Rainbows over the world's public health: determinants of health models in the past, present, and future.

The need to visualise the complexity of the determinants of population health and their interactions inspired the development of the rainbow model. In this commentary we chronicle how variations of this model have emerged, including the initial models of Haglund and Svanström (1982), Dahlgren and Whitehead (1991), and the Östgöta model (2014), and we illustrate how these models have been influential in both public health and beyond. All these models have strong Nordic connections and are thus an important Nordic contribution to public health. Further, these models have underpinned and facilitated other examples of Nordic leadership in public health, including practical efforts to address health inequalities and design new health policy approaches.Apart from documenting the emergence of rainbow models and their wide range of contemporary uses, we examine a range of criticisms levelled at these models - including limitations in methodological development and in scope. We propose the time is ripe for an updated generic determinants of health model, one that elucidates and preserves the core value in older models, while recognising the developments that have occurred over the past decades in our understanding of the determinants of health. We conclude with an example of a generic model that fulfills the general purposes of a determinants of health model while maintaining the necessary scope for further adjustments to be made in the future, as well as adjustments to location or context-specific purposes, in education, research, health promotion and beyond.

Milestones in Nordic Health Promotion research.

Based on the storytelling tradition and analyses of conference material, this article provides an overview of the evolving Nordic Health Promotion Research Network (NHPRN) and its conferences over the last 20 years. The story goes from the planning of the first conference in Bergen, Norway, back in 1996 to the eighth conference in Jyväskylä, Finland, in 2016. There have been three phases of development. During the first phase, 1996-2007, the five first conferences were initiated and implemented by departments of public health in the Nordic countries. The World Health Organization (WHO) collaborative centres of Health Promotion in Bergen University and a group at Karolinska Institute, Department of Social Medicine, creating supportive environments for health in Stockholm played key roles in initiating and supporting NHPRN. During the second phase, 2007-2014, the network was strengthened and supported by the Nordic School of Public Health (NHV) in Gothenburg. The third phase started when NHV closed down in 2015 and networking activities were transferred to the European Office of WHO in Copenhagen. The Nordic Health Promotion Research Conference series has served several purposes and will continue to do so. They are important Nordic meeting places, stimulating Health Promotion research, as well as explicitly managing ongoing concerns in the international Health Promotion community. This is reflected in the shift of foci over time. The content of the conferences has been highly responsive to whatever challenges are particularly relevant at different points in time, while also contributing to developing Health Promotion as a discipline, given that every conference has built on the previous ones.

Does social capital travel? Influences on the life satisfaction of young people living in England and Spain.

BACKGROUND: This study used a social capital framework to examine the relationship between a set of potential protective ('health assets') factors and the wellbeing of 15 year adolescents living in Spain and England. The overall purpose of the study was to compare the consistency of these relationships between countries and to investigate their respective relative importance. METHODS: Data were drawn from the 2002, English and Spanish components of the WHO Health Behaviour in School-Aged Children (HBSC) survey A total of 3,591 respondents (1884, Spain; 1707, England) aged 15, drawn from random samples of students in 215 and 80 schools respectively were included in the study. A series of univariate, bivariate and multivariate (general linear modelling and decision tree) analyses were used to establish the relationships. RESULTS: Results showed that the wellbeing of Spanish and English adolescents is similar and good. Three measures of social capital and 2 measures of social support were found to be important factors in the general linear model. Namely, family autonomy and control; family and school sense of belonging; and social support at home and school. However, there were differences in how the sub components of social capital manifest themselves in each country--feelings of autonomy of control, were more important in England and social support factors in Spain. CONCLUSIONS: There is some evidence to suggest that social capital (and its related concept of social support) do travel and are applicable to young people living in Spain and England. Given the different constellation of assets found in each country, it is not possible to define exactly the precise formula for applying social capital across cultures. This should more appropriately be defined at the programme planning stage.

Readability of online health information: implications for health literacy.

Accessibility is one of six quality criteria articulated by the European Commission in its code of conduct for health websites. Readability plays an integral part in determining a website's accessibility. Health information that is hard to read may remain inaccessible to people with low health literacy. This study aimed to calculate the readability of websites on various causes of disease. The names of 22 health conditions were entered into five search engines, and the readability of the first 10 results for each search were evaluated using Gunning FOG, SMOG, Flesch-Kincaid and Flesch Reading Ease tests (n=352). Readability was stratified and assessed by search term, search term complexity, top-level domain and paragraph position. The mean reading grade was 12.30, and the mean FRE was 46.08, scores considered 'difficult'. Websites on certain topics were found to be even harder to read than average. Where conditions had multiple names, searching for the simplest one led to the most readable results. Websites with .gov and .nhs TLDs were the most readable while .edu sites were the least. Within texts, a trend of increasing difficulty was found with concluding paragraphs being the hardest to read. It was also found that some of the most frequent search results (such as Wikipedia pages) were amongst the hardest to read. Health professionals, with the help of public and specialised libraries, need to create and direct patients towards high-quality, plain language health information in multiple languages.

Health promoting settings in primary health care - "hälsotorg": an implementation analysis.

