Perspectives in Public Health

Editorial

Health Literacy
Welcome to a New Year and a new look Perspectives. We would like to thank Patrick Keady for his enthusiasm and professionalism during the last year as deputy editor and we are delighted that Dr Rosalind Stanwell-Smith has agreed to take up the position from him. In the spirit of refreshing content we are introducing a new column entitled, Peep into Parliament and Beyond, sharing with readers the latest debates and government views that impact policy. Another exciting development is that three times a year we intend to write an Economic Social Research Council (ESRC) report, which will make the link between research and practice. With the public health lens on outcomes and evidence base, we hope that readers will be stimulated by the cutting edge of new research and the potential translation of this into frontline engagement. We would also like to welcome Dr Michael Popejoy from America who will be joining the International Advisory Board. Michael’s interests lie primarily in global public administration and public health policy initiatives in areas such as disaster preparedness and response as well as pandemic disease surveillance and interdiction. Lastly, I would like to take the opportunity to thank all our reviewers for their sterling effort last year in making the journal such a credible and robust publication, your commitment is much appreciated. Policy documents ask us to become ‘informed patients’, ‘engaged and active citizens’ and ‘empowered communities’. But most of us do not have the necessary skills to drive decisions for our health.1 Health literacy is therefore topical and important. With the increasing use of technology and the wealth of information available at the press of a button, the ability to decipher messages and make sense of them becomes ever more urgent. The ‘heal thyself’ mentality is rife particularly amongst men who tend to be reluctant to visit their GPs. Global access to knowledge is quick, easy and stress free. It is no wonder therefore that much health information is received this way. Health literacy as defined by Marshall et al. “is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” and debate within this issue of Perspectives centres on this inherent ability. However, information is only as good as the author. The credibility of some health advice and websites could be severely criticised as could some columns in newspapers. Access to good, reliable information is the cornerstone for informed decision making. The Ottawa Charter for health promotion states that: “health is created in the context of everyday life, where people live, love, work and play”.2 It follows therefore that we need health literacy skills, that also include the ability to judge the value of knowledge, in our capacity as citizens, consumers, and patients. Authors in this issue discuss the position of health literacy within the curriculum and the role of education in developing informed individuals. We surely also need to build professional health literacy, especially as in the new public health climate, confidence in the competency of frontline workers to provide accurate and consistent information is paramount. Health literacy has become a vibrant area of research and within the UK there is an active group, whose mission is to raise the profile of this topic especially as low health literacy may be a strong contributor to health inequalities.3 Perspectives provides a platform for comment and research and we thank Dr Selwyn Hodge for his thought provoking guest editorial. Heather Hartwell Honorary Editor References
1. Kickbusch I, Wait S, Maag D, McGuire P, Banks I, Navigating Health: The role of health literacy, 2006, Alliance for Health and the Future, International Longevity Centre-UK, London. Available from http://www.emhf.org/resource_images/NavigatingHealth_FINAL.pdf (last accessed 26/10/11) 2. The Ottawa Charter for Health Promotion, World Health Organization, 1986 3. For more information visit http://www.healthliteracy.org.uk (last accessed 26/10/11)

Nutrition labels need to be central
A US study has found that labels containing nutritional information should be placed in the centre of food packaging to ensure shoppers read the information. The study had 203 participants and used an eye-tracking device to find that the average consumer only reads the top part of a food content label. When the nutritional label was placed in the centre 61% read it, compared to 37% and 34% when the labels were on the left and right hand side. Knowledge of a food’s nutrients can influence consumers to make healthier purchases, and so the positioning of labels can have a substantial impact on public health. Source: Journal of the American Dietetic Association (2011), Vol 111 Issue 11, pp. 1704-1711

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News

The University of East London lead the way in the fight against MRSA
The University of east London (UeL) has made a breakthrough in the fight against a wide range of microbials, including MRsA and e.coli. The new range of substances is a series of molecules completely different from conventional antibiotics. Dr John George from the school of Health, sport and Bioscience, has made a bank of laboratory-produced molecules; all of these were tested to be successful in test tubes. These molecules have been shown to be far more effective than other similar molecules against bacteria, especially antibiotic-resistant strains and superbugs. The molecules also appear to have high safety levels, with very little toxicity (sideeffects) even at very high dosage. speaking in response to his findings, Dr George said: “For many years now, health professionals have been desperately trying to find something that will tackle the threat of MRsA. while it is too early to say whether this is the future in terms of fighting superbugs, I do believe it is a significant finding that warrants further investigation.” For more information: www.uel.ac.uk

Saving lives through changing behaviour
Fresh food, more exercise and no smoking. These are some of the choices we need to make in order to lead a healthy lifestyle, which is sustainable in the long term. The Royal society for Public Health (RsPH) has responded to the Government’s white Paper, by developing a suite of training programmes on behaviour change designed specifically to support health and wellbeing professionals to deliver these messages effectively as part of their behaviour change strategy. Rises in obesity, diabetes, heart disease and sexually transmitted infections (sTIs), alongside problems associated with unhealthy eating, drinking and smoking habits, have placed our health service under huge pressure. As many health conditions are both preventable and avoidable, we have a responsibility to ensure that we intervene and steer people towards healthier lifestyle choices. This not only positively impacts the wellbeing of the individual but also their communities. Preventing avoidable conditions is better for both the patient and the health service, but the approach differs depending on the time available, the skill of the individual and the nature of the contact. Professor Richard Parish, Chief executive of RsPH said: “It is our belief that spreading skills and knowledge in this area will have a direct effect on driving behaviour change and reducing health inequalities, resulting in healthier communities across the country.” For more information please email Gina Mohajer, [email protected] or visit www.rsph.org.uk/en/trainingsolutions

Alcohol free days recommended
The Royal College of Physicians has provided oral and written evidence to the science and Technology Committee about alcohol consumption. They recommend a change to the current guidelines of 28 units a week for men and 21 units a week for women. Instead they advise that men should be recommended to drink 0-21 units a week, and women 0-14, across more than 1 or 2 occasions, but with 2 to 3 days alcohol free a week, particularly after heavy drinking. sir Ian Gilmore, special advisor of alcohol, says: “at these levels, most individuals are unlikely to come to harm”. The current guidelines state that regularly drinking small amounts of alcohol is low risk which goes against evidence that regular drinking is a high risk factor for alcoholic liver disease. It is stated that the frequency of drinking and amount of drinking are both hazardous and ‘to ignore either of these components is scientifically unjustified’. Therefore having three alcohol-free days a week is emphasised. source: www.rcplondon.ac.uk ANsweRs The November 2011 CPD paper was: ‘Menu engineering: A strategy for seniors to select healthier meals’ Answers 1d, 2a, 3a and 4d You can also find the answers on the members’ area of our website www.rsph.org.uk The March 2012 issue will be the next CPD issue of the journal

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News

Breast cancer screening to be reviewed
There has been much debate as to the effectiveness of breast cancer screening and now an independent review will assess the evidence in a bid to end the controversy. screening was introduced for breast cancer in 1988 in the UK and now offers tests to women, over the age of 50, every three years. Professor Mike Richards, the National Cancer Director for england will lead the study jointly with Cancer Research UK, which will aim to determine whether breast screening causes more harm than good. whilst the NHs says that 1,400 lives are saved through screening in england, other researchers suggest that screening can produce false positive results which cause unnecessary stress for women. The director of health information at the charity, sara Hiom, said: “women need more accurate, evidence-based and clear information to be able to make an informed choice about breast screening. The decision whether to be screened is a personal one, but that decision should be made with all of the potential harms and benefits fully explained.” source: BMJ 2011; 343:d6843

10 year use of the contraceptive pill nearly halves the risk of ovarian cancer
A recent study has shown that women who take the pill for over 10 years reduce their risk of ovarian cancer by 45%. shorter term use also has an effect, with women who use the pill for a year having a 28 per 100,000 risk, compared to 15 per 100,000 per year risk for women who took the pill for over 10 years. The research also found that having children reduced the risk. For every child a women has the risk is reduced by a further 8%. Naomi Allen, who works on the study, says: “Ovarian cancer is difficult to detect and so prevention is key to saving women suffering from this disease”. The research does not establish how these factors effects the risk of ovarian cancer, but it is believed it may be because of changing levels of hormones. Additional findings included that a high age for menopause increased the risk, whereas age at first full-term pregnancy, incomplete pregnancies and breastfeeding were not associated with risk. The research is part of the european Prospective Investigation of Cancer (ePIC) which is part funded by Cancer Research UK and is one of the largest studies into the links between cancer, diet and lifestyle. source: British Journal of Cancer (2011), 105, 1436-1442 doi:10.1038/ bjc.2011.371

Recent analysis of eye health studies has found that the more time children spend outdoors the less likely they are to be shortsighted, also known as myopia. It has been suggested that exposure to natural light and looking at distant objects are key factors. The data used came from eight different studies on myopia and time spent outdoors by children and adolescents and included 10, 400 participants. It was found that children who were short-sighted spent on average 3.7 fewer hours outside per week than those with normal vision. Dr Khawaja, from the University of Cambridge, says: “Increasing children’s outdoor time could be a simple and cost-effective measure with important benefits for their vision and general health. If we want to make clear recommendations, however, we’ll need more precise data”. It is not yet clear why spending time outdoors effects eyesight. There doesn’t appear to be a relationship between those children spending time outdoors also spending less time undertaking near work, for example playing computer games. Future studies will look into these factors and also consider whether increasing outdoor time will stop eyesight getting worse. source: American Academy of Ophthalmology www.aao.org

Risk of short-sightedness reduced by time spent outdoors

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News

Diary
9th February 2012, 28 Portland Place, London, W1B 1LY

Arts and Wellbeing: Recent Developments, Future Challenges
Throughout the UK, health professionals and creative artists have worked together for over 25 years in using the arts to support healthcare and health promotion. Given the current uncertainties over reforms to the NHs and public health, and the Big society agenda, it is timely to examine the achievements of arts and health collaborations to date and look forward to new challenges and opportunities. speakers will look at the growing evidence-base for the value of involvement in creative activity for wellbeing and health – both in the UK and internationally. workshops will provide opportunities for participants to learn about current arts for wellbeing projects from leading arts for health practitioners. For more information go to www.rsph.org.uk or contact Claire Robins at [email protected] 27th February-9th March, 2012, 28 Portland Place, London, W1B 1LY

Obesity limits the effectiveness of flu vaccines
A study from the University of south Carolina (UNC) has found that obesity may make annual flu shots less effective. The study found that influenza vaccine antibody levels decline significantly in obese people compared to healthy weight individuals. The research also found that the response of a certain type of white blood cell, which plays a key role in the body’s immune system (CD8+T) are defective in overweight people. Researchers studied people at the university clinic who had been vaccinated with the common flu vaccine in late 2009. They found that whilst obese, overweight and healthy weight individuals all developed antibodies to flu viruses within the first month, the antibody levels in the blood declined more rapidly in obese and overweight individuals over time. Around 50% of obese participants had a four-fold decrease in antibody levels at 12 months compared to one month post vaccination. However, less than 25% of healthy weight participants had a four-fold decrease in antibody levels. Melinda Beck, Professor and Associate Chair of Nutrition at the UNC Gillings school of Global Public Health and senior author of the study, said: “These results suggest that overweight and obese people would be more likely than healthy weight people to experience flu illness following exposure to the flu virus. Previous studies have indicated the possibility that obesity might impair the human body’s ability to fight flu viruses. These new findings seem to give us a reason why obese people were more susceptible to influenza illness during the H1N1 pandemic compared to healthy weight people.” source: International Journal of Obesity, 2011, DOI: 10.1038/

Diploma in Occupational Medicine
The RsPH runs the Faculty of Occupational Medicine (FOM) approved course to prepare candidates for the Diploma in Occupational Medicine’s written examination and the oral examination based on a portfolio. The FOM Diploma has been designed for registered practitioners. It demonstrates that the holder has achieved a competence appropriate to a generalist working in occupational health. This course is the foundation level qualification required for occupational medicine. For more information go to www.rsph.org.uk or contact Claire Robins at [email protected] 7th March-9th March 2012, SECC, Glasgow

Diabetes UK Professional Conference 2012
Diabetes UK Professional Conference is one of the largest healthcare conferences in the UK attracting up to 3000 attendees. Innovative and invaluable to healthcare professionals, the conference delivers information on the latest global developments in diabetes care and research, offering a unique opportunity for delegates to network with professionals from varying fields. The exhibition brings together those from the voluntary, corporate and pharmaceutical sectors who share an interest in diabetes care. For more information: www.diabetes.org.uk/pc 2nd May-3rd May 2012, 28 Portland Place, London, W1B 1LY

Norovirus Infection in Health and Social Care - How do we deal with the problem?
Norovirus outbreaks cause major clinical and organisational challenges for all parts of the health and social care services. This conference will explore the most effective ways in which health and social care professionals can deal with a Norovirus outbreak while maintaining a normal level of services and activities. The conference will coincide with the launch of new guidelines from the Professional Bodies and the Department of Health in time for the 2011-12 “Norovirus season”. For more information go to www.rsph.org.uk or contact Claire Robins at [email protected]

ijo.2011.208

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LeTTeR TO eDITOR

Not all about bones: the non classical role of vitamin D in public health
Vitamin D and its therapeutic roles and functions in public health nutrition are well documented; however less information is widespread about its ‘non- classical’ roles. Vitamin D is a secosteroid derived from dual sources: via the diet or by photolytic cleavage of 7 dehydrocholesterol by ultra violet light in the epidermis.1 The more prodigious and efficient source of the pro hormone is exposure to sunlight.2 Nutritional sources include green vegetables (ergocalciferol), animal fat and egg yolk (cholecalciferol). The genomic action of vitamin D is mediated by the vitamin D nuclear receptor.3 Calcitriol exerts its physiological action by high affinity binding to the vitamin D nuclear receptors. They are not only present in the bone, kidney, skin and intestine (what could be called the ‘classical organs’) but also in the ‘non-classical’ organs including the brain, eyes, pancreas, muscle, heart and the immune cells. This recognition of the ‘non classical’ (non calcium homeostasis) role therefore links vitamin D to cardiovascular disease, tuberculosis, diabetes mellitus and susceptibility to sepsis.4,5 Vitamin D supplementation is being increasingly suggested as an adjuvant in prevention and therapy for these disorders.6 Vitamin D is postulated to play roles in the modulation of adaptive and innate immunity.3 Vitamin D nuclear receptors are abundant in immune cells1 and vitamin D enhances the microbicidal activity of macrophages and monocytes. This is achieved by being pro differentiating and enhancing macrophage chemotaxis and phagocytosis.7,8 The latter achieves increased microbicidal activity against intracellular bacteria.9 whilst vitamin D as treatment for Tuberculosis (TB) appears interesting, there is little published evidence to support routine VDs in the general TB populace. Furthermore, no randomised controlled trials (RCT) support vitamin D nuclear receptors in the management of HIV infection at this stage. Although a Cochrane review10 looking at adult and paediatric micronutrient supplementation in HIV evidences one RCT in Africa that reduced morbidity, the one that used only vitamin D nuclear receptors did not show any clinical benefits. Vitamin D has several disease modifying actions in cardiovascular disease11,12,13 but no large scale trials support supplementation. On the other hand vitamin D’s possible role in auto immune disorders is widely reported.14 However, such studies are often small and use differing doses. It is pertinent to consider that the larger doses required to achieve these non classical benefits may cause toxicity unless newer vitamin D analogues are used. Vitamin D is now recognised as having a broader role in human physiology than just calcium homeostasis. The role of vitamin D in bone homeostasis is evidenced and the world Health Organization in addition to national medical bodies have recommendations in place for its supplementation. In this capacity, there is some evidence to support its role in high risk populations including breast fed infants and others who by reason of attire, latitudes or skin colouring are unable to harness solar synthesis. Yet the search for information to lamppost other roles is hurdled by lack of large RCTs, differing recommendations of adequate levels and fears of toxicity in human trials. evolutionary arguments, mechanistic data and epidemiological data support its role in infection and auto immune disorders. A resolution may be possible if large scale placebo controlled RCTs are conducted across latitudes and seasons. This may present data to support or refute current practices. Dr John Philip, M.B.B.s.,D.C.H.,M.sc,MRsPH Paediatric Clinical Research Fellow, Oxford Vaccine Group, CVVTM, University of Oxford, drjohnphilip@gmail. com

References
1. Baeke F, Takiishi T, Korf H, Gysemans C., Mathieu C. Vitamin D: Modulator of the immune system, Pharmacology 2010, 10 :482-496 2. wHO, Vitamin and mineral requirements in human nutrition: report of a joint FAO/wHO expert consultation, Bangkok, Thailand, 21–30 september 1998 (revised 2004) 3. Borges M C, Martini L, Rogero M, Current perspectives on vitamin D, immune system, and chronic diseases, Nutrition, 2011, 27(4): 399-404 4. wang L, Manson J e, song Y, sesso H D, systematic Review: Vitamin D and Calcium supplementation in Prevention of Cardiovascular events, Annals Internal Medicine, 2010 152:315-323 5. Grant w, solar Ultraviolet-B irradiance and vitamin D may reduce the risk of septicaemia, Dermato endocrinology, 2009, 1(1): 37-42 6. Zittermann A, Vitamin D in preventive medicine: are we ignoring the evidence? British Journal of Nutrition, 2003, 89:552–572 7. Griffin M, Xing N and Kumar R, Vitamin D and its analogs as regulators of immune activation and antigen presentation, Annu Rev Nutr, 2003, 23:117–45 8. Griffin M, Dong X, Kumar R, Vitamin D receptor-mediated suppression of RelB in antigen presenting cells: A paradigm for ligand-augmented negative transcriptional regulation, Archives of Biochemistry and Biophysics, 2007, 460:218–226 ] 9. Liu P.T, stenger s, Li H, wenzel L, Tan B.H, Krutzik s.R, et al, Antimicrobial Response Toll-Like Receptor Triggering of a Vitamin D-Mediated Human, science, 2006, 311(5768): 1770-1773 10. Adorini, L, Penna, G, Control of autoimmune diseases by the vitamin D endocrine system. Nat Clin Pract Rheumatol, 2008, 4(8): 404-12 11. Zittermann A, Vitamin D and disease prevention with special reference to cardiovascular disease, Progress in Biophysics and Molecular Biology, 2006, 92(1):39-48 12. wang TJ, Pencina MJ, Booth sL, Jacques PF, Ingelsson e, Lanier K, et al. Vitamin D deficiency and risk of cardiovascular disease. Circulation, 2008. 117:503-11. 13. Hsia J, Heiss G, Ren H, Allison M, Dolan NC, Greenland P, et al., women’s Health Initiative. Calcium/vitamin D supplementation and cardiovascular events, Circulation, 2007, 115:846-54 14. Adorini, L, Penna, G, Control of autoimmune diseases by the vitamin D endocrine system, Nat Clin Pract Rheumatol, 2008, 4(8): 404-12

Editor’s response
we thank Dr John Philip for this interesting letter about the non classical roles of vitamin D. This letter once again draws attention to the importance of vitamin D and opens up further discussion about how vitamin D could have an important role to play in the prevention of such disorders as diabetes and cardiovascular disease.

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LeTTeR TO eDITOR Sun exposure and vitamin D
Dear editor, every year, as summer approaches, advice on ways to stay safe in the sun and reduce the risk of cancer dominates the public health agenda. A parameter negligee is that during summer, under the influence of ultraviolet sun light, our skin synthesizes vitamin D3 which after hydroxylation in the liver turns into 25-hydroxyvitamin D (25(OH)D), an active metabolite that can be measured in serum.1 Vitamin D deficiency is defined by a serum 25-hydroxyvitamin D (25(OH)D) level below 30 ng/mL 2 and affects people worldwide. Nearly one billion people are deficient in vitamin D, of which 40-100% are American and european elderly individuals.3 In June 2007 the American Journal of Clinical Nutrition published a four year interventional study on more than 1000 community women, which proved that increasing vitamin D levels (in addition to calcium) reduces all-cancer risk in postmenopausal women.4 In January 2011 Thacher TD and Clarke BL revealed a variety of nonskeletal benefits of vitamin D.2 Following this we decided to investigate the serum 25(OH) D levels of 23 healthy young hospital personnel aged between 20 and 40 years, all of whom were Greek Caucasian, during the sunny season.5 The average serum 25(OH)D was 16.3±10.1 ng/ml (range:5.1-51.4), significantly lower than 30 ng/ml. After log-transformation of the values for the achievement of normality, the sample mean differed significantly statistically with p<0.0001 from 1 sample meancomparison t-test. Given that our comment comes from Greece, a south european country with a long sunny summer and extensive sun protection campaigns, should we consider a middle ground between avoiding the sun altogether and prolonged exposure without protection? Note that prescribing vitamin D carries the risk of toxic side effects due to the induction of hypercalcemia.6 so, how about embracing some of the power of the sun that our ancestries in all cultures have adored as a life-giver god. Nikol Panou, sotirios Georgopoulos*, Marios Panou*, Theodoros N. sergentanis, Georgios Maropoulos, efstathios Papalambros
*equally contributed authors 1st Department of surgery, Athens University school of Medicine, Laikon General Hospital, 17 Ag. Thoma st, Athens, 11527, Greece, [email protected]

References
1. 2. 3. 4. Lips P. Vitamin D physiology. Prog Biophys Mol Biol. 2006;92(1):4-8. Thacher TD, Clarke BL. Vitamin D insufficiency. Mayo Clin Proc. 2011;86(1):50-60. Holick, M.F. Vitamin D deficiency. N Engl J Med 2007;357:266-281. J. M Lappe, D. Travers-Gustafson, K M. Davies, R. R Recker, and R. P Heaney. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Am J Clin Nutr 2007;85(6):1586 - 1591. Gozdzik A, Barta JL, weir A, Cole De, Vieth R, whiting sJ, Parra eJ. serum 25-hydroxyvitamin D concentrations fluctuate seasonally in young adults of diverse ancestry living in Toronto. J Nutr. 2010 Dec;140(12):2213-20. epub 2010 Oct 27. Masterjohn C. Vitamin D toxicity redefined: vitamin K and the molecular mechanism. Med Hypotheses. 2007;68(5): 1026-34.

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6.

Editor’s response we thank the authors for their letter and agree that there is much debate at present on this topic. Potential conflict can arise when considering public health advice regarding skin cancer and the use of sunscreen, while concurrently recognising that some sunlight is required to prevent Vitamin D deficiency. It has been suggested that within the UK population, groups at greatest risk of a lack of vitamin D are pregnant women, children under five, the elderly and those that consistently cover their skin.1 The National Institute for Health and Clinical effectiveness (NICe) suggest that being out in the sun is beneficial but do not define the metrics, except to clarify that excessive exposure would be dangerous (notwithstanding depending on skin colour and type this will vary between individuals). Unfortunately, clarity of advice is lacking which makes specific policy difficult for healthcare professionals to implement and follow.

Acknowledgements
we thank the state scholarships Foundation of Greece (IKY) for supporting this work.

Reference
1. Cooke L., 2011, Vitamin D and the Impact on the health of the UK; our role as healthcare professionals, Complete Nutrition, 11, 57-60.

