurtubise et al.

Melanie Rock, PhD, MSW Assistant Professor University of Calgary Department of Community Health Sciences Health Sciences Centre 3330 Hospital Drive NW Calgary, AB, Canada T2N 4N1 Tel: 403.210.8585 Fax: 403.210.9747 Email: mrock@ucalgary.ca

has assisted community workers in transcending day-to-day routines, so as to reflect on the politics of food insecurity and institutionalised responses to this problem. Coalition members have defined food security as an objective whose achievement will entail comprehensive reform. One noteworthy outcome has been to

recommend that member groups not redistribute a number of foodstuffs commonly donated by individuals and corporations. In grappling with a tension between responding to immediate needs for food and addressing the root causes of these needs, community workers have paid attention to public health.

2000; Edward and Evers 2001; Marquis, Thomson et al. 2001).

extent of food insecurity and its multiple root causes – a key ﬁnding of previous studies – appears to have been mitigated by this coalition’s explicit concern for social justice. Indeed, a dual concern with hunger and social justice is reﬂected in the coalition’s name: la Table de concertation sur la faim et le développement social du Montréal metropolitan (Taskforce on Hunger and Social Development for Metropolitan Montreal).

Research on food insecurity in Canada has found that these prevailing responses to food insecurity tend to reproduce – not reduce – social disparities (Jacobs Starkey, Kuhnlein et al. 1998; Poppendieck 1998; Tarasuk and Reynolds 1999; McIntyre, Travers et al. 1999; Hamelin, Beaudry et al. 2002; McIntyre, Officer et al. 2003; Raine, McInytre et al. 2003; Williams, McIntyre et al. 2003). Moreover, a recent Canadian study suggests that reliance on food donations ultimately serves to obscure whether or not recipients’ nutritional requirements are met. ‘The only decision latitude [food bank] workers had’, this study found, ‘was in deciding whether or not a particular food was fit for consumption. Given the limited supply, however, they appeared more likely to try to salvage food than discard it.’ (Tarasuk & Eakin 2003: 1509). The present article features a Canadian case study that provides a counterpoint to previous studies. Unlike these studies, it is not based on the analysis of the dayto-day activities involved in redistributing charitable food assistance. Instead, it features a coalition that is grappling with the problem of food insecurity. More specifically, it profiles a Montreal-based coalition’s recent efforts to foster reflection among its members and in Quebec society at large about the nature, extent, causes and consequences of chronic food insecurity in their midst. This reflective process has led to the identification and promulgation of food security as an overarching social and public policy objective. The potential for charitable food assistance to mask the

To deal with a tension between responding to immediate needs for food and addressing the social roots of these needs, community workers have given consideration to current and projected health disparities. The Taskforce has articulated a political vision in which equal access to life, to health, has become a crucible for deepening democracy (as per Appadurai 2002). One noteworthy outcome of this reﬂective process has been to recommend that member groups not redistribute a number of foodstuffs commonly donated by individuals and corporations. This Taskforce’s position on unacceptable charitable food assistance has emerged through reﬂection on unequal living conditions and life chances.

Methods This case study is based mainly on the analysis of more than ﬁfty documents produced by Taskforce staff members, including meeting minutes, annual

Keywords • food security • charity • Canada

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Advocacy reports and monthly newsletters. It is also informed by ﬁeldnotes documenting observations made during ﬁve face-toface and telephone encounters with key Taskforce members, observations made at three Taskforce meetings, and observations made at a workshop on food insecurity organised by the Taskforce in June 2003. Taskforce staff and its members are aware that I am a university-based researcher, and that I was attending their meetings and workshop in that capacity. The observations were made in the process of a negotiating a partnership between a university-based Chair in health promotion research and community organisations in Montreal, including the Taskforce. As rapport was still being built

Table 1

(Lecompte & Schensul 1999, 10-12) in a climate initially characterised by wariness and some distrust on the part of the Taskforce, it would have been premature to apply for formal ethics review. (Research currently underway with the Taskforce under the auspices of the Chair is part of a formal research protocol.) For ethical reasons and also to help verify the analysis, the Taskforce president read this text and approved it for publication. For ethical reasons and also in keeping with this article’s focus on how Taskforce members have sought to politicize food security, the present article limits direct quotes to information placed deliberately in the public domain. The analysis of these public domain sources, however, has been informed by

Elements of a comprehensive food security policy

1. Agriculture

3. Education

a. Production policies that respect the environment. Today, the right to produce and export as much as possible is upheld.

a. Policies that take the organization of paid work and its consequences, including poor child nutrition and the loss of cooking skills. Such a policy approach could draw inspiration from certain European cities and regions, which have brought together decision-makers in a bid to improve lived experience among the citizenry.

b. Policies that support organic production and that support democratic access to organic products. c. Policies governing agro-food transformation that respect regional dynamics and differences. We are witnessing a concentration in large centres, to the disadvantage of those living in less densely populated regions. d. Policies governing agro-food distribution that take regional disparities into account. The dictates of the market should be complemented by interventions to adjust for regional disparities. We are particularly thinking of populations in the far north. 2. Health a. Policies to ensure that the population is informed about product quality and risks posed by innovations such as geneticallymodified organisms; b. Policies to ensure that charitable food distribution promotes health. Nutritional supplements should be included with emergency food provisions. It is insufficient and dangerous to simply count on corporation donations of surplus stock. c. Population health promotion policies that address the effects of fast-food on the most fragile and vulnerable. d. Policies providing free access to medication for the most fragile and vulnerable, some of whom must currently choose between food and medical treatment.

4. Social Security a. Adequate income security policies. The current formulas are inadequate and do not allow the most fragile and vulnerable to eat properly. A right to food supposes a right to eat and to feed one’s family. b. Housing security policies. The short supply of rental housing in cities and rental rates force impoverished people to cut back on food or to eat poorly. Access to affordable electricity and natural gas should be part of such as policy approach. c. Policies that support the social inclusion of people with intellectual and other disabilities. The initiatives undertaken by civil society organizations should be supported and extended. d. Family policies that take the organization of paid work into account. A public network of meals for school-aged children should be put into place where the need exists. e. Funding policies for community organizations and coalitions. Current government programs often favour authoritarian responses and reduce community-based initiatives to providing services that the state does not want to or can no longer offer.

Source: Table de concertation sur la faim et le développement social du Montréal métropolitan. Une politique transversale. Colloque: La faim, problème politique: Pour une politique de sécurité alimentaire 2003. (Author’s translation)

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a comparison with the ﬁeldnotes; this analytic technique obliges researchers to identify evidence supporting their conclusions, as well as evidence that could temper or refute the explanations being developed (Emerson, Fretz et al. 1995, 160; Lecompte & Schensul 1999, 75-78; Prior 2003, 160-161).

Findings As an ensemble, the Taskforce documents analysed for this study reveal a deeply felt tension between responding to immediate hunger with charitable food assistance, versus tackling the myriad ways in which hunger stems from social injustice. This tension accompanied the rise of food banks and related forms of charitable food assistance in Canada in the early 1980s, and it is reﬂected in the Taskforce’s composition. By way of illustration of this heterogeneity, the more than seventy members of the Taskforce include a food bank on the scale of a warehouse that supplies local food banks; local food banks where individual clients receive charitable food donations; a Catholic order whose mission is to offer assistance to all those in urgent need; an organisation staffed by registered dieticians; organisations that have deliberately developed responses to food insecurity other than food banks, such as collective kitchens and food buying clubs. Some member organisations mainly serve Anglophones or Francophones descended from Europeans who migrated to Quebec more than a hundred years ago, while other member organisations primarily serve recent immigrants. At a Taskforce meeting held 14 January 2002, under the banner of «Paths toward a policy for community food security,» staff members circulated a text that had been adopted by its board on 23 February 1998, in which the existence across the Montreal region of emergency food assistance is decried (Bouchard, Ambeault et al. 2003). Emergency food assistance is not itself condemned, however. The text notes that emergency food assistance reﬂects compassion. Yet the bulk of the text presents arguments in favour of initiatives besides emergency food relief. Similarly, the January 2003 newsletter noted three generations in recent responses to food insecurity in the Montreal area: from emergency food relief in the context of the economic

Table 2

List of foods deemed unacceptable due to harmful long-term, medium-term or shortterm effects

Food Products

Health Danger

Harmful re: future purchase patterns

Obesity

Diabetes

Candy & sweets

Chocolate

Chips

Marmalade & commercial jellies

Cakes, cake mixes & bakery products (croissants, pastries, icing, etc.)

Ready-to-eat puddings

Sweetened breakfast cereals

Bars covered in chocolate, marshmallow, etc.

Salubrity1 Canned goods • Unidentified • Dented • Swollen • Rusty

n n n n

Fruits and vegetables • Rusty in colour • Putrid • Bruised • Mouldy • Rotten

n n n n n

Past-date products

Debatable

Harmful re: culinary abilities

Diet products Popsicles & equivalents

Beverages • Latte-type mix • Sweet mix in powder form (e.g., Kool-Aid) • Punch or cocktail

Powder mix to coat meat before roasting (e.g., Shake & Bake)

Shortening

Hydrogenated margarine

Battered fish-sticks

Cheese-type spread (e.g., CheezWhiz)

Frozen dinners (e.g., TV dinner)

Packets or boxes of pasta with powder mix for sauce (e.g., Kraft Dinner, Lipton Sidekicks)

Sugar substitutes, diet products

Commercial salad dressings and mayonnaise

• Also any frozen food that has been unfrozen and then refrozen, as well as any donation whose nutritional value is debatable or that is offered with the objective, whether stated or not, of promoting a new product. • This list may be discussed, lengthened or adapted according to the context, with an obligation to avoid harming those seeking help as the guiding criterion. Source: Bouchard M, Ambeault S, Cournoyer F, Lachance T, Massicotte C, Paquette M, Ranti I, Roosevelt J-M. Nos interventions et l’innocuité alimentaire. Montréal: Comité sur l’innocuité, Table de concertation sur la faim et le développement social du Montréal métropolitan; 2003. (Adapted and translated by the author) 1. “Salubrité” in the original, which can be taken to mean clean and wholesome.

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Advocacy crisis experienced in the early 1980s; to the establishment of initiatives such as community kitchens and bulk buying clubs in response to recognition, in the late 1980s and early 1990s, of social exclusion among individuals and families experiencing food insecurity; to a growing realisation that food security can only be realised through broad political, economic and social reform (Paiement 2003). In 2002-2003, committees met regularly to reflect on food security and to develop policy proposals. The work of these committees culminated in a workshop held in June 2003, when these propositions were tabled and discussed further with a view to implementation. Table 1 summarises these propositions. The work of the committee on food safety (comité sur l’innocuité alimentaire) illustrates the scope of reflective process spearheaded by the Taskforce, and the emphasis placed on translating reflection into action. Until now, public health questions about food safety have focused mostly on spoilage. Indeed, storing perishable foods properly, checking vigilantly for spoilage, sanitisation and respecting product ‘best before’ dates feature prominently in the guidelines endorsed by the Federal-ProvincialTerritorial Commitee on Food Safety Policy for charitable food assistance in Canada (Federal-Provincial-Territorial Committee on Food Safety Policy 1999). The Taskforce’s committee on food safety did address such concerns, but it interpreted the issue far more broadly. Stating that the primary obligation in public health is to do no harm (Bouchard, Ambeault et al. 2003), they sought to take into account Canada’s current socio-economic and epidemiological profile, in which infectious diseases are less prominent than they once were, while chronic conditions such as type 2 diabetes and obesity are prominent, not least among people who have low incomes and have received little formal education. The committee expressed concern about the potential, over time, for members of socio-economically disadvantaged groups to lose culinary skills, and about purchasing patterns that could fuel public health problems such as diabetes and obesity in disadvantaged populations. For example, parents who

receive cereal loaded with sugar from a food bank might be more inclined to buy this brand when they have the means to do so, the committee noted. The committee also noted that it is not necessary to suspect corporations of donating products as a form of publicity, but that it would be negligent to ignore the potential for donations to serve this purpose. The committee thus recommended that member groups refrain from distributing many types of food (see Table 2) that are regularly donated and distributed in Montreal food banks (Jacobs Starkey 1994). Several dieticians with academic appointments have endorsed their recommendations, as has the Professional Order of Dieticians of Quebec. One indication of the deeply felt tension within the coalition between responding to immediate hunger versus tackling the roots of disparities through social development initiatives is how carefully this committee worded the written statement tabled in June 2003 at the Taskforce’s workshop on food security. Therein the food safety committee acknowledged that consuming the foods hitherto not recommended for charitable distribution is not always or necessarily harmful. ‘But,’ the document continued (author’s translation), ‘the situation becomes quite different when these same foods are all that the people in difﬁculty, whom we want to help, have at their disposal’ (Bouchard, Ambeault et al. 2003). The committee determined that certain food distribution practices might, in the aggregate, detract from a positive self-image and otherwise negatively affect future health status. ‘It is not our responsibility to recycle anything and everything,’ the committee declared, ‘under the pretext that otherwise these products would go to waste.’ (Bouchard, Ambeault et al. 2003). In the ﬁnal plenary session of the Taskforce’s June 2003 workshop on food security (to which journalists were formally invited), the most striking theme to emerge focused on how public policies, socio-economic circumstances and the organisation of charitable food assistance make community workers into veritable managers of poverty. One participant approached the microphone and said that he worries that anti-poverty groups end up sliding into the management of poverty. ‘We don’t want

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to manage poverty,’ this participant said succinctly, and to combat food insecurity, he called for income security. In the closing remarks for this workshop, the Taskforce president noted that ‘the hardest thing’ about working towards food insecurity today is to feel forced to become ‘a manager of poverty.’ And he said that the Taskforce and its members must refuse to take on the role of poverty manager. Indeed, the Taskforce’s board has adopted a very different position. A position paper adopted by the Taskforce about the appropriate response to hunger in Montreal reads (author’s translation): ‘The objective is not to, in effect, entrench enduring structures of dependence and poverty management’ (Bouchard, Ambeault et al. 2003). An abridged version of the Taskforce president’s address to inaugurate the workshop, which was published on the front page of a Montreal daily newspaper (see Paiement 2003) also emphasised that hunger is inherently political, and that food security needs to be an overarching policy objective.

Discussion Previous research on emergency food assistance has pointed to the deeplyrooted character of poverty in the contemporary period, of which food insecurity forms part (Jacobs Starkey, Kuhnlein et al. 1998; Poppendieck 1998; Jacobs Starkey, Gray-Donald et al. 1999; Tarasuk & Reynolds 1999; Tarusuk & Beaton 1999; Jacobs Starkey & Kuhnlein 2000; Sabourin, Hurtubise et al. 2000; Jacobs Starkey, Johnson-Down et al. 2001; Tarasuk & Eakin 2003). With the institutionalisation of charitable food assistance, it has been suggested that community groups may unwittingly become part of the problem. Reliance on donations means that the supply available for distribution is limited, variable and largely beyond the control of the community groups that provide food assistance. Preoccupied with ‘the problem of supply,’ paid staff and volunteers may pay less attention to ‘the problem of demand’ (Tarasuk & Eakin 2003). While previous research has usefully documented the day-to-day dimensions of charitable food assistance in Canada, from quantifying what is donated to

documenting how donations are distributed and received, this case study has focused attention on a coalition. Coalition-building can be critically important, this case study suggests, for such activities can provide an opportunity for workers and recipients to think critically about the roots, day-to-day dimensions and long-term implications of charitable food assistance. The present study suggests that, in Montreal at least, community workers are well aware that a limited and unpredictable supply of donated food combined with chronic demand can lead them to become veritable ‘managers of poverty.’ To improve the overall prospects of disadvantaged populations, the coalition proﬁled in this article has underscored the importance of public policy and other forms of social development. They are moving in the direction of a broad understanding of food security and intersectoral collaboration, in the name of deeper democracy and more meaningful citizenship (Webb, Hawe et al. 2001; Appadurai 2002). Through participation in a coalition, they remind each other about unmet needs and demands that might otherwise remain invisible within their respective organizations, and more broadly in society. These unmet needs include adequate nutrition for all on a day-to-day basis, which is a cornerstone of public health. Considering the politics of food insecurity has led to questioning the practice of distributing charitable food donations, to the point of recommending that many common donations be refused. Recall, by contrast, that food bank workers in Southern Ontario seem to feel obliged to distribute any and all kinds of donated food products, in any amounts, if these products could serve to

abate the immediate sensation of hunger (Tarasuk & Eakin 2003: 1509). Given the present study’s reliance on documents placed deliberately in the public domain, it has not been possible to chronicle debates within the Taskforce regarding the recommendation to cease distributing the foods outlined in Table 2. And it is not possible to report on whether member groups – and ultimately food recipients – are willing to manage with less food in the short term, in order to work towards the achievement of the long-term objectives adopted by the Taskforce. Such questions should be addressed through future research. Taskforce staff members readily acknowledge that the amount of food given as emergency relief is not sufﬁcient, on its own, to cause health problems such as type 2 diabetes. But it is clear from their documents that they question the wisdom of redistributing emergency food supplies that depart from recommended dietary guidelines, especially when it is known that food bank users tend not to have optimal diets on a day-to-day basis (Jacobs Starkey 1994; Jacobs Starkey, GrayDonald et al. 1999; Jacobs Starkey and Kuhnlein 2000). They also are concerned about the lived experience of food insecurity, which in the contemporary period in the province of Quebec encompasses the lived experience of accepting and partly subsisting on charitable food assistance. Research conducted in the province of Quebec has underlined dietary monotony, feelings of alienation, and the importance of paying close attention to the emotional reactions engendered by food insecurity (Hamelin, Beaudry et al. 2002). Taskforce documents manifest concern for all of these facets of food insecurity.

It is precisely because emergency food relief constitutes something like a drop in the dietary bucket, in disease causation terms, that the Taskforce’s internal reflections and its public advocacy have dealt with what is not appropriate for charitable redistribution. The Taskforce is advocating for an expansive political vision, one in which emergency food distribution would be unnecessary because health-promoting conditions would be in place and available equally to all. The rationale for refusing to redistribute donations deemed inappropriate is tightly linked to refusing to manage poverty, and instead seeking to strengthen advocacy and other social development efforts. Adopting a formal policy on unacceptable food redistribution is meant to call attention to inappropriate donation practices, on the part of corporations and also the general public. The bodies of the poor are not to be used, from the Taskforce’s perspective, as so many recycling bins. A key finding of this study is that public health considerations proved crucial to the coalition’s efforts to reflect critically on the problem of food insecurity. Yet knowledge about public health problems such as type 2 diabetes was unevenly spread among coalition members. The acquisition and sharing of health knowledge, especially epidemiological knowledge, proved crucial for building consensus about the importance of curbing the expression of social inequality in health disparities. Community-based groups concerned with hunger, this study thus suggests, should be sought out more often as partners in public health education and health promotion. Not only are such groups eager to refine their knowledge about public health problems, they can also apply this knowledge through changes to practice and in advocacy efforts.

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Advocacy References Appadurai, A. (2002). “Deep democracy: Urban governmentality and the horizon of politics.” Public Culture 14(1): 419-438. Bouchard, M., S. Ambeault, et al. (2003). Nos interventions et l’innocuité alimentaire. Montréal, Comité sur l’innocuité, Table de concertation sur la faim et le développement social du Montréal métropolitan. Edward, H. G. and S. Evers (2001). “Benefits and barriers associated with participation in food programs in three lowincome Ontario communities.” Canadian Journal of Dietetic Practice Research 62(2): 76-81. Emerson, R. M., R. I. Fretz, et al. (1995). Writing Ethnographic Fieldnotes. Chicago, University of Chicago Press. Federal-Provincial-Territorial Committee on Food Safety Policy (1999). Model guideline for food safety in food banks. Ottawa, Federal-Provincial-Territorial Committee on Food Safety Policy Secretariat, Health Canada: 26. Hamelin, A.-M., M. Beaudry, et al. (2002). “Characterization of household food insecurity in Québec: Food and feelings.” Social Science & Medicine 54: 119-132. Jacobs Starkey, L. (1994). “An evaluation of emergency food bags.” Journal of the Canadian Dietetic Association 55(4): 175178. Jacobs Starkey, L., K. Gray-Donald, et al. (1999). “Nutrient intake of food bank users is related to frequency of food bank use, household size, smoking, education and country of birth.” Journal of Nutrition 129(4): 883-889. Jacobs Starkey, L., L. Johnson-Down, et al. (2001). “Food habits of Canadians: Comparison of intakes in adults and adolescents to Canada’s Food Guide to Healthy Eating.” Canadian Journal of Dietetic Practice Research 62(2): 61-69. Jacobs Starkey, L. and H. V. Kuhnlein (2000). “Montreal food bank users’ intakes compared with recommendations of Canada’s Food Guide to Healthy Eating.” Journal of the Canadian Dietetic Association 61(2): 73-5.

Jacobs Starkey, L., H. V. Kuhnlein, et al. (1998). “Food bank users: Sociodemographic and nutritional characteristics.” Canadian Medical Association Journal 158(9): 1143-9. Lecompte, M. D. and J. J. Schensul (1999). Analyzing and Interpreting Ethnographic Data. Walnut Creek, CA, USA, AltaMira Press. Lecompte, M. D. and J. J. Schensul (1999). Designing and Conducting Ethnographic Research. Walnut Creek, CA, USA, AltaMira Press. Macintyre, S. (1997). “The Black Report and beyond.” Social Science and Medicine 44: 173. Marquis, S., C. Thomson, et al. (2001). “Assisting people with a low income to start and maintain their own community kitchens.” Canadian Journal of Dietetic Practice Research 62(3): 130-2. McIntyre, L., S. Officer, et al. (2003). “Feeling poor: The felt experience of lowincome lone mothers.” Affilia: Journal of Women and Social Work 18(3): 316-331. McIntyre, L., K. Raine, et al. (2001). “The institutionalization of children’s feeding programs in Atlantic Canada.” Can J Diet Prac Res 62(2): 53-57. McIntyre, L., K. Travers, et al. (1999). “Children’s feeding programs in Atlantic Canada: Reducing or reproducing inequities?” Canadian Journal of Public Health 90(3): 196-200. Paiement, G. (2003). La faim, un problème politique. Le Devoir. Montréal: A8. Paiement, G. (2003). « Où serons-nous rendus dans cinq ans ? » À Table: Bulletin de la Table de concertation sur la faim et le développement social du Montréal métropolitan 7(1): 1-2.

Prior, L. (2003). Using Documents in Social Research. London, Sage Publications. Racine, S. and M. St-Onge (2000). «Les cuisines collectives: une voie vers la promotion de la santé mentale.» Canadian Journal of Community Mental Health 19(1): 37-62. Raine, K., L. McInytre, et al. (2003). «The failure of charitable school- and communitybased nutrition programs to feed hungry children.» Critical Public Health 13(2): 155169. Ross, N., M. Wolfson, et al. (2000). “Relation between income inequality and mortality in Canada and the in the United States: Crosssectional assessment using census data and vital statistics.” British Medical Journal 320: 898-902. Sabourin, P., R. Hurtubise, et al. (2000). Citoyens, bénéficiaires ou exclus: usages sociaux et modes de distribution de l’aide alimentaire dans deux régions du Québec; La Mauricie et l’Estrie, Rapport de recherche, CQRS: 480. Tarasuk, V. and J. M. Eakin (2003). “Charitable food assistance as symbolic gesture: an ethnographic study of food banks in Ontario.” Social Science & Medicine 56(7): 1505-1515. Tarasuk, V. and R. Reynolds (1999). “A qualitative study of community kitchens as a response to income-related food insecurity.” Canadian Journal of Dietetic Practice Research 60(1): 11-16. Tarusuk, V. and G. H. Beaton (1999). “Household food insecurity and hunger among families using food banks.» Canadian Journal of Public Health 90(2): 109-113.

Poppendieck, J. (1998). Sweet Charity? Emergency Food and the End of Entitlement. New York, N.Y., Viking.

Webb, K., P. Hawe, et al. (2001). “Collaborative intersectoral approaches to nutrition in a community on the urban fringe.” Health Education & Behavior 28(3): 30619.

Potvin, L., R. Lessard, et al. (2002). “Inégalités sociales de santé.” Revue canadienne de santé publique / Canadian Journal of Public Health 93(2): 134-137.

Williams, P., L. McIntyre, et al. (2003). “The ‘wonderfulness’of children’s feeding programs.” Health Promotion International 18(2): 163-170.

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Lynn M. Meadows, Wilfreda E. Thurston, Darryl Quantz and Mary Bobey

Women’s Health Resources: facilitating a community of care for midlife women Abstract: Since 1981 research has explored the role of women’s health centres in providing health information and education to women in a nontraditional setting. These settings have been designed to provide more appropriate, and often more comprehensive, care by responding to the specific health issues and needs of women across the age continuum. The type of care and resources provided by these centres make a significant contribution to women’s capacity for participation in decisions and action around their own health. This article examines the service delivery and perceived roles of one such centre, the

This manuscript was submitted on March 4, 2004. It received blind peer review and was accepted for publication on September 20, 2005.

Lynn M. Meadows, PhD Associate Professor, Departments of Family Medicine & Community Health Sciences Shopper’s Drug Mart Professor in Women’s Health University of Calgary 3330 Hospital Drive NW Calgary, AB T2N 4N1 Canada Tel: (403) 220-2752 Email: meadows@ucalgary.ca Wilfreda E. Thurston, PhD Professor Department of Community Health Sciences Director, Institute for Gender Research University of Calgary 3330 Hospital Drive NW Calgary, AB T2N 4N1 Darryl Quantz, MSc Institute of Health Promotion Research University of British Columbia 2206 East Mall, Rm. 411 Vancouver, BC V6T 1Z3 Mary Bobey, MSc, CPsych Manager Women’s Health Resources Grace Women’s Health Centre 1441 29th Street NW Calgary, AB T2N 4J8

Women’s Health Resources (WHR) centre in Calgary, Canada. Data for this paper were extracted from WHR evaluation forms for 199 midlife women seeking individual consultation, as well as personal interviews that were conducted with four female staff members. Clients of the WHR cited numerous reasons for seeking service at the centre, the most common being for emotional health care, nutritional consultation or more comprehensive information on a specific illness. Three major components of service provision at the centre were identified: information, psychological care and complementarity of services. Women

used the information they gained from WHR services to aid in health decisionmaking and as a resource for empowerment in being partners in their own health. Clients noted that the WHR was a valuable source of additional information beyond what their own family physician and/or specialist were able to provide. The feminist and woman-centred care at WHR, in conjunction with the emphasis on education, offers an invaluable source of information and services for women. Through the shared experiences of both the clients and staff of this centre, this article provides an outline of how such services are perceived and utilized.

Introduction

health centres (Curbow et al., 1998), key services (e.g., mental health services) are absent in a more general comprehensive medical care environment.

Since 1981 research has documented the emergence of women’s health centres and the services they provide to women across the age continuum. These centres were primarily developed in response to the delivery model found within a traditional health care setting, which often lacked interest in and sensitivity to women’s concerns (Phillips, 1995, 1996; Phillips and Ferguson, 1999; Williams, 1996; Bierman and Clancy, 2000; Collins, 2002; Ericksen et al., 2002; Goodman et al., 2002; Mort, 2001). Evidence suggests that for some non-biomedical services, women prefer the resources found at such centres over the care provided by their family physician (Meadows et al., 2001a, Meadows et al., 2001b). While early centres focused largely on reproduction-related services (Bruce, 1981), recently more comprehensive services are available, including general internal medicine (Ryan, et al., 1999). One of the major advantages of women’s health centres is the attention paid to gender differences in service delivery and receptivity (Phelan et al., 2000). There is some evidence that the populations served by women’s health centres are biased toward certain groups (e.g., younger, less chronic illness, middle socioeconomic status) and that women are better served by general medical facilities (Phelan et al., 2000). However, when compared to women’s

This article examines the service delivery model and role of the Women’s Health Resources (WHR) centre in Calgary, Canada as a resource for comprehensive health care for midlife women (i.e., women between the ages of 40 and 65). We focused on this age group to allow comparisons with several other concurrent studies that we are conducting on midlife women’s health in which we explore the reasons why midlife women are not participating in screening as frequently as recommended in guidelines (Champion & Huster, 1995; Herman, Speroff, & Cebul, 1995; Lantz et al., 1995). We argue that urban centres such as this provide an essential service to the women and the community they serve. Women’s Health Resources provides a vital source of health-related services and information for women’s health that fulﬁlls a complementary role with that of more traditional biomedical services.

Keywords • women • community health

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Networking

Women’s Health Resources history and development The Salvation Army Grace Women’s Health Centre (SAGWHC) is the current iteration of a facility that began to provide women’s health services in 1904 as a home for “unwed mothers” [sic]. Throughout the ensuing 95+ years, the facility developed into the Grace Maternity Hospital and Girl’s Home and evolved into an obstetrical and gynecological hospital that gradually acquired broader surgical capacity. In recent years it was amalgamated into the local health authority to provide nonacute and acute care for women, and currently combines diagnostic and treatment services. The SAGWHC has moved from an independent and freestanding site to its current location adjacent to the acute and teaching medical care centre. The Women’s Health Resources (WHR) centre is part of the SAGWHC. It was established in 1986 as a response to women’s demands for greater participation in their health care. The WHR programmes are designed to respond to women’s health needs beyond pregnancy and reproduction; programmes also include health promotion and illness prevention. WHR has a multidisciplinary team including psychologists, a dietician and a clinical nurse specialist who provide individual consultations to women from all backgrounds and socio-economic statuses. It was the first centre of its kind in Canada and follows a woman-centred model of care. Its stated purpose is: To meet women’s needs for health education, information and counselling to enable women to make informed decisions about their own and their families’ health, and to promote the recognition and acceptance that health and well being are the individual’s responsibility. In this article we examine reflections of midlife women on the current role of WHR and argue that centres such as this provide essential information and services that make a significant contribution to women’s well-being.

