Language and framing as determinants of the predominance of behavioural health promotion: an Australian view.

The language used in health promotion warrants attention as it shapes how health promotion is understood, constraining or opening up possibilities for action. The 2016 Shanghai Declaration and the 1986 Ottawa Charter for Health Promotion call for comprehensive approaches which include policy and environmental changes. Yet many health promotion programmes in Australia continue to focus on informational and/or behavioural strategies, and there is a contemporary tendency for such programmes to be described as 'sending messages'. This paper uses frame analysis to discuss the role of language, and specifically language that frames health promotion as sending messages, in contributing to and reinforcing the predominance of informational and/or behavioural strategies. It argues such 'message' language helps to set a pattern in which informational and/or behavioural strategies are assumed to be the primary goal and extent of health promotion; rather than one component of a comprehensive, multi-strategic approach. It discusses how frames can be 'taken for granted' and ways in which such frames can be challenged and broadened. It argues that the message frame and associated behavioural framings set narrow boundaries for health promotion, contributing to the continuation of health inequities. These frames can also displace the language of the Ottawa Charter, which has capacity to reframe health issues socio-ecologically and include collective strategies. The paper concludes that a first step (of the many needed) towards applying the Charter's approach and multi-level, multi-strategic framework is to use the innovative vocabulary it offers. The words matter.

Applying the Ottawa Charter to inform health promotion programme design.

There is evidence of a correlation between adoption of the Ottawa Charter's framework of five action areas and health promotion programme effectiveness, but the Charter's framework has not been as fully implemented as hoped, nor is generally used by formal programme design models. In response, we aimed to translate the Charter's framework into a method to inform programme design. Our resulting design process uses detailed definitions of the Charter's action areas and evidence of predicted effectiveness to prompt greater consideration and use of the Charter's framework. We piloted the process by applying it to the design of four programmes of the Healthy Children's Initiative in New South Wales, Australia; refined the criteria via consensus; and made consensus decisions on the extent to which programme designs reflected the Charter's framework. The design process has broad potential applicability to health promotion programmes; facilitating greater use of the Ottawa Charter framework, which evidence indicates can increase programme effectiveness.

Health promotion and secondary prevention: response to Milat, O'Hara and Develin.

This paper responds to a recent HPJA article by Milat, O'Hara and Develin, which called for health promotion practitioners to be more closely involved in secondary prevention of Type 2 diabetes. It considers the resources currently available to health promotion in Australia, and examines and critiques the terminology of prevention used by Milat et al. The paper argues that Milat et al. give insufficient attention to the central role of social determinants of health in preventing Type 2 diabetes and in reducing health inequalities in the population. The paper agrees that increased health promotion involvement in Type 2 diabetes prevention programs may be beneficial, but argues that funds for such programs should come from the services that run them, not from the tiny health promotion budget. Given the current and projected scale of Type 2 diabetes in Australia, there is value in applying the concept of 'moving upstream' to this health issue. The paper concludes that, given current resources, the best use of Australia's specialist health promotion workforce is in 'upstream' programs that can benefit the whole population as well as those at risk of Type 2 diabetes.

Increasing active travel to school: are we on the right track? A cluster randomised controlled trial from Sydney, Australia.

OBJECTIVE: To evaluate the effectiveness of a program to increase walking to and from school. DESIGN: A cluster randomised controlled trial. SETTING: 24 primary public schools in inner west Sydney, Australia. PARTICIPANTS: 1996 students aged 10-12 years and their parents. INTERVENTION: A two-year multi-component program included classroom activities, development of school Travel Access Guides, parent newsletters and improving environments with local councils. MEASURES: Two measures were used: a survey completed by students on how they travelled to and from school over five days, and a survey completed by their parents on how their child travelled to and from school in a usual week. RESULTS: The percentage of students who walked to and from school increased in both the intervention and control schools. Data from parent surveys found that 28.8% of students in the intervention group increased their walking, compared with 19% in the control group (a net increase of 9.8%, p=0.05). However this effect was not evident in the student data. CONCLUSION: The study produced a mixed result, with a high variation in travel patterns from school to school. Intervention research should address the complexity of multiple factors influencing student travel to school with a focus on changing local environments and parents' travel to work.

Factors associated with children being driven to school: implications for walk to school programs.

In this study, we examined factors associated with children being driven to school. Participants were 1603 students (aged 9-11 years) and their parents from 24 public primary schools in inner western Sydney, Australia. Students recorded their modes of travel to and from school for 5 days in a student survey. Parents recorded their demographic data, their attitudes to travel, and their modes of travel to work, using a self-administered survey. An analysis of the two linked data sets found that 41% of students travelled by car to or from school for more than 5 trips per week. Almost a third (32%) of students walked all the way. Only 1% of students rode a bike and 22% used more than one mode of travel. Of those who were driven, 29% lived less than 1 km and a further 18% lived between 1 and 1.5 km from school. Factors associated with car travel (after adjusting for other potential confounders) were mode of parents' travel to work, parent attitudes, number of cars in the household, and distance from home to school. To be effective, walk to school programs need to address the link between parent journey to work and student journey to school.

Building an evidence base for community health: a review of the quality of program evaluations.

An assessment of the quality of program evaluations conducted in South Australian community health services investigated how effective evaluation reporting is in producing an evidence base for community health. Evaluation reports were assessed by a team of reviewers. Practitioner workshops allowed an understanding of the uses of evaluation and what promotes or acts as a barrier to undertaking evaluations. Community health services do undertake a good deal of evaluation. However, reports were not generally explicit in dealing with the principles that underpin community health. Few engaged with program theory or rationale. Typically, reports were of short-term projects with uncertain futures so there may seem little point in considering issues of long-term health outcomes and transferability to other settings. The most important issue from our study is the lack of investment in applied health services research of the sort that will be required to produce the evidence for practice that policy makers desire. The current lack of evidence for community health reflects failure of the system to invest in research and evaluation that is adequately resourced and designed for complex community settings.