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Policy aNd Politics

Intersections of context and HIV/AIDS in sub-Saharan Africa: what can we learn from feminist theory?
HiV/aids is a global pandemic. the epicentre of this pandemic is sub-saharan africa, where 15% of the population is infected versus the global average of 3.9%.1 Within sub-saharan africa, 60% of those infected with HiV/aids are girls or women.2 looking at the general female population, those who are poor and uneducated are much more likely to be or become infected than their more privileged counterparts.3 other markers of difference such as geographical location within countries, sexual orientation and marital status also differentially affect the probability of infection, thus demonstrating the complexity of characteristics and interactions to be considered when responding to the HiV/ aids epidemic. this brief paper will explore some of the limitations of the northern response to the HiV/aids epidemic in sub-saharan africa, namely how context is currently inadequately understood. We will detail social mechanisms that powerfully affect the female experience of the epidemic. then, borrowing from the field of feminist scholarship, we will suggest a framework for exploring complex power structures to enable northern organizations to better understand the intricacies of context as they help to formulate a contextualized response to the epidemic. encouraging condom use without considering either a woman’s ability to ask her husband to use one or the repercussions she may face if she does; or the proliferation of abstinence programmes without defining ‘sex’ or considering the drivers of people’s sex lives.5 in the first case, a better understanding of existing power structures is necessary, and in the second, special attention must be paid to cultural norms and social interactions around sexual activity. to devise more effective programmes, practitioners and scholars from the North must look more closely at the local context and its impact on health behaviours. their will and 30% report that their first sexual encounter was forced.7 this imbalance of power between girls and men unfortunately increases within marriage. one study found that married girls in Zambia and Kenya had higher rates of infection than their unmarried counterparts, citing increased frequency of sexual relations, decreased safe sex practices and the ‘virtual elimination’ of a girl’s ability to refuse sex.8 in subsaharan africa, married girls do not typically have multiple partners, yet their husbands are three times more likely to be infected than younger men and adolescent boys.8 the situation for women is much the same. discriminatory laws often prevent women from any recourse against violence and also contribute to their increased risk of infection by impeding their access to divorce, inheriting property or protecting themselves from forced marriage. Men control all the resources and retain all decision-making power. Women lack education both in terms of general schooling and knowledge of HiV transmission. this lack of schooling also hinders their future employment prospects thus increasing poverty among women. Poverty and HiV/ aids have a bidirectional relationship: poverty is strongly linked to HiV infection and being infected with HiV/aids increases the likelihood of being impoverished.9

Mechanisms of context affecting HIV/AIDS among females in sub-Saharan Africa
Girls and women are at much greater risk of contracting HiV/aids because of both unique biological vulnerabilities and social determinants. Biologically, risk of infection is increased by hormonal fluctuations, a higher prevalence of other sexually transmitted diseases, vaginal ecology and physiology.3 Gender disparities, poverty, lack of education, lack of power and gender violence all contribute to the increased risk of infection for females in sub-saharan africa. We will look first at the situation for girls (approximate age 15–19) and then for women (20 and older). Nancy luke,6 conducted a literature review of 45 quantitative and qualitative studies of sexual relationships of unmarried adolescent girls in sub-saharan africa. the review established that sex with older men that involves economic transactions are commonplace and are associated with unsafe sex, thus increasing the risk of HiV transmission. a study from tanzania found that girls as young as 10 had exchanged sex for a bottle of coca-cola.6 one south african study found that 11% of girls report being raped, 71% report having sex against

The Northern response to HIV/ AIDS in sub-Saharan Africa
a number of northern programmes have been developed to address the HiV/aids epidemic. Numerous international organizations have been created to fund and implement programmes around the world. in 2003, Us$4.7 billion was available for HiV/aids programmes worldwide. Unfortunately, many of the funded programmes were built on topdown approaches to address HiV/aids, which often fail to take the local context into account and can result in programmes that are not effective.4 Examples of these approaches include:

The contribution of feminist theory
these complex structures of gender disparity make any analysis of HiV/aids and women in sub-saharan africa daunting at best. the most commonly used models and frameworks tend to focus on either microsociological or macrosociological questions rather than an integrative approach of both layers. Having a ‘broad framework of macro and micro relations, institutions and processes that are involved in the social construction of

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Policy aNd Politics
inequity’10 can help overcome the traditional challenges that social theorists face with this sort of complexity. the theory of intersectionality, popularized by Kimberlé crenshaw in 1989,11,12 aims to fully encompass both micro- and macrosociological layers. davis defines intersectionality as: ‘the interaction between gender, race and other categories of difference in individual lives, social practices, institutional arrangements, and cultural ideologies and the outcomes of these interactions in terms of power.’12 intersectionality involves the examination of ‘difference’. Morris and Bunjun13 highlight the need to examine multiple social categories such as ethnicity, religion, history, gender, sexuality, geographic location and family status. these many different attributes intersect to create a social location, which subsequently influences a person’s ability to navigate their way in a social world. Morris and Bunjun also stress the importance of acknowledging how history and social and economic structures work together to reinforce the status quo and prevent progress for women. intersectionality provides researchers with a lens for examining the complexities of power and the ability to view how these identities interact in the social construction of inequities, oppression and, in this case, HiV/ aids infection. in brief, intersectionality can be thought of as a ‘research and policy paradigm’ that ‘provides a theoretical foundation for the pursuit of social justice’.14 in a complex arena, intersectionality gives us more than the social determinants of health approach: it advances the examination of the ‘causes of the causes’ by providing a systematic way of inquiring about which social determinants are of concern for a particular group of people based on their experience of privilege or oppression on several interlocking fronts. to apply an intersectional analysis to women and girls in sub-saharan africa in relationship to HiV/aids, northern organizations could adopt a systemised technique of ‘asking the other question’, which is often employed in intersectional analyses.12 We can apply this framework to a concrete problem such as trying to improve female adherence to anti-retroviral therapy (aRV) in a given region. asking the ‘other’ question implies that there is an initial question that only addresses part of the potential problem. in this case, that initial question might be: ‘Why don’t women take their medicine?’ applying intersectionality to this issue would require digging deeper, asking questions to get at the structural limitations of why a given woman might not be adhering; programme planning might include exploring issues that pertain to her ethnicity, religion, history, gender, sexuality, geographic location, family status, social role, economic situation and so on. such inquiry might find, for instance, that women might not be adhering because they are poor, they cannot afford the food needed to take the medication, they cannot get to the clinic where they receive the aRV because they are in a geographic location that is too remote and they cannot spare the time (or money) to take buses because they are required to work to support the family because of the designated familial role reinforced by their communities and religious beliefs, and so on. as we ask these ‘other’ questions, a holistic picture of the women’s lives comes to the fore, which facilitates a much more realistic, contextualized view of a population’s circumstances and may provide invaluable knowledge for the planning for HiV/ aids prevention and treatment programmes. applying intersectionality to HiV/aids in sub-saharan africa allows an analysis that considers the structures that surround women that create and recreate vulnerability and marginalisation. intersectionality applied to public health offers an important lens with which to view the nuances of health and illness for a particular group of people, in the context of their environment and the unique obstacles faced. Using this type of inquiry could go a long way to enable northern organizations to deliver a much more appropriate response to health issues everywhere, but certainly to protect the health of girls and women in sub-saharan africa. J. Corbin, Department of Health Promotion and Development, University of Bergen, Norway and Laura Tomm Bonde, School of Nursing, University of Victoria, Canada

References
1 Bongaarts JP, Pelletier F, Gerland P. Global trends in aids Mortality. in: Rogers RG, crimmins EM, editors. International Handbook of Adult Mortality. dordrecht: springer Netherlands, 2011, pp. 171–83. available at <http://www. springerlink.com/content/hr781408720h3v48> last accessed 4/11/11 UNaids Report on the Global AIDS Epidemic [online], 2008. available at <http://www.unaids. org/en/dataanalysis/epidemiology/2008reportont heglobalaidsepidemic> last accessed 4/11/11 Quinn tc, overbaugh J. HiV/aids in Women: an Expanding Epidemic. Science 2005; 308: 1582–3 coovadia HM, Hadingham J. HiV/aids: Global trends, global funds and delivery bottlenecks. Global Health 2005; 1: 13, doi:10.1186/17448603-1-13 Barnett t, Parkhurst J. HiV/aids: sex, abstinence, and behaviour change. The Lancet Infectious Diseases 2005; 5: 590–3 luke N. age and Economic asymmetries in the sexual Relationships of adolescent Girls in subsaharan africa. Studies in Family Planning 2003; 34: 67–86 türmen t. Gender and HiV/aids. International Journal of Gynecology & Obstetrics 2003; 82: 411–8 clark s. Early Marriage and HiV Risks in subsaharan africa. Studies in Family Planning 2004; 35: 149–60 UNaids. Gender and HIV/AIDS Technical Update [online], 1998. available at <http://data. unaids.org/publications/iRc-pub05/jc459-gender-tu_en.pdf> last accessed 4/11/11 Bilge s. Recent feminist outlooks on intersectionality. Diogenes 2010; 57: 58–72 Walby s. complexity theory, systems theory, and multiple intersecting social inequalities. Philosophy of the Social Sciences 2007; 37: 449–70 davis K. intersectionality as buzzword. Feminist Theory 2008; 9: 67–85 Morris M, Bunjun B. Using Intersectional Feminist Frameworks in Research: A Resource for Embracing the Complexities of Women’s Lives. ottawa: canadian Research institute for the advancement of Women, 2007, p. 51 Hankivsky o, cormier R, Merich dd, Women’s Health Research Network. Intersectionality: Moving Women’s Health Research and Policy Forward. Vancouver: Women’s Health Research Network, 2009, p. 68

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PeeP iNto ParliameNt

Cutting edge
according to a new study, drinking a lot of fizzy drinks can cause violence in teenagers. researchers found that teenagers who drink more than five cans of non-diet, fizzy soft drinks every week are significantly more likely to behave aggressively. the study involved asking 1,878 teenagers from 22 public schools in Boston about their fizzy drink consumption and violent behaviour. Keep the lid on fizzy drinks. The ‘Twinkie Defence’: the relationship between carbonated non-diet soft drinks and violence perpetration among Boston high school students. Injury Prevention, 2011; DOI: 10.1136/ injuryprev-20011-040117 the number of walking trips taken by Britons has dropped by over a quarter compared to the 1990s, according to the latest National travel Survey. every year, 10,000 cases of cancer could be prevented by a daily half hour walk. So time to grab those walking shoes! Source: www.wcrf-uk.org New research from the london School of Hygiene and tropical medicine has shown that 16% of phones are contaminated with e-coli, with 92% of phones and 82% of hands having bacteria on them. research was undertaken across 12 cities with 390 participants, showing that this is a nationwide problem. So remember to keep washing your hands! Source: www.lshtm.ac.uk a study by the Colorado Centre for reproductive medicine has found that the quality of sperm decreases with age. the study tested mice, but suggests that after the age of 40 men will find it harder to conceive. So women are not the only ones that should be concerned about their biological clocks! Source: www.colocrm.com

Peep into parliament and beyond
Cannon to right of them. Cannon to left of them. Into the valley of Death rode the four hundred. this was the famous Charge of the Public Health Brigade in a mass letter to The Telegraph expressing concerns about the NHS Bill and calling for its withdrawal, just ahead of the lord’s debate back in october. it was a brave and glorious moment in public health history. Brave because many of the 400 or so public health experts who put their names to the letter also put their careers on the line. Stories have emerged of hapless directors of public health being hauled over the coals for insubordination – some being brutally stripped of their rank or hideously reconfigured. Glorious because, although the Bill survived and continued inexorably on its way, the number of times the words ‘health protection’ and ‘health improvement’ and ‘joint strategic needs assessment’ were heard ringing round the venerable red-benched chamber broke all known records. Never before had so many noble lords expounded so knowledgably on the nuances and niceties of public health. For two head-spinning days our humble profession was the talk of the highest talking shop in the land. and it was by no means a foolhardy and futile gesture. this wasn’t mere light cavalry – there were some pretty heavy guns on that impressive list of signatories – and ministers were truly shaken. the sleeping giant that was public health had risen up and rudely rattled the Government’s cage. indeed the repercussions are still echoing round the ever more empty corridors of the Department of Health as we speak. looking back now, what was most interesting about the Great Public Health Charge was the way it apparently came from nowhere, suddenly, without warning, and rapidly went viral. it was the closest thing i’ve seen to a public health flash-mob in action. and also the fact that representatives of the main public health bodies were notably absent. indeed it was partly triggered by a feeling of frustration born of the impression that the public health community was doing nothing to challenge the Bill and just letting it all happen – an impression fuelled by a hard-hitting piece by Lancet editor richard Horton, criticising in particular the Faculty of Public Health (FPH). in fact, throughout the autumn, a great deal of lobbying by all the main public health stakeholders had been going on behind the scenes: mass-petitioning of mPs; buttonholing of various peers; submitting statements to select committees; tossing ideas into the transition team and the Future Forum. and athough things might have seemed rather quiet on the outside, the pressure on the inside was (and still is) forceful and sustained. the trouble with behind-the-scenes lobbying is that it can all too easily be sidelined and ignored, however skilfully and cogently applied. Plus it has the inbuilt snag of being invisible to the world at large – which of course is precisely why it gains so little external credit and why it can so easily be sidelined and ignored. the stuff that really gets ministers jumping is the stuff that gets onto the front pages – and this is what the plucky 400 certainly managed to achieve in some style, although to what ultimate effect remains in doubt. anyway, here we are in the New Year with just over 12 months to go, and we still haven’t got the full picture. it’s like painting-by-numbers with half the numbers missing. How much longer can we wait? the frustration’s bubbling up again. i feel another flash-mob coming on. Forward the Public Health Brigade. lower your lances. Charge! Professor Alan Maryon-Davis, Hon Professor of Public Health, Kings College London

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Cutting edge
according to a new study, drinking a lot of fizzy drinks can cause violence in teenagers. researchers found that teenagers who drink more than five cans of non-diet, fizzy soft drinks every week are significantly more likely to behave aggressively. the study involved asking 1,878 teenagers from 22 public schools in Boston about their fizzy drink consumption and violent behaviour. Keep the lid on fizzy drinks. The ‘Twinkie Defence’: the relationship between carbonated non-diet soft drinks and violence perpetration among Boston high school students. Injury Prevention, 2011; DOI: 10.1136/ injuryprev-20011-040117 the number of walking trips taken by Britons has dropped by over a quarter compared to the 1990s, according to the latest National travel Survey. every year, 10,000 cases of cancer could be prevented by a daily half hour walk. So time to grab those walking shoes! Source: www.wcrf-uk.org New research from the london School of Hygiene and tropical medicine has shown that 16% of phones are contaminated with e-coli, with 92% of phones and 82% of hands having bacteria on them. research was undertaken across 12 cities with 390 participants, showing that this is a nationwide problem. So remember to keep washing your hands! Source: www.lshtm.ac.uk a study by the Colorado Centre for reproductive medicine has found that the quality of sperm decreases with age. the study tested mice, but suggests that after the age of 40 men will find it harder to conceive. So women are not the only ones that should be concerned about their biological clocks! Source: www.colocrm.com

Peep into parliament and beyond
Cannon to right of them. Cannon to left of them. Into the valley of Death rode the four hundred. this was the famous Charge of the Public Health Brigade in a mass letter to The Telegraph expressing concerns about the NHS Bill and calling for its withdrawal, just ahead of the lord’s debate back in october. it was a brave and glorious moment in public health history. Brave because many of the 400 or so public health experts who put their names to the letter also put their careers on the line. Stories have emerged of hapless directors of public health being hauled over the coals for insubordination – some being brutally stripped of their rank or hideously reconfigured. Glorious because, although the Bill survived and continued inexorably on its way, the number of times the words ‘health protection’ and ‘health improvement’ and ‘joint strategic needs assessment’ were heard ringing round the venerable red-benched chamber broke all known records. Never before had so many noble lords expounded so knowledgably on the nuances and niceties of public health. For two head-spinning days our humble profession was the talk of the highest talking shop in the land. and it was by no means a foolhardy and futile gesture. this wasn’t mere light cavalry – there were some pretty heavy guns on that impressive list of signatories – and ministers were truly shaken. the sleeping giant that was public health had risen up and rudely rattled the Government’s cage. indeed the repercussions are still echoing round the ever more empty corridors of the Department of Health as we speak. looking back now, what was most interesting about the Great Public Health Charge was the way it apparently came from nowhere, suddenly, without warning, and rapidly went viral. it was the closest thing i’ve seen to a public health flash-mob in action. and also the fact that representatives of the main public health bodies were notably absent. indeed it was partly triggered by a feeling of frustration born of the impression that the public health community was doing nothing to challenge the Bill and just letting it all happen – an impression fuelled by a hard-hitting piece by Lancet editor richard Horton, criticising in particular the Faculty of Public Health (FPH). in fact, throughout the autumn, a great deal of lobbying by all the main public health stakeholders had been going on behind the scenes: mass-petitioning of mPs; buttonholing of various peers; submitting statements to select committees; tossing ideas into the transition team and the Future Forum. and athough things might have seemed rather quiet on the outside, the pressure on the inside was (and still is) forceful and sustained. the trouble with behind-the-scenes lobbying is that it can all too easily be sidelined and ignored, however skilfully and cogently applied. Plus it has the inbuilt snag of being invisible to the world at large – which of course is precisely why it gains so little external credit and why it can so easily be sidelined and ignored. the stuff that really gets ministers jumping is the stuff that gets onto the front pages – and this is what the plucky 400 certainly managed to achieve in some style, although to what ultimate effect remains in doubt. anyway, here we are in the New Year with just over 12 months to go, and we still haven’t got the full picture. it’s like painting-by-numbers with half the numbers missing. How much longer can we wait? the frustration’s bubbling up again. i feel another flash-mob coming on. Forward the Public Health Brigade. lower your lances. Charge! Professor Alan Maryon-Davis, Hon Professor of Public Health, Kings College London

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Media Maladies

dr lisa ackerley wins “most significant contribution” award
dr lisa ackerley, co-founder of Hygiene audit systems and specialist food safety adviser to the Royal society of Public Health, has been awarded sOFHT’s prestigious “Most significant Contribution to the Food industry” award for “raising the profile of food hygiene in the best possible way.” The society of Food Hygiene and Technology’s Board of directors chose dr ackerley, one of the UK’s leading food safety experts, in recognition of her valuable work within the media and the industry generally, championing a clear, well-informed consumer food safety message. sOFHT Chairman simon Houghton-dodd commented: “she has restored credibility to the word “expert.” a lot of people purport to be experts, but dr lisa ackerley, with her eloquence, factual knowledge and ability to put it across in layman’s terms, truly is. she is a credible, proper expert in every sense of the word and thanks to the work she has done throughout the media - from local radio to Watchdog, and within the industry at conferences and presentations, she has helped raise the profile of the food industry and food hygiene in the best possible way. We are delighted to recognize her contribution. The award was presented at sOFHT’s annual luncheon, attended by 360 guests from all sectors of the food industry at london’s landmark Hotel on Nov 24. “i am thrilled to have been chosen to receive this award,” said a delighted dr ackerley, who is Visiting Professor of environmental Health at salford University. My passion has always been to help to get the food safety and public health message across as simply and widely as possible, to help people understand why it’s important for them to do something so that they can act to improve their well-being. Hygiene audit systems, which celebrates its 25th birthday next year, is a leading food safety and health and safety consultancy, which provides advice, training and support to businesses in the food industry, leisure, catering and hospitality sectors. For more information: www. hygieneauditsystems.com

Media maladies
Media Maladies: Desert Island discs for public health
during World War ii a freelance broadcaster, Roy Plomley, pitched an idea for a radio programme. launched in January 1942 in a bomb damaged BBC radio studio as desert island discs, it has run ever since with only a brief post war interruption. UK residents will hardly need reminding that someone is asked to imagine being marooned on a desert island with eight pieces of recorded music or speech, a book in addition to the Bible and works of shakespeare, and a luxury. Very few of the castaways have come from the field of medicine or specifically from public health, although they have included Professor Hugh Pennington and the late sir Richard doll, the latter choosing a sensible down pillow for his luxury. For this final column in the ‘Media Maladies’ series, let’s consider a possible selection from, say, the “Unknown Warrior of Public Health”. With the continuing uncertainty and upheaval associated with the health service reforms, possibly several public health warriors would apply to be castaways. But what music would they choose? You Tube offers several health care reform ditties on the plight of health services in the United states. sung to the tune of “I can’t help falling in love with you”, there’s a Pandemic flu song (“i can’t help catching a deadly flu”) and a tribute to the 1918 flu pandemic. For those interested in diet and obesity, try a worthy song for young children “Healthy and Wise”, with the admonition to “eat right, sleep right and exercise” i’d prefer “Food, glorious food” from the musical Oliver or for a stronger message, “It’s illegal or immoral or it makes you fat”. The Us Centers for disease Control reworded ‘The Twelve days of Christmas” in their ‘12 ways to holiday health’: “The twelfth way to health, said the CdC to me: eat well and get moving, prepare dinner safely, practice fire safety, monitor the children, get your vaccinations, get exams and screenings, fasten belts while driving, Be sMOKe-FRee, don’t drink and drive, manage stress, bundle up for warmth, and wash hands to be safe and healthy.” Too much like work for castaways? How about some of the old classics: while public health is a team effort, our castaway could enjoy singing along with sinatra to ‘My Way’ and commiserating with far off colleagues to irving Berlin’s ‘Let’s face the music and dance’. This was used in a TV advertisement, which brings to mind a much loved reference to mental health with “Everyone’s a fruit and nut case”. “Chariots of Fire” (Vangelis) could recall teambuilding events or how it feels to get a public health innovation through a committee. The spectrum of public health is life itself so the selection could include “What a wonderful world” (louis armstrong), “The Rhythm of Life” from sweet Charity or “The Circle of Life” from The lion King, listening to advice such as “More to be done than can ever be done” while sipping on a coconut cocktail; followed possibly by Michael Jackson’s “Heal the world”: “There are ways to get there if you care enough.” There are several medical songs to pick, starting with “Goodness Gracious Me”, or the “St James Infirmary Blues” and working through one of the lists on the web. There’s not enough space to whittle down these choices or to debate the book (perhaps ‘Catch-22’ (Joseph Heller) for a start) but the luxury would be easy – a water pump to remind the castaway of dr John snow’s iconic intervention. Or just the handle, if a pump seems too useful. do send in your own choices: after all, “There may be trouble ahead….” Dr Rosalind Stanwell-Smith scientific adviser to RsPH

For a list of websites to listen to the songs please contact the editorial office

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A BRIEF INTRODUCTION TO...

Public Health and Midwifery
‘The foundations of adult health are laid in early childhood and before birth’ (WHO 2003) Public health has historically been closely related to and integrated within midwifery practice. However, more recently the role of the midwife has come to the fore with the focus on the impact of pregnancy, the reproductive period and early years of life on longer term health. Within the UK, the Marmot Review highlights, as its primary objective, that every child should have the best start to life. This places the midwife firmly at the centre of public health policy. Midwifery 2020,1 was set up to review the work of midwives and their contribution to women’s experiences of pregnancy and childbirth including a specific strand focusing on the public health role of the midwife. Evidence based pre and postnatal interventions that reduce adverse outcomes and promote well-being in pregnancy and infancy are needed to achieve this policy objective. We conducted a systematic review of reviews on the public health role of the midwife which was incorporated into the final public health report. A number of effective interventions that could promote public health which are currently part of routine midwifery care were highlighted in the review however overall systematic review evidence of effectiveness in this area was limited. Three key areas were identified as central to the future public health role of midwives: reducing the social gradient through promoting well-being and preventing ill health; enabling children to have the best start in life through early intervention; and the opportunity for midwives as co-ordinators of care to identify vulnerable groups. Reducing the social gradient in order to promote well-being and prevent ill health has significant implications for the delivery of care, particularly in relation to how public health interventions are implemented across the childbearing population. Viewing health inequalities in society on a gradient means that greater intensity of action can be directed towards those with greatest disadvantage, which is particularly relevant in the current economic context. Internationally, there has been a shift away from relying solely on measures of mortality and morbidity to reflect global health to include measures of well-being. This policy shift to support the measurement of well-being as an outcome is of particular value for midwifery care where the goal for most women is enhancement of well-being rather than absence of illness. Ideally, ensuring the best start in life begins even before conception but for the midwife a major opportunity to contribute to maternal and child health is through antenatal care. The perinatal period is a time when women are in regular contact with health care services and midwives are in a key position to educate and support women in relation to health and wellbeing, to identify women who are vulnerable and require additional support or services. Antenatal care provides the overarching mechanism to facilitate the delivery of education and support in relation to pregnancy, childbirth and parenting. However many antenatal interventions used by midwives have not been evaluated for example the effectiveness of the content, delivery and format of antenatal education classes on birth outcomes. The third key area is the potential for midwives to identify vulnerable groups of women and co-ordinate their care. The Marmot Review highlighted a number of vulnerable groups who need additional support through policy and practice including those with mental illness, disability or chronic illness, ethnic minorities, asylum seekers and those on low incomes. Midwifery led models of care are recommended for most women and for those women with significant medical or obstetric complications there is also a role for midwives to be involved in their care. The final report from Midwifery 2020 also identifies the midwife as the lead health professional to promote well-being for women with straightforward pregnancies, and it also outlines a pivotal role for midwives in coordinating the journey through pregnancy for all women, ensuring they are referred to other services where appropriate and that holistic care is provided to optimise each woman’s birth experience regardless of risk status. Looking to the future, more obvious professional leadership in public health is required to optimise the impact of midwives on the long term health of the population. A shift is already evident with the appointment of consultant midwives with a specific public health remit. However to achieve current policy objectives more leadership is required in the development and implementation of effective public health interventions which are midwifery led. Midwifery and public health are inextricably linked. It is therefore important in going forward that the midwifery profession and those external to the profession work together to identify and implement effective care in the perinatal period that can have significant short, medium and long term impact on the health and well-being of women and their families. Author Biographies Jenny McNeill is a Lecturer in Midwifery Research, School of Nursing and Midwifery, Queen’s University Belfast and primary author of a review of systematic reviews on the public health role of the midwife funded by NHS Education for Scotland. Denise Boulter is the first Consultant Midwife in Public Health in Northern Ireland Fiona Alderdice is Professor in Perinatal Health and Well-being, School of Nursing and Midwifery Queens University Belfast and co-author of a review of systematic reviews on the public health role of the midwife funded by NHS Education for Scotland. Reference
1. For more information: www.midwfery2020.org (last accessed 25/10/11)

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In practIce

In Practice
Claire Haigh, North West Employers

Championing health in your community
With the emergence of the new Localism Bill, which will devolve greater power to councils and neighbourhoods and give more control over housing and planning, the decisions that will impact on the wider determinants of health will rest in the hands of the local community. The shift in power from central government back into the hands of individuals, communities and councils comes as the Government’s strategy for public health in England, ‘Healthy Lives, Healthy People’ (November 2010) moves forward through a series of public health system reforms placing public health within local authorities. ‘Promoting the wellbeing of individuals and communities is fundamental to the work of local government, and is a strong motivator for local councillors everywhere,’ writes Councillor David Rogers OBE, chair of the Local Government Association Community Wellbeing Programme Board, in his foreword to the 2010 report, The Role of Local Government in Promoting Wellbeing. The Role of Local Government in Promoting Wellbeing (commissioned by Local Government Improvement and Development and the National Mental Health Development Unit) examined how local government can support a better life for its citizens to help build resilient communities, now and in the long term. So how will elected members of councils reshape their role in making decisions that will prevent long-term health problems and achieve reductions in expenditure and efficiency savings? North West Employers recognised the challenge early and, with the Healthy Communities team at NHS Central Lancashire, undertook a health literacy knowledge and skills assessment. Building on the findings from this work and in collaboration with the Royal Society for Public Health (RSPH) Training Solutions team, North West Employers and NHS Central Lancashire successfully designed an innovative programme on health improvement to develop the councillor health champion. North West Employers exists to help organizations deliver public services with and for local people that reflect their priorities. It believes that a highly motivated, productive workforce, together with skilled and supported councillors, are key to making this happen. Central to its work is supporting councillors with new and emerging agendas, such as the move of many public health functions to local government. The collaboration brought together the experience of RSPH Training Solutions with North West Employers in order to identify and anticipate needs so that councillors could prepare to take a more proactive role in improving the well-being of residents in their communities. Gulab Singh MBE, assistant director of Healthy Communities at NHS Central Lancashire, also a speaker on the programme and whose initial work provided the evidence base, identified that while elected members had a high understanding of the different determinants of health, they had a lower understanding of public health terms and techniques. Also, low levels of awareness about a number of public health terms and tools indicated a need for support in responding to future challenges. A series of Quick Guides, which complemented the programme, were developed as a result of the health literacy knowledge and skills assessment.1 The key areas covered were: understanding health and well-being; a look at the national policy changes in relation to health and well-being; a focus on local health and well-being inequalities and how local councillors can positively influence them; practical tools and techniques; how the decisions local government make impact health and well-being; and the role of the councillor health champion. Combined with the learning outcomes for RSPH Understanding Health Improvement, this provided a programme that led to the level 2 accredited award, which is assessed by simple multiple-choice questions. Councillor Val Slater, North West Employers associate and local councillor in Bradford, anchored the programme, providing expert knowledge and drawing on her experience as chair of the Regeneration and Economy Improvement Committee and her work in the Scrutiny of Affordable Housing 2009. The design of the programme has been such that there is capacity to embrace local context and flavour by incorporating specialist local speakers of relevance into the public health needs of the area. The programme is both theoretical and practical in nature. In planning the programme, the aim was to ensure that it could be replicable across the country while at the same time reflective and determined by the health needs of the particular region in which it is delivered. The programme helps delegates to understand and navigate the key terms and concepts of health and well-being. North West Employers and the RSPH are able to offer this programme to member organizations. It is suitable for both district and upper-tier councils and for both ward councillors and those with a leadership role. For more information please contact Claire Haigh, Leadership and Transformation Gateway Coordinator (email: [email protected]).

