Don Nutbeam

The importance of the social environment for physically active lifestyle — results from an international study

Physically active lifestyles are regularly associated with improved health and quality of life. Differences in lifestyles in society can partly be understood through the differences in the social and physical environment. This study examines the relationships between reported physical activity, and the extent of perceived support for physical activity in the physical and policy environment (e.g. facilities, programmes and other opportunities), and in the social environment. The data for the study come from a cross-cultural health policy study called MAREPS. In total, 3342 adults, 18 years or older, from six countries (Belgium, Finland, Germany, The Netherlands, Spain, Switzerland) were interviewed via telephone. Respondents were categorised as active or inactive according to self-reported physical activity. Social environmental factors and physical and policy environmental factors were also assessed. The analysis of the data was informed by social cognitive theory, although the study was not originally designed for this purpose. Sixty-eight percent of females and 70% of males were active. The proportions of active and inactive varied by countries to a great extent. The strongest independent predictor of being physically active was social environment. Those who perceived low social support from their personal environment (i.e. family, friends, school and workplace) were more than twice as likely to be sedentary compared to those who reported high social support from their personal environment. Specific knowledge of the programmes and actions for physical activity and sport was also a strong predictor of being active. A supportive physical and policy environment was not associated with participation in physical activity as strongly as had been anticipated. The variation between countries was stronger predictor of being active than the physical and policy environment variables. This study generates the hypotheses and raises the questions that in a preliminary way, there appears to be some relationships between aspects of physical and social environment and physical activity participation. However, future research is needed to refine and clarify this.

A decision aid to support informed choices about bowel cancer screening among adults with low education: randomised controlled trial

Objective To determine whether a decision aid designed for adults with low education and literacy can support informed choice and involvement in decisions about screening for bowel cancer. Design Randomised controlled trial. Setting Areas in New South Wales, Australia identified as socioeconomically disadvantaged (low education attainment, high unemployment, and unskilled occupations). Participants 572 adults aged between 55 and 64 with low educational attainment, eligible for bowel cancer screening. Intervention Patient decision aid comprising a paper based interactive booklet (with and without a question prompt list) and a DVD, presenting quantitative risk information on the possible outcomes of screening using faecal occult blood testing compared with no testing. The control group received standard information developed for the Australian national bowel screening programme. All materials and a faecal occult blood test kit were posted directly to people’s homes. Main outcome measures Informed choice (adequate knowledge and consistency between attitudes and screening behaviour) and preferences for involvement in screening decisions. Results Participants who received the decision aid showed higher levels of knowledge than the controls; the mean score (maximum score 12) for the decision aid group was 6.50 (95% confidence interval 6.15 to 6.84) and for the control group was 4.10 (3.85 to 4.36; P<0.001). Attitudes towards screening were less positive in the decision aid group, with 51% of the participants expressing favourable attitudes compared with 65% of participants in the control group (14% difference, 95% confidence interval 5% to 23%; P=0.002). The participation rate for screening was reduced in the decision aid group: completion of faecal occult blood testing was 59% v 75% in the control group (16% difference, 8% to 24%; P=0.001). The decision aid increased the proportion of participants who made an informed choice, from 12% in the control group to 34% in the decision aid group (22% difference, 15% to 29%; P<0.001). More participants in the decision aid group had no decisional conflict about the screening decision compared with the controls (51% v 38%; P=0.02). The groups did not differ for general anxiety or worry about bowel cancer. Conclusions Tailored decision support information can be effective in supporting informed choices and greater involvement in decisions about faecal occult blood testing among adults with low levels of education, without increasing anxiety or worry about developing bowel cancer. Using a decision aid to make an informed choice may, however, lead to lower uptake of screening. Trial registration ClinicalTrials.gov NCT00765869 and Australian New Zealand Clinical Trials Registry 12608000011381.

Defining and measuring health literacy: what can we learn from literacy studies?