Methods All WHR clients seeking an individual consultation are asked to complete a selfadministered questionnaire that collects

information on demographics; perceptions and beliefs about health; health-related behaviours; a summary of health status; and the use of other health resources. The majority of questions on this form are in an open-ended format, with space available for clients to make any additional comments. This study was designed to blend the insight provided by having both qualitative and quantitative data. For this analysis, data were available from all forms collected between January 1996 and mid-June 1999. Only women between the ages of 40 and 65 were included in this analysis to allow comparisons with several other concurrent studies that we are conducting on midlife women’s health. Data from staff members at WHR were also collected using short, semistructured personal interviews that were audio-recorded and transcribed verbatim. As this was an internal quality control study, permission for the use of these data was obtained from the manager of WHR. Data from the forms were coded and entered into SPSS for analysis using descriptive and summary statistics. Qualitative data were summarised and coded using thematic analysis aided by the techniques of immersion and crystallization (Borkan, 1999). Multiple team members met regularly to discuss emergent categories and connections, and to focus on interpretation.

Results Data discussed here are from 199 questionnaires and interviews with 4 (female) staff members. The mean age of clients was 49.2 years (median 49), and included the full range of ages from 40 to 65. Fifty-four percent of women who obtained services from WHR have household incomes of $40,000 or greater; this is comparable to statistics for the City of Calgary which indicate that 48% of the population have household incomes of $40,000 or greater (Statistics Canada, 1996). Only 2.6% of our sample had less than a high school education, while 24.2% had a high school education, 60.8% had post secondary education and 11.3% had post graduate education. This again reﬂects the high educational status of most people in our city. Nearly two-thirds (64.3%) reported that they were married, while 23% reported that they were

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divorced or separated. Approximately 80% reported a Christian religious affiliation and 97% stated that they currently had a family physician. Women learned about WHR by word of mouth or from a friend/family member (32.2%) or from a health professional such as a nurse or physician (31.2%). The most common reasons reported for visiting WHR were emotional health (25%); specific illness/health information (20%); and nutritional consultation (17%). Many women reported more than one reason for visiting WHR. Staff members had been at the centre from 6 to 14 years and were chosen as key informants through their roles as care providers in psychological, physical and nutritional health, and administration. Three major components of WHR’s services were identified in the qualitative analysis: the provision of information; the provision of psychological care; and complementarity of services. These are explored below. Information provision Women highlighted the important role WHR played in the provision of health information. Those most frequently citing information needs as a reason for their visit were women with educational levels of post secondary or graduate education. These women sought information for a specific issue (e.g., menopause, osteoporosis) while others utilised WHR to get more general information. For example, a concern over peri-menopause articulated in a previous patientphysician encounter could be followed by a visit to WHR for information on hormone replacement therapy, lifestyle changes and other relevant issues. With a well-informed patient, the next patientphysician encounter could then move to decision-making regarding management. The need for education is seen in women who do not realise that a Pap smear cannot be done during menstruation, or that the best time for physical examinations is a couple of weeks after a period when breasts are less tender and lumpy, or that not consuming caffeine for 48 hours before a mammogram may help to reduce discomfort. The information resources at WHR are available for use both on an individual basis and/or with guidance from a staff member at WHR. These include an extensive library, Internet access and a

variety of workshops including such topics as hormone replacement therapy, stress management and incontinence. Women viewed these resources as invaluable in gaining access to information. One woman commented: “The centre is up to date on state of the art issues in women’s health.” Staff at WHR also echoed these sentiments: “The health consultants are very experienced [and] have a breadth of knowledge. We have professional resources at our fingertips so that we can give [women] the answers that they’re looking for.“ Women used the information obtained from WHR in decision-making and in preparation for interactions with other health professionals. A philosophy of empowerment was highlighted by both clients and staff members. One woman wanted “more information on treatments by doctors.” In expressing a need for “more of a support group…” however, women were referring to information and resources from professionals at WHR to aid in their decision-making and preparation for visits to their own physicians. One staff member noted: “We’re helping women get information so they’re better informed, and to help in their interactions in referrals to other experts. They are prepared to sit down one on one with a health professional and actually draw up an action plan.” Another staff member emphasised the breadth of information: “They can gather various kinds of information so they’re getting a more rounded approach…to make their decision. It gives them a broader perspective.” One client wrote: “I’m seeking an understanding of my needs and problems for myself, seeking knowledge so I can be more active in my health care.” At WHR women also have access to referral information whether seeking a family physician or names of other specialists or professional health services. The staff of WHR do not, however, make direct referrals. One woman noted: “I was wondering about changing doctors…I hope to find clarification for my feelings here.” Psychological services Twenty-five percent of women seeking an individual consultation at WHR were requesting help for emotional health issues through an appointment with one of the four part-time psychologists. Use of

these services was almost uniform across educational levels, with slightly greater use of these services by women with high school education and least use by women with graduate level education. Individual counselling is provided through self-referral, without charge and in a timely manner for issues ranging from depression and anxiety to dealing with stress associated with work or family. One woman wrote: “When I’ve come here I’ve believed there is a real caring for us.” Both clients and providers indicated that the focus on the client’s needs and feelings provides an ideal environment for woman-centred care. Over two-thirds of clients identified emotional health as a key aspect of being healthy, yet less than half rated their own emotional health as good or excellent, compared to 64% who rated their physical health as good or excellent. One way of meeting this need is through this service, “More networking between women provides more info[sic] that helps women in their search for wellbeing.” The staff members at WHR recognize the importance of this service: “They [the women] find it supporting because somebody listens. Because they’re not rushed to put it [their problem] in five minutes.” The approach taken at WHR also aids in communicating problems that may be difficult to articulate. Emotional problems that are not viewed as “really serious” (e.g., mild depression, general anxiety, relationship problems, or verbally abusive situations) are often discounted or missed in typical clinical encounters. One staff member noted: “I think the best thing that we do here is that we listen and we care.” Complementary services Women usually consulted their family practitioner prior to requesting an individual consultation at WHR. Although women are encouraged to selfrefer, health professionals were the source of referral for 63% of clients at WHR. This reflects a general recognition by physicians and other health providers of the importance of WHR. Women noted that WHR allows them the time and freedom to explore issues related to their health care needs including questions regarding patient/physician relations, lifestyle,

exercise, and assertive communication. Of particular note was the use of WHR for nutrition related information, especially among those with less than high school education and those with graduate education. Women are aware of time limits that constrain their interactions with physicians, often encountering limits of one presenting problem per visit. Sometimes women need more information about a problem: “I have concerns that are not answered by my doctor,” or underlying issues that may not be addressed in a clinical encounter: “My doctor has been unable to explain reasons for extreme problems…” Women also want information about typical treatments and greater detail than is usually supplied in a clinical encounter. Our data suggest that family physicians are providing information and services but women have health needs beyond what can be dealt with in a brief, often rushed, clinical encounter. The fact that physicians or nurses initiate many referrals to WHR suggests their support of WHR in this community.

Discussion Women are well aware of the need to take responsibility for their own health and well-being (Meadows, Thurston and Berenson, 2001). Increasingly the ideal model is one of shared care; an approach that best utilises available resources and avoids placing undue and inappropriate responsibility on either women or their physicians (Meadows, Thurston and Berenson, 2001). Women who seek health related information and resources through WHR reported three main areas of need: information to aid in their understanding and decision-making related to health problems or concerns; support for emotional health issues; and a source of complementary services to augment what is available in the physician/patient encounter. This information is important for primary, secondary and tertiary preventive care, and includes some services such as nutritional information that are not typically classiﬁed as complementary to those supplied by physicians, but form an important part of the determinants of health. Women who have reliable information regarding their personal health concerns can play an active role in their decisions (Mechanic & Cleary, 1980; Sherwin, 1992). Both women and

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Case studies “S. had an extremely emotionally and physically abusive father. She stated that, as a result, she always carried a lot of inner pain, hurt and anger, and she was deeply dissatisfied with her life. She had had several relationships with unsuitable and sometimes abusive men. She believed that she has been so desperate for love that she would go into a relationship with any man who showed interest in her. After six sessions she reported that she feels “really good” and “healed of many negative feelings from the past”. She was also able to remember more of her past, which felt like a release. She was able to feel calm and unaffected when a man she had just met cancelled his first date with her. She commented: “‘the counselling I have received has healed me tremendously...this is the most loving, nurturing and helpful program that I have ever come upon.’” L. was peri-menopausal and had done a considerable amount of self-help reading but was still struggling with anxiety and heavy bleeding. When she came to Women’s Health Resources lifestyle changes (diet, exercise and stress management) were suggested and the Clinical Nurse Specialist helped her with questions to discuss with her physician. L. followed up with lifestyle

the staff at WHR share a vision of women as knowledgeable individuals, preparing for and augmenting information from their physicians with that available at and through WHR. The philosophy that guides WHR encourages the perspective that a physician appointment is a professional encounter, not a social visit. WHR programmes and staff support women’s efforts to meet with their physicians with clearly deﬁned problems and as much information as possible. The programmes are designed to teach women that, like their physicians, they need to be prepared for the clinical encounter. For both emotional and physical health, information is one of the ﬁrst steps toward self-help for women with health issues (Waller & Batt, 1999). This sharing of information empowers women through joint ownership of knowledge that could

changes and there was a significant improvement in her general health however her heavy bleeding continued. Her physician referred her to a gynecologist. L. was not happy with the consultation. WHR’s Clinical Nurse Specialist encouraged her to seek another opinion. L. did and tried prescription drugs to control her bleeding. These did not help and a hysterectomy was suggested. L. returned to WHR. Information about hysterectomies, including whether to retain ovaries or not was provided along with stress management. L. subsequently had the hysterectomy and phoned WHR to express her thanks for “hanging in with her” while she made her decisions and for the “huge difference it made” in her life. B. arrived at Women’s Health Resources devastated and in shock. He husband of 34 years had just told her he was leaving her for another woman. B. felt totally alone, rejected and extremely ashamed. She described looking in the mirror and not being able to see the reflection of her face. Counselling helped her recognize that she had options and resources available to cope with this difficult situation. B. commented on how coming to Women’s Health Resources made her feel “normal and that there was life after being dumped by her husband”.

otherwise be a symbol of power (Symon, 2000). Such information is essential in order for women to advocate for a better health care system that reﬂects their needs (Deetz & Mumby, 1990; Waller et al., 1999). The staff and resources at WHR support a holistic and feminist philosophy of care that views women as active partners in their search for health and well-being. As part of this feminist approach it is emphasized that women’s perceptions, experiences and knowledge are valid and that WHR has a commitment to providing resources that empower women to partner in their own pursuit of health. WHR programmes and staff provide an invaluable source of information and services that make a signiﬁcant contribution to women’s well-being, particularly in our current provincial (if not arguably nation-wide) environment of

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having too few primary health care resources for preventive care (Meadows, Thurston and Berenson, 2001). At WHR the staff is available to take an unbiased approach to dealing with women’s emotional health problems. For example, depression arising from an abusive situation is viewed positively, an appropriate reaction to a bad situation. Counselling takes into account the wholeness of the woman’s life. Women come to WHR because there is a staff of qualified professionals who are able to provide them with evidence-based information, counselling and other resources. The evaluative feedback from women who use the services of WHR suggest a convergence of provider services and consumer needs. Physicians and other professionals from whom women seek help view WHR as a complementary resource for health. The focus on education, a holistic approach and being a professional resource for women has earned WHR a well-deserved reputation. A comprehensive review of women’s health centres identified the SAGWHC as providing exceptional service. In discussing her interview with the Coordinators for WHR, Crook (1995) wrote, “During the interview I thought fleetingly that if someone would just give these women a couple of million dollars to implement resource centres like this one across the country, women’s health would be transformed” (p. 229). Our research suggest that this women’s health centre provides invaluable services that make important contributions to women’s capacity for health and therefore for women’s active participation in preventive health care.

Acknowledgements The authors would like to thank Dr. Catherine Scott for feedback regarding the manuscript and Kathy Dirk for editorial assistance.

References Bierman, A.S., & Clancy, C.M. (2000). Making capitated Medicare work for women: Policy and research challenges. Women’s Health Issues, 10, 59-69. Borkan, J. (1999). Immersion/crystallization. In B.F. Crabtree & W.L. Miller (Eds.), Doing qualitative research (2nd ed., pp. 179-194). Thousand Oaks, CA: Sage Publications. Bruce, J. (1981). Women-oriented health care: New Hampshire Feminist Health Center. Studies in Family Planning, 12, 353-363. Champion, V., & Huster, G. (1995). Effect of interventions onstage of mammography adherence. Journal of Behavioral Medicine, 18, 169-187. Collins, K.S. (2002). Evaluation of the National Centers of Excellence in Women’s Health: Sustaining the promise. Women’s Health Issues, 12, 287-290. Crook, M. (1995). My body: Women speak out about their health care. New York: Plenum Press. Curbow, B., Khoury, A.J., & Weisman, C.S. (1998). Provision of mental health services in women’s health centers. Women’s Health, 4, 71-91. Deetz, S., & Mumby, D.K. (1990). Power, discourse, and the workplace: Reclaiming the critical tradition. In J.A. Anderson (Ed.), Communication yearbook/13 (pp. 18-47). Thousand Oaks, CA: Sage Publications. Ericksen, J., Dudley, C., McIntosh, G., Ritch, L., Shumay, S., & Simpson, M. (2002). Clients’experiences with a specialized sexual assault service. Journal of Emergency Nursing, 28, 86-90. Goodman, R.M., Seaver, M.R., Yoo, S., Dibble, S., Shada, R., Sherman, B., Urmston, F., Milliken, N., & Freund, K.M. (2002). A

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Members of the Board of Trustees 2007-2013 President 2007-2010 Every three years, in accordance with the IUHPE’s Constitution and Bye-Laws, Members of the Board of Trustees are elected by the General Membership of the IUHPE. The voting process takes place before the World Conference in order to provide each member with an equal opportunity to elect the members of the IUHPE Board of Trustees. The incoming Board of Trustees elects in turn the IUHPE President and administers and governs the IUHPE between the sessions of the General Assembly. The nomination process will take place between the 13th of August 2006 and the 12th of December 2006, and the names of all candidates who have confirmed in writing their ability and willingness to stand for election will be enclosed on the ballot paper, according to the Region in which they live. All procedures and guidelines to propose candidates to stand for election for the Board of Trustees for the period 2007-2013 will be clearly outlined in the call for nominations which will be sent in writing to all members of the IUHPE across the world. The timetable summarises the main steps and deadlines for each of these nomination and election processes. For any further information that you may need, please send an email to Marie-Claude Lamarre, Executive Director, (mclamarre@iuhpe.org).

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Summary of timetable 8-10 May, 2006

Nominations by the Board of Trustees of an Electoral Committee. The Board of Trustees at its meeting in Kenya in May 2006 has agreed that each Regional Vice-President would be part of the Committee, which will be chaired by the Vice President for Coordination, Administration and Membership Services, Dr Pierre Arwidson. 13 August 2006 Nominations requested for Membership of the Global Board, 2007-2013 12 December 2006 Deadline to receive nominations and written confirmations of candidates plus their election statements 13 January 2006 Mailing of voting papers to the General Membership with a booklet of statements, instructions to vote, and ballot papers 27 May 2007 Deadline to receive ballot papers at headquarters 3 June 2007 Counting of votes by the Electoral Committee 9 or 10 June 2007 Announcement of the results of the Board of Trustees 2007-2013 elections at the outgoing meeting of the Board of Trustees 11 June 2007 Formal announcement of Elections of Members of the Board, 2007-2013 12 June 2007 Election of the President, 2007-2010 at an extraordinary session of the incoming Board of Trustees (members elected in 2004 until 2010 + 2007-2013 members) 13 June 2007 Formal announcement of Election of the President, 2007-2010 15 June 2007 World Conference closing ceremony – Hand over of presidency 16 June 2007 In-coming Board meeting with new President presiding

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IUHPE Global Elections

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In memoriam The IUHPE has learned with profound sadness of the recent passing of two major figures from IUHPE history: Mr Paul Hindson, from Australia served as President of the IUHPE from 1982 through 1985. He organised the IUHPE’s 11th World Conference on Health Education in Hobbart, Tasmania in 1982. He dedicated most of his Presidency to the Regional development of the IUHPE and was instrumental in the establishment of the IUHPE Regional structures in South-East Asia and in the Northern Part of the Western Pacific. As an economist, he familiarised himself with health education through community development for Aborigines. He earned a Master’s degree in Public Health Education from the University of California at Berkeley, United-States. Twenty years ago, he was already highlighting priority areas of the work of the IUHPE, upon which we continue to focus today: “We should educate our decision makers by keeping them better informed about the real needs of the population, and in the health aspects of the community they serve; […] The action of the IUHE should not be limited to educating people. Action implies that each one of us become involved in establishing public health interventions in our own countries, involved in lobbying our governments to commit resources to public health programmes, and to share resources with other countries”. (Hygie, Oct 83 – Vol. II, 1983/3)

Dr V. Ramakrishna was a former Regional Advisor in Health Education of WHO/SEARO and the first Regional Director and then Vice President of IUHPE South-East Asian Regional Bureau. He is acknowledged as the Father of Health Education in India. As mentioned by Dr N. R. Vaidyanathan, current IUHPE/SEARB Regional Director “he was a man of humility, erudition and compassion. Affectionately called as Dr Ram by his friends and admirers, he occupied positions of distinction right from the State level to International level in Medicine, Public Health and Health promotion. He established the Central Health Education Bureau in the Ministry of Health & Family Welfare of the Government of India and laid the foundation for setting up State Health Education Bureau in all States of the country.”

Paul Hindson

Dr V. Ramakrishna

Nutrition and an Active Life: From Knowledge to Action Pan American Health Organization Publication 2005, 247p., ISBN 92 75 11612 1 Order code: SP 612 Price: US$30.00 / US$20.00 in Latin America and the Caribbean Languages Available: English, Spanish This publication, written by leading international public health professionals, highlights 13 case studies on a variety of topics including control of vitamin A deficiency, folic acid fortification of bread, control of iodine deficiency disorders, and the contribution of research to infant breast-feeding policies, as well as successful community projects to promote increased physical activity and the role of urban planning and public transportation in reducing the prevalence of sedentary lifestyles, among other important topics. Nutrition and an Active Life: From Knowledge to Action will become an important resource on best practices at the national and community levels for professionals working in health promotion, maternal and child health, nutrition, fitness, social marketing, and public health education. This publication can be acquired by visiting PAHO Online Bookstore at http://publications.paho.org or through PAHO Sales and Distribution Center, P.O. Box 27, Annapolis Junction, MD 20701-0027, U.S.A.; Tel: (301) 617-7806, Fax: (301) 2069789; Email: paho@pmds.com. You can also contact Maria Recio, PAHO Publications, at reciomar@paho.org

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

Vancouver, Canada, June 10-15, 2007 The official launch of the 19th IUHPE World Conference on Health Promotion & Health Education was celebrated on March 24, 2006 at the Pan Pacific Hotel, at the same venue as the Vancouver Convention & Exhibition Centre, where the World Conference will take place next year. The meeting was attended by a large audience of public health and health promotion professionals from government, academic and non governmental local, national and international institutions as well as from all the other sectors involved in the preparation of the event. The celebration was hosted by Dr Marcia Hills, President of the Canadian Consortium for Health Promotion Research, and Chair of the Conference, and by Dr David Butler-Jones, Chief Public Health Officer of Canada, and Honorary Co-Chair of the Conference. Twenty years ago the Ottawa Charter for Health Promotion marked the first international conference on health promotion, kicking off, in the words of IUHPE President Maurice Mittelmark, “A healthy, vigorous, effective and growing movement”. With the hosting of the 19th IUHPE World Conference in Vancouver in June 2007, we will be celebrating the true

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“coming of age” of the health promotion movement with thousands of participants from around the world. The 19th World Conference provides a great opportunity to renew our commitment to health promotion as we enter the 21st century. The 2007 conference will focus on four key themes: • Reducing Health Inequities • Assets for Health and Development • Enabling Systems Transformation • Assessing the Effectiveness of Health Promotion. All participants at the launch were encouraged to be active ambassadors for health promotion and education and for an as broad as possible attendance at the World Conference, next year in Vancouver. In turn we would like to urge you to use your professional and personal networks to promote the conference and the signiﬁcant sponsorship opportunities this unique world assembly provides. We would also like to encourage you to visit as often as possible the conference website and use it as a vehicle to encourage others to become engaged and willing to participate: www.iuhpeconference.org

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The 19th IUHPE World Conference on Health Promotion & Health Education

Mark Dooris

Milieux de vie et promotion de la santé : orientations futures Un coup d’œil rétrospectif : réflexions En 1986, la Charte d’Ottawa (OMS, 1986) déclarait que « la santé est créée et vécue dans les divers cadres de la vie quotidienne : là où l’on apprend, où l’on travaille, où l’on joue et où l’on aime ». La charte est bien connue pour avoir été le catalyseur du mouvement en faveur des milieux de vie promoteurs de santé – faisant de cette approche le point de départ des programmes de promotion de la santé de l’OMS, avec un engagement à « s’éloigner du modèle insufﬁsant de la santé en seuls termes de maladie pour s’intéresser au potentiel que constituent pour la santé les cadres sociaux et institutionnels de la vie quotidienne » (Kickbusch 1996 : 5). Deux décennies plus tard, il est évident que cette approche par les milieux de vie a capturé l’imagination des organisations, des communautés et des décideurs à travers le monde. Depuis la Charte d’Ottawa, une pléthore de réseaux et de programmes nationaux et internationaux a vu le jour, couvrant des environnements aussi divers que des régions, des districts, des villes, des îles, des écoles, des hôpitaux, des lieux de travail, des prisons, des universités et des places de marché. Parallèlement à cela, le concept des milieux de vie promoteurs de santé s’est fermement ancré dans les politiques internationales de promotion de la santé. Par exemple, la Déclaration de Djakarta a fortement appuyé cette approche dans le contexte de l’Investissement pour la Santé (OMS, 1997) ; l’OMS a inclus le terme ‘milieux favorables à la santé’ dans son Glossaire

Mark Dooris Directeur Unité de Développement des milieux de vie en Santé Ecole de la Santé et de la Médecine universitaire du Lancashire Faculté de la Santé Université du Central Lancashire Royaume-Uni Email : mtdooris@uclan.ac.uk

de la Promotion de la Santé, le définissant comme « le lieu ou le contexte social dans lequel les individus s’investissent dans leurs activités quotidiennes et dans lequel les facteurs personnels, organisationnels et environnementaux influent sur leur santé et leur bien-être » (OMS, 1998a : 19) ; Santé 21, la nouvelle Politique-cadre européenne de la Santé pour Tous, comportait parmi ses objectifs un point spécialement consacré aux cadres de vie favorables à la santé (OMS, 1998b : 100) ; et plus récemment, la Charte de Bangkok (OMS, 2005) a souligné l’importance du milieu de vie dans le développement de stratégies de promotion de la santé ainsi que la nécessité d’une approche de politique intégrée et d’un engagement à travailler à travers les différents environnements. Pourtant, malgré sa popularité et ses nombreux défenseurs, cette approche n’a sans doute pas eu autant d’influence qu’elle aurait dû en avoir – notamment en favorisant l’élargissement des politiques internationales ou en poussant des stratégies nationales de santé publique. À ce sujet, le point de vue d’Ilona Kickbusch, précurseur de cette approche peut nous éclairer. Elle suggère en effet que cette approche par les milieux de vie, du fait de sa logique non médicale, est plus facilement comprise par les membres d’une communauté et les responsables politiques que par les professionnels de santé (Kickbusch, 1996) ; ainsi, selon elle, les résultats qui découlent des initiatives en milieux de vie « s’intègrent difficilement dans un cadre épidémiologique de ‘données scientifiques’ mais doivent plutôt être analysés en terme de processus politiques et sociaux » (Kickbusch, 2003 : 386).

Un coup d’œil vers l’avenir : les défis Lorsqu’on envisage, à l’avenir, d’accroître l’impact de cette approche par les milieux de vie, on se retrouve aussitôt confrontés à un certain nombre de déﬁs liés les uns aux autres. Clariﬁer la base théorique pour agir dans les milieux de vie promoteurs de santé

Tout d’abord, des termes variés ont été utilisés et des conceptions et pratiques diverses ont été regroupées sous la ‘bannière’ des milieux de vie promoteurs de santé. Si des termes tels que ‘health promoting settings’ (milieux de vie promoteurs de santé) et ‘healthy settings’ (milieux de vie favorables à la santé) ont été de plus en plus utilisés de façon interchangeable, l’accent étant mis à la fois sur le contexte et les méthodes, il est cependant important de reconnaître les différences sémantiques entre les deux termes et l’influence éventuelle qu’ils ont pu avoir sur la compréhension et la pratique – le premier mettant plus clairement l’accent sur les personnes et le fait que le milieu de vie doive tenir compte de l’impact externe qu’il peut avoir sur la santé. Cela nous renvoie aux premiers travaux de Bari_ (1993), selon lequel les critères de référence devaient comporter trois dimensions clés – un cadre de vie et de travail favorable à la santé, l’intégration de la promotion de la santé dans les activités quotidiennes du cadre de vie, et l’établissement de liens avec la communauté. À un niveau conceptuel, Wenzel (1997) a souligné la tendance à confondre « la promotion de la santé dans les milieux de vie » avec « les milieux de vie promoteurs de santé ’, indiquant que cette approche a souvent été utilisée pour finalement perpétuer des programmes traditionnels d’interventions isolées. L’article de Whitelaw et al. (2001) a abordé les divergences qui existent dans la conception et la pratique, en insistant sur la difficulté de traduire une philosophie en action et en présentant une typologie des pratiques mises en œuvre dans les lieux de vie. Quant à Poland et al. (2000), il se concentre sur les différences qui existent dans et entre les catégories de milieux – par exemple, les lieux de travail diffèrent de par leur taille, leur structure et leur culture ; et une « institution globale » comme un hôpital ou une école est très différente d’un environnement moins formel

Mots-clés • milieux de vie • base des données probantes

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éditorial

comme une maison ou un quartier. Ces différences apparaissent encore plus lorsque l’on considère les milieux de vie à l’échelle mondiale et qu’il faut prendre en compte l’influence des différents facteurs culturels, économiques et politiques. Toutes ces questions indiquent à quel point il est important de trouver un juste équilibre entre une certaine acceptation de l’hétérogénéité et de la différence avec comme objectif complémentaire de développer une compréhension conceptuelle commune de l’approche des milieux de vie. S’il peut effectivement y avoir une certaine forme de « tyrannie…dans l’affirmation ou la création d’un consensus » (Poland et al, 2000 : 26), l’articulation de la théorie peut être constructive pour orienter les pratiques futures. C’est à cette fin que Dooris (2005) s’est appuyé sur la littérature pour dégager trois caractéristiques essentielles de cette approche : un modèle écologique de la santé, une perspective systémique et une orientation axée sur le changement et le développement d’une organisation du système dans sa globalité.

Conserver une vue d’ensemble Le second déﬁ, étroitement lié à cette conceptualisation des milieux de vie, est d’avoir et de conserver une vision large. Même si les personnes évoluent dans différents lieux de vie (que ce soit de façon simultanée ou consécutive), il existe bel et bien un danger que l’approche par les milieux puisse encourager une certaine forme d’isolement et de fragmentation, et de détourner involontairement l’attention des grands facteurs sociaux, économiques et environnementaux qui inﬂuent sur la santé. Par conséquent, il est important d’établir des connections à la fois vers l’extérieur et en amont. Les milieux de vie fonctionnent à différents niveaux et peuvent, comme des « poupées russes », s’imbriquer les uns dans les autres. C’est ce dont parlent Galea et al. (2000), qui estiment qu’il faut faire une distinction entre différents niveaux de milieux de vie « élémentaires » et « contextuels ». Par exemple, un hôpital ou une école fera partie d’un quartier particulier, au sein d’une ville plus large, puis d’un district, d’une région ou d’une île. À l’instar des

travaux de Bronfenbrenner sur l’écologie sociale (Bronfenbrenner, 1994), nous devons considérer les milieux particuliers comme faisant partie d’un ensemble plus grand – et travailler à améliorer leur synergie et à maximiser leur contribution au bien-être des communautés et des villes. Nous devons élargir notre point de vue et observer ce qui rend les lieux agréables et dynamiques, et en déduire un diagnostic pour l’appliquer aux environnements avec lesquels nous travaillons. Nous devons peut-être prendre le risque de perdre un peu du langage explicite de la santé, pour ﬁnalement libérer l’énergie qui va faciliter les changements novateurs et créatifs pouvant mener à un bien-être plus durable au niveau de l’ensemble du système. Comme l’a souligné la Charte de Bangkok (OMS, 2005), il est également nécessaire de recourir au plaidoyer et au développement de politiques pour favoriser l’action pour aborder les déterminants de la santé dans le contexte de la mondialisation. Cela suppose de garantir une approche intégrée au sein des milieux de vie, approche par laquelle les connexions entre la santé et d’autres domaines sont connues et comprises ; de développer une responsabilité sociale plus large des entreprises comme partie intégrante de l’approche par les milieux de vie, en mettant ainsi en lumière l’impact institutionnel externe aussi bien qu’interne (Dooris, 2004) ; et de regrouper les différents milieux de vie en partenariats pour unir leurs voix et maximiser ainsi leur capacité collective à inﬂuencer les politiques régionales, nationales et internationales.