Note
For more information visit: www.nwemployers. org.uk

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FEATURE

Health Promotion Awards 2011: recognising today’s health promotion
Nelly Araujo from the RSPH development team provides an overview on the Health Promotion Awards 2011 and its winners’ good practice – highlighting that in a changing public health landscape, health promotion still features as a mainstream approach to address the wider social determinants of health
to learn and recognise the contribution to health promotion and health improvement made by nontraditional health sector organizations as well. This year the award scheme has been further enhanced by the participation of a diverse range of organizations, ranging from local authorities to community radio. The winners of the 2011 awards are as follows. managers, as well as valued partners such as the local NHS, fire service, police, the voluntary sector and community groups. Over 100 projects and initiatives have been delivered in light of the strategy. The outcomes clearly demonstrate success in improving people’s health and inciting behaviour change, and this is down to strong and effective partnership working, engagement with elected members and the clear strategic support and individual leadership of East Herts Council’s public health role.

Awaaz FM
Although Awaaz FM is a small and newly created community radio station, it is already showing how public health service can take different forms. Awaaz FM not only provides entertainment to Asian communities in Southampton but also focuses on wider health issues through its innovative programmes, which are transmitted in English, Hindi, Punjabi, Urdu, Pushto and Potohari. Awaaz FM plays a pivotal role in collecting information on health issues and services and then translating them into messages for ‘hard-to-reach’ populations. Its ground knowledge of how Asian communities work (culturally and structurally) is clearly an asset to public health. The evidence suggests that Awaaz FM has already been instrumental in positively influencing local health awareness and behaviours in Southampton.

For the fourth year running, the Royal Society for Public Health (RSPH) continues to support and encourage good practice in East Herts Council health promotion through the Health Even prior to the NHS reforms many local Promotion and Community Well-Being councils had been heavily involved in the Organization and Partnership Awards. The public health arena. This has been the case aim of the awards is to recognise at East Herts Council which launched its achievement in the development and Public Health Strategy 2008–2013 with the implementation of health promotion and purpose of providing a framework of action community well-being strategies and for the prevention of ill health, the initiatives. protection of health and the promotion of The awards support the work that positive health and well-being.2 organizations do in empowering people This strategy and communities to gain has been a control over the underlying catalyst in factors that influence their The aim of the awards is motivating likehealth and well-being. The to recognise achievement minded criteria have at their heart partners to the Ottawa Charter,1 in the development and work together whose principles are still implementation of health on health widely used as a promotion and projects in East benchmark for good Herts. As such health promotion practice. community well-being The award scheme is strategies and initiatives the Health Engagement also developmental. Each Panel, which year the criteria feed from oversees and current public health develops the strategy, has good policy and from the experience and representation and input from elected knowledge new applicants bring. As such, members, senior and operational the scheme has widened its reach in order

Sefton Partnership
The Sefton Partnership is a group of seven agencies with a long-lasting and collaborative working relationship towards tackling health inequalities. The agencies involved include Sefton Borough Council, Merseyside Fire and Rescue, One Vision Housing, Sefton Community Service Volunteers, May Logan Health Centre and Sefton Primary Care Trust. This is the second time that the Sefton Partnership has achieved the RSPH award

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FEATURE
due to its high level of joint working, as well as its strong commitment to the Ottawa Charter principles. The Sefton Partnership is committed to the community development approach, a key element for health promotion and for the sustainability of any project. This year’s winners illustrate the sector organization can initiate health importance of partnership working and the promotion programmes through enduring relevance of the Ottawa Charter partnerships (with both private and public approach to sector organizations). improving and Purely Nutrition In a changing public sustaining community illustrates how initiatives can be made health landscape, health health and well-being. scalable through promotion still features The impact that each project has had on its public-sector as a mainstream local community structures (primary approach to improve shows that when it schools) and sustainable through health and address the comes to improving corporate sponsorship. wider social determinants health, a joined-up approach is key. This Purely Nutrition’s of health is a sentiment that Sir PhunkyFoods initiative Michael Marmot, is a unique and Director, UCL Institute of Health Equity, was innovative primary school programme that keen to emphasise when he congratulated involves healthy eating and physical activity one of the winners: lesson plans, resources, training and support for teachers. So far 800 primary If we are to reduce health inequities it is schools have taken part in PhunkyFoods essential to take action on the social over the past seven years, and the appeal determinants of health – the “causes of for this type of initiative is increasing rapidly the causes” of ill health. That means as a further 175 primary schools are getting working in partnership at local level to involved this year. improve the social conditions in which This initiative epitomises the contempowe are born, live, grow, work and rary public health strategy embodied in the age. The Well London Alliance white paper Healthy Lives, Healthy People: Partnership does just that. Empowering Update and the Way Forward4 and the individuals and communities, and giving National Institute for Health and Clinical people a voice is integral to addressing Exellence (NICE) guidelines and embraces health inequalities. I am delighted the the Big Society approach through privatePartnership has achieved well-deserved sector contribution in corporate and social recognition for its work. responsibility. This year’s winners show how truly varied the programmes and organizations Centre for Workplace Health – The undertaking health promotion initiatives can Active Workplaces Project be. Equally important is that they represent The Centre for Workplace Health (CWH) is examples of how policy can be translated a health-promotion service based within St into practice. Mary’s University College London with an To apply for the 2012 Health Promotion emphasis on creating healthier businesses Award Scheme or for further information and healthier working communities, using please contact Nelly Araujo on naraujo@ sustainable, practical and cost-effective rsph.org.uk or 020 7265 7322. approaches. The CWH draws upon its academic background to act as a knowledge transfer unit, working with the private and public References sector and policy makers. The CWH’s success in translating theory into practice is 1 Ottawa Charter for Health Promotion. supported by a sustainable business model Available at <http://www.who.int/hpr/NPH/ that compromises tailored projects and docs/ottawa_charter_hp.pdf> Last accessed 4/11/11 bespoke training for businesses, and the 2 East Herts Council Public Health Strategy provision of commissioned services for 2008–2013. Available at <http://www. local authorities.

School Food Trust
The Coalition Government has emphasised its support for charities and social enterprises to expand their work and have greater involvement in the provision of social service projects.3 In line with this objective, the School Food Trust (SFT) was originally set up by the Government as an agency to promote good nutrition in schools. The SFT’s focus is on health promotion through advice, research, resources, support and training to help improve the nutritional quality of school food for children. The SFT’s Let’s Get Cooking initiative has established the country’s largest network of healthy cooking clubs for children and has had a demonstrable impact on children’s health. The SFT is moving to a self-funding model with emphasis on the delivery of a commissioned project. There is huge potential for the SFT to expand its reach to other settings such as universities, care homes and workplaces.

Well London
Well London is an initiative led by a partnership that consists of seven principal agencies: London Health Commission, Arts Council England, Groundwork London, Central YMCA, London Sustainability Exchange, South London and Maudsley NHS Foundation Trust, and the University of East London. Well London’s health promotion practice is based on a community development and capacity building approach, which allows communities to have greater involvement in identifying their problems and developing solutions. This approach is also of direct relevance to the current policy context, including the Big Society and Localism. After five years of working with 20 of London’s most deprived neighbourhoods, the Well London initiative has produced a sustainable and positive impact on people’s health and well-being. Its approach is highly transferable to other communities and a second wave of communities is imminent.

This is what good practice in health promotion looks like!
In a changing public health landscape, health promotion still features as a mainstream approach to improve health and address the wider social determinants of health.

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Purely Nutrition – PhunkyFoods
Purely Nutrition is a small privately owned company and demonstrates how a private-

eastherts.gov.uk/index.jsp?articleid=9326> Last accessed 4/11/11 Building the Big Society. Available at <http:// www.cabinetoffice.gov.uk/news/building-bigsociety> Last accessed 4/11/11 Healthy Lives, Healthy People: Update and Way Forward. Available at <http://www.dh. gov.uk/en/Publichealth/ Healthyliveshealthypeople/index.htm> Last accessed 4/11/11

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GUEST EDITORIAL

Guest Editorial
The current economic crisis has re-energised the debate about the purposes of education. Whereas utilitarians continue to argue that fundamentally schools should prepare children to serve the economic and employment needs of the nation, academic idealists look to the value of education for its own sake and the need to nurture thinking skills, research and high culture. While the policy balance between these two ideologies will undoubtedly become readjusted again in due course, the one aspect which continues to be missing from this discussion is what learners themselves require. In particular, how they can be helped to lead purposeful existences in which they are capable of making decisions about their own life and health choices through effective understanding and evaluation of the options available to them. At present, most health education is piecemeal and focussed on specific crises in the nation’s well-being – e.g. increasing levels of obesity or drug usage (Sanderson, p. 19). In order to introduce some much needed coherence, a planned health literacy implementation model is required that is holistic and develops skills and attitudes as well as basic knowledge.1 Key to this will be how and by whom the messages are delivered. Firstly we consider how teachers and health professionals are not always best suited to delivering such messages and the article on page 17 describes a successful peer education strategy in which the students themselves take a leading role. Essentially, health literacy is about empowering people to take better control of their lives through appropriate experiences and understanding.2 Marshall et al. (p. 31) argue also that: “An investment in health literacy will ultimately increase a patient’s self-esteem, compliance and capacity to self-manage”. In addition, the resultant improvement in people’s health literacy levels should help increase their proficiency as parents to pass on appropriate attitudes and behaviours to their children, which in turn will help create a sustainably healthier population in the future.2 I have previously argued for health literacy to be on an equal standing with English language & literacy and numeracy in the primary school curriculum,1 on the basis that this is the most effective way of generating the behavioural changes that will allow society to move to a position where prevention of ill health becomes more fundamental and acceptable than treatment alone. Clearly, proficiency in English language is an essential prerequisite for the development of good health literacy, and with the increasing numbers of UK residents with mother tongue languages other than English, the need for approaches that successfully link learning in English language and health literacy is becoming critical. Stewart (p. 21) describes how one college in Birmingham has been tackling this issue. The role of social marketing in assisting individuals to make appropriate decisions about their lives is also an important component in improving health literacy. Fortunately, Reynolds (p. 24) concludes that the future ahead for social marketing seems positive, both at the operational level of individual behavioural change and at the strategic level of the emerging Government’s public health policy. Worryingly, though, Brosnan et al. (p. 39) have shown that more than a quarter of the Irish population have marginal or low health literacy, while Marshall et al. (p. 29) consider health literacy to be a national issue in Ireland, which could have drastic consequences yet is readily surmountable. Of most concern, however, is that previous research into health literacy has been limited and focussed mainly on adults; largely around helping them understand better the illnesses that they have developed already e.g. cancers.3 As a result, little attention has been paid to the best ways of developing health literacy in children. Indeed Sanderson (p. 19) argues that despite substantial investment in the Healthy Schools programme, there has been little evaluation of its real effectiveness, and in many respects health education has now lost its sense of direction and purpose. There is, therefore, an urgent need for the current debate about the purposes of education, particularly for young children, to focus much more on health and wellbeing and the development of health literacy, since this will not only support the establishment of a healthier population but also reduce the economic costs of ill-health and healthcare; help diminish health and social inequalities; and enable health professionals to have a much more powerful impact upon the lives of a properly informed and aware population. The RSPH recently organized a workshop to examine the current state of health literacy development among primary age school children and to establish possible policy changes and practical interventions that could be introduced in the future. The outcomes of this workshop are described in a report assembled by Menzies (p. 43), which concludes with a series of suggestions for further action. Readers are most welcome to write to the Editor of this journal about the views expressed in this report and to become actively involved in advancing the discussion around this vital aspect of health improvement. As Sanderson concludes: “There should be a clear commitment at all levels that children do deserve better than they have had so far”. References
1. Healthipedia; S J Hodge, Perspectives in Public Health 2011; Vol 131 No 2 2. Vaccination education – more than just information campaigns; S J Hodge, Vaccines in Practice 2010; Vol 3 No 4 3. Health Literacy and Cancer Communication; Terry C. Davis, Mark V Williams, Estela Marin, Ruth M Parker, Jonathan Glass, CA Cancer J Clin 2002; 52:134 -149

Dr Selwyn Hodge Chair, RSPH Author Biography Selwyn Hodge is a former Deputy Head Teacher; University Lecturer in Science Education; Research Fellow in Educational Management; Schools Adviser; LEA Chief Education Adviser; LEA Director of Education, and an OFSTED Inspector of Schools

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How to avoid ‘dad dancing’: a peer-led approach to the delivery of health education in secondary schools
Martin Page, from Manningtree High School, looks at how a peer-led approach could be the way forward in delivering health education in secondary schools
shapes’ that were, it has to be said, pretty impressive. So what are your alternatives if you are not that gifted a dancer? Very simple: if you cannot dance you go for comedy. Just ask the great Sir Bruce Forsyth, one of the last remaining British performers with his roots in 1950s variety theatre – a dancer, musician and comedian – the complete ‘entertainer’. Hence the concept of ‘dad dancing’ was born. Safety in numbers was always necessary when attempting ‘dad dancing’ – a minimum of three but no more than six participants. One did not want to raise the dander of the local ‘marines’ in a naval city. A simple concept, one would simply enter the circle created in the centre of the dance floor for maximum effect and replicate Dad’s dancing at Auntie Margaret’s 50th birthday party to be copied by all participants. Each member took their turn to lead in ever-increasing levels of un-coordinated, non-rhythmical hilarity. Until everyone on the periphery was watching, suitably impressed, or the record ended – whichever came first. Why this parody of dancing like your father? Well, quite simply, as a teenager the perception was that everything your parents did was ‘un-cool’, whether it was the music they listened to, the clothes they wore or many of their views on how you should live your life. If there were a coolness perception table, parents would undoubtedly be bottom of the league, closely followed by teachers. So why do many schools still continue to deliver health education via nonspecialist teachers? I accept that there is some excellent practice that takes place in many secondary schools in delivering this important message. But let’s be honest, schools’ priorities are about achieving exam results in ever-tighter financial circumstances and in many cases personal, social and health education (PSHE) is a statutory afterthought that is all too often delivered by non-specialists who are uncomfortable or disinterested with the content. This can create, at worst, a scenario where teachers cringe at the thought of delivering PSHE, while the students are slowly sliding down their chairs with embarrassment. Now bring on the entertainers that will engage and educate: youth health champions (YHCs). This initiative has been piloted by North East Essex Primary Care Trust. It is innovative and uses 15- and 16-year-old students as facilitators of health education and also to act as a signpost for their peers when further professional advice is needed. It is

I am sure many remember in our younger days the importance of having a certain level of skill on the dance floor in order to impress and catch the eye of a partner. In my case I am talking about a time when Strictly Come Dancing was still the glint in the eye of a junior BBC researcher. No sequins and lycra here, just clubs and discos and nonchoreographed mayhem. All educationalists and coaches know that skill needs to be rehearsed and refined but at that time in my life the skills I wanted to rehearse were firmly focused on the sports fields of the West Country and not its dance floors. Nevertheless, there were always one or two people at these discos that could (and I use the parlance of the time) ‘throw some

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The benefits are clear for all to see, know that it is them from whom they can simplicity itself and yet so effective. Who whether it is the engagement of the seek help. will students listen to if it’s not parents students when working in a small group The YHCs have a and teachers? with a YHC during their PSHE session or year-long coordinated Each other, of the feedback from the students approach in the school course. The The power of the peer themselves. They clearly advocate this calendar with Health power of the message cannot be peer approach stating that it is far more Awareness weeks, peer message underestimated relevant and easy to understand when it which include a visual cannot be is delivered by one of their display staffed by the underestimated contemporaries. YHC students at and what is the As with anything innovative, it requires different venues around the school site, cost to the school? Nothing. Yes, leadership in conjunction with the absolutely nothing. that will delivery of an hour-long What is needed is a forward-thinking overcome the targeted health session primary care trust that is willing to invest this approach is so doubting during a PSHE lesson some of its resources into three days’ effective because it uses voices, but that week. intensive training for the YHCs, to the argument The YHCs, in educate them on all the relevant health the very best resource in this case is consultation with a lead issues that our young people are now that any school has: the persuasive. member of staff, decide faced with. It also requires a school that students themselves As the YHCs the content of the session recognises the value of ‘student voice’ have become and which year group it is and the benefits of a peer-led approach. more to be targeted. The YHCs At Manningtree High School we already experienced, their sessions and their also have a very important signposting had a strong base of ‘student voice’ with involvement have improved. After all, any role when peers may stop them in the Pupil Observers of Learning (POOL) and skill needs to be practised and rehearsed corridor or on the field if there is an active school council. The YHC was to become accomplished, but most something they need advice with. The the next obvious step – students leading importantly this approach is so effective YHCs are fully trained in where their learning in health education. because it uses the very best resource responsibilities start and finish and This peer-led approach has created a confidentiality training is paramount. They that any school has: the students group of 12 well-trained, approachable, themselves. also have the knowledge that they can easily identifiable students (they wear refer things to the school nurse when purple YHC polo shirts on their duty necessary. days) who their peers look up to and

References
1. Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M, et al. Fair Society, Healthy Lives. The Marmot Review. Strategic Review of Health Inequalities in England post-2010. London: The Marmot Review, 2010 2. HM Government. Confident communities, brighter futures: a DH framework for developing well-being. London: DH, 2010 3. Davidson M, Roys M, Nicol S, Ormandy D, and Ambrose P. The real cost of poor housing. Bracknell: IHS BRE Press, 2009 4. Audit Commission. Building Better Lives: getting the best from strategic housing. London: Audit Commission, 2009 5. Minton C. Generation Squalor: Shelter’s National Investigation into the Housing Crisis. London: Shelter, 2005 6. Stewart J and Rhoden M. Children, housing and health, International Journal of Sociology and Social Policy. 2006; 26 (7/8), pp. 326–341 7. Gloyn E. Overcrowding and Health: an issue or an answer? Conference Proceedings, Warwick Healthy Housing Conference, 2007 8. Means R. Safe as houses? Ageing in place and vulnerable older people in the UK. Social Policy & Administration 2007; 41 (1) pp. 65–85 9. Croucher K, Hicks, and Jackson K. Housing with care for later life: a literature review. York: Joseph Rowntree Foundation, 2006 10. DEFRA and DTI. The UK Fuel Poverty Strategy 4th Annual Progress Report, HMSO, 2006 11. Stewart J. and Habgood V. The Benefits of a Health Impact Assessment in relation to Fuel Poverty: assessing Luton’s Affordable Warmth Strategy and the need for a national strategy. Journal of the Royal Society for the Promotion of Health, (now Perspectives in Public Health) 2008; 128 (03), pp. 124–130 12. Scottish Power Energy People Trust, NHS Blackpool and Blackpool Council. Project Counter Attack: End Project Report. Scottish Power Energy People Trust, NHS Blackpool and Blackpool Council Blackpool Council, 2009 13. IDeA Knowledge. Housing & Health Working in Partnership Example One: SEASHORE in Blackpool Case Study Housing & Health Working in Partnership. London: IDeA, 2006 14. Central, North and South Liverpool PCT, City of Liverpool, Strategic Housing Partnership in Liverpool and Liverpool Partnership Group. Health Impact Assessment of Liverpool City Council’s Housing Strategy Statement, 2003 15. Chapman, Howden-Chapman, Viggers, O’Dea, Kennedy. Retrofitting houses with insulation: a cost benefit analysis of a random community trial. Journal of Epidemiology and Community Health. 2009; 63(4): 271–277

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Health education in schools: strengths and weaknesses in relation to long-term behaviour development
It has been 25 years since the Government first provided specific funding for health education in schools, but has this continued investment had much impact? Kath Sanderson, former Senior Manager in Children’s Services, Rochdale MBC, assesses health education in schools
knowledge and information in the naive belief that they would then make the healthy decisions. Rosenstock1 and others suggested that life skills, decision-making skills and assertiveness are key determinants of agreement that drug individual health action. PSHE education should be programmes were therefore developed part of wider PSHE that included activities to nurture skills in programmes and risk taking, decision making, where to consequently this fairly get help and coping with peer pressure, high-profile initiative became an incentive to and also to promote healthy attitudes. Lessons were developed for each year review the wider provision, including sex group based on the premise that if all children received good quality PSHE and relationships throughout their school lives, then the education. likelihood would be that we would equip Health education them to make healthier choices and to messages are not live healthier lives now and in the future. always simple. While A plethora of resources were produced there is general to support the teaching. Although there agreement to just say is some well-documented research on no to illicit drugs and tobacco, we need the effectiveness of specific projects, to tread more carefully where parents there has been little robust long-term and other family members smoke. evaluation Alcohol often comes across into what as ‘not now, but it is OK to influences drink sensibly later’, and There is undoubtedly behaviour healthy eating and exercise some very good PSHE either now or messages are not clear as provision in schools, in the future. we can eat chocolate but on the whole it There is occasionally and we do not undoubtedly remains patchy have to exercise every day. some very Not only was there much good PSHE debate about what to teach, provision in but also how to teach it. schools, but on the whole it remains There was some success in moving patchy. Through my work with schools away from the ‘tell them and they won’t over many years, there seem to be a do it’ and the ‘fear’ approaches and also number of key issues that continue to from one-off talks. We also moved away detract from its success: from just giving children the appropriate

In 1986, in response to growing concerns about drug use by young people, the Government provided the first of many years’ funding to local authorities to ensure that drug education was developed in all schools. Prior to this, most schools had provided some form of health education ranging from hygiene and dental health to lessons in wider personal, social and health education (PSHE), while a small number of national organizations provided support and resources for teachers. There was reticence from many schools, both primary and secondary, to this initiative, since they were concerned that providing drug education would lead parents and others to think the school had a drug problem. There was general

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• The status for PSHE remains low in many schools and local authorities. • Many teachers do not want to teach it. • Both initial teacher training and in-service training for teachers is patchy, particularly in terms of purpose and methodology. • Not all children and young people receive the same PSHE and there is a lack of consistency across year groups in individual schools as well as across schools. • There remains a vagueness about what we are trying to do and the key messages we wish to deliver. • There is remarkably little robust evidence about the effectiveness of PSHE as it is currently taught. to the process and to policy long-term behaviour. Schools are only development, there seems to be less one influence on children and young focus on high-quality teaching and people, but they are the only agency in learning of PSHE. Many schools collapse very regular contact with all of them. As PSHE into Health Weeks, again with no such, schools can have a huge impact evidence of impact. on their students’ Independent research in health and we need 20093 revealed to pursue this 97% of schools are opportunity to the significant links between very best of our achieving and working currently involved ability. towards the NHSS, and with the Healthy At present, we better Ofsted ratings of Schools programme seem to be at an school-effectiveness. at some level impasse, continuing While this is very to do what we have positive, there is still little always done. In order evaluation of the impact to move forward we need the following: of Healthy Schools on long-term healthrelated behaviour changes. • A clear understanding and agreement The government funding has provided about the intentions of health additional support to schools, and 97% promotion for children and young of schools are currently involved with the people. Healthy Schools programme at some • Clarity about the desired outcomes level;4 it has been hailed as a success by and the evidence we need to ministers. The current Healthy Schools demonstrate success. toolkit provides a ‘plan–do–review’ • An understanding and agreement approach and suggests that schools about the role schools should play develop action plans and choose and the impact they can have. evidence-based activities to meet the • A review of how best this can be desired outcomes. Given that there is delivered in schools, in particular little evaluation to work with, this is which interventions will deliver the probably a difficult task for schools. desired outcomes. The current Department for Education • Clarity about what is required of (DfE) website highlights the NHSS aims:4 schools and individual teachers to To improve standards in health and achieve this. education and to tackle health • Consensus about the role of other inequalities and to make children, agencies. teachers, parents and communities • Clear commitment, at all levels, that more aware of the opportunities children deserve better than they have that exist in schools for improving had so far. health. While these are laudable aims, they are somewhat removed from ensuring longterm healthy behaviour.

