Europe is currently undergoing a far-reaching process of social and economic changes. At the same time it is facing greater health challenges than at any other time since the end of the Second World War. Only recently has the European Union taken the decision to invite an additional 13 European countries to the Enlargement process. The challenges and the prospects for a peaceful and sustainable development on this continent are enormous.

More and more, health promoters recognize that social inequalities are strongly linked with health inequalities. The evidence available clearly indicates that the quality of our social life is a powerful contributing factor to our health. Poor health is the result of poverty, unemployment, poor sanitation and other social breakdowns.

Health promotion can help resolve some of the social problems in our societies and contribute to the reduction of health inequalities. Participatory health promotion approaches, which are based on a systematic involvement of the relevant stakeholders can contribute to an improved social cohesion within the target setting, and thus increase social capital. The workplace represents a very important setting for health promotion action and also has a strong impact on family and community life.

Enterprise for Health:
the contribution of workplace health promotion

The health circle approach should be viewed as a methodology similar to the quality circle concept and is part of corporate health and human resource management. The health circle approach consists of a series of group meetings during paid working time which focus on short- and medium-term improvements of working conditions and aspects of job design. The health circle members represent all involved stakeholders of a target area within an organization (employees, human resource department, company doctor, safety officer, employees’ representatives etc.).

An important pre-condition to help ensure the effective running of a health circle, is the establishment of an overall steering group with representation from key members (including management, health and safety officers, personnel department, union representatives and works council members). Furthermore a health circle needs to be based on a sound needs analysis (including an analysis of absenteeism data, staff turnover, productivity and health- relevant risks). The results of a health circle are presented to the steering committee which decides about the implementation of specific suggestions whilst monitoring the whole process.

Does it work?

• A high acceptance by employees as well as employers 
• A reduction in health complaints 
• An improved working climate and satisfaction at work

The health circle concept has been further developed into several specific applications, one of which addresses communication and management style issues in particular.

The enormous success of this approach is due to the fact that health circles are able to address the social factors of health within enterprises. They contribute to an improved mutual understanding of each others perspective and facilitate the identification of practical solutions to highly ranked problems which, of course, in most cases are related to the so-called soft factors such as co-operation, communication, settling of conflicts and management style. In this way, employees are empowered and their capacity to influence their own working environment is strengthened.

In those cases in which enterprises utilize this concept more and more in a systematic way (i.e. on a regular basis and addressing all levels and areas of an organization), the contribution to building social capital (understood as the capacity of an organization to manage the needs and goals of all members in a coherent and sustainable way), is also supported.

Gregor Breucker can be reached at the European Information Centre at the Federal Association of Company Health Insurance Funds (BKK), Essen, Germany. Dr. Breucker’s e-mail is BreuckerG@bkk-bv.de 

The Igbos are among the three dominant ethnic groups in Nigeria. They are geographically located in the eastern part of the country and have increased very substantially, adding to the country's overall population size. The tragic consequences of the Nigerian civil war has left an enduring mark in the lives and aspirations of this celebrated group of dynamic, hardworking and innovative people. And in a bid to survive the hard realities of daily living in a highly competitive Nigeria, many of them have migrated to different parts, states, villages and urban settlements outside their places of ethnic origin. Wherever they are found, even in heterogeneous urban settings, the Igbo identity is highly projected, sustained and maintained through social networks (age grade associations, social clubs, kinship associations, women groups, youth associations, etc.). Although the Igbo ethnic community is basically patrilineal, women also play an active role in the networks. Membership is not compulsory but necessary. The spirit of cordiality, "Nwanne di na mba" (meaning "brethren in diaspora"), binds them together; a network relationship that brings life, trust, confidence, health, hope, social and economic empowerment and security to all members.

Network Support

The social network generates emotionally sustaining and problem-solving behaviors among members. Talking and listening to the needs of members provide intimacy, companionship and accompaniment in stressful situations (as well as clarification, suggestions, direction and information about sources of stress.) At times, referral, material aid and/or direct service are provided to alleviate the suffering of members.

Health Promotion Efforts

Each social network determines their own immediate needs and build upon their collective strength to solve collective problems. Where necessary, resources from richer urban kinsmen are mobilized and disbursed to support community development initiatives, including health-related projects in their ethnic hometown.

The mechanisms and processes by which social network interactions are health promoting, protective or destructive among the Igbos, are yet to be studied. However, the harmonious relationship that exists between this group of people cannot be over estimated. Interaction among members could lead to increased knowledge, positive attitude and enhanced ability to cope with situations, including health problems. Supporting one another in time of need promotes psychological wellbeing of members. However, studies elsewhere have also indicated that migration of social network members from urban to rural areas (members of these networks travel to their ethnic home base for holidays) has led to high prevalence rate of HIV/AIDS (Ajuwon, 1990; Caldwell et al, 1990 a, b;); illicit sexual relationships; high rate of drug use, abuse and misuse; including fighting and quarrels.

National Health Policy

Involving social networks in all aspects of health policy is essential. If actively involved in setting priorities, "lay" expertise is brought into health planning, implementation and coordination.