Développer la base des données probantes Le troisième déﬁ concerne les preuves. Si l’approche par les milieux de vie est largement perçue comme ayant de nombreux avantages, et que les analyses d’évaluation et de preuves d’efﬁcacité se concentrent maintenant aussi sur les lieux de vie (Union Internationale de Promotion de la Santé et d’Education pour la Santé, 2000 ; Rootman et al, 2001), il n’en reste pas moins vrai que : L’approche par les lieux de vie a été davantage légitimée par un acte de foi que par des travaux rigoureux de recherche et d’évaluation…Il est

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nécessaire d’accorder une attention beaucoup plus grande à la collecte de données probantes et aux leçons que l’on peut en tirer (St Leger, 1997: 100). Il existe plusieurs problèmes spécifiques qui rendent difficile la constitution d’une base de données convaincante (Dooris, 2005). Premièrement, la manière dont est financée l’ évaluation et dont est constituée la base de données probantes destinée à la santé publique et à la promotion de la santé reflète la priorité que l’on continue à accorder à des maladies spécifiques et aux interventions sur des facteurs de risques individuels. Deuxièmement, la diversité des conceptions et des pratiques qui a été évoquée auparavant entraîne des difficultés évidentes à générer une quantité substantielle de recherches qui permette la comparabilité et la transférabilité. Troisièmement, il est complexe d’évaluer l’approche de promotion de la santé par les milieux de vie telle qu’on l’a définie, en termes d’approche écologique et d’une réflexion sur des systèmes – ce qui, comme l’a indiqué Senge (1990), constituerait un cadre permettant de considérer les interrelations et les modèles de changement plutôt que des ‘clichés’ instantanés et statiques. Cela requiert une approche non linéaire qui reconnaisse les interrelations, les interactions et les synergies au sein des différents milieux de vie ainsi qu’entre eux. Les chercheurs doivent également reconnaître les effets synergétiques qui résultent de l’association de différentes méthodes pour répondre à différentes questions de recherche et d’évaluation (Baum, 1995, Steckler et al, 1992) et pour combiner les mesures spécifiques ‘à la santé’ avec des mesures axées sur l’activité centrale propre à un milieu de vie particulier (Lee et al, 2005). Il résulte donc de ces difficultés une tendance à évaluer des projets particuliers plutôt que des initiatives dans leur globalité, ce qui affaiblit la production de données probantes crédibles pour appuyer l’efficacité de cette approche en termes de ‘valeur ajoutée’ et de synergie. Il serait possible de progresser à ce niveau en s’appuyant sur l’expérience de « l’évaluation fondée sur la théorie », mais pour cela il faut clarifier au préalable la base théorique, engager le dialogue avec les décideurs

pour être certains que les données probantes vont être générées dans un but défini (de Leeuw et Skovgaard, 2005), et garantir un financement à long terme qui soit approprié.

voudra pas admetre que les systèmes sociaux sont complexes et entrelacés, et que leur interconnexions sont cruciales pour créer de la santé. »

Conclusion

L’approche par les milieux de vie peut apporter une contribution très utile pour planifier et apporter de la santé et du bien-être d’une manière qui tienne compte de cette complexité, au sein des lieux mêmes où vivent les personnes. Pour cela, il est nécessaire de se pencher sur les difficultés mentionnées ci-dessus, en clarifiant la théorie, en ayant à lesprit une vision large et en produisant des preuves de l’efficacité des interventions.

Ziglio et al. (2000) soutiennent qu’en dépit d’une acceptation apparente largement répandue d’un modèle socio écologique de la santé, la promotion de la santé a continué à se focaliser sur des problèmes particuliers, ne parvenant ainsi à avoir qu’un faible impact sur les déterminants de la santé ou sur le développement de politiques. Ils continuent en laissant entendre que ces impacts n’auront pas lieu « tant que la création de la santé ne sera pas le point de départ des actions… [et] qu’on ne

L’UIPES est engagée dans ce processus et a précisément développé cette vision des milieux de vie promoteurs de santé

‘connectés’ les uns aux autres. Elle s’efforce de rassembler des preuves de l’efﬁcacité de cette approche et d’encourager le dialogue et le débat dans le cadre des Conférences qu’elle organise ou auxquelles elle est associée – notamment la Conférence nordique de Recherche en Promotion de la Santé, en juin 2006, ainsi que les Conférences mondiales à Vancouver et à Hong Kong, en 2007 et 2010. Nous vous invitons à y apporter votre contribution et à y participer !

Remerciements J’adresse mon plus vif remerciement à Christiane Stock, Jürgen Pelikan, Albert Lee et Catherine Jones pour leurs commentaires et suggestions utiles lors de l’élaboration de cet éditorial.

References Baríc, L. (1993) The settings approach – implications for policy and strategy. Journal of the Institute of Health Education, 31, 17-24. Bronfenbrenner, U. (1994) Ecological models of human development. Dans Husen, T. & Postlethwaite, T. (eds.), International Encyclopedia of Education, Vol. 3, 2e éd., 1643-1647. Pergamon Press/Elseiver Science, Oxford. Baum, F. (1995) Researching public health: beyond the qualitative and quantitative methodological debate. Social Science and Medicine, 55, 459-468. Dooris, M. (2004) Joining up settings for health: a valuable investment for strategic partnerships ? Critical Public Health, 14, 3749. Dooris, M. (2005) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International, Advance Access publié le 9 décembre. http://heapro.oxfordjournals.org/cgi/reprint/dai 030 ?ijkey=oWMpTL3VLnizG7G&keytype=ref (dernier accès le 26 janvier 2006). Galea, G., Powis, B. et Tamplin, S. (2000) Healthy islands in the Western Pacific – international settings development. Health Promotion International, 15, 169-178. Union Internationale de Promotion de la Santé et d’Education pour la Santé (2000) Les Preuves de l’Efficacité de la Promotion de la Santé. Déterminer la santé publique dans une nouvelle Europe. Deuxième partie. ECSC-EC-EAEC, Bruxelles. Kickbusch, I. (1996) Tribute to Aaron Antonovsky – ‘what creates health’. Health

Kickbusch, I. (2003) The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93, 383-388.

Wenzel, E. (1997) A comment on settings in health promotion. Internet Journal of Health Promotion. http://elecpress.monash.edu.au/IJHP/1997/1/ index.htm (dernier accès le 26 janvier 2006).

Lee, A., Cheng, F., St Leger, L. (2005). Evaluating health promoting schools in Hong Kong : the development of a framework. Health Promotion International, 20(2) : 177-186.

Whitelaw, S., Baxendale, A., Bryce, C., Machardy, L., Young, I. & Witney, E. (2001) Settings based health promotion : a review. Health Promotion International, 16, 339353.

de Leeuw, E. et Skovgaard, T. (2005) Utilitydriven evidence for healthy cities : problems with evidence generation and application. Social Science and Medicine, 61, 1331–1341.

Ziglio, E., Hagard, S. et Griffiths, J. (2000) Health promotion development in Europe : achievements and challenges. Health Promotion International, 15, 143-153.

Promotion International, 11, 5-6.

Poland, B., Green, L. et Rootman, I. (2001) Reflections on settings for health promotion. In Poland, B., Green, L. & Rootman, I. (eds) Settings for Health Promotion : Linking Theory and Practice. Sage, Londres. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D., Potvin, L., Springett, J. et Ziglio, E. (eds) (2001) Evaluation in Health Promotion : Principles and Perspectives. Bureau regional de l’Organisation mondiale de la Santé en Europe, Copenhague. Senge P. (1990) The Fifth Discipline : The Art and Practice of the Learning Organization. Random House, Londres. Steckler, A., McLeray, K. et Goodman R. (1992) Towards integrating qualitative and quantitative methods : an introduction (Éditorial). Health Education Quarterly, 19, 1-8. St Leger, L. (1997) Health promoting settings : from Ottawa to Jakarta. Health Promotion International, 12, 99-101.

Organisation mondiale de la Santé (OMS) (1986) Charte d’Ottawa pour la Promotion de la Santé. OMS, Genève. Organisation mondiale de la Santé (OMS) (1997) Déclaration de Djakarta sur la Promotion de la Santé au 21e siècle. OMS, Genève. Organisation mondiale de la Santé (OMS) (1998a) Glossaire de la Promotion de la Santé. OMS, Genève. Organisation mondiale de la Santé (OMS) (1998b) Santé21 – La politique de la Santé pour Tous de la région européenne de l’OMS – 21 Cibles pour le 21e siècle. Bureau régional de l’OMS en Europe, Copenhague. Organisation mondiale de la Santé (OMS) (2005) La Charte de Bangkok pour la promotion de la santé à l’heure de la mondialisation. OMS, Genève.

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Sania Nishtar, Marco Akerman, Mary Amuyunzu-Nyamongo, Daniel Becker, Simon Carroll, Eberhard Goepel, Marcia Hills, Marie-Claude Lamarre, Alok Mukopadhyay, Martha Perry et Jan Ritchie

Le Consortium mondial sur la promotion de la santé communautaire Sania Nishtar Heartfile Islamabad, Pakistan Email : Sania@heartfile.org Marco Akerman Facultade do ABC Sao Paolo, Brazil Mary Amuyunzu-Nyamongo African Institute for Health and Development Nairobi, Kenya Daniel Becker Centre for Health Promotion- CEDAPS Rio de Janeiro, Brazil Simon Carroll Centre for Community Health Promotion Research University of Victoria Victoria, Canada Eberhard Goepel University of Magdeburg Magdeburg, Germany Marcia Hills Centre for Community Health Promotion Research University of Victoria Victoria, Canada Marie-Claude Lamarre Union internationale de Promotion de la Santé et d’Éducation pour la santé Alok Mukopadhyay Voluntary Health Association of India New Delhi, India Martha Perry Union internationale de Promotion de la Santé et d’Éducation pour la santé Jan Ritchie University of New South Wales Sydney, Australia

z Le Consortium mondial sur la promotion de la santé communautaire – une collaboration à l’initiative de l’Union internationale de Promotion de la Santé et d’Education pour la Santé (UIPES) – a été établi pour favoriser et renforcer l’efﬁcacité des efforts de promotion de la santé communautaire aux niveaux international, régional, national et local, de manière à permettre aux populations, au sein même de leur communauté, d’augmenter leur propre contrôle sur leur santé et d’améliorer celle-ci. La promotion de la santé communautaire englobe des actions diverses et complémentaires qui ciblent les déterminants de la santé et met l’accent sur la communauté prise dans son ensemble, dans le contexte de la vie quotidienne. Le concept de ‘promotion de la santé communautaire’ s’appuie sur la Charte d’Ottawa , sur les valeurs et le processus de la promotion de la santé qui renforce les capacités et les moyens des personnes d’agir dans leur communauté sur les déterminants de la santé et de mieux les contrôler. C’est ce processus focalisé sur l’équité, le développement et le renforcement des capacités et la participation qui constitue le fondement de la promotion de la santé communautaire. Ce concept vise également à renforcer les liens entre les professionnels de la santé qui exercent dans les différents lieux de vie d’une communauté et les individus qui y vivent, pour élargir la base des systèmes de santé, et les faire évoluer à partir de systèmes principalement orientés vers les ‘soins’ vers des systèmes plus focalisés sur l’amélioration de la santé. Dans ce contexte, une série de paramètres stratégiques et opérationnels sont décrits. Ils sont les pierres angulaires de l’initiative de promotion de la santé communautaire.

Paramètres stratégiques Mot-clé • promotion de la santé communautaire

Le Consortium sur la Promotion de la Santé communautaire s’est ﬁxé comme mission pour l’avenir de contribuer à ce que toutes les populations aient une opportunité égale d’atteindre le meilleur

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niveau possible de santé et de bien-être ; à ce que le droit à la santé pour tous les peuples soit respecté et réalisé comme un principe fondamental de justice sociale et à ce que les inégalités de santé soient éliminées et les atouts communautaires pour la santé pleinement utilisés. Cette initiative reconnaît que la promotion de la santé est essentielle pour faire avancer l’équité en santé et la justice sociale tout au long de la vie, et est primordiale au bien-être et à la qualité de la vie. Le Consortium reconnaît également que la participation communautaire est essentielle et doit conduire chaque étape des actions promotrices de santé – établissement des priorités, prise de décisions, planiﬁcation des stratégies et conduite des évaluations. Le Consortium reconnaît encore que les communautés possèdent des atouts et des savoirs locaux qui doivent être reconnus et pris en compte, et qu’elles ont également besoin d’être soutenues et encouragées pour créer les conditions nécessaires à leur santé. Le Consortium soutient qu’il est fondamental de développer et de mettre en œuvre des politiques publiques de santé participatives pour garantir à toutes les populations le droit de vivre dans des environnements favorables à la santé, et qu’il s’agit là d’une condition préalable pour pouvoir aller au-delà des approches principalement centrées sur les changements individuels de comportement. Les stratégies du Consortium mettent en évidence la nécessité d’approches intégrées et complémentaires, ciblées sur les déterminants de la santé. Le Consortium est convaincu que ces approches sont essentielles pour pouvoir avoir un impact sur la santé du monde et les cibles de développement contenues dans les Objectifs du Millénaire pour le Développement. Il est primordial d’inscrire la promotion de la santé dans des politiques de santé à l’échelle mondiale, régionale et

nationale, de même que d’intégrer les résultats obtenus dans un contexte politique plus large pour améliorer les gains de santé. Le Consortium reconnaît que les facteurs qui influent sur l’état de santé sont beaucoup plus larges que ceux qui se revendiquent du seul secteur de la santé, et englobent l’aide sociale, le développement économique, la justice sociale, la politique, le commerce, l’environnement et la sécurité nationale. Le Consortium estime que les objectifs et les cibles du secteur de la santé doivent prendre en compte les facteurs sociétaux mentionnés ci-dessus et que ceux-ci doivent être inscrits dans un cadre politique plus explicite afin de favoriser la collaboration intersectorielle entre les différents acteurs et personnes concernées, à la fois à l’intérieur et à l’extérieur du secteur traditionnel de la santé. Le Consortium souligne la nécessité de disposer de ressources appropriées pour pouvoir garantir une mise en œuvre efficace de ces politiques ainsi que l’adoption d’approches de la santé basées sur l’action intersectorielle qui prenne en compte les populations dans leur environnement. Le Consortium s’emploie à plaider auprès des agences internationales, des gouvernements et d’autres parties prenantes pour que la promotion de la santé communautaire soit inscrite à l’ordre du jour du développement tant mondial que national, et s’efforce d’obtenir les ressources nécessaires à cette approche. En se fondant sur les valeurs et principes que nous avons énoncés, le but premier du Consortium est de promouvoir l’application de méthodes participatives durables pour améliorer la santé communautaire. Dans ce contexte, nous identifierons, examinerons et analyserons les pratiques et les politiques de différentes parties du monde, dans la mesure où elles sont pertinentes pour le développement et la diffusion de recommandations politiques susceptibles de renforcer les programmes efficaces de promotion de la santé communautaire. Le Consortium fournira également une assistance technique – si nécessaire – pour promouvoir l’utilisation des

données probantes disponibles sur les interventions efficaces en promotion de la santé communautaire, en particulier auprès des réseaux spécialisés ; on pense que cela contribuera au développement de plans stratégiques, lesquels peuvent augmenter l’impact international de la recherche sur les programmes efficaces de santé communautaire. D’autres objectifs mettent l’accent sur les possibilités de travail en réseau entre décideurs et acteurs de terrain, afin de faire mieux connaître la gamme et la variabilité des pratiques de santé communautaire, des opportunités de formation, et des infrastructures à travers le monde ; de catalyser le partages des expériences, de développer et de renforcer les efforts de collaboration pour promouvoir la promotion de la santé communautaire.

Paramètres opérationnels Etant donné ses paramètres stratégiques, le Consortium a mis en évidence un certain nombre d’étapes initiales pour traduire sa vision en action concertée. La création d’un mécanisme institutionnel, sous la forme d’une entité coordonnée par l’UIPES et consistant en un réseau d’experts en promotion de la santé communautaire, a été la première étape dans ce sens. Par la suite, le Consortium s’est mis d’accord pour développer un ‘Dossier sur la Promotion de la Santé communautaire’. Ce Dossier vise à améliorer la compréhension de la promotion de la santé communautaire, présente une analyse des pratiques actuelles dans ce domaine et décrit les données probantes sur leur impact, base sur laquelle seront émises les recommandations politiques pour la promotion de la santé communautaire. Le Consortium va également utiliser le processus de développement du Dossier sur la Promotion de la Santé communautaire comme un outil pour établir des partenariats à l’échelle mondiale en faveur de la promotion de la santé communautaire, sous la direction de l’UIPES. Ce Dossier sera également utilisé comme outil pour plaider au niveau mondial pour que la promotion

de la santé communautaire soit inscrite à l’ordre du jour mondial de la santé et du développement durable. De plus, un prochain numéro de Promotion & Education, la revue officielle de l’UIPES, sera consacré à la Promotion de la Santé communautaire. Enfin, le Consortium fournira des opportunités de travail en réseau entre décideurs et acteurs de terrain afin de catalyser le partage des expériences, de développer et de renforcer les efforts de collaboration pour promouvoir la promotion de la santé communautaire, et plus particulièrement lors d’ une journée de symposium qui précédera, en 2007, la 19e Conférence mondiale de l’UIPES sur la Promotion de la Santé et l’Éducation pour la Santé, qui se tiendra à Vancouver, au Canada. Avec ces modestes débuts, on espère que le Consortium va générer un dynamisme soutenu visant à développer un effort concerté pour inscrire la promotion de la santé communautaire en bonne place à l’ordre du jour de la santé et du développement, tant au niveau mondial que national – une place qu’elle mérite largement.

Remerciements Le Consortium mondial sur la promotion de la santé communautaire est soutenu, en partie, par les fonds provenant des Centres américains pour le Contrôle et de Prévention des Maladies (CDC) dans le cadre de l'accord de coopération n°U50 CCU021856-05 sur « La promotion de la santé et l’éducation pour la santé a l’échelle mondiale » Les auteurs remercient, pour son assistance technique, Madame Marilyn Metzler, Infirmière au McKing Consulting Corporation et détachée auprès du Centre National de la Prévention des Maladies Chroniques et Promotion de la Santé.

Référence Charte d’Ottawa. Actes de la Première Conférence Internationale sur la Promotion de la Santé. Ottawa, Canada, 21 novembre 1986. www.who.int/hpr/NPH/docs/ottawa_chart er_hp.pdf [accédé en mai 2006]

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Plaidoyer L’utilisation de la taxation de produits nocifs pour financer des fondations en promotion de la santé : introduction au débat proposé par l’article de Karen Slama. Commentaire de Michel O’Neill Trouver des ressources pour financer les institutions et les interventions de promotion de la santé est un problème important et récurrent pour tous les pays qui, en général, ne consacrent à ces entreprises qu’une très faible part de leurs investissements en santé. Afin de pallier cette situation, quelques pays innovateurs ont décidé de dédier une portion de leurs revenus de taxes à la promotion de la santé, ces sommes étant à l’occasion totalement ou partiellement dévolues à des fondations publiques ayant la promotion de la santé pour mandat. L’état australien de Victoria a ouvert la voie dans cette direction il y a plusieurs années déjà, suivi par d’autres états australiens puis des pays aussi diversifiés que la Suisse, la Thaïlande ou la Pologne par exemple. Ces fondations publiques se sont regroupées dans un Réseau international des fondations en promotion de la santé <www.hp-foundations.net/>. Elles diffèrent de manière importante des fondations privées oeuvrant dans le domaine de la santé qui, comme celle de Melinda et Bill Gates par exemple <http://www.gatesfoundation.org/ default.htm>, ont un programme de travail plutôt autonome <http://www.gih.org/usr_doc/2003_ Conversion_Report.pdf> ou encore en partenariat avec les instances gouvernementales comme la fondation Lucie et André Chagnon <http://www.fondationchagnon.org>. En effet, dans de nombreux cas, ces fondations publiques sont financées à même des taxes prélevées sur des produits nocifs à la santé comme l’alcool ou le tabac, souvent désignées en anglais sous l’expression « sin taxes », i.e. « taxes du péché ». Afin de réfléchir à ces sujets et éventuellement de prendre position à leur égard, le Conseil d’administration (CA) de l’Union internationale de promotion de la santé et d’éducation pour la santé (UIPES) a commandé une étude1 qui a été présentée à son exécutif à Paris, en décembre 2005. Analysant la situation dans plusieurs pays, ce document se penche d’abord sur l’utilisation de la

taxation du tabac et de l’alcool comme instrument de promotion de la santé ; il analyse à cet effet les problèmes et les bénéfices potentiels reliés à cette pratique et montre qu’ils sont différents pour le tabac et l’alcool. L’étude s’attarde par la suite sur le fait de dédier de manière spécifique le produit de ces taxes à des fins de santé et soulève quelques-uns des dilemmes éthiques et économiques potentiels de cette forme d’utilisation de fonds publics. Finalement, l’enjeu de canaliser en tout ou en partie à travers des fondations publiques de promotion de la santé le produit des « taxes du péché » est abordé et les apprentissages faits à cet égard au cours de la dernière décennie sont également évoqués. La présentation de ce document a soulevé beaucoup d’intérêt et de débats lors de la réunion de l’exécutif de décembre dernier. D’abord, même si elle est fort utilisée dans certains groupes anglo-saxons de militants pour la santé, l’expression « sin tax » y est apparue excessivement moralisatrice, trop culturellement spécifique et en conséquence inappropriée à de nombreuses personnes. Le fait que l’étude avait été demandée pour montrer comment la taxation dédiée et les fondations de promotion de la santé étaient des mécanismes appropriés de promotion de la santé, plutôt que de se poser de manière plus neutre la question si oui ou non ces mécanismes avaient fait la preuve de leur efficacité, a aussi été soulevé. Finalement, de traiter dans le même document de la taxation comme instrument de promotion de la santé et de l’utilisation des taxes prélevées sur des produits nocifs à la santé comme mécanisme de financement de fondations de promotion de la santé est apparu comme une source de confusion à certains membres de l’exécutif. En conséquence, il a été décidé que deux types de réactions seraient recueillies en regard de l’étude de manière à alimenter encore davantage la réflexion du CA sur ces sujets en vue de les débattre et, éventuellement, de prendre position sur le

Sites Web de quelques fondations en promotion de la santé Austrian HPF : www.fgoe.org BC Coalition for Health Promotion : www.vcn.bc.ca/bchpc/ Health 21 Foundation (Hungary) : www.health21.hungary.globalink.org Health Promotion Switzerland : www.promotionsante.ch Health Promotion Foundation (Poland) : www.promocjazdrowia.pl Healthway : www.healthway.wa.gov.au ThaiHealth : www.thaihealth.or.th VicHealth : www.vichealth.vic.gov.au/

sujet. D’une part, sous la direction de la Vice présidente à la prise de positions publiques de l’UIPES, Marilyn Wise, des échanges structurés ont été entrepris à cet effet entre les membres CA sur leur forum de discussion électronique. D’autre part, il a été convenu que l’avis de l’ensemble des membres de l’UIPES serait sollicité à travers la revue électronique de l’Union, RHP&EO. Les membres de l’Union sont donc invités à se rendre sur le site de la revue au www.rhpeo.org et, à travers les mécanismes usuels de réaction aux textes de la revue indiqués en cliquant sur le rectangle vert au bas de la version électronique du présent texte qui se trouve dans la série Nouvelles ressources que nous vous invitons à consulter, à exprimer leur position. Même si vous ne souhaitez pas participer au débat, nous vous encourageons fortement à consulter l’étude de Slama car elle soulève de manière fort appropriée la plupart des enjeux qui se posent si l’on souhaite utiliser la taxation de produits nocifs à la santé (tabac, alcool mais aussi éventuellement malbouffe, armes, etc.) pour le financement d’institutions ou de programmes de promotion de la santé.

Michel O’Neill Rédacteur en chef, RHP&EO Université Laval, Québec Email : Michel.ONeill@fsi.ulaval.ca

1. Slama, K. (2006) « Informations de référence pour l’adoption d’une politique en faveur de taxes sur le tabac et l’alcool qui soient affectées a la création de fondation de promotion de la sante » Promotion & Education. XIII (1) : 56-62.

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Karen Slama

Informations de référence pour l’adoption d’une politique en faveur de taxes sur le tabac et l’alcool affectees à la création de fondations de promotion de la santé Il existe plusieurs manières d’examiner les questions soulevées par, d’une part, le fait de lever des taxes sur des produits spécifiques pour avoir un impact sur la santé et, d’autre part, le fait de consacrer une proportion de ces taxes à des objectifs spécifiques, en l’occurrence, de les affecter à la création et à la maintenance d’une fondation de promotion de la santé. Cet article de référence s’attache à examiner certaines des considérations communes des politiques fiscales liées aux boissons alcoolisées et aux produits du tabac ; en l’occurence, l’impact de l’augmentation des prix de ces produits sur les changements de leur consommation ainsi que les conséquences sociales et sanitaires qui en découlent ; plus spécifiquement les arguments pour ou contre l’affectation d’une partie des taxes sur l’alcool et le tabac à la promotion de la santé ; et enfin certains aspects de la création réussie de fondations de promotion de la santé à partir des taxes affectées.

La politique fiscale appliquée aux boissons alcoolisées et aux produits du tabac Une vérité économique de base veut que le prix d’un produit soit lié à la demande de ce même produit, et l’on s’attend donc à ce qu’une augmentation des prix engendre une diminution de la demande, toutes autres choses étant égales par ailleurs. Ces autres choses peuvent être d’ordre légal, culturel, normatif ou liées aux caractéristiques du produit, comme son potentiel addictif (Cook & Moore, 2002). L’élasticité-prix de la demande est le changement de pourcentage de la consommation consécutif à une augmentation du prix de 1%. Tant que l’élasticité-prix de la demande est inférieure à une valeur de 1, une augmentation des taxes entraînera un bénéﬁce net des recettes ﬁscales

Karen Slama, PhD. Union internationale contre la Tuberculose et les Maladies respiratoires Paris, France Email: kslama@iuatld.org

totales. C’est le cas pour le tabac. Les taxes sur les produits du tabac sont importantes pour générer des recettes. Les principaux critères de choix d’une taxe qui génère des recettes sont l’équité et l’efficacité. L’équité face à la taxation signifie qu’il doit y avoir un fardeau fiscal égal entre les contribuables, que ce soit à travers des taxes basées sur le bénéfice individuel reçu de services fournis par le gouvernement ou par des taxes basées sur la capacité individuelle à payer. Ce que l’on appelle les “sin taxes”, ou taxes “sur les péchés”, appliquent le principe du bénéfice ; à savoir que les individus payent pour l’utilisation de services fournis par le gouvernement proportionnellement aux bénéfices qu’ils en retirent. L’abus d’alcool et la consommation de tabac engendrent un poids économique qui affecte tous les individus d’une société et pas seulement les consommateurs de ces produits, ainsi la recette totale de la taxe prélevée devrait être égale à l’ensemble des coûts infligés à la société. Puisque la consommation diminue même avec des produits inélastiques, les politiques peuvent également avoir des objectifs de santé publique. Si une politique des prix a pour but de réduire la consommation de produits dangereux comme les boissons alcoolisées ou les produits du tabac, c’est généralement un impôt indirect qui est prélevé (Chaloupka et al, 2002) ; le coût est répercuté sur les consommateurs par le biais de prix à la consommation plus élevés. Une augmentation de 10 % des prix du tabac réduit la consommation de 4 % en moyenne dans les pays développés, et de 8% dans les pays à faibles et moyens revenus (OMS, 2002). En Thaïlande, par exemple, l’élasticité-prix pour le tabac est estimée à -0.7 (Siwraksa, non daté). Lever des taxes sur l’alcool peut ne pas générer de recette substantielle ; il semble qu’il n’y ait pas de consensus sur l’ampleur de l’effet et il existe un désaccord quant à la réactivité des gros buveurs au prix. Cependant, les économistes s’accordent pour dire que même de petites variations des prix ont

un impact sur la consommation modérée (Cook & Moore, 2002). Le tabac peut être taxé plus lourdement que les produits ayant des demandes élastiques (Hu et al, 1998). Mais pour le tabac comme pour l’alcool, de nombreux pays n’ont pas augmenté les taxes pour empêcher une trop forte inflation et ne bénéficient donc pas de la production de recettes ou de gains de santé publique qu’apporteraient des taxes élevées. Dans 11 des 42 pays examinés dans une étude récente, les prix du tabac en l’an 2000 étaient plus abordables qu’ils ne l’étaient en 1990, et en Iran, en Egypte et au Viet Nam, les prix avaient diminué de plus de 50% (Guindon et al, 2002). Aux Etats-Unis, les coûts externes pour l’alcool étaient trois fois plus élevés que le taux de taxation des années 80 (Cook & Moore, 2002). Lorsque le taux de taxation baisse, la consommation monte. Par exemple, en 1999, la Suisse a réformé ses marchés de vins et spiritueux sur la base des accords de l’Organisation mondiale du Commerce, en diminuant les prix et en encourageant la compétition du marché. La consommation d’alcool a alors augmenté de façon significative, en particulier chez les jeunes, et l’on a constaté une augmentation parallèle des problèmes liés à l’alcool (Mohler-Kuo et al, 2004). Lorsque le Canada a réduit les taxes sur le tabac en 1994, pour contrer une augmentation de la contrebande, la consommation s’est accrue de façon spectaculaire, tout comme la prévalence du tabagisme chez les jeunes. Avec la libéralisation du commerce, les pays à faibles revenus qui détenaient auparavant des monopoles sur le tabac sont sujets à la compétition et les prix généraux baissent. Dans les années 90, l’ouverture de leurs marchés a entraîné une nette augmentation de l’usage du tabac au Japon, en Corée et à Taiwan (Chaloupka & Corbett, 1998).