Current Practice
During the mid-1990s, the European Health Promoting Schools model gained acceptance as one of the most powerful approaches to promoting health.2 This was concerned with the whole school experience, not just what was taught. In the Health Promoting School, health, in its broadest sense, was intended to be at the heart of the school. Relationships, respect and consideration for others, together with the development of selfesteem and self-confidence, were seen as underpinning the day-to-day way in which pupils and staff work together. The development of Health Promoting Schools was in its infancy when the government launched its National Healthy Schools Standard (NHSS) in 1998. This was a whole-school approach working in partnership with other agencies and parents and funded by both Health and Education Departments. Although based on the Health Promoting School model, in my view, the concept of Healthy Schools is much less rigorous than its antecedent in respect of process and outcomes. Healthy Schools has certainly raised awareness of health issues and has provided structure and coordination. However, from my own involvement with schools I have found that the wholeschool approach is often not embedded well and although much effort is applied

References
1 Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2: 328–35 Clift S, Jenson BB, Paulus P. Introduction to the Health Promoting School: International Advances in Theory, Evaluation and Practice. Copenhagen: Danish University of Education Press, 2005 National Centre for Social Research. Available at <http://www.natcen.ac.uk/our-researchand-publications> Last accessed 4/11/11 Department for Education. Available at <www. education.gov.uk> Last accessed 4/11/11

Conclusion
Twenty-five years on from the first specific health funding for schools, pupils do receive more health education and the likelihood is that there will have been real benefits. Nevertheless, provision is not equitable between schools, either in terms of quality or quantity. There is still no clear evidence of effectiveness or of any significant impact on short- or
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ESOL for health: helping those with limited English language skills to use the NHS
When it comes to accessing healthcare, poor English language skills can be a major barrier. Selina Stewart, from Joseph Chamberlain Sixth Form College Birmingham, introduces a project that has helped to make the NHS more accessible
giving birth had difficulty reading or speaking English.3 NICE recommended that these women should be offered information on access and entitlement to health care.4 However, access to this information is restricted if women lack JCC has many literacy in English and the problem is years’ experience in made worse if, as with 76% of JCC providing English as a students at Pre-entry level, students lack Second or other literacy in their own languages. For Language (ESOL) Birmingham this is a significant problem. classes for Helping women from patients to the Yemeni, overcome 10.2% of women Pakistani, literacy and giving birth had Bangladeshi language difficulty reading or barriers has and Somali communities. been a real speaking English Colleges have challenge for found that HOBTPCT. many women Over £1 attending these million was spent on interpreters in classes do so 2007/8 in the Heart of Birmingham. If because they want to be able to talk to health professionals rely on family medical professionals. However, in members alone to act as interpreters everyday ESOL classes where teachers then this could potentially cause are preparing students for exams, they embarrassment for the patient or family simply do not have the time to research member, as well as poor-quality and produce materials that focus on interpretation.4 While employing health in the way many students would translators can be costly, failure to like. Students are taught how to say body access services at the appropriate time1 parts but more specific medical or place can increase costs further and terminology is simply not covered lead to poorer health outcomes in the because it is not needed for the exam. long term. Research in 2004 identified HOBTPCT has found that an ability to that language and a lack of speak and read English is essential for understanding prevented women from good health and accessible health care. going for a cervical smear test.5 The In this PCT there is a significant Woman-to-Woman Report into cervical population with limited English skills; one screening among ethnic minority women in every five adults lacks language skills showed that education improves the above Entry 3 level.2 Such statistics are understanding of why smear tests are so not confined to Birmingham alone. The important. This is an issue that can be National Institute for Clinical Evidence extended to many other areas of child (NICE) calculated that 10.2% of women and adult health care.5

In urban areas like Birmingham it is not uncommon for health professionals to treat women who cannot speak English and who have no real understanding of the way the NHS works. This is frustrating for health professionals and for the women concerned and can often lead to poor health outcomes. To help make the health service more accessible, the traditional solution is to bring in interpreters (either official or informal). However, many women do not like using their husbands or family members to translate and they do not necessarily feel comfortable discussing sensitive health issues with an official interpreter.1 Heart of Birmingham Teaching Primary Care Trust (HOBTPCT) and Joseph Chamberlain College (JCC) have worked together to offer a solution to this problem.

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In order to find effective solutions to a lack of English language skills and poor knowledge of the way the NHS functions, HOBTPCT funded a threeyear project to develop high-quality teaching materials and deliver these to over 340 women living in the Heart of Birmingham area. JCC appointed a very experienced ESOL teacher to research the topics and to write the materials at three levels: • Pre-entry, which is best described as a similar level of reading and writing English to a reception child in primary school. • Entry 1 level, which is similar to a first year junior school child of seven or eight years. • Entry 2, which is equivalent to a top junior child of about 11 years. The NHS is notorious among literacy and ESOL teachers for the complexity of its leaflets. JCC ESOL teachers therefore used the medical content of the materials but translated them into straightforward English so that they were easy to read for both non-English speakers and mothertongue English speakers. All the materials were developed in consultation with relevant health professionals from HOBTPCT or other NHS professionals and were then checked by the PCT for accuracy. GHK Consulting was appointed as external evaluator to assess the effectiveness of the project. The materials form a five-module course, which includes over 35 story books available at the three different levels (there are 117 books in total). Videos, audios and interactive exercises for use on an interactive whiteboard or a PC were also developed. The modules cover the following health areas: growing and we have constant requests for further classes, specifically to help mother-tongue English speakers living in outer-city estates who lack basic literacy. Feedback from the children’s centres has been very positive. They have reported that improving the language skills of patients is cost-effective for health centres. Through ensuring awareness of available services and providing knowledge of the right services to access, The scheme was well received among a health outcomes could be improved and number of children’s centres in costs reduced.6 Furthermore, women Birmingham, with many offering rent-free venues and childcare for those who have said that they feel much more able wanted to take up the to make an appointment course. GHK found in its and visit their midwives improving the evaluation that they so and GPs independently.6 welcomed the course The project was initially language skills because of the lack of funded until the end of of patients is low-level ESOL provision cost-effective for March but the PCT has and also the fact that provided some further health centres many women who had funding to support classes not been living in Britain to continue until the end of for three years could not June 2012. JCC will conaccess ESOL classes. Cherry Tree tinue to use the resources in ESOL and Children’s Centre in Lozells, Birmingham literacy classes and the published version was one of the first children’s centres to of the course, which has been accredited work with the project. The staff in the by the Royal Society for Public Health, centre helped to recruit women who will be available for purchase through the needed ESOL for health reasons. Interest ESOL for Health website. Any income in the project has continued to grow at from this will be fed back into extending this centre with 52 women so far taking the provision of ESOL for Health classes the course; a further 50 women queued in the Birmingham area. for places in September 2011. ESOL teachers, children’s centre staff The course was also adopted for and health professionals, especially Chinese people living in Birmingham. The midwives, have seen the real impact of Chinese community is often overlooked the course. Women who have taken the when it comes to literacy and so through course can see what a difference it has the Chinese Community Centre in made to their lives, from the ability to go Birmingham, a Mandarin-speaking ESOL to a GP independently to knowledge teacher was employed. The course has about what basic steps to take to again proved popular with students. improve the diets of their families. The To date, 12 children’s centres have materials are so thorough that it can be helped 320 women across many differdelivered by non-specialists and can ent communities complete at least one have a real impact on the lives of some module of the course. Interest is still of the most hard-to-reach women. • Pregnancy • Childbirth and child development to age three • Healthy living (obesity, drug use, smoking and heart disease) • Women’s health (menopause, mammograms, cervical smears and breast cancer) • Carers

References
1 Phillimore J, Thornehill J, Latif Z, Uwimann M, Goodson L. Delivering in an Age of Super-Diversity: West Midlands Review of Maternity Services for Migrant Women. Birmingham: Institute of Applied Social Studies, University of Birmingham, 2010 Heart of Birmingham Teaching Primary Care Trust. HOB Public Health Report, 2009–10. Available at <www.hobtpct.nhs.uk> Last accessed 4/11/11 UK Statistics Authority. Health Statistics Quarterly 28, Winter 2005. Available at <http://www.ons. gov.uk/ons/rel/hsq/health-statistics-quarterly/ no--28--winter-2005/health-statistics-quarterly. pdf> Last accessed 4/11/11 National Institute for Clinical Excellence. Pregnancy and Complex Social Factors, 2010. Available at <http://guidance.nice.org.uk/ CG110> Last accessed 4/11/11 Chiu LF. Woman-to-Woman: Promoting Cervical Screening amongst Minority Ethnic Women in Primary Care. Leeds: Nuffield Institute for Health, University of Leeds, 2004, p. 27 GHK Consulting. Interim Evaluation of JCC/ HOBTPCT ESOL for Health Project. Birmingham: GHK Consulting, 2011, p. 38

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Health literacy and public health: a framework for developing skills and empowering citizens
Professor Gill Rowlands from London South Bank University and Chair of Health Literacy Group UK looks at how health and education should work alongside each other in order to ensure good health
Health literacy is a growing issue in the fields of public health and health promotion. It provides a framework through which to explore how the health and education fields can work together to improve a range of citizens’ skills throughout the life course to achieve and maintain good health. Health literacy can be defined as: ‘… the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health.’1 Nutbeam’s seminal paper describes how health literacy can be usefully viewed as a set of skills mirroring literacy theory, including:2 • Functional: literacy and numeracy skills need to be able to function effectively in everyday health situations. • Interactive: more advanced cognitive and literacy skills that can be used to actively participate in everyday activities and to apply new information to changing circumstances. • Critical: advanced cognitive skills that can be applied to critically analyse health and health-related information, and to use this information to exert greater control over life events and situations. An individual’s skills are not applied in a vacuum; society, community and the health care systems will mediate the impact of skills on health.3 In the health literacy debate, therefore, both sides of the equation need to be considered; the skills that citizens need to become health central to the definitions adopted and the measures used. In the clinical setting, practitioners and patients are involved in a one-to-one relationship that largely takes place in clinics and hospitals, literate, and the health literacy of society outside people’s everyday lives, with and health and education systems. complex information transmitted from practitioner to patient. The focus for Health Inequalities and Health research in this setting, described above, Literacy has been on the mismatch between the Health inequalities arising from remediafunctional literacy and numeracy skills of ble social and economic causes are well those receiving and those transmitting recognised 4,5 and resistant to change.5 health information. The balance of power Health literacy is increasingly recognised within this paradigm lies with the as one of these social determinants of practitioners health.4 The evidence and the health base for the associaservice within tions between funcHealth literacy is which they tional health literacy2 increasingly recognised operate; they and health inequalities are responsible as one of these social has been largely underfor delivering a taken in the USA, where determinants of health service lack of the former has accessible to been shown to be all, including associated with higher risks of developing, and developing com- those with low basic skills; the responsibility of patients is to act on the plications of, long-term conditions such information they are given. as diabetes mellitus, heart failure and A public health approach, as seen in asthma6–8 and with higher health care Canada,10 takes a different perspective. costs.9 There is currently little or no evidence on the associations between inter- This highlights the importance of active and critical health literacy skills and individuals’ lifestyle decisions on health outcomes; while it is reasonable to promoting health rather than preventing illness.11 It shifts the focus away from the hypothesize that the health inequalities seen with functional skills are augmented practitioner–patient consultation to the skills that individuals employ to evaluate for these more complex skills, research health information within the context of into this area, and potential points for their lives and throughout their life intervention to reduce health literacycourse. The responsibility moves from related inequalities, is urgently required. health practitioners towards the public and policy makers. Policy makers should Health Literacy in Health, Public ensure that societal factors promote Health and Community Settings: equity of access to relevant information, Shifting the Balance of Power the development of individuals’ skills to The settings within which health literacy understand and evaluate such enquiry and practice take place are

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information, and the environment within which change can happen. Individuals then have a responsibility to, where practical and appropriate, incorporate information-based change into their lives. The balance of power, and hence level of responsibility, moves away from being practitioner-dominant to being a partnership between patients and practitioners; practitioners are a trusted source of information with whom to consult (interactive health literacy),2 while patients are ultimately responsible for decisions concerning their health. A further shift of power and responsibility occurs when the focus shifts to communities. Levin & Wills have described supporting communities to develop critical health literacy skills 2 with encouragement to exert more control over their environment and social determinants affecting their health and well-being, leading to better health and more effective use of resources.12 Within this setting, medical-information finding can move out to the community. Such an approach may empower patients to manage their own health and long-term conditions, essential if health services are to cope with everincreasing demands, and hence costs, brought by a combination of increasing life expectancy, rising levels of long-term conditions and advances in modern technology and treatment.13,14 policy makers? All, if adequately funded and appropriately applied, should result in improved health and reduced health disparities, but with significant differences in speed and sustainability that need to be considered. A clinical/biomedical approach, with identification of individual patient risk combined with approaches to improve communication and simplify health systems, will be faster, easier to implement and cost-effective. Those changing and improving practice are clinicians and managers; federal or national standards and targets could be quickly designed and applied, with improvements likely to be demonstrable within a short (three- to five-year) period. The problem is that this does nothing to address the underlying causes of inequality but simply ameliorates its effects. The personal and societal costs of long-term conditions will thus only increase with an aging population and improving medical technology. An alternative approach is one of public health/health promotion to develop interactive and critical health literacy skills. This requires joined-up health and lifelong learning policy, with teachers, health professionals and health promotion experts developing and delivering courses that enable the public to ‘learn how to learn’ through identification and evaluation of information relevant to health and wellbeing. In addition, it involves developing an understanding of how lifestyle and the environment impact on health, and the skills needed to take control of adverse circumstances. This is a longer-term approach, the major effect being a reduction in the development of longterm conditions; it will take five to ten years before benefits start to show, and a generation for the full effects. This approach is not necessarily more expensive, but requires a shift of policy across government departments and interdisciplinary working within the health and education fields. The potential benefits of such an approach are huge: an informed and empowered citizenry in control of its own health. The ultimate proof would be a reduction in the inequalities in the prevalence of longterm conditions, and more effective medical treatments. What is needed now is for national debates on the issues, followed by informed and joined-up policy with clear national leadership and measurable outcomes tailored to the approach adopted. Public health and health promotion experts have the skills and expertise to play a leading role in informing such debates, both through engagement with government to influence policy, and through opening public dialogue in this important area. This article was written on behalf of the steering group of the Health Literacy Group UK, for more information visit www.healthliteracy.org.uk.

Health Literacy and policy
What are the implications of these different approaches for government and

References

References
1 2 Nutbeam D. Health promotion glossary. Health Promotion International 1999; 13: 349–64 Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 2000; 15: 259–67 Nielsen-Bohlman L, Panzer AM, Kindig DA (eds) Health Literacy: A Prescription to End Confusion. Washington, DC: Institute of Medicine, 2004 Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report. Geneva: World Health Organization, 2008 Department of Health. Health Inequalities: Progress and Next Steps. London: Department of Health, 2008 6 Mancuso CA, Rincon M. Impact of health literacy on longitudinal asthma outcomes. Journal of General Internal Medicine 2006; 21: 813–7 Murray M, Tu W, Wu J, Morrow D, Smith F, Brater D. Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clinical Pharmacology and Therapeutics 2009; 85: 651–8 Rothman R, Malone R, Bryant B, Horlen C, DeWalt D, Pignone M. The relationship between literacy and glycemic control in a diabetes disease-management program. The Diabetes Educator 2004; 30: 263–73 Howard DH, Gazmararian J, Parker R. The impact of low health literacy on the medical costs of medicare-managed care enrolees. American Journal of Medicine 2005; 118: 371–7 10 Canadian Council on Learning. Health Literacy in Canada: A Healthy Understanding. Ottowa: Canadian Council on Learning, 2008 Gillis DE, Gray N. Health literacy and healthy lifestyle choices. In: Rowlands G, Begoray D, Gillis DE, editors. Health Literacy in Context: International Perspectives. Hauppauge, NY: Nova Science, in press Levin-Zamir D, Wills J. Health literacy, culture and community. In: Rowlands G, Begoray D, Gillis DE, editors. Health Literacy in Context: International Perspectives. Hauppauge, NY: Nova Science, in press Wanless D. Securing our Future Health: Taking a Long-Term View. London: Department of Health, 2002 Cayton H. The flat-pack patient? Creating health together. Patient Education and Counselling 2006; 62: 288–90

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Understanding and health literacy
Do you understand what is meant by the term “health literacy”? Phil Mackie, Lead Consultant, Scottish Public Health Network and Consultant in Public Health, NHS Health Scotland, suggests that the term can often be confusing and leave us wondering what we are actually suppose to do about it
I first heard the term used back in the 1980s, when I was a graduate student. Back then, it seemed to be used primarily about the relationship between health status and the literacy – for which read (no pun intended) capacity of the individual to comprehend written materials. In any given year there would be a handful of studies published in peer-reviewed journals exploring the readability of health education materials or patient information sheet. Such studies often concluded that the average reading age of such materials was rather high for many in the population with “low literacy”. Yet, then again, health literacy also seemed to be applied to considerations of training health care professionals. In some cases they would consider the levels of literacy in emerging academic health care settings in what were called “developing countries”. In others the concern would be about the necessary literacy to be willing to adopt new technologies for information delivery (aka computers). Then in the 1990s, as the number of papers mounted to a hundred or so a year, the new themes emerged. The predominant theme may be characterised by studies which looked at the effects of literacy – and particularly low literacy – on patient compliance with treatment regimes. This would manifest in various health care settings, though all were exploring how low literacy was a barrier to accessing necessary health care. At the same time, a separate theme could be discerned: that of improving literacy, or finding mechanisms (including using aid such as hand puppets or computers) to enhance understanding as a means of increasing patient participation in health and health care decisions. I can even recall that some of these papers were promoting the view that the more literate a patient, the more likely they would be to being partners in the caring relationship.1 However, it is more recently that my confusion has grown. Not only has the number of papers published since 2000 increased year on year, but also the variation in what

3. Participation: a lack of capacity to follow a course of treatment or selfmanagement that will improve health and wellbeing, or change behaviour to prevent disease processes starting or progressing.

is meant by the term “health literacy” has These components may not be anything increased. A scan at the type of papers new, but they do help to clarify what the being published in peer reviewed journals purpose of any interventions to promote suggest that poor health literacy is a cause health literacy and prevent the consequents of health inequalities, it engenders poor of its absence for individuals within a wider compliance in health care professional and population, as well as for the public health self-management regimes, it reduced and health care professionals who work access to neceswith them. sary health care It may be old fashinterventions, it Health literacy is not a new ioned, but it is almost contributes to illconcept, though it does possible to recognise a judged decisions about health care seem to have developed primary, secondary and tertiary preventative by patients, and over time into something approach could be the list goes on. of a complex one applied to such compoBut these types of nents. So we can take outcomes cannot action to improve gensimply be the coneral literacy and specific health literacy. At sequences of low or poor literacy? If they the same time, for those who have a were, improving basic literacy would have reduced capacity in health literacy we can improved health outcomes long ago and act to militate against the consequences of clearly that has not happened. That health reduced comprehension and also put in literacy is a barrier to effective health care place measure which can improve particidelivery and efficacious health care conpation in health and health care. sumption is clearly not in question.2 But Health literacy is not a new concept, how can we make progress when it is such though it does seem to have developed an all encompassing issue? And where the over time into something of a complex one. evidence suggests that direct interventions Perhaps if we keep in focus what we are to improve literacy and improve health have 3 trying to do to improve literacy, comprehenhad limited impact? sion and participation in our communicaReflecting on three decades of research tions about and for health and health care into health literacy, it is possible to see the we will not go far wrong. emergence of a complex concept. But it also may show the basis of an approach to aid addressing health literacy. At its simplest level, health literacy has three components:

References
1 Baker DW (1999). Reading between the lines: Deciphering the links between literacy and health. Journal of General Internal Medicine. 14: 315–317. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine 155: 97–107 Pignone M, DeWatt DA, Sheridan S, Berkman ND, Lohr KN. (2005). Interventions to improve health outcomes for patients with low literacy: a systematic review. Journal of General Internal Medicine. 20: 185–192.

1. Literacy: a lack of capacity to read, write, communicate, or solve problems which affects the ability of an individual to gain necessary knowledge of health and health systems; 2. Comprehension: a lack of capacity to understand how health and health care services are structured and operate to meet health and health care needs and how they can be accessed; and

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‘No Decision About Me, Without Me’: a place for social marketing within the new public health architecture?

‘No Decision About Me, Without Me’: a place for social marketing within the new public health architecture?
Authors
Lucy Reynolds Senior Consultant, Finnamore Ltd, 6th Floor, Marble Arch Tower, 55 Bryanston Street, London W1H 7AA Email: lreynolds@finnamore. co.uk Corresponding author: Lucy Reynolds, as above

Abstract July 2011 marked the 40th anniversary of social marketing. However, while the previous Labour administration dedicated sustained resources and support to developing the field of social marketing, this was followed by a time of uncertainty during the Coalition Government’s ascent to power. This paper explores the potential future position of social marketing within David Cameron’s evolving public health landscape, outlining areas of synergy between social marketing’s key features, and the coalition’s emergent public health architecture. The paper concludes with an exploration of the development opportunities nascent within social marketing, suggesting that support for the new commissioners (GP and local authority), and an enhanced emphasis on evaluation of financial and social outcomes, will be required if the evidence base for strong practice is to continue to grow and evolve.

Keywords
big society; coalition government; public health; social marketing

IntroductIon
July 2011 marked the 40th anniversary of social marketing as a discipline first defined by Kotler and Zaltman in 1971: ‘Social marketing is the design, implementation, and control of programmes calculated to influence the acceptability of social ideas and involving considerations of product, planning, pricing, communication, distribution and marketing research’.1 More recently, the National Social Marketing Centre (NSMC) in England has defined social marketing as ‘the systematic application of marketing, along with other concepts and techniques, to achieve specific behavioural goals for a social good’.2 In addition, the NSMC has defined the key features (known as the ‘benchmark criteria’), which distinguish social marketing from more generic public advertising or health promotion campaigns. These include Fundamental principles such as ‘Consumer Orientation’, ‘Exchange’, ‘Market Segmentation’,

‘Methods Mix’, ‘Competition Analysis’, and clear ‘Behavioural Goals’.3 In essence, then, the aim of social marketing, is voluntary behaviour change for the benefit of society, and the discipline has a wide range of applications within the public health arena. The evidence base for the impact of social marketing is strong, both internationally and in England. In June 2006, the NSMC published ‘It’s Our Health!’,4 a review of the social marketing evidence base, which demonstrated the impact of the discipline when positioned as part of a more wide-ranging strategic approach to public health, and recommended the development of a national social marketing strategy to ‘improve the impact of our efforts to improve people’s health’.5 As suggested by the ‘It’s Our Health!’ report, one of the unique features of the previous Labour administration was its sustained endorsement of social marketing, both as an academic discipline, and as a potentially effective behaviour change methodology. Under Tony Blair and Gordon Brown, a public commitment to social marketing was sustained, through the 2004 ‘Choosing

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‘No Decision About Me, Without Me’: a place for social marketing within the new public health architecture?