BACKGROUND: Sweden, like many other western countries, faces increasing rates of lifestyle related diseases and corresponding rise in costs for health care. To meet these challenges, a number of efforts have been introduced at different societal levels. One such effort is "Hälsotorg" (HS). HS is a new health promotion setting that emerged in collaboration between the Swedish County Councils and Apoteket AB, a state-owned pharmacy company. HS's overall aim was to improve population health and facilitate inhabitants' responsibility for self-care. A new National Public Health Policy, introduced in 2008, emphasizes more focus on individual's needs and responsibility as well as strong need for county councils to provide supportive environment for individual-centred health services and increased health literacy among the population. In light of this policy, there is a need to examine existing settings that can provide supportive environment for individuals at community level. The aim of this study was to explore HS's policy implementation at local level and analyse HS's activities, in order to provide a deeper understanding of HS's potential as a health promoting setting. METHODS: Materials included a survey and key documents related to the development and nature of HS on local and national levels. A policy analysis inspired by Walt and Gilson was used in data analysis. In addition, an analysis using the principles of health promotion in relation to HS policy process and activities was also carried out. RESULTS: The analysis illuminated strengths and weaknesses in the policy process, its actors, contextual factors and activities. The health communication approach in the analysed documents contained health promoting intentions but the health promoting approach corresponding to a health promoting setting was neither apparent nor shared among the stakeholders. This influenced the interpretation and implementation of HS negatively. CONCLUSIONS: The analysis indicates that HS has potential to be a valuable health promotion setting for both population and individuals, given the strong intentions for a health and empowerment building approach that is expressed in the documents. However, for a more sustainable implementation of HS, there is need for an in- depth understanding of the health promotion approach among HS stakeholders.

The requirements and challenges in preventing of road traffic injury in Iran. A qualitative study.

BACKGROUND: Road traffic injuries (RTIs) are a major public health problem, especially in low- and middle-income countries. Among middle-income countries, Iran has one of the highest mortality rates from RTIs. Action is critical to combat this major public health problem. Stakeholders involved in RTI control are of key importance and their perceptions of barriers and facilitators are a vital source of knowledge. The aim of this study was to explore barriers to the prevention of RTIs and provide appropriate suggestions for prevention, based on the perceptions of stakeholders, victims and road-users as regards RTIs. METHODS: Thirty-eight semi-structured interviews were conducted with informants in the field of RTI prevention including: police officers; public health professionals; experts from the road administrators; representatives from the General Governor, the car industry, firefighters; experts from Emergency Medical Service and the Red Crescent; and some motorcyclists and car drivers as well as victims of RTIs. A qualitative approach using grounded theory method was employed to analyze the material gathered. RESULTS: The core variable was identified as "The lack of a system approach to road-user safety". The following barriers in relation to RTI prevention were identified as: human factors; transportation system; and organizational coordination. Suggestions for improvement included education (for the general public and targeted group training), more effective legislation, more rigorous law enforcement, improved engineering in road infrastructure, and an integrated organization to supervise and coordinate preventive activities. CONCLUSION: The major barriers identified in this study were human factors and efforts to change human behaviour were suggested by means of public education campaigns and stricter law enforcement. However, the lack of a system approach to RTI prevention was also an important concern. There is an urgent need for both an integrated system to coordinate RTI activities and prevention and a major change in stakeholders' attitudes towards RTI prevention. The focus of all activities should take place on road users' safety.

Traffic injury deaths in West Azarbaijan province of Iran: a cross-sectional interview-based study on victims' characteristics and pre-hospital care.

This study highlights the socio-demographics and death circumstances of victims of fatal road traffic injuries (RTIs) in one Iranian province. A representative sample of cases was selected from a national register and interviews were conducted with the victims' family members. The study shows that there is a strong association between victim attributes (e.g. sex, age, occupation, education or marital status) and category of road-user. Although men are over-represented in all categories, women die above all as car passengers or pedestrians. Deaths of vulnerable road-users are more frequent among the younger and older age groups. Two-thirds of all deaths occurred before arrival at the hospital and 11% of the victims received ambulance transport. The patterns of fatal RTIs observed in the province differ somewhat from the rest of Iran and other low- and middle-income countries. Not only pre- but also post-crash counter-measures could help save lives in the region.

Social capital does matter for adolescent health: evidence from the English HBSC study.

Social capital has grown out of the recognition that health-related behaviours are shaped and constrained by a range of social and community contexts and that the ways in which an individual relates to social networks and communities has important effects on their health and well-being. Given the strong and complex inequalities that exist in adolescent health at both the national and international levels, social capital, acting a protective factor (or asset), may help reduce poor outcomes. The aim of this study was to measure and assess the relative importance of a range of social indicators representing the different domains of social capital on the health, wellbeing and health-related behaviours of young people. The study population was a random sample of 6425 school children aged 11-15 years old in 80 schools in England. Data were collected by a standardized questionnaire under supervised conditions in the classroom developed as part of the WHO Health Behaviour in School Aged Children (HBSC) study. This study has shown that social capital matters for young people's health, statistically significant relationships were found between the range of social capital indicators and the health and health-related outcomes selected for study. For example, young people with a low sense of family belonging and low involvement in the neighbourhood were almost twice as likely to report poor health (OR = 1.87 and 1.96, respectively). Low involvement in the neighbourhood was also highly associated with low consumption of fruit (OR = 2.48) and vegetables (OR = 2.62). Overall, however the strength of associations found varied across health behaviours and indicators of social capital and this requires further examination.