Mots-clés • affectations de taxes • fondations de promotion de la santé • politiques ﬁscales

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Plaidoyer Les bénéfices d’une politique de prix pour la lutte contre le tabac et l’alcool Les taxes sur le tabac protègent la santé, dissuadent les uns de commencer à fumer et encouragent les autres à arrêter, et réduisent l’exposition au tabagisme passif (Wilson & Thomson, 2005). Le fait de lever des taxes sur les produits du tabac est considéré comme un des éléments les plus efficaces d’une politique globale de lutte contre le tabac. Même lorsque les taux de prévalence ont diminué de façon significative, les augmentations de prix restent fortement dissuasives, comme nous le montre une étude récente des effets de hausses de prix continues en Californie (Sung et al, 2005). Il est un fait que les prix des cigarettes sont plus élevés et sont devenus au fil des ans moins abordables dans de nombreux pays ayant de solides programmes nationaux de lutte contre le tabac. Selon la Banque mondiale, des taux de taxation appropriés pour le tabac sont équivalents à entre 2/3 et 4/5 du prix à la consommation. L’impact potentiel d’une augmentation du prix de 10% équivaut à 40 millions de gens qui arrêteraient de fumer (soit 4 % du nombre total de fumeurs) et à 10 millions de décès évités (soit 3 % du nombre de décès liés au tabac prévus). Et pour ces décès évités, l’impact le plus grand concernerait les jeunes fumeurs (Ranson et al, 2000). En ce qui concerne l’alcool, les consommateurs boivent moins et ont moins de problèmes si les prix sont augmentés. La bière est généralement le produit qui répond le moins bien à ces hausses de prix, tandis que ce sont les spiritueux qui y répondent le mieux (Chaloupka et al, 2002), mais l’élasticité du prix pour l’alcool est hautement influencée par les valeurs sociales qui régissent l’usage de la boisson. Contrairement au tabac, la consommation d’alcool est extrêmement concentrée dans les 10% de gros buveurs, qui consomment à eux seuls plus de la moitié de tout l’alcool consommé. D’après la “Théorie de la Distribution Unique”, l’ensemble de la population est associé à des modèles de consommation. Pour réduire la consommation des gros buveurs, c’est toute la population qui doit diminuer sa consommation (Cook & Moore, 2002).

Une augmentation de prix réduit la morbidité, la mortalité et les difficultés sociales liées à l’alcool chez les buveurs légers, modérés comme chez les gros consommateurs et entraîne donc une diminution des viols, des vols, des épisodes de maltraitance parentales et conjugales, des épisodes d’inconduite sexuelle, des dégâts matériels et des comportements violents. Et ces conséquences sont les plus significatives pour les moins de 21 ans (Chaloupka et al, 2002). La représentation des jeunes dans les problèmes liés à l’alcool est disproportionnée. Dans les pays riches, la principale cause de décès chez les jeunes de moins de 35 ans est les accidents de la route mortels, dont environ la moitié est imputable à l’alcool. Il existe un lien entre l’abus d’alcool dans l’adolescence et une consommation excessive par la suite (Ludbrook et al, 2001). Ainsi, les politiques destinées à réduire la consommation d’alcool des jeunes sont probablement les plus efficaces pour réduire la consommation de toute la population. Il a été démontré que des mesures sur les prix réduisaient le pourcentage des jeunes qui boivent beaucoup, ainsi que l’abus d’alcool périodique chez les jeunes (Cook & Moore, 2002).

Conséquences négatives possibles des taxes sur le tabac et l’alcool Il n’existe aucune preuve selon laquelle les individus ou les communautés subiraient des conséquences dommageables pour leur santé suite à une consommation réduite de produits du tabac et de boissons alcoolisées. Il pourrait y avoir une diminution possible mais improbable de l’effet protecteur d’une consommation très modérée d’alcool sur les risques de maladies cardio-vasculaires. Augmenter les taxes peut cependant avoir des conséquences négatives en contribuant aux difficultés financières des individus qui ne modifieraient pas leur consommation. Les populations à faibles revenus dépensent une plus grande proportion des moyens dont elles disposent pour acheter des produits du tabac ; les taxes sur le tabac sont donc régressives. Dans de nombreux pays, la prévalence de l’usage du tabac et les taux de

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consommation sont plus élevés dans les groupes à faibles revenus que dans les autres groupes de population, ce qui accroît les difficultés sociales. Mais certains considèrent que les taxes ont un effet utile “d’autocontrôle” dans la mesure où elles aident les gens à arrêter de fumer par la suite. Cet élément “d’autocontrôle” est probablement plus utile pour les populations à faibles revenus ; les taxes sur le tabac peuvent donc leur être bénéfiques dans l’ensemble (Lav, 2002). En d’autres mots, même si les taxes sur le tabac ont un effet régressif, leur augmentation peut être considérée comme progressive en ce qu’elle a plus d’impact sur les groupes à faibles revenus et qu’elle entraîne une réduction des inégalités face à la santé. Des études ont montré que la réactivité par rapport au prix était inversement liée à la classe sociale et au niveau d’éducation. Les fumeurs des groupes à faibles revenus sont plus susceptibles d’arrêter de fumer consécutivement aux hausses de prix que de réduire leur consommation (Guindon et al, 2002). De plus, il existe différentes solutions pour remédier aux privations de certains exacerbées par les taxes à la consommation, comme accorder un allègement fiscal ou utiliser des recettes fiscales spécifiquement pour la promotion de la santé de ces populations. Les modifications fiscales en Australie ont entraîné une diminution de la consommation à la fois chez les cols bleus et les cols blancs, et la proportion de gros fumeurs a baissé. C’est plus qu’un effet parmi les groupes à faibles revenus, qui sont la cible de campagnes antitabac et de campagnes médiatiques (Voir, en anglais : http://www.quitnow.info.au/tobccamp3.ht ml ). En dépit de l’avantage évident que constitue pour la santé publique l’augmentation des taxes sur le tabac et l’alcool, certaines barrières structurelles subsistent. Dans la plupart des pays, les décideurs sont attentifs aux avantages à court terme et au coût des politiques. Dans les pays ayant des secteurs de santé sous-développés, la majeure partie des coûts externes du tabac ou de l’alcool ne sont pas assumés par le gouvernement et il y a donc moins d’empressement à récupérer les coûts. Dans chacune de ces situations, la perception des coûts à court terme parait élevée par rapport à une politique de

Les arguments concernant les taxes affectées peuvent être regroupés dans les catégories suivantes : questions ﬁscales et de gouvernance, questions éthiques, conséquences sanitaires et sociales, questions économiques et questions de justice et d’équité. Les arguments contre les taxes affectées sont présentés en italique et sont suivis des réfutations qu’il est possible de leur opposer ou des preuves des avantages qui découlent de l’affectation de taxes au bénéﬁce de la promotion de la santé.

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Taxes et recettes au Zimbabwe

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Figure 1

Questions fiscales et de gouvernance

contrôle du tabac ou de l’alcool : pression de l’industrie pour empêcher d’agir, pertes d’emploi si la consommation baisse régulièrement, crainte (non fondée) de recettes ﬁscales réduites (Chaloupka et al, 2000). Augmenter les prix à travers la taxation peut cependant susciter de nouvelles recettes à court terme, tout en permettant le plein effet des taxes après de nombreuses années, à mesure que l’incidence des maladies liées à ces produits diminue et que les prix plus élevés réduisent le nombre de nouveaux gros buveurs ou fumeurs. L’une des meilleures utilisations pour une proportion des recettes issues des politiques de prix destinées à réduire la consommation de produits néfastes à la santé est de légiférer sur un mécanisme de ﬁnancement des programmes par le biais d’une fondation de promotion de la santé.

réduire les dommages causés par le tabac et l’alcool. Globalement, les taxes sur ces produits sont justifiées, et il existe de nombreuses étapes pouvant être mises en œuvre pour contrer les méfaits et les injustices causés par ces produits (Wilson & Thomson, 2005). De plus en plus de pays ont recours à l’affectation des taxes sur le tabac dans ce but, et certains y ajoutent les taxes sur l’alcool. L’affectation d’une partie des taxes sur le tabac et l’alcool au financement de fondations de promotion de la santé apporterait les moyens de réaliser de plus grands bénéfices pour la santé qu’en levant seulement des taxes. Et pourtant il existe encore des inquiétudes. Pour plaider en faveur de la création de fondations de promotion de la santé à partir de financements affectés, il faut donc bien comprendre de quoi il s’agit pour pouvoir contrer les arguments contre l’affectation des taxes.

L’affectation de taxes

Cette partie rassemble les arguments généralement mis en avant pour rejeter toute politique de taxes affectées, suivis du raisonnement et des explications qui justiﬁent leur utilisation.

Les décideurs au niveau des gouvernements devraient envisager de recourir à des politiques de prix pour

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Recette issue de la taxation du tabac, Australie, 1995-2004

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Figure 2

• Tous les spécialistes fiscaux ne sont pas convaincus de l’équité et de l’efficacité des justifications fournies quant aux taxes sur le tabac et à l’affectation de ces taxes. Au lieu de considérer les bénéfices, certains ne voient que la perte du consommateur et du producteur, et la perte sèche pour la société. Certains pourraient objecter que l’on fait porter aux jeunes fumeurs les coûts du tabagisme des générations plus âgées. Et en fonction des méthodes d’établissement des coûts, certains voient des économies éventuelles des coûts médicaux et des pensions de retraite due aux décès précoces liés au tabac. Le public soutient généralement les taxes spéciales sur les produits dangereux pour satisfaire des besoins de recette fiscale et des objectifs sociaux. Parce que la consommation de tabac et d’alcool inflige un coût social à travers l’ensemble de la collectivité, les citoyens acceptent qu’on lève des impôts sur ces produits (Hu & Mao, 2002). Un échec majeur en termes de relations publiques s’est produit lorsque le public a rejeté les conclusions de l’Etude internationale de Philip Morris, financée pour le gouvernement tchèque qui tentait de démontrer que le gouvernement réaliserait des économies sur le paiement des pensions de retraite grâce aux décès précoces parmi les fumeurs. Aussi convaincante a-t-elle pu être à une époque, cette méthode comptable n’est plus acceptable. • Il existe une plus grande souplesse de financement si toutes les ressources fiscales sont dans un même pot. L’affectation de taxes signifie que les choix des dépenses n’appartiennent plus

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Plaidoyer à la législature ni au ministère des finances en place ; cela est généralement contraire aux pratiques fiscales gouvernementales d’allocation. Certains estiment que les taxes affectées affaiblissent la discipline financière et introduisent une rigidité budgétaire face à des besoins qui sont en concurrence. L’affectation de taxes atténue la pression sur la recette générale des finances pour des biens ou des services publics particuliers lorsque les utilisateurs ou les bénéficiaires peuvent être facilement identifiés (l’affectation remplace en quelque sorte les charges directes pour les services). La réalité du financement dans l’allocation concurrentielle est que on tient peu compte des besoins des services de prévention et de promotion de la santé par rapport à ceux des hôpitaux et des services de soins. Si des taxes sont levées pour être affectées, cela crée des fonds supplémentaires et les recettes fiscales régulières ne sont donc pas bouleversées. Avec des taxes affectées, le flot de recette est séparé du budget principal. Les ressources sont générées pour atteindre ceux qui ne le seraient pas au travers de l’impôt général, par le biais de programmes spéciaux ou médiatiques. Il s’agit d’un instrument très intéressant pour la lutte contre le tabac ou les décideurs de la promotion de la santé. • L’acceptation du concept de taxes affectées à des fondations de santé peut être bloquée par la crainte qu’un programme extrabudgétaire puisse être une pente dangereuse ouvrant la voie à d’autres programmes spéciaux financés par des taxes affectées. L’allocation de recettes particulières à une fondation de promotion de la santé est très clairement dans l’intérêt du public. L’expérience montre que cela n’entraîne pas pour autant des propositions similaires d’affectation (par exemple, les craintes émises lors de la création de ThaiHealth se sont depuis dissipées). • D’un autre côté, certains craignent que l’affectation de taxes ne sous-entende la possibilité d’une instabilité des recettes dans le temps. C’est-à-dire qu’à mesure que la consommation décline, les recettes à long terme déclinent aussi et le fonctionnement de la fondation s’en voit menacé.

Figure 3

Consommation tabagique et prévalence du tabagisme, Australie, 1974-2001

Il n’existe aucune étude ni aucun document dans le monde attestant de la perte de recettes gouvernementales du fait de l’augmentation des taxes sur le tabac.

Questions éthiques • La principale question éthique réside dans le fait de recevoir des fonds directement de l’industrie impliquée et dans le conflit d’intérêt qui peut en résulter. Aux États-Unis, le Master Settlement Agreement, signé entre 46 états et de grandes compagnies du tabac, a précisé que sur une période de 25 ans, jusqu’à 206 milliards de dollars pourraient être alloués aux états, en fonction des ventes à venir, pour compenser les coûts de santé des maladies liées au tabac. Un conflit d’intérêt survient lorsque la santé fiscale de la source de cet argent, soit l’industrie du tabac, influence les décisions quant à l’utilisation de ces financements (Sindelar & Falba, 2004). Les diminutions de la consommation du tabac ont déjà réduit les paiements aux états de 10 % (-1,6 milliard$) par rapport à ce qui avait été initialement prévu, et l’on estime que le manque à gagner va augmenter de 20 % (Lav, 2002). De nombreux états n’ont pas ou peu investi de cet argent-là dans la lutte contre le tabac. De façon plus générale, un conflit d’intérêt survient lorsque les financeurs peuvent censurer le contenu des programmes de promotion de la santé. La source du financement alloué à la promotion de la santé par le

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gouvernement à travers des taxes affectées ou toute autre mesure fiscale réfute le conflit d’intérêt, car la recette provient de ce qui est payé par les consommateurs eux-mêmes, et non des bénéfices des producteurs ; il n’y a aucune action entreprise pour aider ces industries à maintenir leurs marges bénéficiaires. La promotion de la santé en général et la lutte contre le tabac en particulier sont sous financées de façon chronique. L’industrie du tabac travaille contre le bien public et peut, avec d’autres industries (alcool, alimentation, etc.) utiliser son argent pour fausser les priorités de santé publique, dépensant bien plus que ce que la promotion de la santé est en mesure de financer. Des ressources sont nécessaires pour mettre en place des programmes de lutte contre le tabac ; une politique de prix seule n’est pas suffisante (Hu et al, 1998). En affectant une partie des taxes à la promotion de la santé pour financer toutes les stratégies supplémentaires on va augmenter l’impact total pour le bien public et la promotion de la santé peut alors compenser les déficits dus aux effets des prix.

Conséquences sanitaires et sociales • Une hausse des prix pourrait encourager la contrebande qui induirait des coûts supplémentaires et empêcherait la production de recettes. Les bénéﬁces attendus en terme de consommation et de santé pourraient ne pas être réalisés si les consommateurs ont accès à des produits moins chers, ce qui irait à l’encontre des objectifs de ces taxes (Hyland et al, 2004). La contrebande est davantage liée au

degré de corruption d’un pays qu’au prix d’un produit. La lutte contre la contrebande de tabac avec des solutions techniques sans ambiguïté et coordonnées au niveau mondial ﬁgure actuellement à l’ordre du jour international, au travers du travail de la Convention-cadre pour la Lutte antitabac. Des ﬁnancements affectés pourraient aussi servir à cela.

Justice et équité • Les taxes sont un outil politique abrupt qui réduit le bien-être des fumeurs qui ont choisi d’utiliser ces produits en toute connaissance des conséquences de leur dépendance. Bien que les risques du tabagisme soient généralement compris dans certaines populations, il a été montré que les fumeurs sous-estiment constamment l’étendue du risque, ce qui indique que la prévalence du tabagisme est plus élevée que ce qu’elle serait réellement si les fumeurs étaient bien informés quant aux risques qu’ils encourent. Augmenter les taxes et les affecter contribuent à rendre les informations sur les risques plus percutantes pour les utilisateurs, avec des bénéfices pour les jeunes nettement plus importants que les pertes que peuvent subir les adultes. Des fondations de promotion de la santé garantiraient que les taxes affectées soient bien utilisées pour des programmes de promotion de la santé destinés à réduire les inégalités en santé. L’affectation peut être compatible avec un système global de taxes et de transferts favorisant l’équité puisque de nombreuses activités, parmi celles ﬁnancées par les taxes sur le tabac affectées, réduisent de façon signiﬁcative les pertes résultant de l’augmentation des taxes sur le tabac (Hu et al, 1998). Fumer est nocif pour la santé et entraîne une augmentation des coûts des soins de santé, faisant porter un fardeau à tous, y compris aux non-fumeurs. • Les gouvernements pourraient être réticents quant à augmenter les taxes sur l’alcool parce qu’elles ne touchent pas seulement ceux qui abusent de ces produits, mais également les buveurs modérés qui n’en ont pas une consommation excessive et ne doivent donc pas être découragés de boire.

L’augmentation du prix de l’alcool réduit la morbidité et la mortalité chez les buveurs, y compris chez les petits buveurs, et réduit l’occurrence d’évènements sociaux négatifs liés à l’abus d’alcool, qui sont un fardeau pour l’ensemble de la société. Lever des taxes sur l’alcool produit un bénéfice largement supérieur aux coûts.

somme considérable qui, autrement, n’aurait pas été disponible pour la lutte contre le tabac.

Questions économiques

Il n’est pas nécessaire que les Fondations de Promotion de la Santé soient financées par des taxes affectées. Cependant, là où elles n’existent pas, il y a en général peu d’enthousiasme ou de vraie volonté de les créer et d’assurer leur financement malgré un accord universel “de principe” avec le concept. Mais si les décideurs peuvent être convaincus par les arguments en faveur des taxes affectées, c’est probablement là la meilleure garantie pour qu’une Fondation de Promotion de la Santé soit établie. Dans cette partie sont examinées certaines des questions importantes liées à la création et au financement de Fondations de Promotion de la Santé.

• Si l’augmentation des taxes affectées réduit la consommation de tabac, cela est susceptible d’entraîner des pertes d’emploi faisant ainsi porter à la société un fardeau de plus. Tandis que l’emploi directement lié à la culture et à l’industrie du tabac peut connaître un déclin, l’impact sur l’emploi dans les autres secteurs peut lui augmenter puisque les anciens fumeurs vont dépenser leurs revenus dans d’autres biens et services, avec l’impact macro-économique net de taxes plus élevées étant négligeable ou positif. • Le montant du financement fourni par l’affectation de taxes pourrait ne pas être approprié par rapport aux changements de l’environnement social ou aux conditions économiques, et fausser les dépenses du gouvernement. Même s’il y affectation, les décideurs politiques peuvent intervenir. En Australie et en Californie, des augmentations massives des taxes ont amené une limitation des financements issus de l’affectation mis à la disposition de la promotion de la santé (mais cela a bien créé une certaine instabilité budgétaire). Dans l’ensemble, l’affectation de taxes particulières réduit les fluctuations budgétaires à long terme. En Australie, le système actuel de révision annuelle avec une indexation plus ou moins équivalente à l’augmentation annuelle du coût de la vie signifie que l’on peut disposer d’un financement substantiel et continu grâce à des fonds consolidés dédiés à la promotion de la santé. En Californie, au début des années 90, le budget dédié à la promotion de la santé équivalait à 25% des dépenses de l’industrie du tabac. Suite à l’intervention du gouvernement pour limiter les recettes attribuées à la lutte contre le tabac, l’équivalence est tombée à 12% (Sung et al, 2005). Mais cela reste cependant une

Créer et faire fonctionner des Fondations de Promotion de la Santé : les pratiques exemplaires et les leçons que l’on peut en tirer

Finances En Australie, les collectes de taxes sur le tabac ont continué à augmenter au fil du temps, malgré une baisse de la prévalence et une hausse des prix. Cependant, il est important que le prix du tabac soit indexé et ajusté sur l’indice des prix à la consommation. Les fondations de promotion de la santé en Australie sont aujourd’hui financées par l’allocation directe issue de recettes consolidées, à des taux similaires à ceux d’un financement spécial plafonné, indexé sur l’inflation. Un taux fixé à partir des taxes destinées au financement est meilleur qu’un plafond : le budget de VicHealth a chuté lorsque les plafonds pour les financements issus des taxes affectées ont été modifiés. La possibilité d’une interférence politique existe toujours, mais quelles que soient les conditions des financements affectés, ils tendent toujours à être préférables à des allocations générales du gouvernement. Les allocations peuvent être à leur tour affectées. A VicHealth, 30% des fonds sont utilisés pour la promotion du sport, et 30% pour la promotion de la santé. La priorité est accordée à la lutte contre les inégalités de santé dont souffrent les populations aborigènes, les

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Plaidoyer communautés rurales, les personnes précarisées ou handicapées, tant à travers des activités culturelles que par la promotion de la santé. Selon le Réseau international des Fondations de Promotion de la Santé, ces dernières doivent être créées par le biais d’une législation spéciﬁque qui stipule le mécanisme de ﬁnancement récurrent à long terme et l’administration des fonds. Elles doivent servir à distribuer des fonds pour la promotion de la santé. Elles doivent être supervisées par un Conseil indépendant qui réunisse toutes les parties prenantes ; mais l’organisation doit pouvoir disposer d’un haut niveau d’autonomie quant à la prise de décision. La Fondation de Promotion de la Santé doit avoir une obligation d’impartialité et de travailler avec d’autres secteurs et organisations à tous les niveaux de la société (Philips R., 2003).

Objectifs Les Fondations de Promotion de la Santé allouent généralement des fonds aux programmes de promotion de la santé, aux programmes de prévention du tabac, à la recherche pour la promotion de la santé et la prévention, pour compenser le sponsoring du tabac et de l’alcool, et pour dispenser des services aux fumeurs et aux buveurs excessifs. L’affectation des taxes sur ces produits rend possibles des campagnes de promotion de la santé et d’éducation pour la santé sophistiquées et durables, qu’il s’agisse de santé en milieu scolaire ou de santé publique. En Australie, le modèle de Fondation de Promotion de la Santé a été développé pour remplacer le sponsoring du tabac après de nouvelles restrictions sur la publicité de ce produit, et pour soutenir des stratégies de lutte contre le tabac également après l’élaboration d’une nouvelle législation ; parallèlement à cela, un ﬁnancement supplémentaire a été garanti en faveur de la promotion de la santé et de la recherche. Les Fondations de Promotion de la Santé seraient les sources de programmes les plus à même de réduire les inégalités en santé.

Les leçons Les expériences de VicHealth (Carol A., 2004 ; Sheehan C. & Martin J., communication privée) et de Healthway (Cordova S., 2003) en Australie, de ThaiHealth (Siwraska P.) en Thaïlande,

ainsi que le Fonds coréen de Promotion de la Santé (Nam E.W., communication privée) montrent que l’affectation de taxes particulières, ou de fonds, à des fondations de promotion de la santé peut grandement améliorer les activités de promotion de la santé dans un pays. Ces fondations ont été créées après d’intenses et longs efforts de la part d’activistes qui n’ont eu de cesse de plaider en faveur de la promotion de la santé. Voici quelques unes des leçons apprises en plaidant pour l’affectation des taxes sur le tabac (et l’alcool) pour financer la promotion de la santé ou la création d’une fondation de promotion de la santé : • Le Ministère des Finances, en particulier, a besoin d’une logique convaincante sur les bénéfices économiques et le bien-fondé pour la santé publique de lever et d’affecter une taxe. • Il faut pouvoir s’appuyer sur un large réseau communautaire, qui ait un profil de haut niveau, des porte-parole qui s’expriment bien, qui fassent probablement déjà partie de la bureaucratie. Tous les acteurs doivent s’être mis d’accord sur les objectifs et partager des buts communs. • Il faut pouvoir disposer de données probantes sur l’effet positif attendu en terme de santé et sur l’efficacité coûtsbénéfices de ces effets dans le contexte local. Toutes les données doivent pouvoir être consultées. Le message principal est toujours qu’une taxe supplémentaire protège la communauté et renforce la santé publique. • Il faut mener des enquêtes pour montrer le soutien public en faveur de l’initiative. • Un avant-projet de loi doit être préparé, précisant le mécanisme exact de collecte de la taxe et sa gestion. • Les activités de lobbying doivent inclure des arguments pour convaincre les gouvernements qu’ils doivent agir, et qu’une telle action est une étape visionnaire qui fait l’unanimité et marquera l’histoire. • Il est important de trouver un terrain d’entente avec ceux qui peuvent subir des pertes économiques, par exemple, avec ceux qui perdent le sponsoring du tabac. Les défenseurs de VicHealth ont mis l’accent sur l’objectif de la fondation d’utiliser des fonds pour remplacer la publicité pour le tabac et ont ainsi réussi à convaincre leurs adversaires potentiels. • Les activités de lobbying doivent

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s’inscrire dans de courtes périodes, car l’industrie du tabac a de l’argent et l’utilisera pour détourner le soutien si elle en a le temps. • ThaiHealth a suivi le modèle de VicHealth, qui semblait une structure plus souple et adaptable, avec un soutien législatif et une source garantie de revenu de façon à ne pas avoir à se battre chaque année pour son budget. • D’après l’expérience de ThaiHealth en matière de lobbying, il semble qu’il soit utile de procéder en deux étapes : tout d’abord obtenir l’augmentation de la taxe sur le tabac, puis demander dans un second temps l’affectation de cette taxe au proﬁt d’une fondation de promotion de la santé. • On a constaté que le contexte de base de la création d’une fondation de promotion de la santé était un leadership fort, un gouvernement stable et un engagement envers la santé. Une fois en place, l’évaluation est essentielle pour un soutien qui s’inscrive dans la durée. • L’approche du Master Settlement Agreement comporte des risques : un accord direct passé avec l’industrie du tabac signiﬁe qu’il n’y a aucune restriction de la capacité de l’industrie du tabac à promouvoir des produits du tabac ; en 2001 aux Etats-Unis, l’industrie du tabac a dépensé 11,2 milliards de dollars en publicité, dont les effets ont en partie annihilé les effets des prix plus élevés. • Les questions liées à la taxation de l’alcool semblent plus complexes que celles relatives au tabac. Bien qu’elles réduisent la consommation, elles sont susceptibles de ne pas générer de recette excédentaire. Si des augmentations massives des taxes sur l’alcool sont inacceptables au niveau politique, une approche possible pourrait être l’application progressive d’une taxe proportionnelle à la quantité d’alcool présente dans l’article acheté (Ford, 2004). Des informations supplémentaires sur les questions de création et d’administration peuvent être obtenues auprès du Réseau international des Fondations de Promotion de la Santé (http://www.hpfoundations.net).

Conclusions Des politiques de prix peuvent jouer un rôle important dans la lutte contre le

tabac et l’abus d’alcool. Il est fortement prouvé que l’utilisation de taxes au profit de la promotion de la santé et de la prévention des maladies est d’intérêt public. Les effets des taxes affectées sur la promotion de la santé sont plus élevés que pour les taxes seules et sont un important outil de promotion de la santé publique. Cela pourrait être encore plus étendu et équitable dans le contexte d’une fondation de promotion de la santé. L’affectation de recettes fiscales supplémentaires à la création et au financement d’une fondation de promotion de la santé va générer les moyens de mettre en œuvre tout un arsenal de programmes d’intérêt public et de combattre les inégalités en santé. Les diverses expériences de création de fondations de promotion de la santé à partir de taxes affectées convergent toutes vers ces points. Cela nécessite des données solides, de la persévérance et une planification à long terme. Il y aura encore des hauts et des bas, des pas en arrière et l’opposition non seulement de l’industrie du tabac (et de celle de l’alcool), mais aussi d’autres secteurs de la société. Des malentendus devront être dissipés régulièrement. Mais les bénéfices potentiels que cela représente pour la santé de l’ensemble de la société sont tels qu’ils valent sans aucun doute la peine d’essayer.