Health’ White Paper,6 the 2006 ‘It’s Our Health’ report,7 and the 2008 ‘Ambitions for Health’ Strategic Framework.8 Leading the way amongst the international social marketing community, the Labour Government launched and funded the National Social Marketing Centre9 as a centre of excellence for the discipline, as well as funding large-scale, national social marketing programmes, including Change4Life,10 Think!,11 and national strategies for alcohol12 and tobacco.13 Each of these case studies is published on the NSMC’s evidence resource, ShowCase14 (along with around 50 other successful programmes), and evaluations, where robustly conducted, show a tangible impact on health behaviours (although it is acknowledged that the practice of evaluation still needs to be strengthened within the field).15 However, the ascent of the Lib-Con Coalition Government in May 2010 marked the end of this era of guaranteed centralised support, and a period of uncertainty for the social marketing community, during which budgets were frozen or reviewed, and guidance on future policy direction tenuously anticipated. With Health Secretary Andrew Lansley’s first speech on public health, it became clear that his vision for a new Public Health Service, which would support society to work together to get healthy and live longer, had social marketing very much at its heart: “Effective social marketing is the essential tool to better understand your local population and empower your community to manage their own health and meet the government’s vision”.16 The Public Health White Paper, published on 30 November 2010, confirmed this commitment: “Central government will sequence social marketing for public health through the life course, so that, at each stage in a person’s life, there is a meaningful and trusted voice…We will trial new ways of changing behaviours, using emerging ideas

from behavioural science, such as the use of social norms, changing defaults, and providing incentives. We will publish a social marketing strategy, setting out our plans in more detail, in Spring 2011.”17 Behaviour change tools such as applied social norms theory, or incentivisation (‘exchange’), have underpinned good social marketing practice for decades, and there is little new in Lansley’s statement of intent. The Department of Health’s new social marketing strategy, ‘Changing Behaviour, Improving Outcomes: A New Social Marketing Strategy for Public Health’ (April 2011), makes it increasingly clear that opportunities are emerging from the evolving public health landscape, which offer the potential for alignment between enhanced social marketing practice and the centralised precepts of the Coalition Government.

A landscape of opportunity
“My vision is for a new Public Health Service which…draws together a national strategy and leadership, alongside local leadership and delivery and, above-all, a new sense of community and social responsibility” (Andrew Lansley, Health Secretary).18 The new public health agenda creates significant opportunities for embedding key social marketing principles within local and national work streams. Three significant developments are noted below:

1) Creating a ‘Big Society’: co-owned interventions
Cameron’s vision of the Big Society marks a political aspiration for a redistribution of power to “the man and woman on the street”,19 but has been heavily criticised as being “all about saving money”,20 by creating a volunteerled “cut-price alternative”21 to decent public services. With the withdrawal of Liverpool City Council from big society plans, the initiative received a high profile

public vote of ‘no confidence’ from one of the proposed pilot cities.22 However, this strain of scepticism is underpinned by a feeling amongst local authorities and communities that ‘we have been doing this for years’, as community groups and volunteers have increasingly been given more control over the design and delivery of local services. Social marketing evidence suggests that the big society ambition has its foundations in a proven model, whereby engaging volunteers and local communities in creating their own solutions heralds a significant opportunity for sustainability and impact. At the heart of social marketing is the individual as ‘customer’, and successful programmes ensure that, not only are this customer’s needs and aspirations understood, but they are fully engaged in the process of co-creating solutions that enable long term behaviour change. Despite Liverpool’s withdrawal from the big society, in both Liverpool and Knowsley, ‘Roy Castle’s Fag Ends’ represents an example of exactly this move towards community and individual empowerment, and the results are impressive. Unlike traditional NHS smoking cessation services, which are often run in clinical settings by clinical staff, and follow a more conventional ‘command and control’ approach, ‘Fag Ends’ is a service that has been designed by its users, and which is run ‘by people like us, for people like us’.23 Staff are trained community members, sessions are held in well-liked community venues that have been selected by users, and promotion is carried out locally by word-of-mouth. The service helps thousands of local people to quit each year, and according to 2007-2008 national league tables, more people have quit smoking in Knowsley than anywhere else in England. More importantly, because the service has become embedded locally, in the communities that most need it, it is now co-owned and jointly delivered in such a way as to ensure sustainability.24 It is this type of delivery that will be essential if Cameron’s vision for the Big Society is to be achieved. Instead of

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‘No Decision About Me, Without Me’: a place for social marketing within the new public health architecture?

a top-down dictation of centralised commands, big society ideals promote a redistribution of the power of decisionmaking to the people who are best placed to advise on their own individual requirements. What Cameron needs to ensure is that a distinct separation is made between big society aspirations for community empowerment; and public spending cuts.

2) Shifting from ‘illness’ to ‘wellness’: a focus on social determinants
Amid the Government’s move to re-embed public health within local authorities,25 a strain of anxiety is emerging. At a recent debate, jointly hosted by Finnamore26 and the think tank, Reform,27 top public health professionals and politicians discussed the implications of this move, voicing concern that ring-fencing public health budgets and transferring pre-formed teams directly into local authorities would in fact reinforce the delineation and separation of public health that this move is intended to counter. Whilst this risk should not be overlooked, the move heralds a Government commitment to addressing “the root causes of ill health”,28 and a significant opportunity for health issues to be re-instated within the environmental, social and demographic contexts that drive them. Sir Michael Marmot’s strategic review of Health Inequalities underscores the cumulative impact of social factors such as education, occupation, and social cohesion, reminding us that health is not an isolated issue, but that “action on health inequalities requires action across all the social determinants of health”.29 By seeing the individual as part of a complex web of influences, social marketing has already moved health programmes back towards their social determinants, paving the way for this more holistic, upstream approach. In Liverpool, for instance, poor housing conditions cause up to 500 deaths and 5,000 illnesses requiring medical attention each year,30 with rates of excess winter deaths as high as 242 per

year,31 and accidents in the home accounting for half of all accidents (estimated 77 deaths per year) in Liverpool.32 In response, the innovative ‘Healthy Homes Programme’ has been established as a partnership between Liverpool PCT and City Council. The programme has identified and targeted over 15,000 high risk properties, with a specialist work force visiting each property to assess the health needs of each occupant, and prioritise 2,750 premises for HHSRS33 inspection. At each visit, referrals are made into health and well-being related services across the partnership (e.g. GP, dentist, smoking cessation, benefit maximisation, employment, age concern), and Home Safety promotion is undertaken (particularly for under 11s and over 65s). Through the removal of hazard exposure, the programme is designed to reduce premature deaths by up to 100 when fully implemented and reduce GP consultations and hospital admissions by over 1000 cases. Between April 2009 and December 2010, 13,006 properties were visited, with 13,022 referrals being made to support partners (37% of service users were receiving benefits), and 2,511 HHSRS inspections being carried out. In support, 51 health promotion events have been hosted through the programme, giving a strong public visibility to the social marketing programme.34 By combining health support with tangible housing improvements, the programme is making considerable progress against Marmot’s first and fourth policy objectives: “give every child the best start in life”, and “ensure a healthy standard of living for all”.35

3) Strengthening the role of GPs: public health as everybody’s business
Whilst detailed plans are still under consultation, the Government has committed to strengthening the public health role of GPs, by improving equitability of access to GP public health services and outcomes; increasing public transparency about how effectively GP practices provide public health advice;

and developing a workforce strategy to ensure appropriate GP training around public health.36 Most significantly, incentives and drivers for GP-led public health activity will also be designed, with proposals for a sum that is 15% of the current value of the QOF37 being devoted to evidencebased public health and primary prevention indicators from 2013.38 There are some concerns about the prominence of GPs within the new public health landscape, but social marketing again demonstrates the value that can be gained from engaging GPs in the health improvement agenda. ‘Early Detection of Lung Cancer’ is a social marketing programme, run in Doncaster to raise awareness of early symptoms of lung cancer and increase the number of people with potential symptoms presenting to 11 prioritised GP surgeries.39 The customer ‘push’ side of the programme is pitched around a specific call to action: ‘if you have a persistent cough that lasts for over 3 weeks, ask your GP about a chest x-ray’. For this to be effective, however, a strong service ‘pull’ element has also been developed, to ensure GP preparedness and support for an uplift in service demand. This has involved not only capacity planning and tailored training within targeted GP surgeries (including brief intervention training and reminders about NICE guidance on referral with suspected cancers), but also work with radiology departments to ensure sufficient capacity for increased chest x-rays, and understanding of this capacity amongst GPs to reduce their concerns about overloading radiologists with new referrals. Prior to the programme, 64% of people said they would ask for an X-Ray when visiting the GP with a ‘bad’ cough; this increased to 76% following the intervention. Chest X-Ray referrals were also reviewed, and a comparison with the same 6 weeks of the previous year showed an increase of 40% across Doncaster (31% increase in non-targeted practices; 80% increase in targeted practices). Comparing the 6 weeks pre- and during- the intervention also showed an

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‘No Decision About Me, Without Me’: a place for social marketing within the new public health architecture?

increase of 13% in chest x-ray referrals (9% increase in non-targeted practices; 27% increase in targeted practices).40 Such strong outcomes suggest that, if positioned in such a way as to align service delivery and demand, a strengthened role for GPs within public health harbours significant opportunities for balancing push and pull interventions as standard practice.

approach to identifying and mobilising existing individual and social assets, in order to embed behaviour change locally, and at minimal cost.

3) Development of evaluation competence
The social marketing community has responded well to increased pressure for robust evaluation, and its evidence base is steadily growing. However, this pressure is set to increase further with the introduction of the Public Health Outcomes Framework, and proposed health premiums.41 Not only will programmes need to demonstrate measureable impact going forwards, they will also be required to show return on investment and value for money, demanding a stronger focus on economic evaluation than has previously been the case, and a tighter prioritisation of resource against both outcome and need. Evaluation criteria will be further complicated through the focus on social determinants, requiring a revised focus not just on the health outcomes of specific programmes (e.g. teenage pregnancy indicators), but also on the social determinant outcomes that the programme has been designed to influence (e.g. education, employment, income status). Again, this will put demands on social marketing commissioners to ensure appropriate evaluation and outcome frameworks are developed.

Key challenges: MaKIng the VIsIon real
The new public health landscape remains fraught with uncertainties and debate, and emerging propositions remain contested by opponents and advocates alike. However, there are three key areas where ramifications will be felt within the evolving discipline of social marketing:

1) Support for the new purchasers
Health-related social marketing has traditionally been commissioned by Primary Care Trusts in England. As the new purchasers, GPs and local authorities will need to become familiar both with the business case for, and principles of, effective social marketing. This will require rapid skills development, with appropriate support to ensure quick adoption and spread of social marketing tools, evidence and theory. It will also require dedicated engagement work with GPs who, as a cohort, can traditionally be difficult to engage due to time and resource pressures.

2) Application of low cost approaches
Despite ring-fenced public health funding, widespread cuts across the public sector, and the move towards a volunteer-led ‘Big Society’ (i.e. financefree) horizon, will require a new commitment to delivering social marketing on a shoestring. The discipline is already well positioned in its approach to engaging non-financial resources to achieve change (e.g. using people’s time and skills, or mobilising community leaders and networks). However, a renewed pressure on budgets will demand an even more innovative

conclusIon
Social marketing is a stand-alone, internationally-evolved discipline, with a robust evidence-base to support its continued growth and development across the globe. It is not an appendage of this or the last UK Government, and its continued existence is testimony to strong behavioural outcomes, rather than to any specific era of political endorsement. However, as with all disciplines that are promoted to address a current time’s pressing issues, social marketing does run the risk in England of ‘going out of fashion’, or being discarded by

practitioners and policy-setters alike as ‘the last administration’s fad’. It is encouraging, therefore, to observe that, in spite of a year of unprecedented upheaval within England’s health sector, many of the core concepts of the new public health narrative suggest an important alignment with social marketing’s key tenets. In seeking to change individual and communal behaviours for the collective good, social marketing commits to seeing the person in the round, not seeking to fix an isolated condition, but integrating care, support and encouragement around a person’s holistic needs and aspirations. Today’s evolving public health landscape claims to have a similar commitment at its heart, so that, whilst there may be a need for social marketing to ‘flex’ to new market conditions, this will be underpinned by the core underpinning precepts of customer insight, community mobilisation, and a social determinants approach to change. Rather than leaving social marketing behind, then, as an outmoded Labour trend, the new administration gives political momentum to the discipline, heralding new horizons and a move to integration of its principles throughout the public health landscape. The coalition’s push for big change across society places social marketing at the heart of an exciting opportunity for change, which sees the individual regaining power and the state realigning services around his or her personal needs. As noted by Patrick Ladbury of the National Social Marketing Centre: “The coalition’s emphasis on the big society, and the importance of behaviour change (marked by the establishment of the new ‘Behavioural Insights’ team) show just how important social marketing still is to the work of central and local government”. On this 40th anniversary year, the future ahead seems long for social marketing, both at the operational level of individual behavioural change, and at the strategic level of the emerging Government’s public health policy.

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PEER REVIEW
‘No Decision About Me, Without Me’: a place for social marketing within the new public health architecture?

References
1 Kotler P, Zaltman G. (1971). Social marketing: A planned approach to social change. Journal of Marketing 1971; July(35): 3–12. Available at: http://bit.ly/jBzK88 National Social Marketing Centre, 2006, http:// www.nsmcentre.org.uk/ National Social Marketing Centre, ‘Social Marketing: The Basics’, 2010, http://www. nsmcentre.org.uk/content/starter-10 National Social Marketing Centre, ‘It’s Our Health!’, June 2006, http://www.nsmcentre.org. uk/sites/default/files/itsourhealth.pdf National Social Marketing Centre, ‘It’s Our Health!’, June 2006, http://www.nsmcentre.org. uk/sites/default/files/itsourhealth.pdf ‘Choosing Health’ White Paper, Department of Health, 2004. http://www.dhcarenetworks.org. uk/_library/Resources/ICN/Choosing%20 Health%20White%20Paper.pdf ‘It’s Our Health’, July 2006, was an independent report commissioned jointly by the National Consumer Council (NCC) and the Department of Health (DH) as one of the commitments set out in the public health White Paper Choosing Health. http://www.teespublichealth.nhs.uk/ document.aspx?id=4130&siteID=1012 ‘Ambitions for Health’, Department of Health, 10 July 2008, http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_090348. ‘Ambitions for Health’ was a strategic framework for maximising the potential of social marketing and health-related behaviour, by providing a framework for action on social marketing and public health. Established by Government in 2006, The National Social Marketing Centre is a centre of excellence for social marketing and behaviour change in the UK. http://thensmc.com/about-us. html Change4Life is a national programme to promote increased exercise and improved diet amongst children and parents, in order to address the rising obesity trend. http://www.nhs.uk/ change4life/Pages/change-for-life.aspx Think! Is a national programme to increase road safety. http://www.dft.gov.uk/think/ The previous Government’s national alcohol strategy was firmly grounded in social marketing principles. http://thensmc.com/resources/ showcase/a-z-of-titles.html?task=view&id=98 http://thensmc.com/resources/showcase/ search-case-studies.html?task=view&id=103. ShowCase, National Social Marketing Centre, http://www.nsmcentre.org.uk/resources/ showcase See A Christopoulos and L Reynolds, Evaluating social marketing: Lessons from ShowCase. Perspectives in Public Health 2009; 129(6). Andrew Lansley speech, 7 July 2010, published by Breathe on 15 July 2010. http://www. breathe-media.co.uk/news/home/healthsecretary-encourages-social-marketing/ ‘Healthy lives, healthy people’ White Paper, 30 November 2010. http://www.dh.gov.uk/en/ Publichealth/Healthyliveshealthypeople/index.htm Andrew Lansley, Health Secretary, sets out future of public health, 7 July 2010, http://www.dh.gov. uk/en/MediaCentre/Pressreleases/DH_117228 David Cameron, 19 July 2010, http://www.bbc. co.uk/news/uk-10680062 Dave Prentis, general secretary of Unison, 19 July 2010, http://www.bbc.co.uk/news/ uk-10680062 Dave Prentis, general secretary of Unison, 19 July 2010, http://www.bbc.co.uk/news/ uk-10680062 ‘Liverpool withdraws from government ‘big society’ pilot’, BBC News, 3 February 2011, http://www.bbc.co.uk/news/uk-englandmerseyside-12357450 A full case study is available on the National Social Marketing Centre’s ‘ShowCase’ resource, at: http://thensmc.com/component/nsmccasest udy/?view=single&section=benchmark&id=79 See: http://thensmc.com/component/nsmccase study/?view=single&section=benchmark&id=79 Healthy Lives, Healthy People: our strategy for Public Health in England, November 2010, http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/@dh/@en/@ps/documents/ digitalasset/dh_122347.pdf, p.9. Finnamore is the UK’s largest independent health consultancy, and won the Health Investor’s Award for ‘Best Consultancy 2010’. Finnamore manages 15 national Healthy Places, Healthy Lives sites, as well as overseeing the Core Cities Health Improvement Collaborative, to build public health best practice between England’s 8 largest cities. http://www.finnamore.co.uk/ Reform is an independent, charitable, non-party think tank whose mission is to set out a better way to deliver public services and economic prosperity. http://www.reform.co.uk/About/ Reform/tabid/62/Default.aspx Healthy Lives, Healthy People: our strategy for Public Health in England, November 2010, http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/@dh/@en/@ps/documents/ digitalasset/dh_122347.pdf, p.24. Marmot M. Fair Society, Healthy Lives: The Marmot Review, February 2010, http://www. marmotreview.org/, p.15. Healthy Lives, Healthy People: our strategy for Public Health in England, November 2010, http://www.dh.gov.uk/prod_ consum_dh/groups/dh_digitalassets/@dh/@ en/@ps/documents/digitalasset/dh_122347.pdf, p.4: the White Paper ‘responds to Professor Sir Michael Marmot’s Fair Society, Healthy Lives report and adopts its life course framework for tackling the wider social determinants of health’. BRE estimates. Liverpool’s 5,500 rented properties contain in the region of 7,500 category 1 hazards (2006 stock condition survey); Liverpool has the worst overall rate of fuel poverty in the country at 7.5% - some wards approach 50% (CSE 2003); For each winter death, there are 8 emergency admissions (DoH); 27% of households in Liverpool lack central heating (2006 stock condition survey). www. liverpool.gov.uk/healthyhomes. 2009 NHS profile. www.liverpool.gov.uk/ healthyhomes. 2008 PCT estimate. www.liverpool.gov.uk/ healthyhomes. The Housing Health and Safety Rating System (HHSRS) is a risk based evaluation tool to help local authorities identify and protect against potential risks and hazards to health and safety from any deficiencies identified in dwellings. It was introduced under the Housing Act 2004 and came into effect on 6 April 2006. It applies to residential properties in England. http://www. communities.gov.uk/publications/housing/ hhsrsoperatingguidance For more information, contact Stewart Petrie, [email protected], www.liverpool. gov.uk/healthyhomes. Marmot M. Fair Society, Healthy Lives: The Marmot Review, February 2010, http://www. marmotreview.org/, p.15. See: http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/@dh/@en/@ps/ documents/digitalasset/dh_122347.pdf, p.62. The Quality and Outcomes Framework (QOF) is a voluntary annual reward and incentive programme for all GP surgeries in England, detailing practice achievement results. It is not about performance management but resourcing and then rewarding good practice. http://www. qof.ic.nhs.uk/. The funding for this element of QOF will be within the Public Health England budget. http://www. dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/@ps/documents/ digitalasset/dh_122347.pdf, p.62. A full case study is available on the NSMC’s ShowCase resource, at: http://thensmc.com/ component/nsmccasestudy/?task=view&id=85 Detailed results are available at: http://thensmc. com/component/nsmccasestudy/?view=single& section=evaluation&id=85 Proposed Public Health changes will “be supported by a proposed public health outcomes framework and a ‘health premium’, which will incentivise local government and communities to improve health and reduce inequalities, while leaving them free to decide how best to do this, in line with local needs. Data will be published to make it easier for local communities to compare themselves with others across the country and to incentivise improvements”, http://www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/@dh/@ en/@ps/documents/digitalasset/dh_122347.pdf, p.26.

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PPHXXX10.1177/1757913911431034Marshall et al.Perspectives in Public Health

PEER REVIEW
Health literacy in Ireland: reading between the lines

Health literacy in Ireland: reading between the lines
Authors
Sara Marshall University College Cork, Cork Laura Sahm School of Pharmacy, University College Cork Suzanne McCarthy School of Pharmacy, Cavanagh Pharmacy Building, University College Cork, Cork, Ireland Email: [email protected] Corresponding author: Suzanne McCarthy, as above

Abstract Health literacy may be defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. While health literacy has become a vibrant area of international research, Ireland has lagged behind and to date few data exist. This article summarises the research that has been carried out in Ireland, highlighting key findings and recommendations. With several new initiatives in place such as the Crystal Clear health literacy Awards, it is expected that Ireland will lag behind in this field no longer. Inadequate health literacy is at epidemic levels in Ireland and is fast becoming recognised as a national issue. Simplification of the healthcare system, in its entirety is required but the much needed financial investment will only be made after original research, demonstrating successful interventions has been conducted. With a trend worldwide towards personalized medicine, this theme should be extended to include tailor-made personalized health care information. An investment in health literacy will ultimately increase a patient’s self-esteem, compliance, capacity to self-manage and most importantly patient outcomes and safety. Background
From its humble beginnings, appearing in the literature in 1974,1 health literacy has become a vibrant area of international research.2 With continuous research, its definition has been augmented and has increased in scope and complexity. In 1999, the American Medical Association’s Ad Hoc Committee on health literacy defined health literacy as the “constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment”.3 Other overlapping definitions have been provided by Healthy People 20104 and the Institute of Medicine (IOM),5 defining health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”. These definitions present health literacy as a function of an individual’s capabilities, allowing the patient to acquire and apply new health information.2 These capabilities are modifiable i.e. the level of health literacy may be increased by education programmes or decreased by any process that reduces cognitive function e.g. a pathology or simple aging.6 Being health literate enables an individual to make informed decisions, to influence events and to exert greater control over their own lives i.e. health literacy is crucial to personal empowerment.7 If a health care provider has the ability to determine a patient’s level of health literacy, they may be able to tailor information and materials provided to maximise patient care and increase the likelihood of favourable clinical outcomes. Studies in health literacy research propose a direct link between individual health literacy and health outcomes.8 It has been suggested that inadequate literacy may have a direct, negative effect on health.9 Patients with limited health literacy may have worse selfmanagement skills,10, 11 lower use of preventative services,12, 13 higher hospitalisation rates,14, 15 worse self-rated health16 and higher rates of mortality.17 In addition, those with literacy problems may also have poorer medication adherence18 which is a specific challenge associated with chronic illness management. To conclude, the literacy skills of an individual have consistently been shown to be a stronger predictor of health status than age, income, employment status, education level, and racial or ethnic group.19

Keywords
health literacy; Ireland; reading

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Health literacy in Ireland: Reading between the lines

Screening tools
Several screening tools have been developed which have the ability to predict/ determine health literacy and include the Rapid Estimate of Adult Literacy in Medicine (REALM),20 its 66 item modified form21 and its many variations; the REALM-SF (REALM-Short Form)22 and the REALM-R (REALMRevised).23 The REALM, in particular, has been widely used in health literacy research as it requires only three minutes for administration. It has also recently been validated for use as a screening tool in the UK.24 This is of particular interest as there are little available data regarding the use of any health literacy screening instruments in Ireland25 and the recent UK validation may serve as a model for this country. The Test of Functional health literacy in Adults (TOFHLA)26 was first published in 1995 and is used to measure functional health literacy using health-related materials such as prescription bottle labels and appointment slips to assess both numeracy and reading comprehension. It is designed to assess adult literacy in the health care setting.27 It is available in both English and Spanish and in a full-format (a 22-min test, with 50 reading comprehension items in three passages and 17 numeracy items), and a short form (S-TOFHLA; a 12-min test, with 36 reading comprehension items in two passages and four numeracy items).28 The passages use a modified Cloze procedure where every fifth to seventh word is omitted and subjects select the correct word from among a set of four options. The Newest Vital Sign (NVS) requires only 3 minutes for administration, but achieves an estimate of functional health literacy by measuring comprehension and numeracy skills in addition to reading ability.29,30 The NVS consists of a nutrition label from an ice-cream container which is presented to the patient and to which they refer to during the test. The patient is then asked six questions in relation to the information on the label and scores range from 0 to 6. Total scores can be classified into limited (0-1), possibility of limited (2-3), and adequate (4-6) literacy.

