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Case studies on health promotion initiatives from the Nordic countries

Compiled by Leif Edvard Aarø

Leading health promotion into the next century
4th International Conference on Health Promotion
Jakarta, Indonesia, 21-25 July 1997

Publication Date: 29 December 1998

Aarø LE, Case Studies On Health Promotion Initiatives From The Nordic Countries. Internet Journal of Health Promotion, 1998. URL: ijhp-articles/1998/15/index.htm.

Introduction

The northernmost countries in Europe (Denmark, Finland, the Faeroey Islands, Greenland, Iceland, Norway, Sweden) are democracies with relatively well developed health care systems and education for all. Human rights are to a large extent respected by the governments. In a global context these countries must be characterized as affluent. Fundamental prerequisites for health (peace, housing, education, food, income, material resources) are present for most people. A long-lasting struggle for women's rights has brought more women into paid jobs and into more influential positions in the Nordic societies than in most other parts of the world. Socioeconomic equity has been a high priority issue in Nordic politics, particularly during the period after the Second World War. Still it is obvious that as far as women's rights and the situation of underpriviledged groups is concerned, much remains to be done.

In the Nordic countries, the principles of the Ottawa Charter for Health Promotion (World Health Organization, 1995) are widely accepted. When the Ottawa Charter was developed, it fitted well with current thoughts and ideologies in the field of health promotion and disease prevention in the Nordic countries, and the Nordic countries have long traditions for disease prevention and health promotion strategies and practices which have much in common with the principles advocated by the health promotion movement. Community based health promotion programmes are rather common, and so is combined use of legislation, price policies, interventions in the physical environment and health education (orchestration). Voluntary organizations have long traditions and considerable experience in mobilizing lay people for health.

Still the Nordic countries are confronted with serious challenges to the health of their populations. While the life expectancy for women at birth varies between 79.6 and 81.4 years in the other Nordic countries, it is only 77.9 for Danish women and 68.4 years for women in Greenland. Among men life expectancy at birth varies between 74.9 and 77.1 in the other Nordic countries, but is comparatively lower in Finland (72.8), the Faroe Islands (72.8), Denmark (72.6) and Greenland (60.7) (Nordic Council of Ministers, 1996) . The variation in life expectancy at birth is pronounced. This indicates that there is still a potential for improvements, at least for some countries.

Unemployment has repeatedly been shown to have an impact on health and mortality. In Iceland and Norway the enemplyment rates are 5.3 and 5.4 respectively. In Sweden and Denmark the unemployment rates are 7.8 and 8.0, while Finland has the highest unemployment rate among the Nordic countries (18.4) (Nordic Council of Ministers, 1986). From a public health perspective it is reasonable to conclude that In all Nordic countries unemployment is unacceptably high.

Coronary heart disease and cancer are major causes of premature deaths in all the Nordic countries. Presently the insidence of coronary heart disease is decreasing markedly in most of the Nordic countries, and the decrease is particularly consistent and pronounced for men. This trend is parallelled by a long-term decrease in smoking and a reduction in the intake of fat.

The change in overall death rates from malignant neoplasms is less consistent. Although a decreasing trend is observed in some age groups, particularly among 45-54 year old men, increasing death rates are observed among men in other age groups and among women. Injury rates in homes, traffic and other arenas are still high.

A white paper on health promotion was presented to the Norwegian Parliament in 1993. It was proposed by the Ministry of Health and Social Affairs and accepted by the Parliament (Stortinget) that effects on mortality should not be the only criterion underlying priorities in health promotion and disease prevention. Priority should also ge given to health problems that people have to live with, which reduce quality of life, and which often represent heavy burdens to the health care sector. Among the new priority areas are (i) psychosocial and mental health problems, (ii) asthma, allergies and the quality of inhouse air as well as (iii) the prevention of injuries and (iv) musculo-sceletal diseases.

Resources allocated for disease prevention and health promotion purposes are limited. In some of the Nordic countries, preventive and health promotion services and activities are not adequately organized and coordinated. Although the ideas presented in the Ottawa Charter and further elaborated at the Adelaide and Sundsvall conferences (World Health Organization, 1992) are widely accepted in the Nordic countries, the funding, organization, cross- sectoral cooperation and practices among health and other personnel are in many cases inadequate.

The Nordic countries have strong traditions for cooperation with developing countries. Through GO's such as Danida, Finida, Norad, and Sida, as well as through NGO's, substantial resources have been channelled into bilateral as well as multilateral cooperation and developmental projects. There has been an ongoing debate regarding the policies in the field of aid to developing countries, and due to the present economic recession the budgets for developmental aid have been decreasing in most of the Nordic countries.

Selection of case studies for the Jakarta conference

For the Jakarta conference seven case studies from the Nordic countries have been selected. Two of the case studies are focusing on projects carried out in developing countries, while five cases are based on projects carried out in the Nordic countries.