Post-crash management of road traffic injury victims in Iran. Stakeholders' views on current barriers and potential facilitators.

BACKGROUND: Road traffic injuries are a major public health problem, especially in low- and middle-income countries. Post-crash management can play a significant role in minimizing crash consequences and saving lives. Iran has one of the highest mortality rates from road traffic injuries in the world. The present study attempts to fill the knowledge gap and explores stakeholders' perceptions of barriers to - and facilitators of - effective post-crash management in Iranian regions. METHODS: Thirty-six semi-structured interviews were conducted with medical services personnel, police officers, members of Red Crescent, firefighters, public-health professionals, road administrators; some road users and traffic injury victims. A qualitative approach using grounded theory method was employed to analyze the material gathered. RESULTS: The core variable was identified as "poor quality of post crash management". Barriers to effective post-crash management were identified as: involvement of laypeople; lack of coordination; inadequate pre-hospital services; shortcomings in infrastructure. Suggestions for laypeople included: 1) a public education campaign in first aid, the role of the emergency services, cooperation of the public at the crash site, and 2) target-group training for professional drivers, police officers and volunteers involved at the crash scene. An integrated trauma system and infrastructure improvement also is crucial to be considered for effective post-crash management. CONCLUSION: To sum up, it seems that the involvement of laypeople could be a key factor in making post-crash management more effective. But system improvements are also crucial, including the integration of the trauma system and its development in terms of human resources (staffing and training) and physical resources as well as the infrastructure development.

Estimating road traffic mortality more accurately: use of the capture-recapture method in the West Azarbaijan province of Iran.

The study estimates the rate of fatal road traffic injuries (RTIs) by population and road-users group in one Iranian province. The capture - recapture method was employed, using both the death register and the forensic medicine register over one year. They recorded totals of 669 and 665 RTIs respectively, giving a non-overlapping number of 897 cases. An estimate of 1018 fatalities occurred, at rates of 34 per 100,000 of the population for all road users aggregated, 10 per 100,000 for pedestrians and 25 per 100,000 for other road users. Coverage was somewhat better for victims less than 15 years of age, and also for males. The method showed 121 under-reported cases in both sources; however, it can help Iranian policy-makers to produce a good estimation of fatal RTIs number each year, when following up current RTIs-prevention programmes. Yet, given that each registry operates separately, optimum coverage will only be obtained when both sources are integrated and work together.

Leadership, organization and health at work: a case study of a Swedish industrial company.

The application of knowledge on organization and leadership is important for the promotion of health at workplace. The purpose of this article is to analyse the leadership and organization, including the organizational culture, of a Swedish industrial company in relation to the health of the employees. The leadership in this company has been oriented towards developing and actively promoting a culture and a structure of organization where the employees have a high degree of control over their work situation. According to the employees, this means extensive possibilities for personal development and responsibility, as well as good companionship, which makes them feel well at work. This is also supported by the low sickness rate of the company. The results indicate that the leadership and organization of this company may have been conducive to the health of the employees interviewed. However, the culture of personal responsibility and the structure of self-managed teams seemed to suit only those who were able to manage the demands of the company and adapt to that kind of organization. Therefore, the findings indicate that the specific context of the technology, the environment and the professional level of the employees need to be taken into consideration when analysing the relation between leadership, organization and health at work.

Implementation of a Health Impact Assessment (HIA) tool in a regional health organization in Sweden--a feasibility study.

During the last decade, Health Impact Assessment (HIA) has been discussed worldwide as being an important tool for the development of healthy public policy. In Sweden, the Swedish Federation of County Councils and the Swedish Association of Local Authorities have taken the initiative to and are responsible for the development of an HIA tool concerning proposed policy decisions at local and regional levels. The HIA tool was developed as three different templates to be adapted to local conditions and needs: the Health Question, the Health Matrix and the Health Impact Analysis. In this paper we present a feasibility study of the experiences of implementing this HIA tool at regional level in a Health Care District (SWHCD) of Stockholm County Council, based on an inductive approach and on principles of data triangulation. The main findings include the need for continuous revision of the HIA templates during the pilot period. The following factors were instrumental in successfully using the HIA tool in local policy making and management: political consensus, agreement between politicians and public officials on political intentions, a clear- cut decision from management, and offering an opportunity for training. Respondents felt that all public officials should use the HIA as part of their normal work routines. In conclusion, the HIA tool has to be locally adapted and the implementation process has to include close collaboration between politicians and public officials and be followed by continuing education, providing possibilities for a dialogue around the HIA tool, in order to ensure the quality of the instrument. Implications of the study are that the process of developing the tool has worked well but that the possible impacts of its use in this case remain an open question. However, this was not the focus of our study.