Previous contributions to this series of editorials and otherrecent papers have highlighted the growth in interest inhealth literacy, as well as continuing debate about its def-inition, measurement and importance (Kickbusch 2009;Wills 2009; Abel 2008; Nutbeam 2008; Coulter and Ellins2007). In further advancing these debates there is much tobe gained from an appraisal of the underlying concept ofliteracy.Literacy is an important but complex concept. Generallyit is acknowledged as having two distinctive elements:those that are task-based, and those that are skill-based(National Assessment of Adult Literacy 2003). Task-basedliteracy focuses on the extent to which a person can per-form key literacy tasks such as read a basic text and write asimple statement. Skill-based literacy focuses on theknowledge and skills an adult must possess in order toperform these tasks. These skills range from basic, word-level skills (such as recognising words) to higher levelskills (such as drawing appropriate inferences from con-tinuous text).It follows that literacy can be measured in absoluteterms by distinguishing between those who can read andwrite basic text and those who cannot, and in relative termsby assessing the skill differences between adults who areable to perform relatively challenging literacy tasks andthose who are not.The reason why we care so much about literacy is thateven the most basic functional literacy skills enable peopleto better develop their knowledge and improve the poten-tial to achieve personal goals, and through this toparticipate more fully in society, both economically andsocially. Given this background, it is not surprising to findthat literacy levels in a population are associated bothdirectly and indirectly with a range of health outcomes.Low literacy is often linked to poor socio-economic cir-cumstances, and in turn with adverse effects on health thatare independent of other risk factors (Jahan 2008). This isespecially the case in the relationship between female lit-eracy and maternal and child health outcomes (Schell et al.2007). People with poor literacy tend to be less responsiveto health education, less likely to use disease preventionservices, and to successfully manage chronic disease(Dewalt et al. 2004).Responding to low levels of literacy in a populationinvolves improving access to effective school education,and providing adult literacy programs for those in need.Achieving high levels of literacy in a population is not onlya vital development goal, but will also produce substantialpublic health benefits.To better understand health literacy as a distinct concept,it is helpful to delve into current discourse on different‘‘literacies’’, recognising that literacy is both content andcontext specific. This is especially the case in relation to‘‘new literacies’’ emerging in response to new informationtechnologies (Coiro 2003), and context-specific literaciessuch as media literacy and financial literacy (Primack andHobbs 2009; Kozup and Hogarth 2008). This furtherrefinement in the concept reflects the fact that individuals

Evaluation of two school smoking education programmes under normal classroom conditions.

OBJECTIVES--To assess the effectiveness of two school based smoking education projects in delaying onset of smoking behaviour and in improving health knowledge, beliefs, and values. DESIGN--Cluster randomised controlled trial of two projects taught under normal classroom conditions. Schools were allocated to one of four groups to receive the family smoking education project (FSE); the smoking and me project (SAM); both projects in sequence (FSE/SAM); or no intervention at all. SETTING--39 schools in Wales and England matched for size and catchment profile. SUBJECTS--All first year pupils in the schools were included and were assessed on three occasions (4538 before teaching (1988), 3930 immediately after teaching (1989), 3786 at one year follow up (1990)). MAIN OUTCOME MEASURES--Self reported smoking behaviour (backed by saliva sample) and change in relevant health knowledge, beliefs, and values. RESULTS--No consistent significant differences in smoking behaviour, health knowledge, beliefs, or values were found between the four groups. For never smokers at baseline the rate of remaining never smokers in 1990 was 74% (594/804) in the control group, 65% (455/704) in the FSE group, 70% (440/625) in the SAM group, and 69% (549/791) in the FSE/SAM group (chi 2adj = 6.1, df = 3, p = 0.1). Knowledge about effects of smoking rose in all groups from a mean score of 5.4 in 1988 to 6.4 in 1989 and 6.5 in 1990. CONCLUSIONS--More comprehensive interventions than school health education alone will be needed to reduce teenage smoking. Other measures including further restrictions on access to cigarettes and on the promotion of tobacco products need to be considered. Further research will be needed to develop effective school based health education projects, which should be formally field tested under normal conditions before widespread dissemination.

Schools for health, education and development: a call for action

In 2007, the World Health Organization, together with United Nations and international organization as well as experts, met to draw upon existing evidence and practical experience from regions, countries and individual schools in promoting health through schools. The goal of the meeting was to identify current and emerging global factors affecting schools, and to help them respond more effectively to health, education and development opportunities. At the meeting, a Statement was developed describing effective approaches and strategies that can be adopted by schools to promote health, education and development. Five key challenges were identified. These described the need to continue building evidence and capturing practical experience in school health; the importance of improving implementation processes to ensure optimal transfer of evidence into practice; the need to alleviating social and economic disadvantage in access to and successful completion of school education; the opportunity to harness media influences for positive benefit, and the continuing challenge to improve partnerships among different sectors and organizations. The participants also identified a range of actions needed to respond to these challenges, highlighting the need for action by local school communities, governments and international organizations to invest in quality education, and to increase participation of children and young people in school education. This paper describes the rationale for and process of the meeting and the development of the Statement and outlines some of the most immediate efforts made to implement the actions identified in the Statement. It also suggests further joint actions required for the implementation of the Statement.

