Constructing a healthy balance : action and research ingredients to facilitate the process of health promotion

There is a strong consensus that nutrition issues in Europe play an important role in public health. During the last half century Western diets have become unbalanced. They now contain too much fat, too much sugar and salt, and not enough fibre. The best diet to reduce the risk of heart disease is one which protects against obesity, diabetes, common cancers and other western diseases, and also promotes general good health. Nutrition education, or transfer of information, is known to be a relatively unsuccessful strategy to improve diets because only modest correlations have been found between knowledge about diet and eating behaviour. What people buy and eat depends on individual, social, cultural, economic and environmental factors, In short, food choice is a complex process. Information supply on its own is insufficient as a strategy to promote healthy eating. Public health professionals in five European cities (Eindhoven, Horsens, Liverpool, Rennes and Valencia) decided to start a joint project trying to use the health promotion approach as an alternative strategy. This so-called SUPER project is analysed in this doctoral dissertation, because it could give many insights in the health promotion approach. The three main research questions are:(1) Is the health promotion approach suitable for promoting healthy nutrition?(2) What factors contribute to success or failure in developing a health promotion approach aimed at improving public nutrition?(3) Is the knowledge gained by this multiple case study suitable for other cities and other topics?The main objective of this doctoral dissertation is the development of strategies for facilitating processes of local, national and international collaboration in the field of nutrition. In The Netherlands the SUPER project was financially supported by the Dutch 'Praeventiefonds'. The European network is financially supported by the European Commission (BIOMED).In chapter I the discussion focuses on existing strategies to promote healthy eating which have not been very successful. It is argued that the starting-points for health promotion are fundamentally different from health education. Health promotion uses a broader perspective, is more context specific, is partly unpredictable and requires flexibility for practice as well as for research. A basic principle of health promotion is a shift from interventions imposed from the 'top' to facilitation of an ongoing process, creating a physical and social environment which enables individuals to interact and gain more control over enviromnental factors and thus their own health.In chapter 2 food consumption patterns, prevalence of nutrition related diseases and nutrition policy in the countries participating in the project are presented. The countries can be divided in two comparable groups for general diet characteristics, diet related diseases as well as for the development of nutrition policy. The first group includes Denmark, the Netherlands and the United Kingdom, the second group includes Spain and France. The latter has a higher consumption of fruit and vegetables whereas the first group has a higher consumption of fat and sugar. There is also a clear gradient of coronary heart disease mortality across Europe ranging from high in the North to low in the South. Since the United Kingdom, Denmark and the Netherlands have higher rates of cardiovascular disease they have been more active in the field of developing nutrition policies. Slow development of nutrition policies in Spain and France is also related to the fact that the Spanish, and especially the French are very proud of their diet and are quite convinced that their diet is healthy. For a nutrition policy on a national level two factors seem to be important: (1) a sound supply of food stuffs and (2) promotion of healthy eating habits. The first factor is well taken care of in the five countries whereas the second leaves much to be desired. It seems desirable to find a better balance between the individual choice strategy and the structural change strategy.The answer to the seemingly simple question 'why do individuals and population groups eat what they do?' is difficult because the choice of food involves a multitude of factors. As illustrated in chapter 3, various models of food choice have been proposed in the course of time. Some have emphasized internal motivation, other have concentrated on environmental factors. Food choice is discussed from several disciplines such as anthropology, social psychology, nutrition science and sensory research. Each of these theoretical insights, viewpoints and models have contributed to an understanding of the factors which shape food choices, at the same time leaving many questions unanswered. Furthermore, since food choice behaviour is a dynamic process these insights are constantly developing.Without taking the broader context into account health education has been criticized as 'victim-blaming'. This led to a shift in thinking about health which is comparable to the shift in thinking in the field of agricultural extension. Many present-day viewpoints in this field are similar to those in the field of health promotion. This is described in chapter 4 and it is explained how this has resulted in the choice for the systems perspective. From this perspective, change in one sector usually implies that adjustments or responses also have to occur in other parts of the system. Not only change of individuals, but change of all actors in the food and health system is required. Community participation and intersectoral collaboration are perceived to be important elements of health promotion. A variety of interpretations of these concepts exists. The interpretation of these concepts has clear consequences for the choice of success factors. The more facilitative the approach becomes, the more one is interested in process indicators. For the SUPER project participation