These tools have been widely used in the research setting however in the clinical setting, their use may pose a number of challenges including; time taken to administer and associated staffing requirements, along with potential negative feelings on the part of the patient.31 The NVS is a relatively new test which measures reading comprehension and numeracy in the same time it takes to administer the REALM instrument.32 Studies of patient acceptability mentioned above suggest that the NVS could possibly be more acceptable to patients than the REALM.33,34 This was also hypothesised by Baker in his 2006 review of health literacy measurement, 35 where he mentions that a nutrition label, a material which is likely to be encountered in daily life, may feel more comfortable and natural than instruments which appear more as academic tests of reading ability. This issue of patient acceptability with respect to the various instruments will be an interesting future area of study.

population, aged between 16 and 66 years have low literacy skills and cannot satisfactorily read medication instructions. An additional 30 percent can only comprehend simple, noncomplex information.37 Given that an estimated 55 percent of the general population has reduced general literacy, it may be assumed that the proportion of individuals with inadequate health literacy is even more significant.

Impact of limited health literacy
It is well established that low health literacy can significantly limit a patient’s ability to prevent and manage disease.38 According to research, individuals with limited health literacy are less likely to participate in preventive measures, such as mammograms and immunisation schemes.39 It has also been demonstrated that limited health literacy is associated with an increased frequency of chronic conditions such as diabetes and hypertension.40 Similarly, these individuals are more likely to take medication incorrectly and become hospitalised.41 This increased frequency of hospital visits results in increased healthcare costs for the individual and, if applicable, the supporting economy.42 With patients retaining an average of 12 percent of explanations provided by healthcare providers,43, 44 it is clear there is a significant gap between what a patient understands and what a healthcare professional expects them to know.45

Literacy and health literacy
In the past, it was believed that there was a direct correlation between being generally literate i.e. the ability to read and write, and being health literate. However it has been demonstrated that even when a person has advanced general literacy, their ability to obtain, understand and apply health information can be inadequate.7 While it is now evident that general literacy and health literacy are not synonymous, measurement of general literacy may be used as a surrogate to estimate health literacy. There is a high correlation between the Basic Skills Agency Initial Assessment Test (BSAIT), a general literacy screening tool and the REALM (r = 0.7; P < 0.001).36 As adequate health literacy requires the ability to comprehend and apply unfamiliar and sometimes complex health terminology and technology, it is accurate to assume that an individual’s health literacy level will be below their general literacy level. The International Adult Literacy Survey (IALS), carried out from 1994 to 1998, demonstrated that 25 percent of the Irish

Literature search
Table 1 summarises the findings of a literature review on the main research which has been conducted in Ireland in the field of health literacy. ScienceDirect and PubMed databases were searched using a wide variety of search terms including ‘Ireland health literacy’, ‘Irish health literacy’, ‘health literacy levels Ireland’ and health literacy Irish population’. The results of this search yielded only five studies which were of specific relevance to the Irish context. The most recent study published was a European-wide comparative analysis,

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Health literacy in Ireland: Reading between the lines

Table 1
Summary of the literature on health literacy research in Ireland Year 2011 Study/ report Education is a key determinant of health in Europe: a comparative analysis of 11 countries (46) n • 130 000 (across all countries) • 16 559 in Ireland Methodology • Self-reported health status and education levels analysed key Findings • Positive correlation between health status and education level • Irish data: 2nd and 3rd level education exert identical effects on health status • Coordination is required between education and health policies to improve health literacy • Mean readability level of broadsheet newspaper: 12 • Mean readability level of patient education leaflets: 12.57 (9.38-16.33) • 100% patient education leaflets: readability level of 9th grade or higher (equivalent to 2nd/ 3rd year in Irish secondary school context) • Immigrant patients have lower health literacy levels (REALM 52.7 vs. 61.4, P = 0.01) • Poorer glycemic control in immigrant patients

2010

Readability Level of patient information leaflets for older people(47)

• 45 (PILs)

• SMOG1 applied to PILs

2009

Globalization, immigration and diabetes selfmanagement: an empirical study amongst immigrants with type 2 diabetes mellitus in Ireland(48) Mental health literacy among Internet users(49)

• 52 Immigrant • 48 Irish

• REALM • Interview

2008

• 998

Online survey combining vignettes depicting depression and psychosis and knowledge based MCQs2

• Internet users in Ireland have a high level of mental Health Literacy • 78% identified depression • 93% identified psychosis • 5% supported assertion that ‘people with psychosis are violent’ and 51% described schizophrenia as ‘split-personality disorder’ • 20% not confident they completely understand GP instructions • 43% do not seek clarification if they do not understand • 20% have difficulty understanding instructions/information contained in medicine packaging • 10% have made medication errors due to a lack of understanding • Two thirds have difficulty understanding signs and directions in Irish hospitals • 20% were unable to identify to what part of the body the cardiology department referred to (continued)

2007

Adult Health Literacy Survey (51)

1000

Interview

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Table 1 (continued)
Year 2002 Study/ report Understanding the needs of people using a cancer information service in Northern Ireland(50) n 571 Methodology Analysis of inquiry information forms key Findings • Inflammation’ and ‘Lymphoedema’ indicative of malignancy • Misunderstanding of negative result • health literacy level lowest amongst women with repeat cervical smear requests (27% assuming sinister problem) • 2 women viewed treatment lasers as ‘Star Wars-like weapons’ • Validity of national campaigns: 18% reporting breast changes within 4 weeks of campaign • Importance of the health practitioner’s conduct; patients reporting positive experience when a health care professional treated them with courtesy and made an effort to ensure complete understanding of materials provided • Main issues: low levels of self-esteem, management of chronic illness, embarrassment • Lack of knowledge regarding availability of healthcare services among young men • Excessive variety in printed materials • Complex hospital infrastructure leads to difficult navigation • Poor general literacy, learning difficulties and low educational levels can hamper access to required information • Shame, embarrassment and anxiety associated with inadequate Health Literacy • Anxiety associated with illness can exacerbate literacy deficits • Printed media most common means of presentation (70%) • Address print size, jargon and contrast issues • Aim for age-proof and literacy-proof media • 17.4% unable to read and comprehend health information, preventing health improvement • 6.4% reported their health would be improved if easier to read health information was available

2002

Health Literacy Policy and Strategy(52) www.nala.ie

• Group 1: 80 adult literacy learners • Group 2: 10 health professionals

• Group 1: Interview and discussion group • Group 2: Interview

2002

Meeting the Health, Social Care and Welfare Services Information Needs of Older People in Ireland(53) www.ncaop.ie

95 (>65 years)

Interview

1999

The National Health & Lifestyle Surveys: Survey of Lifesyle, Attitudes and Nutrition, (SLÁN) & The Irish Health Behaviour in School-Aged children survey (HBSC) (54) www.nuigalway.ie

5992

Questionnaire

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Health literacy in Ireland: Reading between the lines

collaborating data from 11 countries.46 The sheer magnitude of this research is its major strength i.e. n = 130 000. However it is not without weaknesses. Assumptions were made regarding health literacy levels i.e. screening tools discussed previously were not employed. This research demonstrates a positive correlation between education level and health function, relying on self-reported health status as a key variant. This may arguably be prone to bias. In addition, the number of Irish participants was significantly lower than the other participating countries e.g. 16,559 from Ireland versus 43,355 from Germany. The second study focussed on the readability levels of Patient Information Leaflets (PILs) for older people.47 The strength of this research lies in the fact that limited health literacy has been demonstrated to be more prevalent in the older person and by focussing on PILs aimed at this sub-population; follow-on initiatives based on this research may be highly beneficial. However, when expressing readability levels of PILs, results were stated in American terms i.e. 6th grade, without any conversion to the Irish education system. The third study examined the link between health literacy and the ability to manage a chronic condition i.e. type 2 diabetes mellitus.48 This was the only research retrieved that employed one of the validated screening tools for health literacy i.e. REALM. It was demonstrated that non-Irish-national patients had lower health literacy levels than those of the Irish national patients and as a population demonstrated poorer glycaemic control. However this research failed to provide a direct correlation between lower health literacy and poor self-management. In spite of this, it demonstrates the need to address the discrepancies within the healthcare system and the need to provide, simplified multi-lingual educational material to the ever-increasing immigrant population. Fortunately the Health Promotion Unit of the Health Service Executive has begun to embrace Ireland as the multi-ethnic, multi-lingual country it has become and has published information pamphlets on topics such as

drug abuse, smoking cessation and alcohol addiction in a variety of languages including Czech, French and Spanish (www.healthpromotion.ie). The fourth study examined the levels of mental health literacy among internet users in Ireland.49 Involving a large number of participants (n = 998), this research boasts high power but once again makes assumptions regarding levels of health literacy without using any direct assessment. The fifth study examined users of a cancer information service in Northern Ireland.50 Once again, this study involved a high number of participants (n = 571) but has several shortcomings; there was no direct measurement of health literacy and while the researchers strove to record all inquiries made to the service, it was reported that this was not always possible. Researchers failed to report the percentage of inquiry forms with incomplete information thus the final data presented may not be representative. As health literacy is an interdisciplinary topic, a thorough search of the internet, using Google as a search engine was also carried out. The aim of this search was to find articles, studies or reports which are not available on the databases already examined. A wide variety of search terms were employed, in various combinations to maximise the probability of finding all relevant health literacy work, carried out by many disciplines. Focus was then made on organisations known to have particular interest in health literacy, such as the National Adult Literacy Agency (NALA). This search yielded a further four relevant studies, which had not appeared in the database search. The first of these studies was the 2007 Adult Health Literacy Survey, undertaken by Lansdowne Market Research on behalf of Merck Sharp and Dohme Ireland51 Data from this research were obtained directly from the organization. The strength of these data lies in the fact that the 1000 participants are considered representative of the Irish population in terms of gender, socioeconomic class, age and national: non-national ratios. The research deals exclusively with the participants’ attitudes towards and

experience of navigating the healthcare system. Once again this research makes assumptions regarding health literacy without direct measurement and has not been peer-reviewed. The second study is the health literacy Policy and Strategy Research Report conducted, written and edited by NALA.52 This report ‘marks the first time literacy has significantly entered the health debate in Ireland’ and aims to act as a platform for policy reform. Assessment of health literacy in the general public and medical professionals was inferred through interview without any direct measurement. The third study is entitled ‘Meeting the Health, Social Care and Welfare Services Information Needs of Older People in Ireland’.53 Once again health literacy was not directly assessed, nor is this research peerreviewed but through a series of personal interviews, general literacy barriers in the healthcare system as a whole were revealed. This study also highlights the emotional impact of limited health literacy and how an illness coupled by the complex health system can elicit unnecessary stress and anxiety. The final study is The National Health & Lifestyle Surveys54 conducted in 1999. It remains the only national survey which directly addresses the issue of health literacy. Despite involving nearly 6000 participants, it has not been peerreviewed and a direct measurement of health literacy was not carried out. In addition, data are more than a decade old and may no longer be representative of the current Irish population which includes a greater number of immigrants and older adults, two groups which have been identified as exhibiting low levels of health literacy. Thus in many studies, while conclusions were made regarding health literacy levels in the population groups studied, there was often no indication as to how these levels were determined i.e. the established screening tools were rarely employed. The sample sizes among studies varied from less than 50 participants to almost 17,000 participants. The methodologies used also varied from conducting interviews with participants to the use of online surveys. Despite the heterogeneous

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nature of the studies identified, they all demonstrated significant levels of health Illiteracy in their samples, particularly certain sub-populations, where health literacy levels are disproportionately lower, i.e. the elderly and the immigrant population.

Health literacy in Ireland: implications for policy and practice
NALA research report of 2002 stated that at the time minimal research in the field of health literacy had been carried out in Ireland.52 However this situation is changing fast with researchers and practitioners recognising its validity for inclusion in healthcare strategies. In fact a bibliometric analysis found that Ireland is one of the top countries regarding research productivity in this field (after adjustment for GDP).55 Recent advances include the establishment of a PhD study in health literacy in University College Dublin and the launch of the Crystal Clear MSD health literacy Awards in 2007, which recognise and reward excellence in programmes in this field. In September 2009, NALA published a report entitled ‘NALA Policy Belief on health literacy in Ireland’.56 The policy offers several recommendations which have direct implications for health literacy. NALA recommends that health literacy should be considered during all national initiatives by the Department of Health and Children, suggesting that all published materials be tested with focus groups, written in plain English and frequently incorporate images. The government funded Breastcheck programme is an example of a national initiative which has recognised the merits of employing plain English, integrating visual information and ensuring frontline employees are literacy aware, an effort which has been acknowledged in the Crystal Clear health literacy Awards 2010 (www.breastcheck.ie). The report also reiterated the point that while individuals may not experience literacy difficulties in everyday life, they may encounter obstacles in the healthcare setting due to

unfamiliarity or the use of complex terminology, obstacles that ought to be addressed. It suggested that health literacy audits be routinely conducted in the healthcare setting to assess literacy barriers and to implement systems to address them. It also stresses the importance of establishing a training framework for administrative and medical practitioners which would highlight the low health literacy levels in Ireland while also promoting self-assessment. The ignorance of the issue has been highlighted in a recent survey which identified that only 31 percent of Irish general practitioners are aware of the extent of low literacy in the Irish population.57 While the SLAN survey of 1999 included the concept of health literacy,54 it has not been integrated into any further work thus this report recommends its inclusion in all national surveys. In 2008 the HSE published the National Intercultural Health Strategy which recognised the need for an increased use of visual and spoken communication in the healthcare environment. In addition, it promoted the use of clear, understandable English which will allow individuals from minority groups e.g. the travelling community and ethnic groups as well as individuals with reduced literacy to gain full advantage of the healthcare system.58 In June 2010, a health literacy Report was published detailing the proceedings of the National health literacy Conference entitled ‘Linking Policy with Practice’. At this conference, Ireland’s inclusion in the European Union health literacy Survey (EU-HLS) was confirmed. In contrast to previous research which has concentrated on general literacy, this survey focuses solely on the concept of health literacy. A total of 1000 participants over the age of 15 years from across 8 different countries are included and analysis involves a specially designed questionnaire coupled with personal interviews. Results of the survey are expected to be published by the Maastricht University by September 201159 and it is hoped that these findings will propel the concept of health literacy

to the forefront, stimulating national interest, recognition and much needed funding. As is evident from the literature search, there are few study data available in the field of health literacy in Ireland. Although research on health literacy is largely conducted in the US, it is important to assess the prevalence of inadequate health literacy in the Irish setting as the results will not be transferable, due to demographic differences between the two countries. The changing profile of the Irish population, specifically the increase in the number of older adults, will pose increased challenges to healthcare professionals as the literature has shown that older patients are more likely to have limited health literacy. Research strategies in the US developed to aid patients with limited health literacy will also need to be investigated in the Irish setting due to inherent differences in healthcare systems. Research in this group has focused on addressing a number of these issues specifically with regard to the prevalence of limited health literacy and targeted approaches to improving prescription drug labels to aid patient comprehension (unpublished). This work is currently submitted and under Peer-review. Future randomised controlled trials (RCTs) are planned to investigate interventions to improve patient knowledge and understanding of healthcare-related materials. Reports have been published, as summarised in Table 1, which speculate on the topic but it is clear that more original research in the general population is required, particularly with a focus on providing successful interventions and combatting this modifiable obstacle to health.

concLuSIon
To conclude, it is evident that health literacy is a national issue, one which can have drastic consequences yet is readily surmountable. Healthcare professionals must be made aware of the levels of health illiteracy and receive training on how to address the issue, to maximize patient care. Literacy levels of health

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Health literacy in Ireland: Reading between the lines

information needs to be analysed and the ‘one size fits all’ policy that is currently established must be eliminated. With a trend worldwide towards personalised medicine, this theme should be extended to include tailor-made

personalized health care information. An investment in health literacy will ultimately increase a patient’s selfesteem, compliance, capacity to self manage and most importantly their safety.

noteS
1. SMOG (Simple Measure of Gobbledegook) 2. MCQs (Multiple Choice Questions)

References
1. Simonds SK. Health education as social policy. Health Education Monograph 1974: 1–25. 2. Baker DW. The meaning and the measure of health literacy. Journal of General Internal Medicine 2006; 21(8): 878–83. 3. Health Literacy. The Journal of the American Medical Association 1999; 281(6): 552–7. 4. Healthy People 2010: Understanding and Improving Health. Washington, DC: U.S. Government Printing Office, 2000. 5. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004. 6. Baker DW, Gazmararian JA, Sudano J, Patterson M. The association between age and health literacy among elderly patients. The journals of gerontology Series B, Psychological sciences and social sciences 2000; 55(6): S368–74. 7. Nutbeam D. Health Promotion Glossary. Health Promotion International 1998; 13(4): 349–64. 8. Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press; 2004 [16 June 2011]; Available from: www.iom.edu/healthliteracy.html. 9. Dewalt DA, Pignone MP. The role of literacy in health and health care. Am Fam Physician 2005; 72(3): 387-8. Epub 2005/08/17. 10. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest 1998; 114(4): 1008-15. Epub 1998/10/29. 11. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C et al. Association of health literacy with diabetes outcomes. Jama 2002; 288(4): 475-82. Epub 2002/07/23. 12. Miller DP, Jr., Brownlee CD, McCoy TP, Pignone MP. The effect of health literacy on knowledge and receipt of colorectal cancer screening: a survey study. BMC Fam Pract 2007; 8: 16. Epub 2007/03/31. 13. Garbers S, Chiasson MA. Inadequate functional health literacy in Spanish as a barrier to cervical cancer screening among immigrant Latinas in New York City. Prev Chronic Dis 2004; 1(4): A07. Epub 2005/01/27. 14. Cho YI, Lee SY, Arozullah AM, Crittenden KS. Effects of health literacy on health status and health service utilization amongst the elderly. Soc Sci Med 2008; 66(8): 1809-16. Epub 2008/02/26. 15. Baker DW, Parker RM, Williams MV, Clark WS. health literacy and the risk of hospital admission. J Gen Intern Med 1998; 13(12): 791-8. Epub 1998/12/09. 16. Baker DW, Parker RM, Williams MV, Clark WS, Nurss J. The relationship of patient reading ability to self-reported health and use of health services. Am J Public Health 1997; 87(6): 1027-30. Epub 1997/06/01. 17. Sudore RL, Yaffe K, Satterfield S, Harris TB, Mehta KM, Simonsick EM et al. Limited literacy and mortality in the elderly: the health, aging, and body composition study. J Gen Intern Med 2006; 21(8): 806-12. Epub 2006/08/03. Gazmararian JA, Kripalani S, Miller MJ, Echt KV, Ren J, Rask K. Factors associated with medication refill adherence in cardiovascularrelated diseases: a focus on health literacy. J Gen Intern Med 2006; 21(12): 1215-21. Epub 2006/11/16. Wolf MS, Davis TC, Osborn CY, Skripkauskas S, Bennett CL, Makoul G. Literacy, self-efficacy, and HIV medication adherence. Patient Educ Couns 2007; 65(2): 253-60. Epub 2006/11/23. Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, et al. Rapid assessment of literacy levels of adult primary care patients. Family medicine 199; 23(6): 433–5. Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW et al. Rapid Estimate of Adult Literacy in Medicine: A Shortened Screening Instrument. Clinical Research and Methods 1993; 25(6): 391–5. Arozullah AM, Yarnold PR, Bennett CL, Soltysik RC, Wolf MS, Ferreira RM et al. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care 2007; 45(11): 1026–33. Bass PF, Wilson JF, Griffith CH. A Shortened Instrument for Literacy Screening. Journal of General Internal Medicine 2003; 18: 1036–8. Ibrahim SY, Reid F, Shaw A, Rowlands G, Gomez GB, Chesnokov M et al. Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease. J Public Health (Oxf) 2008; 30(4): 449-55. Epub 2008/07/29. National Adult Literacy Agency. [16 June 2011]; Available from: www.nala.ie. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. Journal of general internal medicine 1995; 10: 537–41. Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med 1995; 10(10): 537-41. Epub 1995/10/01. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns 1999; 38(1): 33-42. Epub 2003/10/08. Weiss BD, Mays MZ, Martz W, Merriam Castro K, DeWalt DA, Pignone MP, et al. Quick Assessment of Literacy in Primary Care: The Newest Vital Sign. Annals of Family Medicine 2005; 3(6): 514–22. Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005; 3(6): 514-22. Epub 2005/12/13. von Wagner C, Steptoe A, Wolf MS, Wardle J. health literacy and health actions: A review and a framework from health psychology. Health Educ Behav 2009; 36(5): 860-77. Epub 2008/08/30. Johnson K, Weiss BD. How long does it take to assess literacy skills in clinical practice? J Am Board Fam Med 2008; 21(3): 211-4. Epub 2008/05/10. Brez SM, Taylor M. Assessing literacy for patient teaching: perspectives of adults with low literacy skills. J Adv Nurs 1997; 25(5): 1040-7. Epub 1997/05/01. Ryan JG, Leguen F, Weiss BD, Albury S, Jennings T, Velez F, et al. Will patients agree to have their literacy skills assessed in clinical practice? Health Educ Res 2008; 23(4): 603-11. Epub 2007/09/25. Baker DW. The meaning and the measure of health literacy. J Gen Intern Med 2006; 21(8): 878-83. Epub 2006/08/03. Ibrahim SY, Reid F, Shaw A, Rowlands G, Gomez GB, Chesnokov M et al. Validation of a health literacy screening tool (REALM) in a UK population with coronary heart disease. Journal of public health 2008; 30(4): 449–55. International Adult Literacy Survey: Results for Ireland. 1997. Williams M, Baker D, Honig E, Lee T, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998; 114: 1008–15. Scott TL, Gazmararian JA, Williams MV, Baker DW. health literacy and preventive health care use among Medicare enrollees in a managed care organization. Medical Care 2002; 40(5): 395–404. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Archives of Internal Medicine 1998;158(2): 66–72. Baker D, Parker R, Williams M, Clark W. health literacy and the risk of hospital admission. Journal of general internal medicine 1998; 13(2): 791–8. Friedland R, editor. New estimates of the high costs of inadequate health literacy. Proceedings of Pfizer Conference “Promoting Health Literacy: A Call to Action” 1998; Washington, DC: Pfizer, Inc. Kirsch I, Jungeblut A, Jenkins I, Kolstad A. A first look at the findings of the national adult literacy survey. National Centre for Education Statistics, US Department of Education, 1999. French S. On equal terms: working with disabled people. Oxford: Butterworth-Heinemann, 1994. Dougall A, Fiske J. Access to special care dentistry, part 3. Consent and capacity. British Dental Journal 2008; 205: 71–81.

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46. Albert C, Davia MA. Education is a key determinant of health in Europe: a comparative analysis of 11 countries. Health Promotion International 2011; 26(2): 163–70. 47. Cronin M, O’Hanlon S, O’Connor M. Readability level of patient information leaflets for older people. Irish Journal of Medical Science. 2010; 180(1): 39–42. 48. Thabit H, Shah S, Nash M, Brema I, Nolan JJ, Martin G. Globalization, immigration and diabetes self-management: an empirical study amongst immigrants with type 2 diabetes mellitus in Ireland. OJM: An International Journal of Medicine 2009; 102(10): 713–20. 49. Lawlor E, Breslin JG, Renwick L, Foley S, Mulkerrin U, Kinsella A et al. Mental health

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literacy among Internet users. Early Intervention in Psychiatry 2008; 2: 247–55. Manning DL, Quigley P. Understanding the needs of people using a cancer information service in Northern Ireland. European Jounal of Cancer Care 2002; 11(2): 139–42. Adult Health Literacy Survey. 2007. Health Literacy Policy and Strategy. 2002. Ruddle H, Prizeman G, Haslett D, Mulvihill R, Kelly E. Meeting the Health, Social Care and Welfare Services Information Needs of Older People in Ireland. Dublin: National Council on Ageing and Older People, 2002. Friel S, Nic Gabhainn S, Kelleher C. The National Lifestyle Surveys: Survey of Lifestyle, Attitudes

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and Nutrition (SLÁN) and the Irish Health Behaviour in School-Aged children survey (HBSC). Dublin: Department of Health and Children, 1999. Kondilis BK, Kiriaze IJ, Athanasoulia AP, Falagas ME. Mapping Health Literacy Research in the European Union: A Bibliometric Analysis. PLoS one 2008; 3(6): e2519. NALA Policy Brief on Health Literacy in Ireland. National Adult Literacy Agency, 2009. GP Omnibus Survey. 2009. National Intercultural Health Strategy 2007-2012. Kildare: Health Service Executive, 2008. National Health Literacy Conference ’Linking Policy with Practice’. 2010.