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Site Web du Réseau international des Fondations de Promotion de la Santé, accédé le 10/10/2005 http://www.hpfoundations.net/new/ehpf_earmarking_taxes. html Lav IJ. Cigarette tax increases: cautions and considerations. Revised 2002 Center on Budget and Policy Priorities. http://www.Cbpp1\data\media\michelle\pos tings\7-3-02sfp-rev.doc Ludbrook A, Godfrey C, Wyness L, Parrott S, Haw S, Napper M, van Teijlingen E. Effective and cost-effective measures to reduce alcohol misuse in Scotland: A literature review. Scottish Executive, 2001. Pour le rapport final : http://www.alcoholinformation.isdscotland.or g/alcohol_misuse/files/MeasureReduce_Full .pdf Mohler-Kuo M, Rehm J, Heeb JL, Gmel G. Decreased taxation, spirits consumption and alcohol-related problems in Switzerland. J Stud Alcohol 2004; 65:266-73; Phipps R. Report on the 3rd Meeting of the International Network of Health Promotion Foundations, Budapest, Avril 2003 Ranson K, Jha P, Chaloupka FJ, Nguyen S. The effectiveness and cost-effectiveness of price increases and other tobacco-control policies. In Jha P, Chaloupka F (eds). Tobacco Control in Developing Countries. Oxford: Oxford University Press. 2000; pp427—447. Sindelar J, Falba T. Securitization of tobacco settlement payments to reduce states’ conflict of interest. Health Affairs 2004; 23:188-193. Siwraksa P. version anglaise traduite par V. Isarabhakdi. The Birth of the ThaiHealth Fund (publié par ThaiHealth) http://www.thaihealth.or.th/en/download/The BirthOfTheThaiHealthFund.pdf

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Résumés

« Nous ne voulons pas gérer la pauvreté » : des groupes communautaires M. Rock, p. 36 politisent l’insécurité alimentaire et l’aide caritative Dans de nombreux pays favorisés, l’aide caritative est une réponse courante à l’insécurité alimentaire. La coalition dont il est question dans cette étude de cas s’est engagée de façon explicite dans la justice sociale, en s’opposant à ce que l’aide alimentaire ne masque l’étendue du problème, ses causes et ses conséquences à long terme. La structure de cette coalition a aidé les travailleurs

communautaires à dépasser les routines quotidiennes, et notamment à réfléchir sur les politiques relatives à la précarité alimentaire et sur les réponses institutionnelles à ces problèmes. Les membres de la coalition ont défini la sécurité alimentaire comme un objectif dont la réalisation entraînerait une réforme globale. L’un des résultats notables a été de recommander aux

groupes membres de ne pas redistribuer certaines denrées généralement données par des particuliers et des sociétés. En se débattant entre la nécessité de répondre aux besoins alimentaires immédiats et celle de prendre les causes de ces besoins à la racine, les travailleurs communautaires ont pris en considération la santé publique.

Influences culturelles et occidentales sur la transition nutritionnelle K. L. Craven et S. R. Hawks, p. 14 en Thaïlande L’impact du développement économique et de l’urbanisation sur la nutrition et les changements de mode alimentaire dans les pays en transition a été bien étudié. D’une manière générale, on a pu constater qu’il existait bien une corrélation entre le développement économique, l’urbanisation, et des transitions nutritionnelles négatives ayant pour conséquence une augmentation de l’obésité et des maladies non transmissibles liées à la façon de s’alimenter. Cependant, l’impact de l’influence et de la culture occidentales sur les modes alimentaires spécifiques associés à la transition nutritionnelle a été moins étudié. On a une information limitée sur les influences culturelles occidentales sur les habitudes alimentaires en Thaïlande. Des chiffres récents indiquent que la Thaïlande pourrait bien avoir avancé plus vite vers un modèle de transition nutritionnelle comportant des habitudes alimentaires défavorables à la santé que ce à quoi on pouvait s’attendre compte tenu de son développement économique. Cette étude est destinée à déterminer la prévalence des modes alimentaires actuels et des motivations des étudiants thaïlandais en matière d’alimentation. Les étudiants

universitaires ont été choisis pour cette évaluation car on estime qu’ils sont les premiers à adopter de nouvelles tendances alimentaires et des changements nutritionnels dans l’ensemble d’une population. Des échantillons aléatoires ont été sélectionnés auprès de quatre universités différentes dans le sud, le centre et le nord du pays. Les échelles suivantes ont été utilisées pour évaluer quels étaient les modes et les comportements alimentaires de 662 étudiants thaïlandais de différents niveaux d’études : l’échelle de motivation alimentaire (MFES), le test26 sur les comportements alimentaires (EAT-26), et l’échelle cognitive de comportement alimentaire (CBDS). Toutes ces échelles se sont avérées fiables et utilisables lors de recherches antérieures. Pour cette étude, les échelles ont été traduites en langue thaï, puis traduites à nouveau, du thaï vers l’anglais, et testées au préalable pour garantir leur pertinence culturelle et la concordance des significations voulues. On a également obtenu des informations démographiques de base, notamment sur l’âge, le sexe, le nombre d’années d’études, le statut marital, la taille et le poids, ainsi que les revenus

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des participants. Les résultats, basés sur les scores élevés des CBDS et des MFES (à l’exception de l’alimentation liée à l’environnement), ont montré que les étudiants thaïlandais avaient une forte tendance à suivre des régimes et à se nourrir hors domicile. Pour la plupart des modes alimentaires négatifs, les filles obtenaient des scores plus élevés que les garçons. On a également trouvé qu’il y avait une corrélation entre la tendance à se soumettre à des régimes et à se nourrir à l’extérieur avec l’indice de masse corporelle, ce qui indique un risque futur de prise de poids et d’obésité. Tandis que la fréquence des troubles du comportement alimentaire, sur la base des scores EAT-26, était faible (13%), l’analyse de ces scores a indiqué que la fréquence des troubles du comportement alimentaire était fortement liée à cette tendance générale à faire des régimes. Ces résultats indiquent la nécessité d’un programme d’éducation à destination des étudiants thaïlandais, et plus particulièrement des filles, pour les informer sur les façons saines de se nourrir et sur les habitudes alimentaires saines à adopter, de façon à prévenir la prise de poids et les troubles alimentaires annoncés par ce modèle de transition nutritionnelle.

Politiques de promotion de la santé en République de Corée E. W. Nam et al., p. 20 et au Japon : une étude comparative Dans certains pays asiatiques, des stratégies de promotion de la santé ont été développées et mises en œuvre, en particulier en République de Corée (Corée) et au Japon. Il serait utile de comprendre les caractéristiques de la promotion de la santé de chacun des deux pays pour pouvoir comparer leurs stratégies. Dans cette étude, une analyse comparative des stratégies de promotion de la santé de la Corée et du Japon a été effectuée en utilisant les catégories développées par HPSource.net, afin de comprendre les caractéristiques de chacun des deux pays dans le domaine particulier de la promotion de la santé et de contribuer à l’amélioration de la santé des populations. En Corée, l’un des buts du Plan santé 2010 est d’évaluer ses réalisations avec

des objectifs numériques, ce qui est également le cas au Japon. L’un des points importants de la discussion implique la décision à prendre quant au nombre optimal de cibles pour l’évaluation. Il existe une différence majeure entre la Corée et le Japon au niveau du financement des activités en promotion de la santé. Au Japon, celles-ci sont financées par les comptes publics tandis qu’en Corée, une fondation pour la promotion de la santé a été instaurée et les revenus issus de la taxe sur le tabac sont alloués à ce fonds. Il est nécessaire d’adapter la base de données et la méthodologie d’HPSource.net pour qu’elles puissent être utilisées partout dans le monde. Nous avons rencontrés certaines difficultés en

Preffi 2.0 – un outil d’évaluation de la qualité Les résultats de nombreuses métaanalyses des effets des programmes de promotion de la santé indiquent que la qualité de ces programmes peut encore être grandement améliorée. Les indications fournies par la recherche sont rarement appliquées dans la pratique. Les praticiens et les décideurs trouvent souvent difficile d’estimer la valeur des résultats de recherches nombreux et parfois contradictoires, notamment parce que les informations contextuelles nécessaires font souvent défaut. Des considérations pratiques les contraignent à apporter des réponses à court terme à des problèmes spécifiques, sous la forme de programmes qui s’efforcent d’être aussi efficaces que possible. Ainsi, pour une promotion de la santé efficace, il faut non seulement que les programmes ayant fait leurs preuves soient diffusés, mais également que l’on dispose d’indications sur les principes qui sous-tendent cette efficacité, et sur les manières dont les professionnels utilisent ces indications. C’est dans ce contexte que l’Institut

utilisant son cadre actuel pour comparer et analyser les informations relatives à la promotion de la santé en Corée et au Japon. Il a été reconnu qu’HP-Source.net était susceptible d’influencer le développement et la mise en œuvre de stratégies de promotion de la santé en d’autres endroits du monde. Les outils de promotion de la santé peuvent aider les décideurs, les planificateurs et les chercheurs à concevoir et à développer des plans globaux. Cette étude a permis de tirer de nombreuses leçons en appliquant ces outils à l’extérieur de la région où ils ont été conçus, pour contribuer au développement de politiques et de pratiques efficaces de promotion de la santé.

G. R. M. Molleman et al., p. 9

Néerlandais de Promotion de la Santé et de Prévention des maladies (NIGZ) a développé et mis en œuvre l’outil Preffi. Cet outil consiste en une série de directives avec des questions relatives à l’efficacité des projets de prévention et de promotion de la santé, développées à partir des connaissances scientifiques et pratiques dont on dispose sur les prédicteurs d’effet. Le présent article décrit le processus de développement systématique, en sept étapes, de la seconde version de l’outil Preffi 2.0 ; un processus tout au long duquel les scientifiques et les praticiens se sont étroitement impliqués. Il décrit également le modèle Preffi et sa méthode d’appréciation. Pour établir la pertinence de cet outil, sa version préliminaire a été testée auprès de 35 praticiens expérimentés issus de nombreux instituts de promotion de la santé. On leur a demandé d’utiliser cette version préliminaire pour évaluer deux descriptions de projets, puis de commenter leur expérience par rapport à l’utilisation de cet outil. Ils ont accordé à

Preffi 2.0 une note moyenne de 7,7 sur 10, et la grande majorité d’entre eux a estimé qu’il était utile, complet, clair, bien organisé et novateur. Les résultats de cet essai ont été utilisés pour élaborer la version définitive de Preffi 2.0. Pour un utilisateur confirmé, appliquer Preffi pour évaluer un projet prend moins d’une heure. Preffi est utilisé comme un outil de diagnostic permettant de garantir la qualité d’un projet à chacune de ses différentes étapes, que se soit pour évaluer de façon critique ses propres projets ou pour commenter les projets proposés par d’autres. Evaluer les projets d’autres personnes peut être difficile si les informations nécessaires font défaut ou sont imprécises. Une discussion complémentaire avec le directeur de projet s’avère donc nécessaire. Les utilisateurs ont rapporté que l’application de Preffi à un projet particulier fournissait une évaluation équilibrée et utile du projet, ainsi qu’un aperçu clair et précis des points à améliorer.

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Résumés

Women’s health resources : favoriser une communauté de soins L. M. Meadows et al., p. 42 pour les femmes d’âge moyen Depuis 1981, des études de recherche ont examiné le rôle joué par les centres de santé destinés aux femmes dans la transmission aux femmes de l’information sur la santé et de l’éducation à la santé, dans des lieux différents des lieux traditionnels. Ces endroits ont été conçus pour apporter aux femmes des soins plus adaptés, et souvent plus globaux, en répondant aux questions et aux besoins qui leur sont spécifiques à toutes les étapes de leur vie. Le type de soins et de ressources procurés par ces centres contribue à la capacité de ces femmes à décider et à agir pour leur propre santé. Cet article examine à la fois les services fournis par l’un de ces centres et la façon dont son rôle est perçu. Il s’agit du Women’s Health Resources (WHR, Ressources

en Santé pour les Femmes) de Calgary, au Canada. Les données utilisées pour cet article ont été tirées des formulaires d’évaluation du WHR concernant 199 femmes d’âge moyen venues pour des consultations individuelles, ainsi que les interviews personnelles menées par quatre membres féminins du personnel. Les patientes du WHR ont mentionné de nombreuses raisons de recourir aux services proposés par le centre, les plus courantes étant l’aide psychologique, la consultation nutritionnelle ou des informations plus globales sur une pathologie particulière. Trois composantes majeures de la prestation de services du centre ont été identifiées : l’information, l’aide psychologique et la complémentarité des services. Les femmes ont utilisé les

informations qu’elles avaient reçues au centre WHR pour participer à la prise de décisions en santé, et comme une ressource pour renforcer leur capacité à être partenaires de leur propre santé. Ces patientes ont constaté que le WHR constituait une source très utile d’informations complémentaires qui allait au-delà de ce que leur médecin généraliste et/ou leurs spécialistes pouvaient leur fournir. Au WHR, le fait que les soins soient axés sur les femmes, et que l’on y mette l’accent sur l’éducation, offre aux femmes une source inestimable d’informations. À travers les expériences partagées des patientes et du personnel du centre, cet article nous donne un aperçu de la façon dont ces services sont perçus et utilisés.

C’est avec une profonde tristesse que l’UIPES a appris le décès de deux figures éminentes de son histoire : M. Paul Hindson, d’Australie, a été Président de l’UIPES de 1982 à 1985. Il a organisé, en 1982, la 11e Conférence mondiale de l’UIPES d’Education pour la Santé à Hobbart, en Tasmanie. Il a consacré la majeure partie de son mandat au développement régional de l’UIPES et a joué un rôle déterminant dans l’établissement des structures régionales de l’Union en Asie du Sud-est, ainsi que dans la partie occidentale du Pacifique Ouest. Économiste de formation, c’est à travers le développement communautaire pour les Aborigènes qu’il s’est familiarisé avec l’éducation pour la santé. Il a obtenu une maîtrise en Education pour la Santé et Santé publique à l’Université de Californie, à Berkeley, aux États-Unis. Il y a vingt ans, il mettait déjà en avant des secteurs prioritaires pour le travail de l’UIPES, sur lesquels nous mettons encore l’accent aujourd’hui. « Nous devons éduquer nos responsables politiques en les maintenant mieux informés des besoins réels de la population, et des aspects de santé de la communauté qu’ils servent ; […] L’action de l’UIES ne doit pas se limiter à éduquer. Notre action implique que chacun de nous s’engage pour mettre en place des interventions de santé publique dans nos pays pour influencer nos gouvernements afin qu’ils accordent des ressources aux programmes de santé publique, et pour partager nos ressources avec d’autres pays ». (Hygie, oct 83 – Vol. II, 1983/3)

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Le Dr. V. Ramakrishna était un ancien Conseiller régional en Education pour la Santé de l’OMS/SEARO et le premier Directeur régional puis vice-Président du Bureau régional de l’UIPES pour l’Asie du Sud-est. Il est connu comme le père de l’Éducation pour la Santé en Inde. Comme l’a mentionné le Dr. N. R. Vaidyanathan, Directeur régional actuel de l’UIPES/SEARB, « il était un homme d’humilité, d’érudition et de compassion. Ses amis et admirateurs l’appelaient affectueusement le Dr. Ram, et il a occupé des postes importants tant au niveau national qu’international, en Médecine, en Santé publique et en Promotion de la Santé. Il a mis en place le Bureau central d’Éducation pour la Santé au sein du Ministère chargé de la Santé & du Bien-être de la Famille du Gouvernement indien, et a posé les fondations pour établir des Bureaux nationaux d’Éducation pour la Santé dans tous les états de son pays. »

Paul Hindson

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In memoriam

Dr V. Ramakrishna

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Élections mondiales de l’UIPES Membres du Conseil d’Administration 2007-2013 Président 2007-2010 Tous les trois ans, conformément à la Constitution et au Statuts de l’UIPES, les membres du Conseil d’Administration sont élus par l’ensemble des Membres de l’Union. Les élections sont organisées avant la Conférence mondiale afin de donner à tous les membres la possibilité d’élire les membres du Conseil d’Administration de l’UIPES. Le nouveau Conseil d’Administration élit à son tour le Président de l’UIPES et assume l’administration et la gouvernance de l’UIPES entre les sessions de l’Assemblée Générale. Le processus de nomination aura lieu entre le 13 août et le 12 décembre 2006, et les noms de tous les candidats qui auront confirmé par écrit leur capacité et leur désir de participer aux élections figureront sur le bulletin de vote, en fonction de la Région où ils résident. Toutes les procédures et la marche à suivre pour proposer des candidats à l’élection du Conseil d’Administration pour la période 2007-2013 seront clairement détaillées dans l’appel aux candidatures qui sera envoyé par écrit à tous les membres de l’UIPES à travers le monde. Le calendrier résume les principales étapes et les dates limites pour chacun de ces processus de candidature et d’élection. Pour toute information supplémentaire dont vous auriez besoin, veuillez contacter par e-mail Marie-Claude Lamarre, Directeur Exécutif, à mclamarre@iuhpe.org

Calendrier 8-10 mai 2006 Nomination par le Conseil d’Administration d’un Comité des Élections. Le Conseil d’Administration, lors de sa réunion au Kenya, en mai 2006, a convenu que chaque viceprésident régional ferait partie de ce Comité, qui sera présidé par le vice-Président chargé de la Coordination, de l’Administration et des Services aux Membres, le Dr. Pierre Arwidson. 13 août 2006 Appel à candidatures pour les Membres du Conseil d’Administration pour la période 20072013 12 déc. 2006 Date limite pour recevoir les candidatures et les confirmations écrites des candidats ainsi que leur déclaration de motivation 13 janv. 2006 Envoi des bulletins de vote à l’ensemble des membres avec une brochure contenant les déclarations de motivation des candidats, les instructions de vote et les bulletins 27 mai 2007 Date limite pour recevoir les bulletins de vote au siège de l’UIPES. 3 juin 2007 Décompte des voix par le Comité des élections 9 juin 2007 Annonce des résultats des élections du Conseil d’Administration 2007-2013 lors de la réunion du Conseil sortant 11 juin 2007 Annonce officielle de l’Élection des Membres du Conseil 2007-2013 12 juin 2007 Élection du Président pour la période 20072010, lors d’une séance extraordinaire du nouveau Conseil d’Administration (les membres élus en 2004 jusqu’en 2010 + les membres 2007-2013) 13 juin 2007 Annonce officielle de l’Election du Président 2007-2010 15 juin 2007 Cérémonie de clôture de la Conférence mondiale – passation de la présidence 16 juin 2007 Le nouveau Conseil se réunit sous la présidence du nouveau Président

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Vancouver, Canada, du 10 au 15 juin 2007 Le lancement officiel de la 19e Conférence mondiale de l’UIPES sur la Promotion de la Santé & l’Education pour la Santé a été célébré le 24 mars dernier au Pan Pacific Hôtel, sur les lieux mêmes du Palais des Congrès & des Expositions de Vancouver, où la Conférence mondiale aura lieu l’an prochain. Cette rencontre a réuni de nombreux participants des secteurs de la santé publique et de la promotion de la santé issus d’institutions gouvernementales, académiques et non gouvernementales, tant de portée locale, que nationale et internationale ; ainsi que de tous les secteurs impliqués dans la préparation de cet évènement. La cérémonie a été accueillie par le Dr. Marcia Hills, Présidente du Consortium canadien pour la Recherche en Promotion de la Santé, et Présidente de la Conférence, ainsi que par le Dr. David Butler-Jones, Administrateur en chef de la Santé publique au Canada, et co-Président honoraire de la Conférence. Il y a vingt ans, la Charte d’Ottawa pour la Promotion de la Santé marquait la première conférence internationale sur la promotion de la santé, donnant le coup d’envoi, selon les mots du Président de l’UIPES, Maurice Mittelmark, “à un mouvement vigoureux, efficace et en pleine expansion”. En organisant la 19e Conférence mondiale de l’UIPES à Vancouver, en juin 2007, nous célébrerons tout le chemin parcouru par le mouvement de la promotion de la santé

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pour arriver réellement à maturité, avec des milliers de participants venus du monde entier. Cette 19E Conférence mondiale est une excellente occasion pour nous de renouveler notre engagement en promotion de la santé. La conférence 2007 mettra l’accent sur quatre thèmes clés : • Réduire les inégalités en santé • Mettre en avant les atouts pour la santé et le développement • Permettre la transformation des systèmes • Évaluer l’efﬁcacité de la promotion de la santé Tous les participants au lancement de la Conférence ont été encouragés à être des ambassadeurs actifs de la promotion de la santé et de l’éducation pour la santé, et à s’impliquer pour une participation aussi large que possible à la Conférence mondiale, l’année prochaine à Vancouver. A notre tour, nous vous encourageons vivement à utiliser vos réseaux professionnels et personnels pour promouvoir la Conférence et les opportunités de sponsoring qu’offre cette assemblée mondiale unique. Nous vous encourageons également à visiter le site Web de la Conférence aussi souvent que possible et de l’utiliser comme un moyen d’inciter les autres autour de vous à s’engager et à participer : www.iuhpeconference.org

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La 19e Conférence mondiale de l’UIPES sur la Promotion de la Santé et l’Éducation pour la Santé

Mark Dooris

Entornos de promoción de la salud: orientaciones de futuro Una mirada atrás: reflexiones En 1986, la Carta de Ottawa (OMS, 1986) afirmaba que “La salud se crea y se vive en los entornos de la vida cotidiana; en aquellos lugares en los que las personas aprenden, trabajan, juegan y aman.” Se reconoce ampliamente que la carta ha sido el catalizador del movimiento a favor de los entornos de promoción de la salud y del enfoque basado en los entornos como punto de partida de los programas de promoción de la salud de la Organización mundial de la salud (OMS), con el compromiso de “pasar de un planteamiento que parte del modelo deficitario centrado en la enfermedad al modelo que pone su atención en el potencial de salud inherente a los entornos sociales e institucionales de la vida cotidiana” (Kickbusch 1996). Veinte años más tarde, ha quedado claro que el enfoque que parte de los entornos ha captado la imaginación de las organizaciones, comunidades y responsables de elaborar las políticas de todo el mundo. Desde la Carta de Ottawa, han surgido un sinfín de programas y redes internacionales y nacionales en entornos muy diversos, ya sean regiones, distritos, ciudades, islas, escuelas, hospitales, lugares de trabajo, cárceles, universidades o mercados. Junto a esto, el concepto de entornos de promoción de la salud se ha introducido con fuerza dentro de las políticas internacionales de promoción de la salud. Por ejemplo, la Declaración de Yakarta respaldó firmemente este enfoque dentro del contexto Invertir en Salud (OMS 1997); la OMS incluyó el concepto «entornos para la salud» en su Glosario de Promoción de la salud, definiéndolo como “el lugar o contexto social en el que las personas desarrollan

Mark Dooris Director Unidad de Desarrollo de Entornos saludables Escuela de Salud y de Medicina de postgrado de Lancashire Facultad de Salud Universidad de Central Lancashire Gran Bretaña Email: mtdooris@uclan.ac.uk

sus actividades cotidianas en el cual los factores medioambientales, organizativos y personales interactúan y afectan a la salud y al bienestar” (OMS 1998a); el nuevo Marco europeo para la política Salud para todos, Salud 21, contenía un objetivo centrado en los entornos (OMS, 1998b); y más recientemente, la Carta de Bangkok (OMS, 2005) subraya el papel que juegan los entornos a la hora de elaborar las estrategias de promoción de la salud y la necesidad de un enfoque integrado de todas las políticas y el compromiso de trabajar transversalmente en unos y otros entornos. No obstante, a pesar de esta popularidad y amparo oficial, podemos decir que este enfoque no ha ejercido tanta influencia como podría en el sentido de orientar políticas internacionales más amplias o impulsar estrategias de salud pública a escala nacional. Para intentar entender este extremo, será útil reflexionar sobre las opiniones de Ilona Kickbusch, una de sus primeras defensoras. Ella viene a decir que puesto que la lógica que sustenta el enfoque basado en los entornos no es médica, la entienden más fácilmente los miembros de la comunidad y los responsables de las decisiones políticas que los profesionales “de salud” (Kickbusch, 1996) y comenta que lo que se consigue gracias a las iniciativas basadas en los entornos “no encaja fácilmente en el marco epidemiológico de “evidencia”, sino que necesita ser analizado en tanto que proceso social y político” (Kickbusch, 2003).

Una mirada al futuro: los retos Si miramos al futuro y pretendemos aumentar la inﬂuencia del enfoque basado en los entornos, nos enfrentamos a una serie de retos relacionados entre sí. Clariﬁcar la base teórica del trabajo de promoción de la salud basado en los entornos En primer lugar, bajo la «bandera» de entornos de promoción de la salud se ha utilizado una amplia gama de términos y se ha reunido una gran diversidad de conceptos y prácticas. Aunque las

expresiones “entornos de promoción de la salud” y “entornos saludables” se han utilizado cada vez más indistintamente, centrándose tanto en el contexto como en los métodos, es importante reconocer las diferencias semánticas que existen entre ellos y las posibles influencias de concepto y de práctica. El primero centra su atención más claramente en las personas y el compromiso de asegurar que el entorno tenga en cuenta los impactos externos sobre la salud. Esto nos recuerda los primeros trabajos de Baric (1993), que proponía que en los estándares se incluyeran tres dimensiones claves: un entorno de trabajo y de vida saludable, integración de la promoción de la salud en las actividades cotidianas del entorno y llegar hasta la comunidad. A nivel conceptual, Wenzel (1997) ha subrayado la tendencia a combinar «la promoción de la salud en los entornos» con “los entornos de promoción de la salud”, dando a entender que el enfoque basado en los entornos se ha utilizado para perpetuar los programas de intervención tradicionales individuales. Whitelaw et al (2001) han comentado la diferencia de concepto y de práctica, haciendo hincapié en las dificultades de trasladar la filosofía a la acción y de presentar una tipología de las prácticas en los entornos. Y Poland et al (2000) se han centrado en las diferencias entre categorías de entornos y en el seno de las mismas. Por ejemplo, los lugares de trabajo pueden diferenciarse por el tamaño, la estructura y la cultura; y una “institución total” como un hospital o una escuela es muy diferente de un entorno menos formal como podría ser el hogar o el vecindario. Estas diferencias se hacen todavía más evidentes cuando contemplamos a los entornos globalmente y tomamos en cuenta la influencia de factores culturales, económicos y políticos diferentes. Todas estas cuestiones apuntan a la importancia de equilibrar la aceptación de la heterogeneidad y de la diferencia

Palabras clave • entornos • base de evidencia

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editorial con una atención especial a la construcción de un concepto compartido del enfoque basado en los entornos. Si bien es cierto que puede haber una cierta “tiranía…en la afirmación o creación de consenso” (Poland et al., 2000: 26), la articulación de la teoría puede ser constructiva a la hora de orientar las prácticas del futuro. A este fin, Dooris (2005) se ha nutrido de la literatura para afirmar que el enfoque en cuestión se caracteriza por tres rasgos claves: un modelo ecológico de salud, una perspectiva de sistemas y centrarse en el desarrollo y el cambio organizativo de todo el sistema. Ampliar la perspectiva El segundo reto, estrechamente relacionado con la conceptualización de los entornos, es ampliar la perspectiva. Aunque la vida de la persona está a caballo sobre diversos entornos (ya sea de manera simultánea o consecutiva), existe el peligro constante de que el enfoque basado en los entornos favorezca una tendencia a la estrechez de miras y a la fragmentación y, de manera inconsciente, deje de lado los factores generales de tipo social, económico y medioambiental que influyen en la salud. En consecuencia, es importante establecer conexiones hacia fuera y hacia arriba. Los entornos funcionan a diversos niveles y como las “muñecas rusas”, unos pueden estar situados dentro del contexto de otros. Gala et al (2000) discuten este extremo, y proponen distinguir diversos niveles de entornos «elementales» y «contextuales». Por ejemplo, un hospital o escuela se ubicará dentro de un barrio concreto, dentro de un pueblo o ciudad más grande, dentro de un distrito, región o isla. Recordando el trabajo de Bronferbrenner sobre ecología social (Bronfenbrenner, 1994), necesitamos considerar los entornos individuales como parte de un todo más amplio y trabajar para mejorar la sinergia entre ellos y optimizar su contribución al bienestar de las comunidades y de las ciudades. Necesitamos elevar nuestro objetivo y tomar en cuenta qué es lo que hace que los lugares sean habitables y vivos, luego aplicar este diagnóstico a los entornos en los que trabajamos. Tal vez tengamos que arriesgarnos a soltar el lenguaje explícito de la salud, pero al hacerlo, liberaremos la energía que facilite el cambio innovador y creador

que puede llevarnos a un bienestar más sostenible a nivel de sistemas. Como subrayaba la Carta de Bangkok (OMS, 2005), también es necesario utilizar la abogacía y el desarrollo de políticas para impulsar acciones que aborden los determinantes de la salud en el contexto de nuestro mundo globalizado. Ello significará asegurar un enfoque integrado en los entornos, en el que se reconozcan y se comprendan las conexiones entre la salud y otros ámbitos de las políticas; desarrollar una responsabilidad social corporativa más amplia como dimensión integrante del enfoque basado en los entornos, subrayando así los impactos institucionales tanto externos como internos (Dooris, 2004); y agrupar unos y otros entornos en partenariados para que se expresen con una sola voz que pueda maximizar su habilidad colectiva de incidir en las políticas regionales, nacionales e internacionales. Elaborar la base de evidencia El tercer reto tiene que ver con la evidencia. Si bien se acepta generalmente que el enfoque basado en los entornos tiene una serie de ventajas, y los estudios sobre evidencia y evaluación han contemplado la cuestión de los entornos (Unión Internacional de Promoción de la Salud y de Educación para la Salud, 2000; Rootman et al., 2001), sigue siendo cierto que: El enfoque basado en los entornos ha sido legitimado más por acto de fe que gracias a estudios rigurosos de investigación y de evaluación…se debe prestar mucha más atención a la construcción de la evidencia y a aprender de la misma. (St Leger, 1997: 100) Existe un conjunto de cuestiones concretas que dificultan la construcción de una base de evidencia convincente (Dooris, 2005). En primer lugar, las formas de financiar la evaluación y de construir la base de evidencia para la salud pública y la promoción de la salud siguen reflejando intervenciones centradas en enfermedades concretas y en factores de riesgo. En segundo lugar, la diversidad de conceptos y de prácticas a la que nos hemos referido más arriba genera problemas evidentes a la hora de crear un cuerpo de conocimientos sustantivo que permita la comparabilidad y la transferibilidad. En tercer lugar, es complejo evaluar el enfoque basado en

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los entornos, si se define en términos de enfoque ecológico y de la idea de sistemas, lo cual, como ha defendido Senge (1990), constituye un marco para ver interrelaciones y modelos de cambio en lugar de «fotos» estáticas. Ello exige un planteamiento no lineal que reconozca las interrelaciones, las interacciones y las sinergias en el seno de los entornos y entre unos y otros. Los investigadores tiene que reconocer también los efectos sinérgicos de combinar métodos diferentes para dar respuesta a diversas preguntas en materia de investigación y de evaluación (Baum, 1995, Steckler et al, 1992) y combinar medidas concretas «de salud» con medidas que se centren en lo nuclear de cada entorno (Lee et al, 2005). El resultado ha sido una tendencia a evaluar proyectos específicos en entornos más que iniciativas en conjunto, en detrimento de la creación de una base creíble de evidencia de la efectividad del enfoque basado en los entornos en términos de «valor añadido» y de sinergia. Una vía de salida posible sería utilizar la experiencia de la «evaluación basada en la teoría» pero para hacerlo tendríamos que clarificar la base teórica, trabajar con los responsables de elaborar las políticas para asegurar que se está creando evidencia con una finalidad determinada (de Leeuw y Skovgaard, 2005) y garantizar una financiación adecuada y a largo plazo.