has been understood as active sharing of information among the different subsectors in the food and health system. Active sharing of information was viewed as an important prerequisite for facilitating change.The use of the health promotion approach in the field of nutrition was new for all participating cities. A continuous learning process throughout the project resulted in redefining goals, research and philosophy with time. In chapter 5 and 6 it is shown how these learning experiences have influenced the project and research methodology. It is explained that action and research are strongly related and that the project was not designed to test hypotheses. Step by step actions have been taken, adapted and improved.Chapter 5 describes the project methodology of the SUPER project. In each city two project areas were selected (a deprived area and a wealthy area). Intersectoral steering groups were set up consisting of people who worked and lived in the project areas, and who were able to plan nutrition promotion activities which were suitable for the local situation and which the local inhabitants believed to have a potential impact. The original idea behind the project was to organize activities in supermarkets, but the project broadened out to other settings such as health centres, schools, libraries and neighbourhood centres. The programme in each city was based on the same principles but differed in detail because of local and cultural differences.Chapter 6 explains the research methodology of the SUPER project. During the development of the project it became clear that measuring a possible change in nutrition behaviour (a behaviourial endpoint) as a result of the activities, was an extremely complex undertaking. Furthermore, although the effect on nutritional behaviour is a valued outcome, collective work with the community on the issues related to nutrition can be seen as equally important. Studying participation processes and formative evaluation therefore achieved more emphasis after the first phase of the project. The effectiveness, feasibility and comparability of the project was evaluated in the course of three years. Research to guide and support the project was carried out on(1) individual level (knowledge, attitudes, behaviour);(2) enviromnental level (local possibilities to buy healthy food or to obtain information about healthy nutrition);(3) community level (social networking, including the quality of participation from the different participants and conditions for cooperation); and(4) the level of the project as a whole (incorporation in the structure).Chapter 7 reports project development, implementation and evaluation of the project in Eindhoven. In chapter 8 the course of the projects in the other cities is described. Networks and the activities initiated in the five project cities have been incorporated into the local structures so that the health promotion approach in the field of nutrition has become a structural approach. Intersectoral collaboration resulted in complementary approaches including creating supportive environments, organizational change and social and individual development. The interactive character and the importance of linking to local possibilities have resulted in independency of the projects, i.e. projects do not only rely on outside funding and outside human resources. Furthermore, practical tools for health promotion programmes have been developed. There has also been a positive change inenvironmental factors (both physical and social) which influence public nutrition. Examples of these changes are the willingness of supermarket managers to continue with activities, repetition of successful nutrition promotion activities in different community settings and schools paying more regular attention to nutrition education. Most importantly, the actors within the local nutrition and health systems are communicating with each other. Interest, curiosity and awareness has been created and those involved have experienced ways of working together effectively. By means of encounters and discussions, mutual dependencies have become clear, thereby creating possibilities for negotiation. Overall, the project was successful in establishing a sustainable basis for continuation and there is enough reason to believe that in the end individual behaviour will also change in the positive direction.Chapter 9 details the results of the project as a whole. It is concluded that experiences of the five case studies taught that it is possible to stimulate and facilitate an ongoing process in the field of nutrition that creates a social foundation for improvements in health. Four success factors are mentioned: (1) reflection and flexibility; (2) cultural change; (3) visibility and transparency; and (4) the role of a community organizer.Reanalysing the situation and reflecting on what had been successful or disappointing, appeared to be an important success factor for continuation. Cultural change refers to the learning process of both professionals as well as community members and their new role models. Visibility is important for four aspects of health promotion in practice: (1) visibility of process and outcomes (output); (2) visibility of activities (input); (3) visibility of possibilities and contribution of the actors involved; and (4) visibility of health promotion principles, procedures and approach.All four function as incentives for action and continuation. A community organizer is important for facilitating the networking process itself.Based on the results it is recommended that local, regional and national governments need to create situations in which actors of the food and health system recognize their interdependence and feel responsible for improving public nutrition. Educational material is necessary, but it is stressed that it is important to make more use of what is available and to try and improve connections to existing questions or questions which are raised through the interaction and participation process.