Case study #1: Promoting healthy school meals for Norwegian children (click to read full case study)

Norway was among the first countries to develop a nutrition and health policy. The consumption of fat (particularly saturated fat), which had been steadily increasing for a long time, levelled off in the seventies, and decreased markedly for some years. This was also the case with smoking, and the coronary heart disease mortality rates have decreased correspondingly.

Surveys conducted in the late 1980s and early 1990s indicated that a substantial group of pupils in primary and secondary schools in Norway did not bring food from home, that the time allocated for school meals often was too short, and that 90% of the pupils were left unattended to eat in their classrooms. The Norwegian National Nutrition Council decided to set up National guidelines for school meals. Furthermore the Council decided to promote the application of these guidelines in schools. The promotional strategy developed consisted of distribution of material, economic incentives for schools to develop appropriate models for how to organize the school meal, a national campaign to promote luch bags among pupils, and the promotion of legislation.

The trend towards fewer students eating lunch every day has been reversed. This case demonstrates the favourable effects of combining several approcahes simultaneously. Through a combination of health education, legislation and through developing models for how to develop a supportive school environment, substantial progress has been made.

Case study #2: From control policy to comprehensive family planning: success stories from Finland (click to read full case study)

In the 1960s, Finland adopted a comprehensive family planning strategy. The focus was moved from control of abortion to prevention of its main cause, the unintended pregnancy, and to elimination of the consequences of unsafe abortions. A new abortion law came into force in 1970. An induced abortion is available on medical, eugenic and socioeconomic grounds.

In the 1990s, several indicators show remarkable improvements in reproductive health. The teenage pregnancy and abortion rates are less than half compared to the rates in the mid-1970s. Compared to other countries, the incidences of sexually transmitted diseases are low. There are no signs of increasing unintended effects like promiscuity or that abortion replaces use of contraceptive methods. The Finnish experience clearly speaks against the argument that a liberal approach to sex education and abortion care as such increases adolescent sexual activity. The keys to this success were: (1) combination of the public health and preventive medicine approaches, (2) well functioning infrastructure of the health and education sector, (3) skilful guidance by the national health authorities, and (4) professional attitudes of nurses and doctors. Unintended pregnancies were primarily understood as a challenge which could be met through education, professional counselling and basic services.

In the 1980s, when the family planning services and safe abortion care were arranged and available, the emphasis moved from the prevention of unintended pregnancies towards more general issues of sexuality. This decade was the time of research, training, sex education, and programmes tailored to the needs of adolescents. Prevention of the HIV infection was integrated into more comprehensive sex education and family planning programmes.

In the 1990s, due to the contextual changes in the society and changes in the health services, revision of the family planning services and strengthening of the skills of professionals became again topical issues. The major goal of the 'Family Planning 2000' -program, launched in 1994, is to apply the lessons from health promotion developments to family planning: a move from national guidance to coalitions at municipal and regional levels, and to action oriented research and development projects at local level. In addition, the key tasks are (1) strengthening counselling skills of key professionals (teachers, social workers, nurses, doctors, etc.) in sexual issues; (2) updating of evidence based clinical guidelines; (3) ensuring quality of services, and (4) strengthening male involvement in family planning.

One of the objectives of the Ottawa Charter, reorientation of health personnel has been one of the cornerstones of the Finnish strategy.

Case study #3: Everybody is needed - Södra Skaraborg, Sweden (click to read full case study)

The mobilization of unemplyed people for health is an example of a highly innovative approach to the promotion of health among unemplyed groups. The initiative was made by a broad coalition of administrators and politicians. It has been shown that psychosocial aspects of health has been markedly improved among those involved. Furthermore it has been demonstrated that unemployed people represent a resource. Present legislation and regulation in many affluent societies contributes to making unemployed people pasive victims of conditions and processes which seem to be an inevitable part of development in the economies of modern societies; the production of unemployment. This cases illustrates the importance of mobilizing people for health.

Case study #4: The promotion of oral health among Danes (click to read full case study)

The basic principles and main features of Danish health policies are equal and free access for all to most health care measures. However, in 1972 only 50 per cent of the schoolchildren received a regular, free oral health care service, and only 1 per cent of Danish children were caries free. Furhtermore, there were big gaps in prevention and treatment of oral health between children living in the big cities and children living in the countryside.

In 1972 the Danish parliament decided to establish a Child Oral Health Care Act. The act required municipalities to establish child oral health care clinics for the treatment of all children under the age of 16. It was stated that oral health care must include regular examination and treatment of each child, general preventive measures including provision of information, and individual preventive measures including counselling of each child and his/her parents. In its section on preventive activities, the act directly requires establishment of staffs within the public health sector to actively perform public health promotion and preventive tasks. This was the first time in the Danish public health policy that such tasks were decreed by law.