Conclusión Ziglio et al. han argumentado que, a pesar de la aparente aceptación generalizada de un modelo socioecológico de salud, la promoción de la salud ha seguido centrándose en cuestiones sueltas, logrando poco impacto en los determinantes de la salud o en el desarrollo de las políticas. Continúan diciendo que este impacto no se conseguirá «hasta que el punto de partida sea generar salud… [y] se acepte que los sistemas sociales son complejos y se hallan entretejidos y que sus interconexiones son fundamentales para la generación de salud.» El enfoque basado en los entornos puede suponer una valiosa contribución a la planiﬁcación y a la prestación de salud y de bienestar de maneras que tengan en cuenta esta complejidad, en los lugares en los que la gente vive. Para hacerlo, es

necesario que aborde los retos que hemos apuntado anteriormente: clariﬁcar la teoría, ampliar la perspectiva y generar pruebas de su efectividad. La UIPES está comprometida con este proceso y con una visión en la que los diversos entornos de la promoción de la salud están agrupados. Intentará recopilar

pruebas de su efectividad y fomentar el diálogo y el debate en sus próximas conferencias, entre ellas, la Conferencia nórdica de investigación en promoción de la Salud, que se celebrará en Junio 2006 y las Conferencias Mundiales de Vancouver y Hong Kong en 2007 y 2010, respectivamente. ¡Quedan Ustedes invitados a contribuir y participar!

Agradecimientos Muchas gracias a Christiane Stock, Jürgen Pelikan, Albert Lee y a Catherine Jones por sus valiosos comentarios y sugerencias a la hora de preparar este editorial.

Referencias Baríc, L. (1993) The settings approach – implications for policy and strategy. Journal of the Institute of Health Education, 31, 17-24. Bronfenbrenner, U. (1994). Ecological models of human development. In Husen, T. & Postlethwaite, T. (eds.), International Encyclopedia of Education, Vol. 3, 2nd ed., 1643-1647. Pergamon Press/Elseiver Science, Oxford. Baum, F. (1995) Researching public health: beyond the qualitative and quantitative method debate. Social Science and Medicine, 55, 459-468. Dooris, M. (2004) Joining up settings for health: a valuable investment for strategic partnerships? Critical Public Health, 14, 3749. Dooris, M. (2005) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International, Advance Access published 09 December. http://heapro.oxfordjournals.org/cgi/reprint/d ai030?ijkey=oWMpTL3VLnizG7G&keytype= ref (consultada por última vez en fecha 26 Enero 2006). Galea, G., Powis, B. & Tamplin, S. (2000) Healthy islands in the Western Pacific – international settings development. Health Promotion International, 15, 169-178. Kickbusch, I. (1996) Tribute to Aaron Antonovsky – ‘what creates health’. Health Promotion International, 11, 5-6. Kickbusch, I. (2003) The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93, 383-388.

Lee, A., Cheng, F., St Leger, L (2005). Evaluating health promoting schools in Hong Kong: the development of a framework. Health Promotion International, 20(2): 177186. de Leeuw, E. & Skovgaard, T. (2005) Utilitydriven evidence for healthy cities: problems with evidence generation and application. Social Science and Medicine, 61, 1331–1341. Organización Mundial de la Salud (OMS) (1986) Carta de Ottawa para la Promocion de la Salud. OMS, Ginebra. Organización Mundial de la Salud (OMS) (1997) Declaración de Yakarta sobre Promoción de la Salud en el siglo XXI. OMS, Ginebra. Organización Mundial de la Salud (OMS) (1998a) Glosario de Promoción de la Salud. OMS, Ginebra. Organización Mundial de la Salud (OMS) (1998b) Health21 – The Health for All Policy for the WHO European Region – 21 Targets for the 21st Century. Oficina regional de la OMS para Europa, Copenhague.

Promotion: Principles and Perspectives. Oficina regional de la OMS para Europa, Copenhague. Senge P. (1990) The Fifth Discipline: The Art and Practice of the Learning Organization. Random House, London. Steckler, A., McLeray, K. & Goodman R. (1992) Towards integrating qualitative and quantitative methods: an introduction (Éditorial). Health Education Quarterly, 19, 1-8. St Leger, L. (1997) Health promoting settings: from Ottawa to Jakarta. Health Promotion International, 12, 99-101. Unión Internacional de Promoción de la Salud y de Educación para la Salud (2000) The Evidence of Health Promotion Effectiveness. Shaping Public Health in a New Europe. Part Two: Evidence Book. ECSC-EC-EAEC, Brussels. Versión española: Ministerio de Sanidad y Consumo (2000), La evidencia de la eficacia de la promoción de la salud. Configurando la salud pública en una nueva Europa. Parte dos: Libro de evidencia.

Organización Mundial de la Salud (OMS) (2005) Carta de Bangkok para la promoción de la salud en un mundo globalizado, OMS, Ginebra.

Wenzel, E. (1997) A comment on settings in health promotion. Internet Journal of Health Promotion. http://elecpress.monash.edu.au/IJHP/1997/ 1/index.htm (consultada por última vez en fecha 26 January 2006).

Poland, B., Green, L. & Rootman, I. (2001) Reflections on settings for health promotion. In Poland, B., Green, L. & Rootman, I. (eds) Settings for Health Promotion: Linking Theory and Practice. Sage, London.

Whitelaw, S., Baxendale, A., Bryce, C., Machardy, L., Young, I. & Witney, E. (2001) Settings based health promotion: a review. Health Promotion International, 16, 339353.

Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D., Potvin, L., Springett, J. & Ziglio, E. (eds) (2001) Evaluation in Health

Ziglio, E., Hagard, S. & Griffiths, J. (2000) Health promotion development in Europe: achievements and challenges.

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declaración Sania Nishtar, Marco Akerman, Mary Amuyunzu-Nyamongo, Daniel Becker, Simon Carroll, Eberhard Goepel, Marcia Hills, Marie-Claude Lamarre, Alok Mukopadhyay, Martha Perry and Jan Ritchie

Declaración del Consorcio Mundial para la Promoción de la Salud Comunitaria

Sania Nishtar Heartfile Islamabad, Pakistan Email: Sania@heartfile.org Marco Akerman Facultade do ABC Sao Paolo, Brazil Mary Amuyunzu-Nyamongo African Institute for Health and Development Nairobi, Kenya Daniel Becker Centre for Health Promotion- CEDAPS Rio de Janeiro, Brazil Simon Carroll Centre for Community Health Promotion Research University of Victoria Victoria, Canada Eberhard Goepel University of Magdeburg Magdeburg, Germany Marcia Hills Centre for Community Health Promotion Research University of Victoria Victoria, Canada Marie-Claude Lamarre Unión internacional de Promoción de la salud y Educación para la salud Alok Mukopadhyay Voluntary Health Association of India New Delhi, India Martha Perry Unión internacional de Promoción de la salud y Educación para la salud Jan Ritchie University of New South Wales Sydney, Australia

Palabra clave • promoción de la salud comunitaria

z El Consorcio Mundial para la Promoción de la Salud Comunitaria –una iniciativa de colaboración de la UIPES- se ha creado para promover y fortalecer los esfuerzos de promoción de la salud comunitaria a nivel internacional, regional, nacional y local a ﬁn de que las personas de las comunidades aumenten el control sobre su salud y la mejoren. Si bien abarca acciones diversas y complementarias entre sí dirigidas a los determinantes de la salud, la promoción de la salud comunitaria se centra en las comunidades como unidad en el contexto de sus vidas cotidianas. La idea de “promoción de la salud comunitaria” hunde sus raíces en la Carta de Ottawa (1986) donde se hace hincapié en que la promoción de la salud tiene que ser un proceso de empoderamiento basado en valores, que enseñe a las personas, en el seno de sus comunidades, a controlar los determinantes de su salud. Es este proceso participativo, capacitador y centrado en la equidad lo que constituye la base y fundamento de la promoción de la salud comunitaria. La idea abarca también el fortalecimiento de los vínculos entre los profesionales de la salud que trabajan en los entornos comunitarios y las poblaciones que viven en ellos para ampliar la base de los sistemas de salud de modo que pasen de estar centrados en los «cuidados de salud» a mejorar la salud. En este contexto, se esbozan una serie de parámetros estratégicos y operativos. Estos constituyen la piedra angular de la iniciativa de Promoción de la Salud Comunitaria.

Parámetros estratégicos El Consorcio Mundial para la Promoción de la Salud Comunitaria ha presentado una visión de futuro en la que todas las poblaciones tengan igualdad de oportunidades para alcanzar el máximo nivel de salud y de bienestar; en la que se deﬁende y se materializa el derecho de todas las personas a la salud, como principio fundamental de justicia social; en la que se eliminan las desigualdades

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en materia de salud y se materializan todos los activos comunitarios en dicha materia. La iniciativa se basa en la constatación de que la promoción de la salud es esencial para mejorar la equidad en materia de salud y la justicia social en todas las etapas de la vida y es decisiva para el bienestar y la calidad de vida. El Consorcio reconoce que la participación de la comunidad es esencial y debe impulsar cada una de las fases de las acciones de promoción de la salud: establecimiento de prioridades, toma de decisiones, planiﬁcación de estrategias y evaluación. El Consorcio reconoce también que las comunidades tienen activos y conocimientos locales que deben ser reconocidos y tenidos en cuenta y que también necesitan apoyo y aliento si queremos crear las condiciones óptimas para la salud. El Consorcio mantiene que el desarrollo y aplicación de políticas públicas saludables y participativas es fundamental para garantizar el derecho de todas las personas a vivir en entornos sanos y que este es un requisito previo para ir más allá de los enfoques que se basan principalmente en la modiﬁcación de conductas individuales. Las estrategias del Consorcio subrayan la necesidad de utilizar planteamientos complementarios e integrados dirigidos a los determinantes de la salud. El Consorcio cree que dichos planteamientos serían decisivos para incidir en los objetivos de salud y de desarrollo consensuados a nivel mundial, y plasmados en los Objetivos de Desarrollo del Milenio. Es de vital importancia integrar la promoción de la salud en las políticas de salud mundiales, regionales y nacionales y enmarcar los resultados de salud en el contexto más amplio de las políticas generales si queremos mejorar dichos resultados. Y eso es así porque el Consorcio cree que los factores que inciden en el estado de salud son mucho

más amplios que los que se contemplan en el ámbito sanitario y abarcan el bienestar social, el desarrollo económico, la justicia social, la política, el comercio, el medio ambiente y la seguridad nacional. El Consorcio cree que los objetivos y las metas del sector sanitario deben tener en cuenta los factores antedichos referidos a la sociedad que deben ser determinados dentro de un marco político más explicito para promover la colaboración entre todas las partes interesadas tanto dentro como fuera del sector sanitario tradicional. El Consorcio subraya la necesidad de contar con recursos suficientes para garantizar la aplicación efectiva de dichas políticas y la formulación de los enfoques de salud basados en la acción intersectorial que relacionan la población con sus entornos. El Consorcio se compromete a defender frente a las agencias internacionales, los gobiernos y otras partes interesadas la necesidad de integrar la promoción de la salud comunitaria dentro de las agendas mundiales y de cada país y a presionar para que se consigan los recursos necesarios para llevar a cabo este enfoque. En base a nuestros valores y principios, la intención primordial del Consorcio es promover el uso de metodologías participativas sostenibles para mejorar la salud de la comunidad. En este contexto, identificaremos, revisaremos y analizaremos prácticas y políticas de diversas partes del mundo que sirvan para desarrollar y divulgar recomendaciones de cara a fortalecer programas de promoción de la salud comunitaria que sean eficaces. Otros objetivos son ofrecer oportunidades de crear redes entre los responsables de las políticas y los profesionales de la salud para tomar más conciencia de la amplia gama de prácticas de salud comunitaria, de oportunidades de formación

profesional y de infraestructuras existentes en todo el mundo; ser catalizadores del intercambio de experiencias y desarrollar y fortalecer las iniciativas de colaboración para promover la promoción de la salud comunitaria.

Parámetros operativos Dados estos parámetros estratégicos, el Consorcio ha establecido una serie de pasos iniciales hacia la materialización de su visión en una acción concertada. El primer paso en esta dirección ha sido la creación de un mecanismo institucional, en tanto que entidad coordinada por la UIPES e integrada por una red de expertos en promoción de la salud comunitaria. El siguiente paso ha sido conseguir un consenso para elaborar un «Informe de Promoción de la Salud Comunitaria». Este Informe pretende mejorar la comprensión de lo que es la promoción de la salud comunitaria; presenta un análisis de las actuales prácticas en esta materia y describe la evidencia relacionada con su impacto, en base a la cual se formularán recomendaciones para las políticas que incidan en la promoción de la salud comunitaria. El Consorcio utilizará el proceso de elaboración del Informe de Promoción de la Salud Comunitaria como herramienta para generar partenariados mundiales para la promoción de la salud comunitaria liderados por la UIPES. El Informe será también una herramienta para la defensa a nivel mundial de nuestros postulados de salud dirigida a integrar la promoción de la salud comunitaria en la agenda mundial en materia de salud y de desarrollo sostenible. Asimismo, uno de los próximos números de la revista oﬁcial de la UIPES, Promotion & Education estará dedicado en 2006 a la Promoción de la Salud Comunitaria. Es más, el Consorcio

ofrecerá la oportunidad de establecer redes entre los responsables de las políticas y los profesionales de la salud para ser catalizadores del intercambio de experiencias y desarrollar y fortalecer las iniciativas de colaboración que promuevan la promoción de la salud comunitaria, especialmente en un simposio de un día de duración, anterior a la próxima 19a Conferencia Mundial de la UIPES de Promoción de la Salud y de Educación para la Salud, que tendrá lugar en Vancouver (Canadá) en 2007. Actualmente prevemos que, con esos modestos inicios, el Consorcio está generando un impulso sostenido dirigido a consolidar una iniciativa concertada que coloque a la promoción de la salud comunitaria en un lugar prominente de las agendas en materia de salud y desarrollo a nivel mundial y de cada país; el lugar que en justicia se merece.

Agradecimientos El Consorcio Mundial para la Promoción de la Salud Comunitaria esta en parte financiado por los Centros para el Control y la Prevención de Enfermedades de los Estados Unidos (CDC) a través del Acuerdo de Cooperación Número U50 CCU021856-05 sobre “Iniciativas de promoción de la salud y educación para la salud relacionadas con las enfermedades crónicas a nivel mundial.” Los autores agradecen el apoyo técnico brindado por Marilyn Metzler, Enfermera titulada, del McKing Consulting Corportation designada al Centro Nacional para la Prevención de Enfermedades Crónicas y Promoción de la salud de los CDC.

Referencias Carta de Ottawa. Actas de la primera conferencia internacional de promoción de la salud. Ottawa, Canadá, 21 Noviembre 1986. ww.who.int/hpr/NPH/docs/ottawa_charter _hp.pdf [consultado 06,05)

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abogacía La utilización de “impuestos del pecado” para financiar fundaciones en promoción de la salud: una introducción al debate presentado por el artículo de Karen Slama Comentario de Michel O’Neill La búsqueda de fondos para infraestructuras e intervenciones en promoción de la salud es un constante y gran problema, la mayoría de los países otorgan un porcentaje muy reducido de su presupuesto de salud a esfuerzos de este tipo. Con la finalidad de aligerar dicho problema, algunos países innovadores han decidido destinar cierta cantidad de dinero fiscal a objetivos de promoción de la salud. Este dinero a veces es canalizado a través de Fundaciones públicas total o parcialmente dedicadas a intervenciones en promoción de la salud. El estado de Victoria en Australia va a la vanguardia en este tipo de iniciativas, seguido por diversos países como Suiza, Tailandia y Polonia, por nombrar algunos. Actualmente estas fundaciones públicas se encuentran organizadas en la Red Internacional de Fundaciones en Promoción de la Salud <www.hp-foundations.net/>, y presentan diferencias respecto a fundaciones privadas como la Fundación de Melinda y Bill Gates <http://www.gatesfoundation.org/default. htm>, respecto a fundaciones que trabajan por separado <http://www.gih.org/usr_doc/2003_Conv ersion_Report.pdf>, o respecto a fundaciones en estrecha colaboración con el gobierno (ver por ejemplo, la Fundación Lucie et André Chagnon <http://www.fondationchagnon.org>). En muchos casos, dichas fundaciones públicas consiguen su financiamiento a través de mecanismos que implican la utilización de los impuestos sobre productos potencialmente dañinos para la salud, como el tabaco o el alcohol, usualmente llamados “impuestos del pecado”. Con la finalidad de reflexionar sobre este complejo tema y eventualmente tomar posición, el Consejo de Administración (CA) de la Unión Internacional de Promoción de la Salud y Educación para la Salud (UIPES) encomendó la realización de este artículo importante1 el cual fue presentado a su ejecutivo en Paris, en diciembre 2005. Tomando en cuenta varios países, el artículo, en primer

lugar, documenta la manera en que los impuestos sobre el alcohol y el tabaco pueden ser utilizados como un instrumento político para promover la salud de las poblaciones; además, el artículo revisa los daños potenciales y los beneficios de tales medidas y muestra que el impacto de los impuestos sobre el tabaco es considerablemente diferente al impacto de los impuestos sobre el alcohol. A continuación, el artículo debate de los impuestos destinados específicamente a objetivos de salud, así como algunos de los dilemas éticos, económicos y de justicia social que este proceso puede levantar. Finalmente, se aborda la cuestión de la canalización de los impuestos destinados, a través de las Fundaciones de Promoción de la Salud, y se exponen algunas lecciones aprendidas en este proceso durante las pasadas décadas. Este artículo generó un interés y un debate significativo en la reunión ejecutiva de la UIPES de diciembre 2005. Aunque la expresión “impuestos de pecado” se utiliza comúnmente en algunos lugares, al parecer, muchos la consideran como moralista, culturalmente específica e inapropiada. También, algunas personas cuestionaron el hecho que el artículo haya sido encomendado para resaltar que la asignación y las fundaciones de promoción de la salud son mecanismos apropiados, en lugar de preguntarse de manera menos comprometida, si en realidad se contaba con evidencia suficiente para defender el punto. Finalmente, en algunos casos, parece haber creado confusión que haya sido abordada en el mismo artículo la utilización de los impuestos como un instrumento político para promover la salud, y la asignación de impuestos para las fundaciones de promoción de la salud. Por consiguiente, se decidió que dos tipos de reacciones tendrían que ser incluidas en el artículo, con la finalidad de proveer información adicional al Consejo de Administración de la UIPES, para su discusión y la eventual adopción. Por un

Páginas web de fundaciones de promoción de la salud Austrian Health Promotion Foundation: www.fgoe.org BC Coalition for Health Promotion: www.vcn.bc.ca/bchpc Health 21 Foundation (Hungary): www.health21.hungary.globalink.org Health Promotion Switzerland: www.promotionsante.ch Health Promotion Foundation (Poland): www.promocjazdrowia.pl Healthway: www.healthway.wa.gov.au ThaiHealth: www.thaihealth.or.th VicHealth: www.vichealth.vic.gov.au

lado, de acuerdo al consejo de Marilyn Wise, Vicepresidenta de la Abogacía de la UIPES, una discusión interna será emprendida en la lista de discusión del Consejo. Por otro lado, y esto es lo que estamos haciendo aquí, sería hecha una llamada a los socios generales de la UIPES para contribuir con reflexiones y reacciones a través de la RHP&EO (www.rhpeo.org). Los miembros de la UIPES están invitados a reaccionar, utilizando las guías habituales para hacerlo, que pueden encontrarse en la pagina web de RHP&EO. Aunque usted no desee reaccionar, la lectura del artículo es seguramente una tarea útil para cualquier persona preocupada por el financiamiento de la infraestructura y de las intervenciones en promoción de la salud, puesto que muestra de manera satisfactoria la mayoría de las cuestiones y dilemas implicados en la utilización de los impuestos sobre el tabaco y el alcohol (y eventualmente la imposición de impuestos sobre otros productos con un elevado potencial de daños a la salud, como la “comida rápida”, las armas, etc). ¡Esperamos sus reacciones!

Michel O’Neill Jefe de Redacción, RHP&EO Universidad Laval Québec, Canada Email: Michel.ONeill@fsi.ulaval.ca

Slama, K. (2006) “Información preparatoria para la adopción de una política que fomente la preasignación de los ingresos derivados de los impuestos sobre el tabaco y el alcohol a la creación de fundaciones de promoción de la salud” Promotion & Education. XIII (1): 74-80.

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

Karen Slama

Información preparatoria para la adopción de una política que fomente la preasignación de los ingresos derivados de los impuestos sobre el tabaco y el alcohol a la creación de fundaciones de promoción de la salud z Existen diversas maneras de examinar las cuestiones que conlleva el hecho de a) aumentar los impuestos sobre unos productos concretos para incidir sobre la salud y b) dedicar una parte de dichos impuestos a fines específicos, en el caso que nos ocupa, destinar el producto de los impuestos a la creación y mantenimiento de una fundación de promoción de la salud. Este trabajo preparatorio estudiará algunas de las consideraciones habituales de la política fiscal relativa a bebidas alcohólicas y productos derivados del tabaco, determinará el impacto que tiene el aumento de precios sobre el consumo y las correspondientes consecuencias sociales y sobre la salud, estudiará más concretamente los pros y contras de preasignar una parte de los ingresos derivados de los impuestos sobre el tabaco y el alcohol a la promoción de la salud, y presentará algunos aspectos de experiencias positivas de creación de fundaciones de promoción de la salud basadas en esta preasignación fiscal.

Política fiscal aplicada a las bebidas alcohólicas y a los productos del tabaco Una verdad económica elemental es que el precio de un producto va ligado a la demanda del mismo y que un aumento del precio suele provocar una disminución de la demanda, si el resto de los factores se mantiene sin cambios. Dichos factores pueden ser legales, culturales, normativos o relacionados con características del producto, como por ejemplo, su potencial adictivo (Cook & Moore, 2002). La elasticidad del precio de la demanda equivale al cambio porcentual de consumo resultante de un aumento de precio del 1%. Siempre que la elasticidad del precio de la demanda sea inferior a -1,

Karen Slama, PhD. International Union Against Tuberculosis and Lung Disease Paris, Francia Email: kslama@iuatld.org

un aumento de los impuestos arrojará una ganancia neta en los ingresos fiscales totales. Este es el caso del tabaco. Los impuestos sobre los productos del tabaco son importantes para generar ingresos. Los principales criterios para elegir un impuesto que genere ingresos son la equidad y la eficiencia. La equidad en la fiscalidad significa que tiene que haber una carga fiscal igual para los contribuyentes, ya sea mediante impuestos que se basan en el beneficio individual procedente de los servicios que presta el gobierno o mediante impuestos basados en la capacidad adquisitiva del individuo. En los denominados impuestos «pecaminosos» se aplica el principio del beneficio; es decir, que los individuos pagan por el uso de los servicios prestados por el gobierno en proporción a los beneficios que obtienen de ellos. El consumo abusivo de alcohol y de tabaco generan una carga económica que afecta a todos los individuos de la sociedad y no sólo a los consumidores, así que el ingreso fiscal total recaudado debería ser igual a los costes totales para la sociedad. Dado que el consumo disminuye incluso en productos inelásticos, la política fiscal puede tener también objetivos de salud pública. Si una política de precios tiene como objetivo reducir el consumo de productos peligrosos como bebidas alcohólicas o productos del tabaco, normalmente se aumentan los impuestos indirectos (Chaloupka et al, 2002); el coste se traslada a los consumidores en forma de precios de venta al público más elevados. En los países desarrollados, un aumento del 10% en el precio del tabaco reduce el consumo una media del 4%, y alrededor de un 8% en los países de rentas bajas y medias (OMS, 2002). En Tailandia, por ejemplo, se calcula que la elasticidad del precio del tabaco es de -0.7 (Siwraksa, sin fecha). El aumento de los impuestos sobre el alcohol puede no generar ingresos importantes; parece que no existe consenso en cuanto a la magnitud del

efecto y hay desacuerdo en cuanto a la capacidad de reacción al precio por parte de los mayores consumidores de alcohol. No obstante, los economistas están de acuerdo en que incluso las pequeñas variaciones de precio inciden en la reducción del consumo (Cook & Moore, 2002). Al tabaco se le puede gravar más que a otros productos cuya demanda es elástica (Hu et al, 1998). Pero muchos países no han aumentado los impuestos del alcohol ni del tabaco para mantenerse al nivel de la inflación y, por lo tanto, no se benefician ni de la generación de ingresos, ni de los beneficios en materia de salud pública que comporta dicho aumento. En 11 países de los 42 objeto de un estudio reciente, los precios del tabaco en 2000 eran más asequibles que en 1990, y en Irán, Egipto y Vietnam, los precios habían descendido más del 50% (Guindon et al, 2002). Durante los años 80, en los Estados Unidos, los costes externos del alcohol fueron tres veces superiores al tipo impositivo. Cuando disminuyen los impuestos, el consumo aumenta. Por ejemplo, en 1999, Suiza reformó su mercado de bebidas alcohólicas de conformidad con los acuerdos de la Organización Mundial del Comercio, bajando los precios y fomentando la competencia. El consumo de alcohol aumentó de manera significativa, en especial entre los jóvenes y se produjeron aumentos correlativos en los problemas relacionados con el alcohol (Mohler-Kuo et al, 2004). Cuando Canadá rebajó los impuestos sobre el tabaco en 1994 para contrarrestar el aumento del contrabando, el consumo aumentó espectacularmente así como la prevalencia del hábito entre los jóvenes. Con la liberalización de comercio, los países de renta baja, que en épocas

Palabras clave • fondos preasignados • fundaciones de promoción de la salud • políticas ﬁscales

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

abogacía anteriores habían tenido monopolios del tabaco, se ven sometidos a la competencia y a reducciones de los precios. En los años 90, la apertura de los mercados desembocó en aumentos netos del consumo del tabaco en Japón, Corea y Taiwán (Chaloupka & Corbett, 1998).