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Health literacy and the Clozapine patient

Health literacy and the Clozapine patient
Authors
Susan Brosnan University of Cork Elizabeth Barron University of Cork LJ Sahm School of Pharmacy, University College Cork, Cork, Ireland. Email: [email protected] Corresponding author: LJ Sahm, as above

Abstract Aims: To estimate the prevalence of limited health literacy in patients receiving clozapine for schizophrenia. To develop and produce a pharmacist-designed clozapine patient information leaflet (PIL) which has a higher readability score than the company–produced PIL. Study design: This was a cross sectional prevalence study. Methods: Ethical approval for the study was granted by the local ethics committee. Patients, over 18 years, attending the Clozapine Clinic of a Cork urban teaching hospital, were asked to participate in the study. Demographics such as gender, age, employment and smoking status, were gathered from all participants. The total daily clozapine dose, duration of clozapine treatment, and information regarding the clozapine DVD was also noted. The Rapid Estimate of Adult Literacy in Medicine (REALM) health literacy (HL) screening tool was then administered to each patient. A user-friendly PIL on clozapine was designed by the pharmacist, which was assessed for readability and compared to the company-produced PIL using the FRES and FKGL. Data were analysed using SPSS Version 15. Results: Forty patients (65% male, 95% unemployed and 70% smokers) of average age 38.0 years (±11.2) completed the REALM. The average score was 60.6 (±8.7). Twenty-nine patients (72.5%) were found to have “adequate” health literacy. The remaining eleven patients were found to have either “marginal” or “low” health literacy. The pharmacist-designed PIL would have been readable by 95% of the study population, in contrast to 72.5% with the companydesigned PIL. Conclusions: More than a quarter of the population were found to have marginal or low health literacy. Patient information should be matched to the health literacy level of the target population.

Keywords
Clozapine; health literacy; patient-information leaflet (PIL); REALM; schizophrenia

IntRoduCtIon
Schizophrenia is a severe form of mental illness, which affects about 24 million people worldwide.1 Schizophrenia has a multi-factorial aetiology2 and is among the most burdensome and costly illnesses globally.3 It requires a disproportionate share of medical resources due to its early onset and chronic and severe nature.2 There are three main aspects to the treatment of schizophrenia: w medications for the treatment and prevention of symptoms, w psychosocial interventions to help patients and families cope with the illness and w rehabilitation to help patients reintegrate into the community and possibly regain employment.3 In the early 1970’s the atypical antipsychotic clozapine was discovered. It was found to be significantly more effective than other antipsychotic drugs without many of the

extra-pyramidal side-effects (EPSEs) seen with the first-generation antipsychotics.4 Significant problems were, however, associated with its use. Shortly after its introduction in Finland in the 1970’s, 17 cases of agranulocytosis were recorded amongst about 3000 patients treated.5 The agranulocytosis led to eight fatalities which resulted in the voluntary withdrawal of clozapine from the market. It was re-introduced in the 1990’s but with compulsory haematological monitoring.6 Clozapine is now licensed in Ireland for treatment-resistant schizophrenia in patients who have severe, untreatable neurological adverse reactions to other antipsychotic agents, including atypical antipsychotics.7 One of the many challenges in medicine is non-adherence with therapy. Adherence has been defined as; “the extent to which a person’s behaviour – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider”.8

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Non-adherence rates in psychiatric disorders have been shown to vary widely 9 however the average rate of non-adherence for schizophrenia is 50%.10 Non-adherence can lead to the development of treatment-resistance schizophrenia.11 Factors which have been found to be consistently associated with non-adherence include: poor insight; negative attitude or subjective response towards medication; previous non-adherence; substance abuse; shorter illness duration; inadequate discharge planning or aftercare environment; and poorer therapeutic alliance.10 Medication-specific factors for non-adherence include adverse effects, ineffectiveness, regimen complexity and cost.9 Studies have shown that patient education can improve medication nonadherence.12-14 Psychiatric patients who received written information with verbal reinforcement were also found to be significantly more adherent with their medication than control subjects.15 Users of psychiatric services are more likely to have an impaired reading ability16 and a recent review has shown patients want information that was tailored to their needs.17 Individuals who suffer from both a mental illness and limited literacy are likely to be unable to effectively use mental health care services.18 HL has been defined as; “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions”.19 A strong link has been found between literacy and health20 and also between health literacy and outcomes.21 Despite this, a considerable proportion of written information currently available for psychiatric patients has been found to be at a reading age of 14 or above.16 In the literature a readability level of grade 6 or lower is considered ideal for patient information as 75% of adult Americans can read at this level without difficulty and is a reasonable goal for most healthcare instructions.22 One of the most common methods of estimating HL levels is to use the REALM.23 This screening tool is a word recognition and pronunciation test that uses medical terms of varying levels of difficulty.24 It is a validated screening instrument that can

be used to identify patients with low health literacy levels and only takes 3-5 minutes to complete. A shortened version of the REALM was validated in 1993, this is more practical for busy primary care settings.25 It allows reading levels to be determined quickly and easily and can be carried out by personnel with minimal training. Patients should be provided with information that is simple and clear to help them understand their medical condition and its treatment. Combining easy-to-read written patient education materials with oral instructions has been shown to greatly enhance patient understanding.26 Education materials are recommended to be short, clear and simple and should include pictures. The effectiveness of a low-literacy educational handout was demonstrated by increasing pneumococcal vaccine rates.27 Foster and Rhoney assessed the readability of printed patient information for epileptic patients using the Flesch Reading Ease Score (FRES) and Flesch-Kincaid Grade Level (FKGL).28 The FRES formula rates text on a 100-point scale based on the average number of syllables per word and words per sentence.29 The higher the FRES, the easier it is to understand the document. The FKGL analyses, and rates, text on an American grade-school level based on the average number of syllables per word and words per sentence e.g. a score of 8.0 means that a person in eighth grade should understand the text. The majority of information tested by Foster and Rhoney was written at a level that exceeded the reading ability of many patients. The provision of such information is impractical. Education materials for patients should be written at the lowest grade possible as this has been shown to increase comprehension.19 In the North Lee Mental Health Services patients who are started on clozapine are given information by the physician and a short digital video disk (DVD).30 They also receive a PIL from the manufacturer of clozapine.31 Thereafter patients receive a weekly/fortnightly/ monthly supply of clozapine. Unless requested, patients do not receive any further formal education. Because treatment with clozapine is usually

started when the patient is acutely symptomatic, it is possible that explanations provided at the time are poorly absorbed or retained.32 No estimate of clozapine patient’s health literacy, relative to the information provided by the PIL, has previously been carried out. We are therefore unaware of how well the patients health literacy level corresponds to the educational materials provided. We hypothesise that the patient information leaflet provided to the clozapine patient was not aligned to the health literacy levels, of this population, as estimated by the REALM.

Methods
Ethical approval was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals and the Clinical Director of the North Lee Mental Health Services. All patients were prescreened by the Clozapine Clinic Nurse Specialist, prior to the patients receiving any request from the pharmacist to be included in the study. The Clozapine Clinic Nurse Specialist works closely in conjunction with all of the psychiatrists (whose patients attend the clinic) and in consultation with these psychiatrists, patients who were acutely psychotic at the time of the study were excluded. The Clinic Nurse gave a brief explanation about the study to all patients and they were then introduced to the research pharmacist. Inclusion criteria for the study were any patient who was receiving clozapine and registered with North Lee Mental Health Services. Exclusion criteria were those aged less than eighteen years of age. Verbal consent was obtained from all participants and the voluntary nature of the study was explained to them. This study was completed between March and July 2010. Demographics such as gender, age, employment, duration of treatment with clozapine and smoking status, were gathered from all participants. The total daily clozapine dose and information regarding the clozapine DVD was also noted. The REALM screening tool was then administered to each patient and scored out of 66. A score of 61 or greater indicates “adequate” HL, a score of

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45-60 indicates “marginal” HL and a score of less than 45 indicates “low” HL. Using the National Adult Literacy Agency (NALA) approved guide to plain English,33 a user-friendly PIL on clozapine was designed by the pharmacist. The FRES and the FKGL were used to assess readability, with the aim of producing a PIL with a higher FRES and a lower FKGL than the company produced PIL. The Flesch Kincaid Readability Formula is inbuilt within the Microsoft Word® application.29

Table 1
Scores and (uS) grade equivalents for the ReAlM screening tool Raw Score 19-44 45-60 61-66 uS Grade (age equivalent in years) 4-6 7-8 9 (9-11) (12-13) (14) no. of patients (%) 2 (5%) 9 (22.5%) 29 (72.5%)

Table 2
Results of the Flesch-Kincaid readability score for PIls FReS* Company-designed PIL Pharmacist-designed PIL 49.7 62.0 FKGl 10.3** 8.1***

Statistical analysis
The statistical package for the Social sciences (SPSS) Version 15 (SPSS, Chicago, Ill.) was used for data analysis. Descriptive statistics include frequencies, percentages and mean values. Means are reported with standard deviation (SD) where appropriate. Bivariate analyses were conducted to determine any statistically significant relationships between varying parameters e.g. REALM score versus dose of clozapine. Pearson’s correlation coefficient is reported for parametric data and Spearman’s rho is used to describe correlations with non-parametric data. Correlations were significant at the 0.05 level unless otherwise specified.

*The higher the score, the easier the document is to understand. **A FKGL of 10.3 equates to an approximate reading age of 15 years. ***A FKGL of 8.1 equates to an approximate reading age of 13 years.

ReSultS
Forty patients (65% male, 95% unemployed and 70% smokers) of average age 38.0 years (±11.2) completed the REALM screening tool. Scores were marked out of 66. The average score was 60.6 (±8.7). Twenty-nine patients (72.5%) were found to have “adequate” health literacy. The remaining eleven patients were found to have either “marginal” or “low” health literacy (Table 1). Only 23% of those interviewed recalled watching the DVD on clozapine which is given to them at the initiation of clozapine therapy. The total daily clozapine dose ranged from 75-600mg, with an average of 373mg (±132.6). Average duration of treatment with clozapine was 39 months (±38.0). Correlation of REALM scores with age were not statistically significant (-0.065, p=0.69). Correlation of REALM and total daily dose (TDD) of clozapine was significant (-0.317, p<0.05).

Table 2 shows the higher readability scores found with the pharmacistproduced PIL. The company-produced PIL was found to have a FKGL of 10.3. This means a person would need to have attained the equivalent of the American tenth grade level (equivalent to age 15) to be able to read this document. The pharmacist-designed PIL was found to have a FKGL of 8.1. This means a person would need to have attained the equivalent of the American eighth grade level (equivalent to age 13) to be able to read this document.

dISCuSSIon
A total of 40 subjects completed the REALM screening tool with the average score of 60.6. This means the average patient from the study population would be expected to be able to read material at the American ninth grade level upwards (equivalent to age 14 upwards),25 which is considered “adequate” health literacy. Of the overall study population, 22.5% were found to have marginal health literacy. This means that they would struggle with most patient education materials, whilst 5% with low health literacy would not be expected to be able to read prescription labels. The REALM results for this

population are in contrast to another study which found 76% of the population to read at or below the US seventh- to eighth-grade level.24 However it should be noted that REALM has never been specifically validated for use in psychiatrically unwell patients. The reading levels for the study population were compared to the readability of the company-produced PIL and the pharmacist-designed PIL. The results of the REALM indicate that 95% of the study population would be expected to be able to read the pharmacist-designed PIL, whereas only 72.5% of the study population would be expected to be able to read the company-produced PIL. Users of psychiatric services have been shown to be more likely to have an impaired reading ability.16 Because of the strong correlation between health literacy and health outcomes,34 it is important to take these facts into consideration.35 When REALM scores for the population were compared with age, no significant correlation was found (p=0.690) which was unexpected36 but may be due to the average age of the study population being 38. When REALM scores were compared with total daily dose of clozapine, a significant correlation was found (p<0.05). It was found that the

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higher the REALM score, the lower the total daily dose of clozapine. This suggests patients with high health literacy are not as ill as those with poor health literacy. This is consistent with other studies, which found inadequate health literacy to be associated with poorer health status.37 Fewer than one in four of the study population recalled watching the DVD on clozapine which is given to them at the initiation of therapy. The importance of educating psychiatric patients has been well documented.15,32 It also serves as a reminder that giving written/visual information to a patient does not necessarily equate to the patient reading/ watching it. The effectiveness of low-literacy educational handouts has been established27 however not all materials are adapted to the reading ability of the target audience and this should be recognised, specifically in vulnerable

groups such as those with mental illness.

ConCluSIonS
More than one in four patients receiving clozapine has either marginal or low health literacy as estimated by the REALM screening tool. As assessed by the FRES and FKGL, the pharmacist-designed PIL was an easier document to read and understand than the company-produced PIL. It is important to be aware of patient’s health literacy when providing them with information as health literacy is strongly correlated to health outcomes. Although the pharmacist-designed PIL may be a more easily read document, further research is required to design a PIL which meets the needs of low literacy patients.

We would especially like to thank the Clozapine Clinic Nurse Specialist; Erin Foley for her assistance. This study was undertaken in part fulfilment of the MSc in Clinical Pharmacy (SB), School of Pharmacy, University College Cork.

Competing interest
The authors wish to declare that there is no conflict of interest in this work.

ethical approval
Ethical approval to undertake this study was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. In addition the Clinical Director of North Lee Mental Health Services was consulted and his permission obtained to undertake the study.

ACKnowledGeMentS
We would like to acknowledge all the participants who took part in the study.

Funding
No funding was received for this study.

References
1 2 World Health Organisation. Schizophrenia Vol. 2011 (2011). Lakhan SE. Schizophrenia proteomics: Biomarkers on the path to laboratory medicine? Diagnostic Pathology 2006; 1: 11. Rossler W, Salize HJ, van Os J, Riecher-Rossler A. Size of burden of schizophrenia and psychotic disorders. Eur Neuropsychopharmacol 2005; 15: 399–409. Freedman R. The choice of antipsychotic drugs for schizophrenia. N Engl J Med 2005; 353: 1286–1288. Idanpaan-Heikkila J, Alhava E, Olkinuora M, Palva IP. Agranulocytosis during treatment with chlozapine. Eur J Clin Pharmacol 1977; 11, 193–198. Chandrasekaran PK. Agranulocytosis monitoring with Clozapine patients: To follow guidelines or to attempt therapeutic controversies? Singapore Med J 2008; 49: 96–99. Summary of Product Characteristics. Clozaril (2009). World Health Organisation. Adherence to longterm therapies – Evidence for action (2003). Breen R, Thornhill JT. Noncompliance with Medication for Psychiatric Disorders.CNS Drugs 1988; 9: 457–471. Lacro JP, Dunn LB, Dolder CR, Leckband SG, Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry 2002; 63: 892–909. Kerwin RW, Bolonna A. Management of clozapine-resistant schizophrenia. Advances in Psychiatric Treatment 2005; 11: 101–106. Seltzer A, Roncari I, Garfinkel P. Effect of patient education on medication compliance. Canadian Journal of Psychiatry 1980; 25: 638–645. Youssef FA. Adherence to therapy in psychiatric patients: An empirical investigation. Int J Nurs Stud 1984; 21: 51–57. Merinder LB. Patient education in schizophrenia: A review. Acta Psychiatr Scand 2000; 102: 98–106. 15 Robinson GL, Gilbertson AD, Litwack L. The effects of a psychiatric patient education to medication program on post-discharge compliance. Psychiatr Q 1986;58, 113–118. 16 Gralton E, Sher M, Drew-Lopez C. Information and readability issues for psychiatric patients: E-learning for users. The Psychiatrist 2010; 34: 376–380. 17 Hafsteinsdottir TB, Vergunst M, Lindeman E, Schuurmans M. Educational needs of patients with a stroke and their caregivers: A systematic review of the literature. Patient Educ Couns 2010. 18 Christensen RC, Grace GD. The Prevalence of low literacy in an indigent psychiatric population. Psychiatric Services 1999; 50: 262–263. 19 Institute of Medicine. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press, 2004 20 Wilson JF. The crucial link between literacy and health. Ann Intern Med 2003; 139: 875–878. 21 Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence. Am J Health Syst Pharm 2009; 66: 657–664. 22 Tuiskula KA, Sullivan KM, Abraham G, Lahoz MR. Revising warfarin patient education materials to meet a National Patient Safety Goal. Am J Health Syst Pharm 2011; 68: 974–978. 23. Davis TC et al. Rapid assessment of literacy levels of adult primary care patients. Fam Med 1991; 23: 433–435. 24 Christensen RC, Grace GD. The prevalence of low literacy in an indigent psychiatric population. Psychiatr Serv 1999; 50: 262–263 . 25 Davis TC et al. Rapid estimate of adult literacy in medicine: A shortened screening instrument. Fam Med 1993; 25: 391–395. 14 26 Mayeaux EJ Jr. et al. Improving patient education for patients with low literacy skills. Am Fam Physician 1996; 53: 205–211. Jackson TH, Thomas DM, Morton FJ. Use of a low-literary patient education tool to enhance pneumococcal vaccination rates. Journal of the American Medical Association 1999; 282: 646–650. Foster DR, Rhoney DH. Readability of printed patient information for epileptic patients. Ann Pharmacother 2002; 36: 1856–1861. Flesch R. A new readability yardstick. Journal of Applied Psychology 1948; 32: 221–233. Novartis. Coming back from Schizophrenia – Clozaril® [DVD]. 2009. Patient Information Leaflet. Clozaril [Internet]. 2009. Paton CW. Haematological monitoring for clozapine: do patients know why? Psychiatric Bulletin 1995; 19: 536–537. National Adult Literacy Agency. Writing and Design Tips [Internet]. 2009. Gatti ME, Jacobson KL, Gazmararian JA, Schmotzer B, Kripalani S. Relationships between beliefs about medications and adherence.m Am J Health Syst Pharm 2009; 66: 657–664. Dewalt DA, Berkman ND, Sheridan S., Lohr KN, Pignone MP. Literacy and health outcomes: A systematic review of the literature. J Gen Intern Med 2004; 19: 1228–1239. Baker DW, Gazmararian JA, Sudano J, Patterson M. The association between age and health literacy among elderly persons. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 2000; 55: S368–374. Andrus MR, Roth MT. Health literacy: A review. Pharmacotherapy 2002; 22: 282–302.

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PPHXX10.1177/1757913911431041MenziesPerspectives in Public Health

PEER REVIEW
Charting a Health Literacy Journey - overview and outcomes from a Stakeholder Workshop

Charting a Health Literacy Journey - overview and outcomes from a Stakeholder Workshop
Authors
Loic Menzies Director and Lead Consultant of LKMco, 12 Grange Gardens, Cambridge CB3 9AT Email: loic.menzies@ lkmconsulting.co.uk Corresponding author: Loic Menzies, as above

Abstract Through a combination of Personal, social, health and economic education (PSHE), Science, Healthy Schools and a range of other initiatives, we are increasingly preparing our children to understand key topics in health education. However, to what extent are we equipping them with a picture of a healthy, happy future and giving them the tools to access this? In June, The Royal Society for Public Health (RSPH) hosted a workshop entitled “Charting a Health Literacy Journey” to examine this. The workshop brought together a broad group of over 20 stakeholders from the health and education sectors. The aims of the day were to address the following six questions:
•• •• •• •• •• •• What is health literacy? What does health literacy look like in action? What are the benefits of health literacy? How is health literacy reflected on the ground at present? How does health literacy fit with the current policy context? What are the options going forward?

Keywords
health education; health literacy journey; stakeholder

This report summarises the key findings of the workshop. What is health literacy?
Considerable ambiguity exists in the meaning of “health literacy” and there are many competing definitions. Kickbusch, Wait and Maag argue that health literacy can provide a “map and a compass on what may be a difficult and unpredictable journey”.1 The rationale behind the workshop was the belief that such a map and compass would provide children and young people with the “skills and confidence to write their own life story”.2 The first aim of the workshop was to see how different stakeholders interpreted the concept of health literacy and to identify its most important characteristics. Discussion was grounded in what were described as the “Three Tiers of Health Literacy”.3 Tier one is the narrowest interpretation of health literacy. Nutbeam describes this as “functional health literacy (ibid).3 It focuses on reading and decoding health information and is popular in the United States. For example, the American Medical Association has referred to “The relationship between patient literacy levels and their ability to comply with prescribed therapeutic regimen.” 4 Instructions on medicines are therefore judged according to how well they match with patients’ “health literacy” levels. Tier two goes beyond this interpretation and considers knowledge and understanding of health and the ability this gives to make judgements. Nutbeam3 calls this “interactive” health literacy. Sihota and Lennard reflect this interpretation in their definition: “The skills to be able to acquire and read health information and successfully apply it to one’s own situation”.5 In practice this might involve pupils learning different food groups and their functions. Tier three is Nutbeam’s preferred view. He calls it “critical literacy”.3 Tier Three is focused on translating understanding into behaviour. In his definition Nutbeam describes “the cognitive and social skills which determine the motivation and

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PEER REVIEw
Charting a Health Literacy Journey - overview and outcomes from a Stakeholder Workshop

ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.” In practice, this might involve giving pupils the confidence to resist peer pressure. Participants each came to the workshop with different ideas of what should be part of Health Literacy but there was an emphasis in most participants’ comments on notions of empowerment and confidence. This suggested that Tier Three had the greatest resonance for them. Terms used to express this included “choice”, “processing” and “resilience.” Discussion also revealed a second dimension in the meaning of Health Literacy: that of scope or breadth. Participants began to discuss “values” and emotional and mental health. These were viewed as critical in living a healthy happy life. Understandings of health literacy are represented in Figure 1. Detailed discussion revealed that C3 was the most popular location for a definition of health literacy. It was not generally felt that health education as it currently stands reflects this view of health literacy. Furthermore, participants emphasised the notion of “lifelong learning,” “cohesiveness” and linking provision to families and communities. These views suggest that there is considerable appetite for the concept of a Health Literacy Journey recognising the full range of factors which contribute to a healthy life and the ability to lead it.

Figure 1
Understanding of health literacy
We can represent understandings of health literacy as follows: Depth
Tier 3 – Behaviour Change

A3

B3

C3

Tier 2Understanding

A2

B2

C2

Tier 1 Decoding

A1

B1

C1

Avoiding illness

Keeping healthy

Emotional well-being

Breadth

What does health literacy look like in action?
Case study 1: Andrew Carter OBE, Head Teacher at the award winning South Farnham Junior School provided an insight into what this approach might look like in practice: In essence health literacy is learning that starts with an understanding of where the child is in terms of their social, intellectual and personal development. It is not necessary to give the child what they want, but instead what they need. This

understanding of ‘need’ should be based on identifying what will enable them to become healthy, social beings. As a result, South Farnham has developed into a school which does not simply respond to deficits by combatting bullying or teaching sex education and healthy eating. Instead, the school ensures that individual children and the whole school community feel supported, nurtured and prepared to take measured risks. Discussions explore the impact of choices on future life and the achievement of physical and emotional wellbeing. This is also the starting point for decisions on curriculum and teaching. For example, Mr Carter explained that very few adults participate in competitive sports, yet they are the focus of most PE teaching. This leaves children with little to turn to once competitive sports are no longer organised for them in later life. He has therefore decided to offer activities which are more likely to be pursued in later life because he is guided by a long term view of children’s journeys towards healthy adulthood. He believes that because the school combines this with an

education that fosters resilience and confidence, children leave the school’s care with the knowledge, understanding and capacity to make healthy choices in the future.

Why does health literacy matter?
With this broad understanding of health literacy established participants explored the potential benefits of Health Literacy. Health inequality continues to be a huge problem. The 2011 Marmot Review reported a gap of over 10 years in disability free life expectancy6 between the poorest and richest areas in around half of the Local Authorities in England. Participants believed that health inequality could be reduced if children learned to recognise the impact of their choices and were equipped to make healthier choices. Health literacy was described as providing “immunisation for better health.” Whilst such health benefits were obvious, participants were quick to go beyond these and to describe societal, economic and educational benefits. Particpants speculate that public health improvements could lead to economic benefits through savings on healthcare and that Tier Three health

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PEER REVIEW
Charting a Health Literacy Journey - overview and outcomes from a Stakeholder Workshop

literacy could also improve resilience, choice making and therefore employability. This might yield further economic benefits. On an educational front, a whole school approach like that described by Andrew Carter would place learning in the context of a journey towards lifelong fulfilment and hence has the potential to bring educational benefits through increased relevance and therefore engagement. Participants recognised that the four way categorisation of health, societal, economic and educational benefits was somewhat arbitrary, and that all four are interrelated. Their overwhelming view was that an early start along a health literacy journey would have long term impact and be a valuable strategic step. Following preliminary identification of potential benefits it now becomes important to gather an evidence base to test whether these hypotheses are justified. The relative strength of the different types of benefit also needs to be assessed. This is where the RSPH will focus its attention over the coming year.