The number of denstists employed by the municipalities increased by 50 per cent from 1972 to 1995, and the number of children treated pr. dentist increased by 160 per cent from 1974 1995. The expenditure on child health care has remained at a lower level than price increases in general. In 1996 71 per cent of the 12 year old children were caries free. In the development of health promotion and disease prevention, the professionals and the associations are skilful in presenting arguments, but decisions in the political arena are necessary in order to influence atction and ensure progress. Since the society and the context continuously change, producing new financial conditions and new disease and health challenges, the health promotion effort, with its approaches and methods, has to change and develop continuously.

Case study #5: Interventions for smoke-free schools. From information deficit to social influence (click to read full case study)

 The first generation of school-based interventions against smoking were based on the assumption that informing about the health consequences of smoking would lead to less smoking. The second generation were the "affective" programmes. None of these models proved effective. Interventions based on the social influence model and the more comprehensive programmes which have been designed and evaluated during the eighties and nineties have, however, proven to be more effective. A new social influence programme has been designed and is presently administered by the Norwegian Cancer Society. A questionnaire-based data collection was carried out before the first intervention, and is thereafter administered annually in three different intervention groups (N=3300) as well as among students in a control group (n=1100). The students were 13 years old at the onset of the programme. The teaching programme covers all three grades of secondary high school. Six months after baseline, the recruitment of smokers has been significantly lower under the optimal intervention (including training courses for teachers and involving parents) (8.2 per cent) compared with the control group (2.4 per cent). After 18 months the recruitment rate is still 40 per cent lower under in the optimal intervention group compared to the control group. The results for the other intervention groups are less convincing. These findings are confirmed when using multiple logistic regression and controlling for smoking habits and gender at baseline. This case study illustrates the benefits of basing our interventions on the best available scientific evidence.

Case study #6: The prevention of night blindness in Bangladesh (click to read full case study)

Night blindness caused by vitamin A deficiency is a threat to children’s health in several developing countries. One such country is Banlgadesh, where almost 100 children go blind every day. Two strategies are available: (a) The distribution of vitamine A capsules and (b) health education aiming at promoting the growing and use of leafy green vegetables and yellow fruits. Center for International Health at the University of Bergen has evaluated a large-scale health education programme carried out in communities in northwestern Banlgadesh in order to examine possible effects. Results indicate that it is possible to reduce the incidence of night blindness by 50 per cent through health education. Growing of vegetables is possible even for underpriviledged segments of the population, and is obviously a more sustainable strategy than making eye health dependent of the distributrion of vitamin A capsules (a strategy presumably preferred by drug industries). The evaluation of the programme has demonstrated the importance of using communication channels which reach the target groups through direct personal contact. Furthermore it has demonstrated the importance of respecting and taking into account local traditions and culture.

Case study #7: Health policy development in Costa Rica (click to read full case study)

Costa Rica is a poor country which has achieved a remarkable success in the field of health promotion. The present case study describes the health problems, the material and social obstacles to development, and points at several prerequisites for the favourable development in this small, democratic nation. In contrast to many other countries Costa Rica has shown that it is possible to create a coalition between politicians, professionals, researchers and the people. This has enabled the development of an evidence-based public health, which guides policy-makers and professionals involved in health programs. Moreover, given an democratic government it is also possible to maintain a committment to equity even in periods of economic recession and recovery. Furthermore, an individual, social, professional and political (governmental) responsibility or justice is possible to combine for the health development in a country. Visions and missions can successfully be fullfilled given that priorities are made and that knowledge and skills are put into use for the benefit of all. The Case of Costa Rica shows how democracy and a policy aiming at achieving equity contributes to the promotion of health.

Conclusion

The case studies presented in more detail below contribute to illustrating in the practical and real world the usefulness and importance of several of the principles of health promotion. However, health promotion is more than applying sound principles in concrete interventions and actions. Health promotion is more than developing personal skills and reorienting health personnel. Health promotion has implications across sectors and for arenas beyond the health care services and health education. The Ottawa charter points to the importance of a healthy public policy, and it points to the importance of a number of societal prerequisites for health. Among the prerequisites listed in the charter are social justice and equity.

Throughout the world many regimes through their policies and practices are in conflict with these fundamental prerequisites for health. Democracy is not respected. The labour force (child workers included) is exploited. Inequity and injustice is tolerated. The rights of minorities are violated. Health promotion has to be based and built on a set of prerequisites which include not only social justice and equity, but also democracy, respect of human rights and involvement from all groups, under-priviledged groups in particular.

References

1. Ministry of Health and Social Affairs (1993). Challenges in health promotion. White paper to the Norwegian Storting (Parliament) 1992-93. Oslo: Ministry of Health and Social Affairs.
2. Nordic Council of Ministers (1996). Yearbook of Nordic Statistics 1996. Copenhagen: Nordic Council of Ministers.
3. World Health Organization (1995). Health promotion. Ottawa charter. Geneva: World Health Organization (WHO/HPR/HEP/95.1).
4. World Health Organization (1992). Sundsvall statement on supportive environments for health. Geneva: World Health Organization (WHO/HED/92.1).

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