Ventajas de la política de precios para el control del tabaco y del alcohol Los impuestos sobre el tabaco protegen la salud, disuaden del consumo, ayudan a abandonar el hábito y reducen la exposición a la contaminación por el humo exhalado (Wilson & Thompson, 2005). El incremento de los impuestos sobre los productos del tabaco está considerado como uno de los elementos más eficaces de una política integral de control del tabaco. Incluso en los casos en los que los índices de prevalencia han disminuido de manera significativa, el aumento del precio sigue siendo un disuasivo económico potente, como demuestra un estudio reciente sobre los efectos del aumento continuado de los precios en California (Sung et al, 2005). En efecto, los cigarrillos son más caros y se han convertido en un producto menos asequible en muchos países con programas fuertes de control del tabaco de ámbito nacional. Según el Banco Mundial, un impuesto adecuado sobre el tabaco debería representar 2/3 o 4/5 del precio de venta al público. El impacto potencial de un aumento de precio del 10% es el abandono del consumo por parte de 40 millones de personas (4% de todos los fumadores) y 10 millones de muertes evitadas (3% de todas las muertes previstas por causa del tabaco). De las muertes evitadas, el efecto más grande se produciría en los fumadores más jóvenes (Ransom et al, 2000). En cuanto al alcohol, se bebe menos y surgen menos problemas derivados del alcohol cuando se aumentan los precios del mismo. El consumo de cerveza pocas veces reacciona a un aumento de precio, en cambio sí lo hacen las bebidas de alta graduación (Chaloupka et al, 2002), pero la elasticidad del precio del alcohol está muy influenciada por los valores sociales que conlleva el hecho de beber. A diferencia del tabaco, el consumo de alcohol está muy concentrado en el 10% de bebedores empedernidos, que consumen más de la mitad de todo el

alcohol consumido. Según la «Teoría de la distribución única», toda la población tiene relación con modelos de consumo de alcohol. Para reducir el consumo entre los mayores bebedores, toda la población tiene que reducir el consumo (Cook & Moore, 2002). El aumento del precio reduce la morbilidad, la mortalidad y los acontecimientos sociales adversos entre los que consumen poco, moderadamente o mucho alcohol y en consecuencia reduce el número de violaciones, robos, incidentes de malos tratos infantiles, malos tratos a la mujer, episodios de mala conducta sexual, daños a la propiedad y participación en actos de violencia. Y estos efectos son muy superiores en personas menores de 21 años (Chaloupka et al, 2002). Los jóvenes se llevan la palma de manera desproporcionada en los problemas relacionados con el alcohol; en los países ricos, la principal causa de muerte en jóvenes de menos de 35 años son los accidentes mortales de tráﬁco, la mitad de los cuales tienen que ver con el consumo de alcohol. El consumo abusivo de alcohol durante la adolescencia se relaciona con el consumo abusivo posterior (Ludbrook et al, 2001). Por lo tanto, las políticas encaminadas a reducir el consumo de bebidas alcohólicas entre los jóvenes son probablemente la forma más eﬁcaz de reducir el consumo en toda la población. Se ha demostrado que las medidas que inciden sobre el precio reducen el porcentaje de jóvenes que beben mucho y también las borracheras (Cook & Moore, 2002).

Posibles efectos perjudiciales del aumento de los impuestos sobre el tabaco o el alcohol No existen pruebas que demuestren que la salud de individuos o comunidades experimente consecuencias perjudiciales debido a una reducción del consumo de productos del tabaco o de bebidas alcohólicas. Podría haber una posible, pero poco probable, reducción del efecto protector que ejerce un consumo muy moderado de alcohol sobre el riesgo de enfermedades cardiovasculares. Lo que sí puede ocurrir, no obstante, es que el aumento de impuestos perjudique a aquellas personas que ya tienen diﬁcultades económicas y, a pesar del aumento, no modiﬁcan su consumo.

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

Las poblaciones de renta baja gastan un porcentaje más alto de sus ingresos disponibles, por lo cual los impuestos sobre el tabaco son regresivos. En muchos países los índices de prevalencia y de consumo de tabaco son superiores en los grupos de renta baja que en los demás grupos, lo que incrementa sus dificultades económicas. Pero algunas personas ven en los impuestos el valor del «autocontrol» en la medida en que el aumento de impuestos ayuda a la persona a abandonar el consumo en el futuro. Probablemente, el elemento de autocontrol es más útil para las personas de rentas bajas, así que los impuestos sobre el tabaco les beneficiarán sobre todo a ellos (Lav, 2002). En otras palabras, aunque los impuestos sobre el tabaco sean regresivos, los aumentos pueden considerarse progresivos en el sentido de que tienen más incidencia en los grupos de renta baja y llevan a la reducción de las desigualdades en materia de salud. Los estudios realizados demuestran que la capacidad de reaccionar a los precios está en relación inversa con la clase social y la educación. Los fumadores pertenecientes a los grupos de renta más bajas tienen más probabilidades de dejar de fumar que de reducir el consumo como reacción a los incrementos de precio (Guindon et al, 2002). Además, existe una serie de remedios posibles cuando la precariedad económica empeora por causa de los impuestos sobre el consumo, como por ejemplo, ofrecer desgravaciones fiscales o emplear los ingresos así recaudados en promocionar la salud de dichas poblaciones. Las modificaciones fiscales en Australia provocaron una disminución del consumo tanto en la población obrera como de trabajadores de oficina y se redujo la proporción de fumadores empedernidos. El efecto ha sido superior en los grupos de renta baja a los que iban destinadas las campañas para dejar de fumar y las de los medios de comunicación (Véase: http://www.quitnow.info.au/tobccamp3) A pesar de las ventajas claras a favor de la salud pública derivadas del aumento de los impuestos sobre el tabaco y el alcohol, siguen existiendo barreras estructurales. En la mayoría de los países, los responsables de las políticas están muy pendientes de los beneficios a corto plazo y de los costes de las políticas. En los países cuyo sector

impuestos. Y aun así, sigue habiendo recelos. Para defender la creación de fundaciones de promoción de la salud ﬁnanciadas con fondos vinculados a los impuestos tenemos que comprender y contrarrestar los argumentos en contra de la práctica de preasignar dichos fondos.

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Impuesto real por paquete Ingreso fiscal real

sanitario está subdesarrollado, los gobiernos no asumen la mayor parte de los costes externos del tabaco y del alcohol, de modo que existe menos presión para recuperar los costes. En ambas situaciones, la percepción de los costes a corto plazo parece elevada en relación a la política de control del tabaco o del alcohol: las presiones que ejerce la industria para que no se actúe; las pérdidas identiﬁcables en puestos de trabajo si el consumo desciende de manera regular, temor (infundado) de una reducción de los ingresos derivados de los impuestos (Chaloupka et al, 2000). El aumento de los precios debido a los impuestos, no obstante, puede recaudar nuevos ingresos a corto plazo, al tiempo que permite que los impuestos surtan sus plenos efectos transcurridos muchos años, puesto que los casos de enfermedad relacionados con el consumo descienden y el encarecimiento reduce el número de bebedores o fumadores empedernidos. Uno de los mejores destinos que puede darse a una parte de los ingresos recién generados gracias a las políticas de

Fondos preasignados Los responsables de las políticas gubernamentales deberían plantearse la posibilidad de utilizar las políticas de precios para reducir los daños provocados por el tabaco y el alcohol. Sobre todo, el gravamen sobre el tabaco y el alcohol está justificado y existen muchas medidas a adoptar para reducir los daños y las injusticias (Wilson & Thomson, 2005). Cada vez hay más países que asignan a este fin los recursos recaudados por los impuestos del tabaco y alguno añade también los derivados de los impuestos de las bebidas alcohólicas. Predestinar una parte de los fondos recaudados por impuestos sobre el tabaco y el alcohol a la financiación de fundaciones de promoción de la salud redundaría mucho más en beneficio de la salud que un simple aumento de

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precios para reducir el consumo de productos nocivos para la salud es legislar un mecanismo de ﬁnanciación de programas a través de una fundación de promoción de la salud.

En este epígrafe se reúnen los argumentos esgrimidos en contra de esta práctica y a continuación se exponen los razonamientos y justiﬁcaciones a favor de la misma. Los argumentos en torno a la preasignación de los ingresos derivados de los impuestos pueden agruparse en las categorías siguientes: cuestiones ﬁscales y de gobernanza, cuestiones éticas, consecuencias sociales y para la salud, justicia y equidad y cuestiones económicas. Los argumentos en contra se exponen en cursiva, y vienen seguidos de refutaciones o pruebas de las ventajas de asignar a la promoción de la salud los fondos recaudados por los impuestos.

Cuestiones fiscales y de gobernanza • No todos los especialistas fiscales están convencidos de los argumentos de equidad y de eficiencia que se esgrimen a favor de los impuestos sobre el tabaco y la preasignación de los fondos recaudados. En lugar de contemplar los beneficios, algunos se fijan en la pérdida de consumo, la pérdida de producción y el lastre (carga excesiva) que recae en la sociedad. Algunos pueden poner objeciones al hecho de trasladar los costes de los fumadores de las generaciones anteriores a los fumadores actuales más jóvenes. Y dependiendo de los métodos empleados para establecer los costes, algunos ven posibles ahorros en el ámbito médico y de jubilaciones debido a las muertes prematuras relacionadas con el tabaco. Por lo general, los contribuyentes apoyan los impuestos especiales sobre productos peligrosos en base a la necesidad de ingresos y a objetivos sociales. Dado que el consumo de tabaco y de alcohol imponen unos costos públicos a las comunidades, los ciudadanos aceptan que los impuestos indirectos no distribuyen ampliamente la carga impositiva de los servicios públicos (Hu & Mao, 2002). Resultó un estruendoso

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abogacía Gráfico 3

Consumo de tabaco y prevalencia de fumadores en Australia, 1974-2001

fracaso de relaciones públicas cuando los ciudadanos rechazaron las conclusiones de un estudio de Philip Morris Internacional financiado por el gobierno checo que demostraban que el gobierno ahorraría en el capítulo de pensiones gracias a que la edad de muerte se adelantaría entre los fumadores. Aunque tuvo su peso en su día, este razonamiento ya no es de recibo. • Si todos los ingresos se agrupan en un mismo cajón, hay una mayor flexibilidad a la hora de financiar. Predestinar unas cantidades a un fin determinado significa eliminar las opciones de asignación de la legislatura y del ministerio del gobierno; esto es, en términos generales, contrario a las prácticas fiscales de asignación del gobierno. Algunos piensan que preasignación de fondos fiscales va contra la disciplina financiera e introduce rigidez presupuestaria cuando las necesidades que entran en conflicto. La preasignación reduce la presión en los presupuestos generales de ciertos bienes o servicios públicos cuando los usuarios o beneficiarios de estas fuentes pueden ser fácilmente identificados. (La preasignación es como una especie de sustitución del cobro directo de los servicios). La realidad es que si la financiación se hace por asignación competitiva, se descarta la prevención y la promoción a la luz de las necesidades hospitalarias y de tratamiento. Si los impuestos se recaudan ya preasignados, se crean fondos adicionales, de modo que no se distorsionan los ingresos fiscales regulares.

En el caso de los impuestos preasignados, el flujo de ingresos se separa del presupuesto principal. Se generan recursos que lleguen a aquellos a los que no llega el propio impuesto a través de programas especiales o de los medios de comunicación. • Aceptar el concepto de impuestos preasignados para las fundaciones a favor de la salud puede encontrar la barrera del miedo a que la existencia de un programa extrapresupuestario pudiera ser el comienzo de una pendiente resbaladiza de otros programas de interés especial financiados por impuestos preasignados. Asignar la recaudación fiscal a una fundación de promoción de la salud es una medida claramente a favor del bien común. La experiencia muestra que esto no lleva necesariamente a otras propuestas de preasignación por imitación (por ej.: se han disipado ya los temores por la creación de ThaiHealth). • Por otro lado, existen temores de que la preasignación conlleve la posibilidad de inestabilidad de los ingresos con el tiempo. Es decir, a medida que el consumo disminuye, los ingresos a largo plazo también serán inferiores y afectarán al funcionamiento de la fundación de promoción de la salud. En ningún lugar del mundo existe constancia de pérdidas en los ingresos presupuestarios por el aumento de los impuestos del tabaco. A continuación presentamos ejemplos de ellos en los gráficos.

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Justicia y equidad • Los impuestos son una herramienta política directa que reduce el bienestar de los consumidores de tabaco que eligen emplear estos productos completamente conscientes de las consecuencias de su adicción. Aunque por lo general en algunas poblaciones se comprenden los riesgos del tabaco, los fumadores demuestran constantemente que infravaloran el riesgo, lo que indica que la prevalencia es más elevada de lo que sería si los consumidores estuvieran bien informados acerca de los riesgos. Aumentar los impuestos y preasignarlos ayuda a que la información acerca de los riesgos resuene más en los consumidores, lo que supone unos beneficios para los jóvenes muy superiores a las pérdidas que puedan experimentar los adultos. Las fundaciones de promoción de la salud garantizarían que los impuestos preasignados se invirtiesen en programas de promoción de la salud para reducir las desigualdades en este campo. La preasignación fiscal puede ser coherente con un sistema general de impuestos y transferencias que promueva la equidad puesto que muchas de las actividades financiadas por los ingresos derivados de los impuestos sobre el tabaco reducen de manera significativa las pérdidas de bienestar derivadas del aumento de dichos impuestos (Hu et al, 1998). Fumar es perjudicial para la salud y provoca un incremento de los costes sanitarios, lo que representa una carga para todos, no sólo para los fumadores. • La reticencia de los gobiernos a incrementar los impuestos sobre el alcohol puede deberse a que dichos impuestos no gravan únicamente a los que abusan del alcoho.l sino también a los que beben con moderación y no abusivamente y no necesitan por lo tanto ser disuadidos de la bebida. El aumento del precio del alcohol reduce la morbilidad, la mortalidad entre los bebedores, incluso los que beben poco, y reduce la cantidad de acontecimientos sociales adversos relacionados con la bebida que representan una carga para toda la sociedad. El aumento de los impuestos sobre el alcohol produce beneficios muy superiores a los costes.

Cuestiones económicas • Si el aumento de impuestos preasignados reduce el consumo de tabaco, provocará perdidas de puestos de trabajo, lo que generará una carga extra en la sociedad. Si bien se reducirá el número de puestos de trabajo relacionados con el cultivo y la fabricación de tabaco, crecerá el empleo en otros sectores, puesto que los exfumadores gastarán su dinero en otros productos y servicios, con lo cual el impacto macroeconómico neto del aumento de impuestos sobre el tabaco será imperceptible o positivo. • La cantidad de fondos procedentes de la preasignación podría ser inadecuada en relación con los entornos sociales o las condiciones económicas cambiantes y distorsionar el gasto gubernamental. Aunque haya preasignación, los políticos pueden intervenir. En Australia y California, los grandes aumentos en los impuestos llevaron a establecer un límite máximo de fondos disponibles para la promoción de la salud derivados de la preasignación (pero eso sí que provoco una cierta inestabilidad presupuestaria). En términos generales, la preasignación reduce las ﬂuctuaciones presupuestarias a largo plazo. En Australia, el actual sistema de revisión anual con indexación respecto del aumento anual del coste de la vida signiﬁca que hay fondos disponibles de manera continuada y en cantidades sustanciales procedentes de los fondos consolidados. A principios de los años 90, el presupuesto de California de promoción de la salud equivalía al 25% de gasto de la industria tabacalera. Tras la intervención del gobierno estableciendo un tope a los ingresos asignados al control del tabaco, la equivalencia pasó a ser del 12% (Sung et al, 2005). Esta es, de todos modos, una cantidad considerable de dinero de la que, de otro modo, no se habría dispuesto.

Creación y funcionamiento de las Fundaciones de promoción de la salud: mejores prácticas y lecciones aprendidas Las Fundaciones de promoción de la salud no tienen por qué ser ﬁnanciadas por los impuestos preasignados. Pero cuando éstos no existen, hay normalmente poco impulso para crearlas y asegurar su ﬁnanciación a pesar de

que “en principio” todo el mundo está de acuerdo con la idea. Pero si podemos convencer a los responsables de las políticas de que aumenten los impuestos para disponer de fondos preasignados, esa será probablemente la mejor garantía de que una Fundación de promoción de la salud cuente con ﬁnanciación. En este epígrafe, abordaremos algunas de las cuestiones importantes relativas a la creación y la ﬁnanciación de las fundaciones de promoción de la salud.

Financiación En Australia, la recaudación fiscal del tabaco ha seguido aumentando con el tiempo a pesar de que el consumo ha disminuido y los precios han aumentado. No obstante, es importante que el precio del tabaco sea indexado y ajustado al índice de precios al consumo. Las fundaciones de promoción de la salud en Australia se financian actualmente mediante asignación directa de los ingresos consolidados a unos tipos variables con techo y vinculados a la tasa de inflación, similares los fondos hipotecarios. Es mejor fijar un tipo fijo sobre los impuestos que fijar un techo: el presupuesto de VicHealth se redujo drásticamente cuando se modificaron los límites máximos de los fondos procedentes de la preasignación. Siempre existe la posibilidad de la interferencia de los políticos, pero, cualesquiera que sean las condiciones de los fondos preasignados, suelen ser mejores que las asignaciones generales del gobierno. La asignación puede predestinarse con anterioridad. En VicHealth, el 30% de los fondos se emplean en promoción del deporte y el 30% en promoción de la salud. Se da prioridad a la lucha contra las desigualdades en materia de salud de la población indígena, las comunidades rurales, la población empobrecida y discapacitada, a través de actividades culturales y de promoción de la salud. De acuerdo con la Red Internacional de Fundaciones de Promoción de la Salud, estas entidades tienen que crearse mediante leyes específicas que establezcan un mecanismo de financiación constante a largo plazo y la administración de los fondos. Tienen que distribuir los fondos de promoción de la salud. Tienen que ser supervisadas por una Junta independiente que represente a todos los interesados; pero la

organización deberá poder ejercer un alto grado de autonomía en sus decisiones. La Fundación de Promoción de la Salud deberá ser imparcial y trabajar con otros sectores y organizaciones de todos los niveles de la sociedad (Phipps R, 2003).

Objetivos Normalmente las fundaciones de promoción de la salud asignan fondos a programas de promoción de la salud, programas de prevención del tabaquismo, estudios de promoción de la salud y de prevención, a la sustitución de los patrocinios del tabaco y del alcohol y a servicios para los fumadores y para aquellas personas que tienen problemas con la bebida. La preasignación de fondos posibilita la existencia de campañas sostenidas y soﬁsticadas de promoción de la salud, de salud escolar y de educación. En Australia, se desarrolló el modelo de Fundación de Promoción de la Salud para sustituir a los patrocinios del tabaco en vista de las nuevas prohibiciones sobre publicidad y en apoyo de las estrategias de control del tabaco también a la luz de la nueva legislación. Además de esto, se garantizaron fondos adicionales para la promoción de la salud y la investigación. Las Fundaciones de promoción de la salud serán la fuente más adecuada para los programas encaminados a reducir las desigualdades en materia de salud.

Lecciones aprendidas Las experiencias de VicHealth (Carol A, 2004; Sheehan C & Martin J, comunicación privada) y de Healthway (Cordova S, 2003) en Australia, de ThaiHealth (Siwraksa P) en Tailandia y de Korean Health Promotion Fund (Nam EW, comunicación privada) muestran que la preasignación de fondos para fundaciones o fondos de promoción de la salud puede mejorar en gran medida las actividades de promoción de la salud de un país. Su creación fue precedida de intensos y prolongados esfuerzos por parte de los defensores de la promoción de la salud. A continuación ﬁguran algunas de las lecciones aprendidas durante la labor de defensa de la preasignación de ingresos derivados de los impuestos del tabaco (y del alcohol) para crear fondos de promoción de la salud o fundaciones de promoción de la salud.

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abogacía • El Ministerio de Hacienda o Finanzas necesita una lógica convincente sobre los beneficios económicos y el beneficio para la salud pública que supone la recaudación y preasignación de dichos impuestos. • Debe crearse una red de apoyo comunitario extensa, cuyos portavoces sean personas de perfil elevado y que se expresen bien, probablemente miembros de la administración. Todos los actores de la misma deberán haber acordado unos objetivos comunes. • Se deben presentar pruebas del efecto positivo que se espera obtener en materia de salud y de la efectividad coste beneficio en el contexto local. Toda la información de expertos debe estar disponible y preparada. El mensaje principal es que el impuesto adicional protegerá a la comunidad y fortalecerá la salud pública. • Será preciso llevar a cabo encuestas que demuestren que la iniciativa cuenta con el apoyo popular. • Habrá que preparar borradores de ley que contemplen el mecanismo de recaudación exacto y la gestión del mismo. • Las medidas de presión política tendrán que emplear argumentos que convenzan al gobierno de la necesidad de actuar, y de que esa actuación beneficiará a unos y a otros, tiene visión de futuro y representará un hito en la historia. • Es importante encontrar intereses comunes con aquellos que puedan experimentar pérdidas económicas, por ejemplo, los que pierden el patrocinio de las industrias tabacaleras. Los defensores de VicHealth acentuaron el objetivo de utilizar los fondos para sustituir la publicidad del tabaco y así consiguieron ganar a potenciales adversarios. • La actividad de presión política debe ser breve, porque la industria

tabacalera tiene dinero y lo utilizará para desmontar los apoyos conseguidos si se les da tiempo. • ThaiHealth siguió el modelo de VicHealth, al considerar que era una estructura más ﬂexible y adaptable, con soporte legislativo y una fuente de ingresos garantizada, de forma que se evitaba tener que luchar cada año su presupuesto. • La experiencia de presión política realizada por ThaiHealth apunta a la utilidad de un proceso en dos etapas: primera, conseguir el aumento de los impuestos del tabaco, y luego, conseguir la preasignación de fondos para la creación de una fundación de promoción de la salud. • Se ha comprobado que el contexto básico para la creación de una Fundación de promoción de la salud es un liderazgo fuerte, un gobierno estable y un compromiso con la salud. Una vez en pie, la evaluación es imprescindible para mantener el apoyo. • El planteamiento del Master Settlement Agreement (Acuerdo Rector con la industria tabacalera) plantea un peligro: el acuerdo directo con la industria tabacalera signiﬁcó la ausencia de restricciones a la promoción de los productos del tabaco; en 2001, las tabacaleras gastaron en EE.UU 11.200 millones de dólares USA en publicidad, cuyos efectos desdibujaron parcialmente los de la subida de precios. • Las cuestiones derivadas de los impuestos sobre el alcohol son más complejas que las del tabaco. Si bien reducen el consumo, puede que no generen ingresos extras. Si un fuerte incremento de los impuestos sobre el alcohol es políticamente inaceptable, un enfoque podría ser la aplicación progresiva del impuesto de conformidad con la cantidad de alcohol contenida en el artículo

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adquirido (Ford, 2004). • En Health Promotion Foundations Network (Red de Fundaciones de Promoción de la Salud) encontrará más información sobre temas de creación y administración de este tipo de entidades (http://www.hpfoundations.net).

Conclusiones La política de precios puede ser un aspecto importante del control del tabaco y el alcohol. Existen muchas pruebas de que la utilización de los impuestos para la promoción de la salud y la prevención de enfermedades redunda en favor del bien común. La preasignación de los fondos derivados de los impuestos tiene mucho más efecto sobre la promoción de la salud que los impuestos ordinarios y es una importante herramienta para promover la salud. El uso de esta herramienta podría ampliarse mucho más y ser más equitativo si se emplease en el contexto de una fundación de promoción de la salud. Si destinamos los fondos adicionales derivados de los impuestos a la creación y financiación de una fundación de promoción de la salud crearemos la manera de implementar todo un arsenal de programas para el bien común y que lucharán contra las desigualdades en materia de salud. Las diversas experiencias de creación de fundaciones de promoción de la salud a partir de la preasignación de impuestos convergen en dichos extremos. Se requiere reunir datos sólidos, perseverancia y planificación a largo plazo. Los contratiempos y la oposición vendrán no sólo de las industrias tabacaleras (y de bebidas alcohólicas), sino también de otros sectores de la sociedad. Habrá que aclarar regularmente los malentendidos. Pero los potenciales beneficios para la salud de la sociedad son enormes y hacen que el esfuerzo valga la pena.

Referencias Carol A. The Establishment and Use of Dedicated Taxes for Health. OMS Región del Pacífico Occidental. 2004. Chaloupka FJ, Grossman M, Saffer H. The effects of price on alcohol consumption and alcohol-related problems. Alcohol Res Health 2002; 26:22-34. http://www.niaaa.nih.gov/publications/arh261/22-34.htm Chaloupka FJ, Hu T, Warner KE, Jacobs R, Yurekli A. The taxation of tobacco products. In Jha P, Chaloupka F (eds). Tobacco Control in Developing Countries. Oxford: Oxford University Press. 2000; pp237-272. Chaloupka F, Corbett M. Trade policy and tobacco: Towards an optimal policy mix. In Abedian I, van der Merwe R, Wilkins N, Jha P. (eds). The Economics of Tobacco Control. Towards an optimal policy mix. Capetown: Applied Fiscal Research Centre, University of Capetown. 1998; pp129-145. Cook PJ, Moore MJ. The economics of alcohol abuse and alcohol-control policies. Health Affairs 2002; 21:120-133. Cordova S. Best practices in tobacco control earmarked tobacco taxes and the role of the Western Australia Health Promotion Foundation (Healthway). WHO Tobacco Control P apers. 2003. http://repositories.cdlib.org/tc/whotcp/WAust ralia2003 European Report on Tobacco control policy (WHO regional office)

Conferencia Ministerial Europea de la OMS para una Europa sin humo 2002

Guindon GE, Tobin S, Yach D. Trends and affordability of cigarette prices: ample room for tax increases and related health gains. Tob Control 2002; 11/35-43.

Ludbrook A, Godfrey C, Wyness L, Parrott S, Haw S, Napper M, van Teijlingen E. Effective and cost-effective measures to reduce alcohol misuse in Scotland: A literature review. Scottish Executive, 2001. Para el informe final: http://www.alcoholinformation.isdscotland.org /alcohol_misuse/files/MeasureReduce_Full.p df

Hyland A, Higbee C, Bauer JE, Giovino GA, Cummings KM. Cigarette purchasing behaviours when prices are high. J Public Health Manag Pract 2004; 10:497-500.

Mohler-Kuo M, Rehm J, Heeb JL, Gmel G. Decreased taxation, spirits consumption and alcohol-related problems in Switzerland. J Stud Alcohol 2004; 65:266-73;

Hu TW, Mao Z. Effects of cigarette tax on cigarette consumption and the Chinese economy. Tob Control 2002; 11:105-108.

Phipps R. Report on the 3rd Meeting of the International Network of Health Promotion Foundations, Budapest, April, 2003

Hu T. Xu X. Keeler T; Earmarked tobacco taxes: Lessons learned. In Abedian I, van der Merwe R, Wilkins N, Jha P. (eds). The Economics of Tobacco Control. Towards an optimal policy mix. Capetown: Applied Fiscal Research Centre, University of Capetown. 1998; pp102-118.

Ranson K, Jha P, Chaloupka FJ, Nguyen S. The effectiveness and cost-effectiveness of price increases and other tobacco-control policies. In Jha P, Chaloupka F (eds). Tobacco Control in Developing Countries. Oxford: Oxford University Press. 2000; pp427—447.

Ford S. letter. Alcohol evidence and policy. BMJ 2004; 328:1202-1203.

International Network of Health Promotion Foundations (sitio visitado en fecha 10/10/2005) http://www.hpfoundations.net/new/ehpf_earmarking_taxes.h tml

Sindelar J, Falba T. Securitization of tobacco settlement payments to reduce states’conflict of interest. Health Affairs 2004; 23:188193.

Lav IJ. Cigarette tax increases: cautions and considerations. Revised 2002 Center on Budget and Policy Priorities. http://www.Cbpp1\data\media\michelle\posti ngs\7-3-02sfp-rev.doc

Siwraksa P. Versión inglesa traducida por by V. Isarabhakdi. The Birth of the ThaiHealth Fund (published by ThaiHealth) http://www.thaihealth.or.th/en/download/The BirthOfTheThaiHealthFund.pdf

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“No queremos gestionar la pobreza”: grupos comunitarios hacen de la inseguridad alimentaria y las donaciones de alimentos M. Rock, p.36 una cuestión política La beneficencia es una respuesta corriente a la inseguridad alimentaria en muchos países ricos. La coalición protagonista de este caso práctico está claramente preocupada por la justicia social, reduciendo así el potencial de la beneficencia de enmascarar el alcance de la inseguridad alimentaria, sus causas principales y sus consecuencias a largo plazo. La

estructura de la coalición ha ayudado a los asistentes sociales a trascender las rutinas del día a día y a reflexionar sobre las repercusiones políticas de la inseguridad alimentaria y las respuestas institucionalizadas a este problema. Los miembros de la coalición han definido la seguridad alimentaria como un objetivo cuya consecución implicará una reforma integral. Un resultado

digno de señalar ha sido recomendar a los miembros del grupo que no redistribuyan una serie de alimentos donados por individuos y empresas. Al enfrentarse al dilema entre responder a las necesidades inmediatas de alimentos o abordar las causas que provocan dichas necesidades, los asistentes sociales han tenido en cuenta la salud pública.