How is health literacy reflected on the ground at present?
There is no lack in the volume of health education available at the moment. Our concern is therefore qualitative rather than quantitative. Elements of health education can be found in the Science, PE and PSHE curricula. These are complimented by initiatives like Healthy Schools and Health Matters as well as programs provided by organizations with interests in particular areas of health. It is worth noting that the Department for Education’s current internal review of the PSHE curriculum and the decision not to make PSHE a statutory requirement could jeopardise curriculum provision for health education. On top of that, changes to the Healthy Schools program and the slimming down of the Ofsted inspection framework could place further pressures on provision. Currently, some schools cleverly dovetail different elements of the curriculum together and map coverage throughout the school. This provides a well-rounded program for pupils. An

example of this approach is Cherry Orchard School in Birmingham, in which Ofsted describe a “very good programme for personal, social and health education (which) ensures that pupils are exceptionally well informed about how to keep healthy and safe”.7 This approach comes very close to providing the type of journey we have described. It is clear that there is a strong emphasis on active decision making around themes such as “making choices”, “responsibility” and “resolving conflict”. Cherry Orchard Primary School makes it clear that developmental and health aims go well beyond just being an aspect of the PSHE curriculum. For this school as with South Farnham Junior School, health and development is at the heart of curriculum, culture and ethos. How widespread this approach is in other schools is not clear and this would be worthy of further study. It will therefore form part of the RSPH’s focus over the coming year. Preliminary indications are provided by the 2010 Ofsted report8 on

Case Study 2: – Joined up planning for PSHE and Citizenship at Cherry Orchard Primary School
Year 1 2 3 4 5 6 Autumn 1 Keeping Safe, Road Safety/personal safety Personal safety/safety in inside/outside environments Keeping safe: Road, Water and Rail Safety Safety in the home Taking responsibility for self. Making choices Feeling safe and feelings Spring 1 1 2 3 4 5 6 Looking after myself Growing up/responsibilities Medicines, drugs, keeping safe Keeping healthy, Diet Legal/illegal Drug use (alcohol/cigarettes) Changes: Growing up (relationships education) Family and friendships Good friendships/bullying Friendship Bullying/respecting differences Resolving conflict Working Together Spring 2 Drugs and medicines Keeping healthy Relationships A balanced lifestyle Peer pressure. Moral responsibility First Citizens (continued) Autumn 2

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PEER REVIEw
Charting a Health Literacy Journey - overview and outcomes from a Stakeholder Workshop

Year Summer 1 1 2 3 4 5 6 Making Choices

Autumn 1 Summer 2

Autumn 2

Responsibilities/caring for others Caring for the environment Making choices: Taking care of the environment The environment and how it can affect us Making choices in the local and global community Moving on

Recognising and respecting differences in others Looking after myself and others Myself, Feelings, Changes and growing up Growing up: Puberty and keeping clean Respecting differences

PSHE which argues that: “in just under one in four of the schools visited, the quality of teaching (in PSHE) was variable and teachers’ subject knowledge and expertise were not good enough.” So long as this is the case, a quarter of young people potentially risk leaving school ill-equipped to make the confident healthy choices that participants at our workshop believed they needed. This is unacceptable.

How does health literacy fit with the current policy context?
Our proposed approach to health literacy would lead to a pedagogy that is not a deficit model and would not simply focus on particular problems. This fits closely with the aims described in 11b of the Executive Summary of the White Paper “Healthy Lives, Healthy People.” This argues for a “coherent approach to different stages of life and key transitions instead of tackling individual risk factors in isolation”.9 This emphasis on life-long learning and a proactive approach chimes with our intentions. Our Tier Three approach

emphasises capacity and competency. It therefore also fits well with arguments made in the Education White Paper “The Importance of Teaching”. Section 4.30 of the White Paper argues that: “Good PSHE supports individual young people to make safe and informed choices”.10 Such an approach would be at the heart of a Health Literacy Journey. A review of the school curriculum is currently under way and its aim is to produce a slimmed down curriculum. This might initially be seen as conflicting with our argument but this need not be the case. We are not arguing for an increase in content but instead for a change of approach, one that would be guided by schools and teachers who are equipped to do so. This fits very well with moves towards school and teacher autonomy and the drive towards increased teacher quality.

Journey is unlikely to take place as a result of curriculum changes and prescription. Instead it should take place by providing teachers and leaders with the skills and tools to do so. We therefore believe that priorities should be to: •• Develop a coherent methodology for teaching health literacy •• Provide training for teachers to enable them to implement the methodology •• Articulate a clear rationale for school leaders to shape their school’s approach using the principles behind our definition of health literacy •• Continue to collect case studies and an evidence base for what works •• Involve young people in charting the journey •• Meet with key stakeholders and identify funding streams For more information about the Royal Society for Public Health’s Health Literacy project please contact Heather Davison: [email protected]

How should we move forward?
As argued above, encouraging schools to take their pupils on a Health Literacy

References
1 Kickbush I, Wait S, Maag D. Navigating Health, The Role of Health Literacy, London: Alliance for Health and the Future, 2006. 2020 Public Service Trust. Shifts in Culture, Power and Finance: A Way Forward for Education? London: The 2020 Public Service Trust, 2010. Nutbeam D. Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International 2000; 15(3): 259–267. 4 Ad Hoc Committee on Health Literacy for the American Council on Scientific Affairs. American Medical Association Health Literacy: Report of the Council on Scientific Affairs. Journal of the American Medical Association 1999; 281: 552–557. Sihota S, Lennard L. Health Literacy: Being Able to Make the Most of Health. London: National Consumer Council, 2004. London Health Observatory, 2011, Health inequalities: a challenge for local authorities. Marmot review 1 year on press release, http:// www.lho.org.uk/viewResource.aspx?id=17016, Accessed 5/9/11 Ofsted, 2010, Personal, social, health and economic education in schools, http://www.ofsted. gov.uk/resources/personal-social-health-andeconomic-education-schools (accessed 5/9/11) Ofsted, 2007, Cherry Orchard Primary School, Inspection Report, London: Ofsted Department of Health, 2010, Healthy Lives, Healthy People, London: The Stationary Office Department for Education, 2010, The Importance of Teaching, London: The Stationary Office.

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Book Reviews

Book Reviews
Fast Facts: Diabetes Mellitus (third edition) By Ian N Scobie and Katherine Samaras. Published by Health Press, Abingdon, 2009. Paperback 115pp. Price £6.00. ISBN 978-1905832-49-1.
This book provides an excellent and concise account of the pathogenesis, complications and management of diabetes. I found this a very well-written and easy-toread book. The figures, photographs and tables are all excellent and appropriate. The book is also well laid out with clear chapter titles that will help the reader target key areas of interest. It is suitable for a wide range of health professionals in primary and secondary care and is of a size that can fit into a jacket pocket or handbag. The importance of a working knowledge of diabetes by health care professionals is underlined by an early statement: ‘Diabetes and its sequelae accounted for about 3.8 million deaths in 2007, approximately 6% of the total world mortality.’ Recent audits in the UK have found that on average 15% of hospital inpatient beds are occupied by a patient with diabetes. So it is important that an understanding of diabetes should extend across speciality barriers and this text would go some way to achieve this. The first two chapters on epidemiology and diagnosis are concise and to the point. These are followed by three chapters on the different types of diabetes (type 1, type 2 and MODY and other types of diabetes). This is very important as it clearly delineates the ‘other causes’ from, in particular, type 2 diabetes, which I know confuses many groups of health care professionals, and also dispels the misconception that there is only either type 1 and type 2 diabetes. This first section is followed by chapters on treatment of the different diabetes disorders and also a chapter on diet and exercise. Then there is a longer, well-illustrated chapter on complications, followed by one each on hypoglycaemia and on diabetic ketoacidosis and HONK. My only criticism with the book is that the section on erectile dysfunction, a condition that affects up to 70% of men with type 2 diabetes, had only a brief mention with no consideration of psychological impact, or the knowledge that there is a high prevalence of hypogonadism and failure of phosphodiesterase inhibitor therapy is associated with low testosterone. In the introduction, the authors state: ‘The aim of this third edition of Fast facts: Diabetes mellitus is to provide readers with an up-todate picture of our understanding of diabetes mellitus and its various causes, its clinical manifestations and the treatment strategies that can be used to reduce the burden of its metabolic consequences.’ In my mind the book has more than adequately achieved this goal. Professor T. Hugh Jones Consultant Physician and Endocrinologist and Hon. Professor of Andrology draughty bed, with legs raised to increase pulmonary circulation and a life governed by terse attendants in white coats. She was relatively fortunate that TB treatment was particularly advanced in Edinburgh, and her physicians quickly applied the results of the first controlled trial of TB drugs and the arrival of para-aminosalicylic acid (PAS) and Isoniazid. However, she initially had to endure regular pleural cavity injections with ‘the most enormous hypodermic syringe’ to induce pneumothorax; also surgery to remove adhesions. She chillingly describes the brutal procedure of bronchoscopy at that time, with no pre-medication, no anaesthetic and no flexible scope; it carried a 1% fatality. Early drug therapy was associated with unpleasant side effects, such as deafness induced by Streptomycin, at first the only effective drug available. Memoirs by patients are of particular value to practitioners. Bella must have kept some notes but clearly many of her experiences are etched into her memory, even the radio programmes of the era that were the only entertainment, and the conversations and jokes with fellow patients as they lay confined to bed, wondering what had happened to those taken away from the ward. So she learned most about her disease and its treatment from more experienced patients. Like the inhabitants of Circe’s Island, she was permanently ‘transformed’ by her illness and her account includes informed comments on TB history, as well as an introduction by Sir John Crofton, a pioneering professor of TB in Edinburgh. The book is charmingly illustrated with line drawings by Jayne Watson and the cover picture is an evocative view through open windows into the secret, closed world of sanatoria patients, which Bella describes as ‘a protective haven for the benighted souls inside’. Her eloquent and short book should be read by all with an interest in the history of TB, as well as for an all-too-rare account by a patient. Dr Rosalind Stanwell-Smith Hon. Senior Lecturer, Centre for History in Public Health, London School of Hygiene and Tropical Medicine

Circe’s Island: A Young Woman’s Memories of Tuberculosis Treatment in the 1950s By Isabel Gillard. Published by Unbound Press, Glasgow, 2010. Paperback 137pp. Price £9.99. ISBN 978-0-9558360-5-3.
Tuberculosis (TB) is probably mankind’s most ancient recognized disease, although its current name was only coined in the early nineteenth century. Bella Gillard was diagnosed with pulmonary TB in 1950 while she was a student, at a time when an estimated 90% of the population had contact with TB. Closure of the hospital sanatoria to make way for wartime casualties in the 1940s had resulted in a rise in TB mortality to Victorian levels: 20% of cases were fatal. Bella’s very readable memoir was inspired by the realization that she had experienced the turning point of TB therapy, when double and triple antibiotic therapy became available. The title of the book refers to the surreal experience of sanatorium confinement for 16 months: in Homer’s Odyssey, Circe was an enchantress who wove a web around those trapped on her island, many of whom she had transformed into animals; they could be turned back, but were never quite the same. When admitted to the TB hospital, Bella’s world was reduced from busy university life, including a boyfriend who soon deserted her, to lying in an icy cold

Copyright © Royal Society for Public Health 2012 January 2012 Vol 132 No 1 l Perspectives in Public Health 47 SAGE Publications Downloaded from rsh.sagepub.com at University of Bedfordshire on March 1, 2012 DOI: 10.1177/1757913911430917

Book Reviews

Book Reviews
Fast Facts: Diabetes Mellitus (third edition) By Ian N Scobie and Katherine Samaras. Published by Health Press, Abingdon, 2009. Paperback 115pp. Price £6.00. ISBN 978-1905832-49-1.
This book provides an excellent and concise account of the pathogenesis, complications and management of diabetes. I found this a very well-written and easy-toread book. The figures, photographs and tables are all excellent and appropriate. The book is also well laid out with clear chapter titles that will help the reader target key areas of interest. It is suitable for a wide range of health professionals in primary and secondary care and is of a size that can fit into a jacket pocket or handbag. The importance of a working knowledge of diabetes by health care professionals is underlined by an early statement: ‘Diabetes and its sequelae accounted for about 3.8 million deaths in 2007, approximately 6% of the total world mortality.’ Recent audits in the UK have found that on average 15% of hospital inpatient beds are occupied by a patient with diabetes. So it is important that an understanding of diabetes should extend across speciality barriers and this text would go some way to achieve this. The first two chapters on epidemiology and diagnosis are concise and to the point. These are followed by three chapters on the different types of diabetes (type 1, type 2 and MODY and other types of diabetes). This is very important as it clearly delineates the ‘other causes’ from, in particular, type 2 diabetes, which I know confuses many groups of health care professionals, and also dispels the misconception that there is only either type 1 and type 2 diabetes. This first section is followed by chapters on treatment of the different diabetes disorders and also a chapter on diet and exercise. Then there is a longer, well-illustrated chapter on complications, followed by one each on hypoglycaemia and on diabetic ketoacidosis and HONK. My only criticism with the book is that the section on erectile dysfunction, a condition that affects up to 70% of men with type 2 diabetes, had only a brief mention with no consideration of psychological impact, or the knowledge that there is a high prevalence of hypogonadism and failure of phosphodiesterase inhibitor therapy is associated with low testosterone. In the introduction, the authors state: ‘The aim of this third edition of Fast facts: Diabetes mellitus is to provide readers with an up-todate picture of our understanding of diabetes mellitus and its various causes, its clinical manifestations and the treatment strategies that can be used to reduce the burden of its metabolic consequences.’ In my mind the book has more than adequately achieved this goal. Professor T. Hugh Jones Consultant Physician and Endocrinologist and Hon. Professor of Andrology draughty bed, with legs raised to increase pulmonary circulation and a life governed by terse attendants in white coats. She was relatively fortunate that TB treatment was particularly advanced in Edinburgh, and her physicians quickly applied the results of the first controlled trial of TB drugs and the arrival of para-aminosalicylic acid (PAS) and Isoniazid. However, she initially had to endure regular pleural cavity injections with ‘the most enormous hypodermic syringe’ to induce pneumothorax; also surgery to remove adhesions. She chillingly describes the brutal procedure of bronchoscopy at that time, with no pre-medication, no anaesthetic and no flexible scope; it carried a 1% fatality. Early drug therapy was associated with unpleasant side effects, such as deafness induced by Streptomycin, at first the only effective drug available. Memoirs by patients are of particular value to practitioners. Bella must have kept some notes but clearly many of her experiences are etched into her memory, even the radio programmes of the era that were the only entertainment, and the conversations and jokes with fellow patients as they lay confined to bed, wondering what had happened to those taken away from the ward. So she learned most about her disease and its treatment from more experienced patients. Like the inhabitants of Circe’s Island, she was permanently ‘transformed’ by her illness and her account includes informed comments on TB history, as well as an introduction by Sir John Crofton, a pioneering professor of TB in Edinburgh. The book is charmingly illustrated with line drawings by Jayne Watson and the cover picture is an evocative view through open windows into the secret, closed world of sanatoria patients, which Bella describes as ‘a protective haven for the benighted souls inside’. Her eloquent and short book should be read by all with an interest in the history of TB, as well as for an all-too-rare account by a patient. Dr Rosalind Stanwell-Smith Hon. Senior Lecturer, Centre for History in Public Health, London School of Hygiene and Tropical Medicine

Circe’s Island: A Young Woman’s Memories of Tuberculosis Treatment in the 1950s By Isabel Gillard. Published by Unbound Press, Glasgow, 2010. Paperback 137pp. Price £9.99. ISBN 978-0-9558360-5-3.
Tuberculosis (TB) is probably mankind’s most ancient recognized disease, although its current name was only coined in the early nineteenth century. Bella Gillard was diagnosed with pulmonary TB in 1950 while she was a student, at a time when an estimated 90% of the population had contact with TB. Closure of the hospital sanatoria to make way for wartime casualties in the 1940s had resulted in a rise in TB mortality to Victorian levels: 20% of cases were fatal. Bella’s very readable memoir was inspired by the realization that she had experienced the turning point of TB therapy, when double and triple antibiotic therapy became available. The title of the book refers to the surreal experience of sanatorium confinement for 16 months: in Homer’s Odyssey, Circe was an enchantress who wove a web around those trapped on her island, many of whom she had transformed into animals; they could be turned back, but were never quite the same. When admitted to the TB hospital, Bella’s world was reduced from busy university life, including a boyfriend who soon deserted her, to lying in an icy cold

Copyright © Royal Society for Public Health 2012 January 2012 Vol 132 No 1 l Perspectives in Public Health 47 SAGE Publications Downloaded from rsh.sagepub.com at University of Bedfordshire on March 1, 2012 DOI: 10.1177/1757913911430917

Book Reviews

Tracking Medicine: A Researcher’s Quest to Understand Health Care. By John E Wennburg. Published by Oxford University Press, UK, 2010. Hardback 344pp. Price £10.99. ISBN: 978-0199731787
Many people are left incredulous when they first come across the figures revealing widespread geographical variations in health care practice. This incredulity can be followed by a stream of questions - does the variation signify inequity of access, or differences in health service efficiency, or is there some acceptable explanation such as differences in population levels of disease? John Wennburg has devoted himself to researching these practice variations. I cannot think of anyone who has contributed more to documenting the extent of the variations, and to providing a framework for helping us differentiate between acceptable and unwarranted variation. His book “Tracking Medicine” starts by describing the moment that he first discovered the small area variations around Vermont, and then proceeds to tell of his subsequent career investigating them across the United States. However, this potted history is merely one of the narrative threads which together document how he and his colleagues slowly pieced together the various causes of practice variation. He illustrates how large variations cannot be explained by population differences, and that it is typically not patient preferences that lie behind the variations we observe but rather the preferences of health care professionals or the supply of services such as hospital beds. From this, Wennburg builds an argument about how US health services should be reformed if unwarranted variations in health care are to be reduced. It is a compelling argument but, as Wennburg notes, the extent of geographical variations in health care utilisation across the US are much the same as they were 30 years

ago. This salutary lesson suggests that practice variations will be with us for a while yet, together with all the inefficiencies and inequities that they imply. I would have wished for an additional chapter that placed the US situation into the broader experience of other developed countries. Nonetheless, the book will repay anyone who takes the time to read it. Dr Dr David Cromwell Director, Clinical Effectiveness Unit The Royal College of Surgeons of England

Water Contamination Emergencies- Monitoring, Understanding and Acting. Edited by Clive Thompson and Ulrich Borchers. Published by Royal Society of Chemistry, UK, 2011. Hardback 178pp. Price £199.95. ISBN 978-1849731560
In the UK alone, the water industry treats and supplies 16 billion litres of water to its domestic and commercial customers in order to meet our average daily per capita usage of 150 litres. The surface and groundwater sources that provide this water face a range of recognised contaminants which are removed during the water treatment process. However in addition to such recognised threats, the industry faces low probability but high impact events termed Water Contamination Emergencies. These are broad ranging encompassing chemical, biological and radioactive sources, introduced both accidentally or deliberately. Inevitably high profile, such as the accidental aluminium contamination at Camelford in 1988, they require constant vigilance and effective monitoring systems to ensure early identification with a consequent reduction in potential impact. This book summarises the proceedings of the fourth conference on Water

Contamination Emergencies held in October 2010 and with a sub-title of Monitoring, Understanding and Acting, an event the editors describe as the most ambitious of the four. Comprising seventeen European and two US-based contributions it focuses predominantly on preventative and response strategies. As such the bulk of the contributions consider the analytical challenges necessary to provide reliable early warning systems and which utilise advances in on-line sensor technologies for chemical and radioactive contaminants and off-line molecular methods for microbiological alerts. But of course the efficacy of any early warning system is only as effective as the procedures in place to deal with an emergency once it has been identified and this book makes clear that in many European countries comprehensive systems of command and control are in place, with appropriate advice available for the relevant authorities. Of course it is the public who bear the brunt of the consequences of water contamination and so an effective communication of the potential risk is crucial. An important conclusion from these deliberations was that water companies will never stop learning how to improve their response to major incidents as the risks are simply too great. Although inevitably with such a tightly focussed subject area the papers in this collection are specialist in nature, although the editors have made a commendable effort to simplify and clarify the important messages. A wide range of professionals might potentially be involved should a water contamination emergency occur and this collection provides for them a valuable synthesis of both our vigilance and our ability to respond. Dr Nigel Horan School of Civil Engineering, University of Leeds

48 Perspectives in Public Health l January 2012 Vol 132 No 1
Downloaded from rsh.sagepub.com at University of Bedfordshire on March 1, 2012

Book Reviews

Tracking Medicine: A Researcher’s Quest to Understand Health Care. By John E Wennburg. Published by Oxford University Press, UK, 2010. Hardback 344pp. Price £10.99. ISBN: 978-0199731787
Many people are left incredulous when they first come across the figures revealing widespread geographical variations in health care practice. This incredulity can be followed by a stream of questions - does the variation signify inequity of access, or differences in health service efficiency, or is there some acceptable explanation such as differences in population levels of disease? John Wennburg has devoted himself to researching these practice variations. I cannot think of anyone who has contributed more to documenting the extent of the variations, and to providing a framework for helping us differentiate between acceptable and unwarranted variation. His book “Tracking Medicine” starts by describing the moment that he first discovered the small area variations around Vermont, and then proceeds to tell of his subsequent career investigating them across the United States. However, this potted history is merely one of the narrative threads which together document how he and his colleagues slowly pieced together the various causes of practice variation. He illustrates how large variations cannot be explained by population differences, and that it is typically not patient preferences that lie behind the variations we observe but rather the preferences of health care professionals or the supply of services such as hospital beds. From this, Wennburg builds an argument about how US health services should be reformed if unwarranted variations in health care are to be reduced. It is a compelling argument but, as Wennburg notes, the extent of geographical variations in health care utilisation across the US are much the same as they were 30 years

ago. This salutary lesson suggests that practice variations will be with us for a while yet, together with all the inefficiencies and inequities that they imply. I would have wished for an additional chapter that placed the US situation into the broader experience of other developed countries. Nonetheless, the book will repay anyone who takes the time to read it. Dr Dr David Cromwell Director, Clinical Effectiveness Unit The Royal College of Surgeons of England

Water Contamination Emergencies- Monitoring, Understanding and Acting. Edited by Clive Thompson and Ulrich Borchers. Published by Royal Society of Chemistry, UK, 2011. Hardback 178pp. Price £199.95. ISBN 978-1849731560
In the UK alone, the water industry treats and supplies 16 billion litres of water to its domestic and commercial customers in order to meet our average daily per capita usage of 150 litres. The surface and groundwater sources that provide this water face a range of recognised contaminants which are removed during the water treatment process. However in addition to such recognised threats, the industry faces low probability but high impact events termed Water Contamination Emergencies. These are broad ranging encompassing chemical, biological and radioactive sources, introduced both accidentally or deliberately. Inevitably high profile, such as the accidental aluminium contamination at Camelford in 1988, they require constant vigilance and effective monitoring systems to ensure early identification with a consequent reduction in potential impact. This book summarises the proceedings of the fourth conference on Water

Contamination Emergencies held in October 2010 and with a sub-title of Monitoring, Understanding and Acting, an event the editors describe as the most ambitious of the four. Comprising seventeen European and two US-based contributions it focuses predominantly on preventative and response strategies. As such the bulk of the contributions consider the analytical challenges necessary to provide reliable early warning systems and which utilise advances in on-line sensor technologies for chemical and radioactive contaminants and off-line molecular methods for microbiological alerts. But of course the efficacy of any early warning system is only as effective as the procedures in place to deal with an emergency once it has been identified and this book makes clear that in many European countries comprehensive systems of command and control are in place, with appropriate advice available for the relevant authorities. Of course it is the public who bear the brunt of the consequences of water contamination and so an effective communication of the potential risk is crucial. An important conclusion from these deliberations was that water companies will never stop learning how to improve their response to major incidents as the risks are simply too great. Although inevitably with such a tightly focussed subject area the papers in this collection are specialist in nature, although the editors have made a commendable effort to simplify and clarify the important messages. A wide range of professionals might potentially be involved should a water contamination emergency occur and this collection provides for them a valuable synthesis of both our vigilance and our ability to respond. Dr Nigel Horan School of Civil Engineering, University of Leeds

48 Perspectives in Public Health l January 2012 Vol 132 No 1
Downloaded from rsh.sagepub.com at University of Bedfordshire on March 1, 2012