Effects of the Heartbeat Wales programme over five years on behavioural risks for cardiovascular disease: quasi-experimental comparison of results from Wales and a matched reference area

Abstract Objective: To assess the net 5 year effects of intervention of a community based demonstration project, the Heartbeat Wales programme, on modifiable behavioural risks for prevention of cardiovascular disease. Design and setting: Quasi-experimental design comparing results from two independent cross sectional population surveys conducted in 1985 and 1990 in Wales and a matched reference area in north east England. Subjects: Random, stratified samples of people aged 18-64 years (18 538 in 1985 and 13 045 in 1990) in Wales and in north east England (1483 and 4534, respectively). Intervention: A coordinated range of activities for heart health promotion in Wales entailing public education campaigns along with supportive policy and infrastructure change. In the reference area no additional community heart health promotion was planned, though considerable activity did take place, “contaminating” the reference area. Main outcome measures: Fifteen self reported behavioural indicators relating to dietary choice, smoking, frequency of exercise, and weight. Results: Positive changes (for health) in behavioural outcomes were observed among the population in Wales, including a reduction in reported smoking prevalence and improvements in dietary choice. There was no net intervention effect for the programme over and above observed change in the reference area. Conclusions: No definite conclusions can be drawn concerning the efficacy of the programme in terms of behavioural outcomes. With hindsight, the difficulties of evaluating such a complex multifaceted intervention were underestimated. Further debate on the most appropriate methods for assessing the effectiveness of community based health promotion programmes is called for. Key messages Heartbeat Wales was set up in 1985 as a community based programme to demonstrate risk reduction for cardiovascular disease Important changes were observed in modifiable risks for cardiovascular disease in Wales between 1985 and 1990 There was an unexpectedly rapid uptake of heart health promotion activity in the reference area No net intervention effects were found for the programme over and above changes in the reference area Improvements in methods of evaluation for community based health promotion programmes are required

Prevalence and associations of limited health literacy in chronic kidney disease: a systematic review

BACKGROUND Health literacy (HL) is important in chronic disease. This review aimed to evaluate the literature evidence on prevalence and associations of limited HL in chronic kidney disease (CKD). METHODS Seven databases were searched using terms for CKD and HL. Studies were included that ascertained the prevalence of limited HL using a validated tool in adults with CKD of any stage. The primary outcome was an objectively measured prevalence of limited HL in a population with CKD. The secondary outcome was associations of limited HL. Two reviewers assessed study inclusion and quality. Prevalence values were combined using a random-effect model to give overall prevalence. RESULTS Eighty-two studies were identified from searching, of which six met the inclusion criteria. The total number of people in all studies was 1405. Five studies were in dialysis or transplant populations, and all were from the USA. There was a significant heterogeneity in the prevalence of limited HL [9-32% (median 25%, inter-quartile range 16%)]. The pooled prevalence of limited HL in all studies was 22.7% (95% confidence interval 20.6-24.8%), but study heterogeneity limited the generalizability of this combined prevalence. The review identified associations between limited HL and socio-economic factors (lower education attainment, lower income), and certain process and outcome measures (lower likelihood of referral for transplant, higher mortality). CONCLUSIONS Limited HL is common among people with CKD and independently associated with socio-economic factors and health outcomes. It may represent an important determinant of inequality in CKD.

Evaluation in health education. A review of progress, possibilities, and problems.

Accepted for publication November 1989 The quality of evaluation in health education has been an important obstacle to better interventions, and wider acknowledgement of the importance of health education in improving public health. In the past, the urgency of immediate health problems, the practical orientation of health educators, and the complex nature of evaluation in health education have usually meant that interventions were established on the basis of limited research, and with little or no consideration given to the need to evaluate. Progress in evaluation has been painfully slow. In the past two decades greater attention has been given to the need to evaluate, particularly in the United States, and there has been a corresponding development in the quality and range of examples of well evaluated health education projects and programmes. This paper has been developed on a review of the growing literature on the subject of evaluation in health education, and illustrates key issues with examples from a range of evaluated programmes. A framework for evaluating health education programmes is proposed and suggestions are made for improved health education research.

Addressing health literacy in patient decision aids.

BackgroundEffective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations.MethodsWe reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.ResultsAim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.ConclusionLower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients.

Asthma, Health Behaviors, Social Adjustment, and Psychosomatic Symptoms in Adolescence

The association of health behaviour, indicators of social adjustment, and psychosomatic symptoms with diagnosed asthma was assessed in a community-based sample of 4550 adolescents in South Western Sydney, Australia. The results of this survey found an asthma prevalence among 11-15-year-olds of 17.5%, being consistent with previous studies. Tobacco use and alcohol consumption were higher among asthmatic compared with nonasthmatic adolescents. Asthmatics reported feeling lonely more often, having a number of negative social perceptions and feelings, and having more frequent psychosomatic symptoms. The findings of the study suggest that adolescents with asthma represent an important vulnerable group of school children. Asthma education may need a greater life-style change focus, besides asthma self-management training.