Influencias culturales y occidentales en la evolución de la dieta en Tailandia K. L. Craven y S. R. Hawks, p. 14 Las consecuencias del desarrollo económico y de la urbanización en la alimentación y en los cambios de dieta de los países que experimentan esta transición han sido objeto de muchos estudios. En líneas generales, se constata una correlación positiva entre desarrollo económico, urbanización y evolución negativa de la dieta lo que desemboca en aumento de los niveles de obesidad y de las enfermedades no transmisibles relacionadas con la alimentación. No obstante, se ha estudiado menos el impacto de las influencias y de la cultura occidental en los estilos de alimentación concretos relacionados con la evolución de la dieta. Existe poca información sobre las influencias culturales y occidentales en los estilos de alimentación de Tailandia. Los datos más recientes apuntan a que Tailandia puede estar avanzando en el modelo de transición alimentario hacia estilos de alimentación poco sanos de lo que cabría esperar si nos atenemos a su desarrollo económico. El estudio que nos ocupa pretendía determinar la prevalencia de estilos alimentarios actuales y las motivaciones alimentarias entre lo estudiantes universitarios tailandeses. Se optó por estudiantes

universitarios porque se considera que representan la vanguardia de las tendencias dietéticas y de los cambios alimentarios en la población. Se seleccionaron muestras convenientes de cuatro universidades diferentes del sur, centro y norte de Tailandia. Para evaluar los estilos y actitudes de alimentación y de dieta entre 662 estudiantes universitarios graduados y no graduados, se emplearon las siguientes escalas: Escala de motivaciones frente a la alimentación (MFRS, en sus siglas en inglés)), Test de Actitudes frente a la alimentación-26(EAT-26) y Escala cognitiva de conductas de dieta (CDBS). En investigaciones anteriores se ha demostrado la validez y la fiabilidad de todas ellas. Para el estudio que nos ocupa, estos cuestionarios se tradujeron al tailandés, se volvieron a traducir en sentido inverso y se realizó una prueba piloto para garantizar la pertinencia cultural y la transmisión de lo que se pretendía comunicar. También se obtuvieron datos demográficos básicos, como la edad, el género, el año escolar, el estado civil, la altura, el peso y los ingresos. Los resultados indicaron que un número elevado de estudiantes tailandeses se somete a dietas y su

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alimentación tiene motivaciones extrínsecas según los resultados que arrojaron el CDBS y el MFES (exceptuando la motivación medioambiental de la alimentación). Las cifras de estilos de alimentación negativos eran más altas en mujeres que en hombres. También se descubrió que existía una correlación positiva entre los niveles elevados de dieta y de alimentación extrínseca con el índice de masa corporal, lo que apunta a un posible riesgo de aumento de peso y de obesidad en un futuro. Si bien se constató una baja incidencia de actitudes de trastorno frente a la alimentación en base al cuestionario EAT-26 (13%), el análisis de los resultados del mismo indicaba que dicha incidencia estaba estrechamente relacionada con las dietas a las que se somete este segmento de la población. Los resultados ratifican la necesidad de apoyar un programa para educar a los estudiantes tailandeses, especialmente a las mujeres, que promueva modelos de alimentación y actitudes frente a la comida sanas para prevenir aumento de peso y trastornos de la alimentación en un futuro, tal como vaticina el modelo nutricional de transición.

Recursos para la salud de la mujer: organizar un centro de atención L. M. Meadows et al., p. 42 comunitario para la mujeres de 40 a 65 años Desde 1981, se ha venido estudiando el papel de los centros de salud para mujeres en la tarea de facilitarles información y educación fuera del entorno sanitario tradicional. Estos nuevos entornos se han concebido para ofrecer una atención más adecuada y, a menudo, más integral en respuesta a las cuestiones y necesidades concretas de las mujeres en materia de salud en esta etapa de su vida. El tipo de atención que prestan y de recursos que ofrecen estos centros fortalecen la capacidad de las mujeres de participar en las decisiones y en las acciones que afectan a su propia salud. El artículo contempla la prestación de servicios de un centro de estas características, el Centro de Recursos de salud para la mujer de Calgary (Canadá) (Women’s

Health Resources -WHR) y los roles que desempeña. Los datos para elaborar el informe se tomaron de los cuestionarios de evaluación del WHR contestados por 199 mujeres de mediana edad que habían acudido a consulta individual, así como de entrevistas personales realizadas por cuatro miembros femeninos del personal. Las clientas del WHR citaron numerosas razones para acudir al centro, las más frecuentes de ellas buscar atención para problemas de tipo emocional, consultas sobre nutrición o información más completa sobre alguna enfermedad concreta. Los tres elementos principales de la prestación de servicio de dicho centro que identificaron son: información, atención psicológica y complementariedad de los

servicios. Las mujeres emplearon la información obtenida en los servicios del WHR para tomar decisiones en materia de salud, y como recurso para aprender a responsabilizarse de su propia salud. Las clientas señalaron que el WHR era una valiosa fuente de información complementaria, más allá de la que podían obtener de su médico de familia y/o especialista. El tipo de atención que ofrece el WHR, de tipo feminista y centrado en la mujer, junto con el énfasis en la educación, representa una inestimable fuente de información y de servicios para las mujeres. A través de la experiencia compartida de clientas y personal del centro, el artículo ofrece un resumen de la manera en que dichos servicios se perciben y se utilizan.

Preffi 2.0 – una herramienta para evaluar la calidad Las conclusiones de muchos estudios sobre los efectos de los programas de promoción de la salud indican que hay mucho que mejorar en la calidad de los mismos. Los nuevos datos que aporta la investigación pocas veces se aplican en la práctica. Con frecuencia, a los profesionales de la salud y a los responsables de elaborar las políticas les resulta difícil valorar las muchas –y a veces contradictorias- conclusiones de la investigación, en parte porque, por lo general, suelen carecer de la necesaria información contextual. Las consideraciones prácticas les obligan responder a problemas concretos en un plazo muy breve de tiempo en forma de programas, lo más efectivos posible. De ahí que una promoción de la salud efectiva requiera no sólo la divulgación de programas efectivos sino también una mejor comprensión de los principios de efectividad y de la forma en que los profesionales utilizan esta comprensión. Con este telón de fondo, el Instituto holandés para la promoción de la salud

y la prevención de enfermedades (NIGZ, en sus siglas en inglés) ha desarrollado y aplicado el instrumento Preffi. Preffi consiste en un conjunto de directrices con diferentes puntos relativos a la efectividad de los proyectos de promoción de la salud y de prevención, que reflejan conocimientos científicos y prácticos sobre los indicadores de efectividad. El artículo describe el proceso de desarrollo sistemático en siete pasos de la segunda versión del instrumento, Preffi 2.0, en el cual han participado estrechamente científicos y profesionales de la salud. El artículo describe el modelo Preffi y su método de puntuación. Se comprobó la utilidad del borrador de Preffi 2.0 entre 35 profesionales de salud con experiencia de una serie de institutos de promoción de la salud. Se les pidió que utilizaran la versión borrador para evaluar dos descripciones de proyecto y para comentar sus experiencias en el uso de Preffi 2.0. La nota media que pusieron al instrumento fue de 7,7 sobre 10, y la

G. R. M. Molleman et al., p. 9

gran mayoría de ellos calificó al instrumentos de valioso, completo, claro, bien organizado e innovador. Las conclusiones de esta aplicación a prueba se utilizaron para elaborar la versión definitiva de Preffi 2.0. Un usuario con experiencia tarda menos de una hora en aplicar Preffi para evaluar un proyecto. Preffi se emplea como instrumento diagnóstico de garantía de calidad en diversas etapas del proyecto, ya sea para realizar una evaluación crítica de un proyecto propio o para comentar proyectos ajenos. La valoración de proyectos ajenos puede ser difícil si la información facilitada es insuficiente o poco clara. Siempre se necesita una entrevista adicional con el director del proyecto. Los usuarios de Preffi han comentado que cuando lo aplican a un proyecto les proporciona una valoración equilibrada y útil, así como un panorama general claro de los puntos del proyecto susceptibles de mejora.

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Resúmenes

Políticas de promoción de la salud en la República de Corea y en Japón: E. W. Nam et al., p. 20 estudio comparativo En algunos países asiáticos se han elaborado y llevado a cabo estrategias de promoción de la salud, especialmente en la República de Corea y en Japón. Para comparar las estrategias de uno y otro país, resultaría útil comprender las características de la promoción de la salud en cada uno de ellos. En este estudio, llevamos a cabo un análisis comparativo de las estrategias de promoción de la salud de Corea y de Japón utilizando las categorías desarrolladas por HPSource.net para comprender las características de la promoción de la salud en cada país y contribuir a la mejora de la salud de la población. Uno de los objetivos del Plan de Salud 2010 es valorar sus logros con objetivos

numéricos, como ocurre también en Japón. Uno de los puntos de discusión importantes es la determinación del número óptimo de objetivos a evaluar. Hay una diferencia importante en la financiación de las actividades de promoción de la salud en Corea y en Japón. En este último país, se financian a cargo de los presupuestos generales, mientras que en Corea se ha creado una fundación para la promoción de la salud que se financia con los ingresos derivados del impuesto sobre el tabaco. La base de datos y la metodología de HP-Source necesitan ser adaptados para su uso en todo el mundo. Hemos encontrado algunos inconvenientes al utilizar su marco actual para comparar y

analizar información sobre la promoción de la salud en Corea y en Japón. Se ha reconocido que HP-Source incidirá en el desarrollo y la aplicación de estrategias de promoción de la salud en otras partes del mundo. Las herramientas de promoción de la salud pueden ayudar a los responsables de las decisiones, a los planificadores y a los investigadores a formular y mejorar planes integrales. En resumen, en este estudio hemos aprendido muchas lecciones en cuanto a ampliar el uso de las herramientas fuera de una región parra contribuir al desarrollo mundial de políticas y prácticas efectivas de promoción de la salud.

Rio de Janeiro, Brasil – 18, 19 y 20 de Agosto 2006 II Foro de Promoción de la Salud de las Américas, foro regional reflexivo, pretende analizar los avances y lecciones aprendidas en los 20 años de Ottawa a Bangkok en el contexto Latinoamericano y Caribeño, identificando necesidades y oportunidades. Objetivos: 1. Consensuar una agenda regional en promoción de la salud y una propuesta de plan de acción para implementar los compromisos de la Carta de Bangkok. 2. Realizar un análisis comparativo y balance de la influencia que la Carta de Ottawa y las declaraciones subsecuentes hasta la Carta de Bangkok, en estos últimos 20 años, y cómo han influenciado en el desarrollo conceptual y la práctica de la promoción de la salud en los países de la región. 3. Actualizar el marco conceptual de promoción de la salud desde Ottawa hasta Bangkok en el contexto Latinoamericano y Caribeño, basándose en la experiencia de Norteamérica.

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4. Reﬂexionar sobre las experiencias de promoción de la salud en la región, especialmente las buenas prácticas y la evidencia de efectividad, incluyendo la presentación y análisis del plano de capacidades institucionales en promoción de la salud (2002-05). 5. Papel del Estado en la promoción de la salud y las relaciones con el sector privado. 6. Implementación de la promoción de la salud como estrategia de salud pública para lograr los compromisos de la Carta de Bangkok. El foro estará presidido por la Dra. Carissa Etienne, el Dr. Antonio Ivo y el Dr. Luiz Augusto Galvao. Comité organizador: ABRASCO, UIPES-ORLA-NARO, ENSPFIOCRUZ, CEPEDOC-USP, OPS/OMS (se están invitando otros socios: CDC, SESC, Petrobras, y otros).

info Uipes

II Foro de Promoción de la Salud de las Américas

Los resultados de este foro estarán disponibles en el otoño en la página web de la UIPES: www.iuhpe.org

info Uipes info Uipes info Uipes

Elecciones mundiales de la UIPES Miembros del Consejo de Administración 2007-2013 Presidente 2007-2010 Cada tres años, de conformidad con la Constitución y con los Estatutos de la UIPES, los miembros del Consejo de Administración son elegidos por los socios de la UIPES. La votación se realiza con anterioridad a la Conferencia Mundial para que todos los socios tengan las mismas oportunidades de elegir a los miembros del Consejo de Administración de la UIPES. El Consejo de Administración resultante elige a su vez al Presidente de la UIPES y administra y gobierna a la organización entre las sesiones de la Asamblea General. Las candidaturas se elaboran entre el 13 de Agosto de 2006 y el 12 de Diciembre del mismo año, tras lo cual se incluyen en las papeletas de voto los nombres de todos los candidatos que han confirmado por escrito su idoneidad y voluntad de presentarse a las elecciones, de acuerdo con la Región en que vive cada uno de ellos. El procedimiento y las directrices para proponer candidatos al Consejo de Administración para el periodo 2007-2013 se explicarán claramente en la convocatoria de candidaturas que se enviará por escrito a los socios de la UIPES en todo el mundo. El resumen del calendario que presentamos a continuación sintetiza los principales trámites y plazos para la propuesta de candidaturas y para las elecciones. Si necesita más información, le rogamos envíe un correo electrónico a Marie-Claude Lamarre, Directora Ejecutiva, a mclamarre@iuhpe.org.

Resumen del calendario de las elecciones 8-10 Mayo2006

Candidaturas al Comité Electoral por parte del Consejo de Administración. El Consejo ha acordado en su reunión de Kenia en Mayo 2006 que cada Vicepresidente Regional sería miembro del Comité, presidido por el Vicepresidente de Coordinación, Administración y Servicio a los Socios, Dr.Pierre Arwidson 13 Agosto 2006 Se solicitan candidaturas para los miembros de Consejo Mundial 2007-2013. 12 Diciembre 2006 Último día para recibir candidaturas y confirmación por escrito de los candidatos junto con su exposición de motivos 13 Enero 2006 Envío por correo de la documentación electoral a todos los socios junto con un folleto con las exposiciones de motivos, instrucciones para votar, y las papeletas de voto 27 Mayo 2007 Último día para recibir las papeletas de votos en la sede. 3 Junio 2007 Recuento de votos por el Comité Electoral 9 o 10 Junio 2007 Anuncio de los resultados de las elecciones al Consejo de Administración 2007-2013 en la reunión del Consejo saliente 11 Junio 2007 Anuncio oficial de los resultados de las elecciones al Consejo de Administración 2007-2013 12 Junio 2007 Elección de Presidente 2007-2010 en una sesión extraordinaria del Consejo de Administración entrante (miembros elegidos en 2004 hasta 2010 + miembros 2007-2013) 13 Junio 2007 Anuncio oficial de la elección de Presidente 2007-2010 15 Junio 2007 Ceremonia de clausura de la Conferencia Mundial - Traspaso de la presidencia 16 Junio 2007 Reunión del Consejo entrante presidida por el nuevo Presidente

Entrega del Premio Dr. Manuel Tolosa Latour El Departamento de Ciencias Sociales de la Escuela Graduada de Salud Pública del Recinto de Ciencias Médicas de la Universidad de Puerto Rico recibió el Premio 2006 Dr. Manuel Tolosa Latour que otorga la Asociación Iberoamericana de Medicina y Salud Escolar y Universitaria. El premio se concede a instituciones prestigiosas que hacen aportes al servicio, la formación profesional y la investigación en los ámbitos de la Educación para la Salud, la Promoción de la Salud y la Salud Escolar. El premio fue entregado el 17 de junio de 2006 en la Universidad de La Rioja, Logroño, España. El Departamento de Ciencias Sociales de la Escuela Graduada de Salud Pública de la Universidad de Puerto Rico es miembro institucional de índole Nacional de la

Unión Internacional de Promoción de la salud y Educación para la salud (UIPES) y mantiene la Sede de la Oficina Regional Latinoamericana (ORLA) de la UIPES. En la foto se ilustra el momento de la entrega del Premio. De izquierda a derecha, el Prof. Dr. Antonio Sáez, Catedrático de la Universidad Complutense de Madrid y Presidente de la Asociación Iberoamericana de Medicina y Salud Escolar y Universitaria, el Dr. Hiram V. Arroyo, Catedrático, Director del Departamento de Ciencias Sociales de la Escuela Graduada de Salud Pública de la Universidad de Puerto Rico y Director Regional de la UIPES/ORLA y el Dr. Manuel Tolosa Latour Alcalá-Galiano, Titular del Premio y Presidente de Honor de la Asociación Española de Medicina y Salud Escolar.

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

Vancouver (Canadá) 10-15 de Junio de 2007 El anuncio oficial de la 19a Conferencia Mundial de la UIPES de Promoción de la Salud y de Educación para la Salud se realizó el 24 de Marzo 2006 en el Hotel Pan Pacific, en el mismo emplazamiento que el Centro de Congresos y de Exposiciones de Vancouver, en donde se celebrará la Conferencia Mundial el año que viene. El evento convocó a un gran número de personas del ámbito de la salud pública y de la promoción de la salud, desde instituciones gubernamentales, académicas, organizaciones no gubernamentales locales, nacionales e internacionales así como procedentes de todos los sectores implicados en la preparación del acto. Los anfitriones de la celebración fueron la Dra. Marcia Hills, Presidenta del Consorcio Canadiense para la Investigación en Promoción de la Salud y Presidenta de la Conferencia y por el Dr. David Butler-Jones, Director de Salud Pública de Canadá y co-Presidente Honorario de la Conferencia. Hace veinte años, la Carta de Ottawa para la Promoción de la Salud marcó la primera conferencia internacional de promoción de la salud, dando el saque inicial, en palabras del presidente de la UIPES, Maurice Mittelmark, “a un movimiento sano, enérgico, eficaz y en expansión”. Con la celebración de la 19ª Conferencia Mundial de la UIPES en Vancouver, en Junio de 2007, celebraremos la

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

auténtica “madurez” del movimiento de promoción de la salud con miles de participantes de todo el mundo. La 19a Conferencia Mundial ofrece una gran oportunidad de renovar nuestro compromiso con la promoción de la salud en el umbral del siglo XXI. La Conferencia de 2007 se centrará en cuatro temas principales: • Reducir las desigualdades en materia de salud • Activos para la Salud y el Desarrollo • Posibilitar la transformación de los sistemas • Evaluar la efectividad de la promoción de la salud Se animó a todos los que participaron en el anuncio de la conferencia a que fueran embajadores activos de la promoción de la salud y de la educación para la salud y a que asistiesen a la Conferencia Mundial el año que viene en Vancouver. Nosotros también le rogamos desde aquí que utilice sus redes profesionales y personales para divulgar la conferencia y las importantes posibilidades de patrocinio que ofrece esta asamblea mundial de carácter único. Le aconsejamos también que visite a menudo la web de la conferencia y la utilice como vehículo para animar a otros a implicarse y participar. www.iuhpeconference.org

info Uipes info Uipes info Uipes

19ª Conferencia Mundial de la UIPES de Promoción de la salud y de Educación para la salud

info Uipes info Uipes info Uipes

In memoriam La UIPES comunica con gran pesar el fallecimiento reciente de dos figuras de primer orden en la historia de la organización: Sr. Paul Hindson, de Australia, fue Presidente de la UIPES de 1982 a 1985. Organizó la XI Conferencia Mundial de Educación para la Salud en Tasmania en 1982. Dedicó casi toda su presidencia al desarrollo regional de la UIPES y contribuyó decisivamente al establecimiento de las estructuras regionales de la región de Asia sudoriental y de la Parte Norte del Pacífico Occidental. Economista de formación, se familiarizó con la educación para la salud a través del desarrollo comunitario de los aborígenes. Obtuvo un máster en Educación para la Salud pública en la Universidad de California, en Berkeley (Estados Unidos). Hace veinte años, ya priorizaba áreas de trabajo de la UIPES en las que seguimos centrados: “Deberíamos educar a los responsables de las decisiones manteniéndolos mejor informados sobre las necesidades reales de la población, y en los aspectos sanitarios de la comunidad a cuyo servicio trabajan: […] La acción de la UIPES no debería limitarse a educar a las personas. La acción significa que cada uno de nosotros se implica en la generación de intervenciones de salud pública en nuestros países, presiona a nuestros gobiernos para que dediquen recursos a los programas de salud pública, y comparte recursos con otros países”. (Hygie, Oct.83 – Vol.II, 1983/3)

Dr. V. Ramakrishna fue Asesor Regional en Educación para la Salud de OMS/SEARO y el primer Director Regional y entonces Vicepresidente de la Oficina Regional de la UIPES en el Sudeste asiático. Se le conoce como el Padre de la Educación para la Salud en la India. En palabras del Dr. N.R. Vaidyanathan, actual Director Regional de la UIPES/SEARB “era un hombre humilde, erudito y compasivo. Sus amigos y admiradores le llamaban cariñosamente Dr. Ram. Ocupó cargos de prestigio tanto a nivel estatal como internacional en Medicina, Salud Pública y Promoción de la Salud. Creó la Oficina Central de Educación para la Salud en el Ministerio de Salud y Bienestar Familiar del gobierno de la India y puso los cimientos para el establecimiento de una Oficina Estatal de Educación para la Salud en todo los estados del país.”

Paul Hindson

Dr V. Ramakrishna

Nutrición y vida activa: del conocimiento a la acción Publicaciones PAHO Nutrición y vida activa: del conocimiento a la acción es una antología escrita por destacados expertos en salud pública de la Organización Panamericana de la Salud y la comunidad internacional de desarrollo. Las selecciones del libro se enfocan en cómo la investigación en nutrición y la promoción de modos de vida activos pueden hacer aportes vitales para la planificación y la formulación de políticas públicas, así como para el diseño, la ejecución, el seguimiento y la evaluación de programas. Todos de un modo u otro podemos beneficiarnos directamente de esta ciencia y su aplicación eficaz. El reconocimiento obtenido de los resultados de investigación presentados aquí tiene el poder de transformar la vida de las madres y los niños, la población económicamente activa, los adultos mayores y todos los grupos de edad cuyo modo de vida sedentario representa un gran riesgo de contraer enfermedades crónicas potencialmente mortales. Nutrición y vida activa: del conocimiento a la acción es una contribución importante de interés particular para los profesionales en servicios, los investigadores y los encargados de tomar decisiones en los campos de promoción de la salud, educación comunitaria, nutrición, salud maternoinfantil, actividad física, formulación de políticas en salud pública y planificación urbana, comunicación social y otras áreas relacionadas.

2006, 263 p. ISBN 92 75 31612 0 Código: PC 612 Precios: US$30.00 / US$20.00 en América Latina y el Caribe Idiomas disponibles: Español, Inglés

Esta publicación puede ser adquirida a través la librería en línea de OPS, http://publications.paho.org; o a través de Centro de Distribución y Ventas de OPS, P.O. Box 27, Annapolis Junction, MD 20701-0027, U.S.A; Tel: (301) 617-7806, Fax: (301) 206-9789; E-mail: paho@pmds.com; Tel. 301-6177806. También puede contactar directamente a María Recio, Publicaciones OPS, reciomar@paho.org

IUHPE – PROMOTION & EDUCATION VOL. XIII, NO. 1 2006

International Union for Health Promotion and Education Union Internationale de Promotion de la Santé et d’Éducation pour la Santé Unión Internacional de Promoción de la Salud y Educación para la Salud

Honorary President: Raoul Senault, France President: Maurice Mittelmark, Norway Past President: Spencer Hagard, United Kingdom Global Vice Presidents: Pierre Arwidson, France Maggie Davie, Unided Kingdom Marcia Hills, Canada Hans Krosse, The Netherlands David McQueen, United States Rob Moodie, Australia Michel O’Neill, Canada Alyson Taub, United States Marilyn Wise, Australia Regional Vice Presidents: John Kenneth Davies, United Kingdom (Europe) Marcia Faria Westphal, Brazil (Latin America) Brick Lancaster, United States (North America) Toshitaka Nakahara, Japan (Northern Part of the Western Pacific) K. Basappa, India (South-East Asia) Michael Sparks, Australia (Southwest Pacific) Regional Directors: Hiram Arroyo, Puerto Rico (Latin America) Claudia Coggin, United States (North America) Masaki Moriyama, Japan (Northern Part of the Western Pacific) N. R. Vaidyanathan, India (South-East Asia) Jan Ritchie, Australia (Southwest Pacific) Regional Offices: Europe c/o J. K. Davies Faculty of Health, Univ. of Brighton Falmer, Brighton BN1 9PH, U.K. E-mail: J.K.Davies@bton.ac.uk South-East Asia N° 56, Hutchins Road 6th Cross, St. Thomas Town Bangalore 560084, India Email : iuhpe_searb@ysnl.net

The mission of the International Union for Health Promotion and Education (IUHPE) is to promote global health and contribute to the achievement of equity in health between and within countries of the world. The IUHPE fulfils its mission by building and operating an independent, global, professional network of people and institutions to encourage the free exchange of ideas, knowledge, know-how, experiences, and the development of relevant collaboration projects both at the global and regional levels. The work of the IUHPE includes: advocating for actions that promote health, improving and advancing the quality and effectiveness of practice, advancing knowledge, and developing capacity globally, regionally and locally to do health promotion and health education. The IUHPE comprises the following membership categories: Trustee Members (organisations of national scope which are responsible for organising and/or supporting health promotion and health education in their country, state, province, region, or equivalent level), Institutional Members (organisations of international, national, or local scope, one of whose main purposes is to undertake, or promote one or more aspects of health promotion and health education, and/or which focus on specific themes, target groups, or settings), Individual Members (individuals who support the mission, goals, and objectives of the IUHPE), and Honorary Members (an individual or organisation who makes a special contribution to the mission of the IUHPE, or to the development of its goals and objectives may be invited to be an Honorary Member).

North America University of North Texas Health Science Center, School of Public Health 3500 Camp Bowie Blvd., Fort Worth, TX 76107-2699 United States E-mail: NARO@hsc.unt.edu Northern Part of the Western Pacific Fukuoka University School of Medicine Department of Public Health 7-45-1 Nanakuma, Jonanku, Fukuoka JAPAN 814-0180 Tel : +81-92-801-1011 x.3315 Fax: +81-92-863-8892 E-mail: masakim@cis.fukuoka-u.ac.jp Latin America Universidad de Puerto Rico Recinto de Ciencias Médicas Facultad de Ciencias Biosociales y Escuela de Salud Pública Departamento de Ciencias Sociales PO Box 365067, San Juan, Puerto Rico 00936-5067 E-mail: harroyo@rcm.upr.edu Southwest Pacific School of Public Health and Community Medicine The University of New South Wales Sydney, NSW 2052, Australia E-mail: j.ritchie@unsw.edu.au Africa This structure is currently being developed

La mission de l’Union internationale de Promotion de la Santé et d’Éducation pour la Santé (UIPES) est de promouvoir la santé dans le monde, et de contribuer à la réduction des inégalités de santé, à l’intérieur des pays, et entre les pays. L’UIPES remplit sa mission en organisant et en animant un réseau mondial, professionnel et indépendant, de personnes et d’institutions, en vue de favoriser le partage des idées, des savoirs, des savoir-faire et des expériences, ainsi que le développement de projets coopératifs, au niveau mondial, ou entre les pays et les régions. L’activité de l’UIPES consiste à : plaider pour la mise en place d’actions de promotion de la santé, faire progresser la qualité et l’efficacité de la promotion de la santé et de l’éducation pour la santé à travers leur pratique et les connaissances acquises, et développer la capacité des pays à entreprendre des programmes de promotion de la santé et d’éducation pour la santé. L’UIPES se compose des catégories de membres suivantes : Membres Administrateurs (les organisations nationales qui ont la responsabilité d’organiser ou de renforcer la promotion de la santé et l’éducation pour la santé dans leur pays, état, province, région ou niveau équivalent), Membres Institutionnels (les organisations internationales, nationales ou locales dont l’un des buts principaux est de mettre en œuvre ou de promouvoir un ou plusieurs aspects de la promotion de la santé et de l’éducation pour la santé, et/ou qui concentrent leur activité sur des thèmes, des groupes cibles ou des lieux de vie spécifiques), Membres Individuels (les personnes qui soutiennent la mission, les buts et les objectifs de l’UIPES), et Membres d’Honneur (une personne ou une organisation contribuant d’une manière spéciale à la réalisation de la mission de l’UIPES peut être invitée à devenir Membre d’Honneur).

Headquarters Staff Executive Director: Marie-Claude Lamarre mclamarre@iuhpe.org

Programme Director: Catherine Jones cjones@iuhpe.org

Membership Officer: Janine Cadinu jcadinu@iuhpe.org

Communications Officer: Martha Perry mperry@iuhpe.org

IUHPE Headquarters 42, boulevard de la Libération 93203 Saint-Denis Cedex Tel: 33 (1) 48 13 71 20 Fax: 33 (1) 48 09 17 67

Website address: www.iuhpe.org

La misión de la Unión Internacional de Promoción de la Salud y Educación para la Salud (UIPES) es promover la salud mundial y contribuir a la consecución de la igualdad entre los países del mundo y en el seno de los mismos en materia de salud. La UIPES lleva a cabo su misión creando y gestionando una red independiente, mundial y profesional de personas e instituciones que fomenta el libre intercambio de ideas, de conocimientos, de experiencias y el desarrollo de proyectos de colaboración relevantes tanto a nivel mundial como regional. La actividad de la UIPES consiste en : explicar publicamente las actuaciones que promueven la salud de las poblaciones en todo el mundo ; mejorar y aumentar la calidad y la eficacia de la práctica y de la teoría de la promoción de la salud y de la educación para la salud ; y contribuir al desarrollo de las capacidades de los países que emprenden actividades de promoción de la salud y de educación para la salud. Los miembros de la UIPES se dividen en las siguientes categorías : Miembros Administradores (aquellas organizaciones de índole nacional responsables de la organización o apoyo de la promoción de la salud y de la educación para la salud en su país, estado, provincia, región o nivel equivalente), Miembros Institucionales (aquellas organizaciones de índole internacional, nacional o local, entre cuyas finalidades esenciales se encuentre la provisión o promoción de uno o más de los aspectos de la promoción de la salud y la educación para la salud (centrados en temas y/o grupos de población o lugares de vida especifícos), Miembros Individuales (individuos que apoyan la misión, las metas y los objetivos de la UIPES), y Miembros de Honor (un individuo u organización que haga una aportación especial al cometido de la UIPES, o al desarrollo de sus fines y objetivos puede ser invitado a convertirse en un Miembro de Honor).

IUHPE/UIPES – 42, boulevard de la Libération 93203 Saint-Denis Cedex – France. Tel: 33 (0)1 48 13 71 20 Fax: 33 (0)1 48 09 17 67 E-mail: cjones@iuhpe.org