Conclusion

The existing traditional social networking among the Igbos can be more properly harnessed for effective health promotion activities. Age grade societies, social clubs, kinship associations, women groups, youth groups and others constitute powerful agents of social change. The emotional support provided by network members to one another is immeasurable. Social networks in Igboland or elsewhere, therefore, need to be more actively involved in health care policy planning and execution in Nigeria.

Godwin Nwadibia Aja is a lecturer in Community Health at the Department of Health Sciences, Babcock University in Nigeria and a HAI Africa Volunteer, Subregional Coordinator for Western Anglophone/Nigeria. He can be reached at hai@infoweb.abs.net (e-mail) or (011234)-37-630149 (phone).

"Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change." (American Journal of Health Promotion, 1989, 3, 3, 5.)

Health as a resource

But the bias has been to equate "health" with expenditure and consumption rather than investment and production. Some analysts indicate that this could be highly counterproductive, and take resources from societies and families that would be better invested in health- (and wealth) producing measures. Evans and Stoddard (1994) state: "A society that spends so much on health care, that it cannot or will not spend adequately on other health enhancing activities, may actually be reducing the health of its population."

Wilkinson (1996) has shown that even in rich societies significant health differentials are at work and that there are significant differences in life expectancy between social groups and between countries. Miringoff and Miringoff (1999) show that while gross domestic product has increased significantly in the USA, the index of social health has decreased, and the two measures now seem to be depicting quite different phenomena and separate dynamics in society. This indicates that health patterns closely mirror not only the economic but also the social characteristics of a society.

Above a certain level of wealth, it is not the wealthiest societies which have the best health, but those that have the smallest income difference between rich and poor. The research indicates that "there are underlying factors that influence susceptibility to a whole range of diseases", that go far beyond our notion of specific risk factors. These factors include the economic, social and physical environment, the individual response and behavior, the sense of individual and social wellbeing and control.

What strategic consequences?

• Social organization, stress and health 
• Early life and child development 
• Social gradients and health throughout the life course 
• Unemployment 
• Psycho social work environment 
• Transport 
• Social support and social cohesion 
• Food 
• Poverty and social exclusion 
• Social patterning of individual behaviors.

Strategically they need to be addressed through "critical path-ways" —which address not one but all potential health outcomes. An example is the health and well being policy of British Columbia, which frames the strategic priorities as follows: 

• Encourage the reinforcement of the individuals potential 
• Provide support in social settings and develop healthy and safe environments 
• Improve living conditions 
• Act for and with groups at risk 
• Coordinate public policy and action to promote health and well being 
• Orient the health and social services system towards the most effective and least costly solutions.

In the mid 1980s the World Health Organization (WHO) developed the "settings approach" to health promotion (Kickbusch 1997) which aims to strengthen the social environment and the participation of people in the production of health. A range of projects and initiatives such as healthy cities, health promoting schools, healthy work places, and the like, all share a set of common characteristics similar to those of healthy societies.

There is something else out there

In summary, our health strategies should focus on the three factors that best predict health: 

• A widely shared economic prosperity and low social gradients 
• The development of a supportive community life and the social capital of a society 
• The investment in people.

References

Blane D. et al (eds) (1996) Health and Social Organization. Routledge, London and New York.

Breslow L. (1999) JAMA.

Evans R.G. and G.L. Stoddart (1994), Producing health, Consuming health care. In: Evans R.G. et al (eds) (1994) Why are some people healthy and others not? Aldine de Gruyter, New York, 27-64.

Kickbusch, I (1997) Think health.: what makes the difference. Health Promotion International. Vol 12, No, 265-272.

Kickbusch, I (1997) Health Promoting Environments: the next steps. In: Australian and New Zealand Journal of Public Health, Special Issue, 21,4, 431-434.

Marmot, MG and R. G. Wilkinson (eds.) (1999) Social determinants of health. Oxford University Press, Oxford.

Miringoff M. and ML Miringoff (1999) The Social health of the nation. Oxford University Press, Oxford and New York.

Rose G. (1992) The Strategy of preventive medicine. Oxford University Press, Oxford.

Sen A. (1999) Health in development. Keynote Address to the 52 World Health Assembly, 18.May, Doc Nr A52/DIV/9.

Wilkinson, R.G. (1996) Unhealthy Societies. The afflictions of Inequality. Routledge, London.

World Health Organization (WHO) (1996) Ottawa Charter for Health Promotion. In: Health Promotion 1, iii-v.

Dr. Kickbusch is the head of the Division of International Health of the Department of Public Health at Yale University. She can be reached at ilona.kickbusch@yale.edu (e-mail) or 1-203-785-2861.

The political situation of Taiwan is hotly discussed nowadays, and not only in the spheres of the southeastern sea of China. Taiwan is not officially recognized by the United Nations, and therefore neither by the World Health Organization (WHO). However, in many ways Taiwan has developed into an independent entity and is appearing as such in many international forums and fields. The same can be said for Taiwan’s activities in the health field, although it does not receive any support from the WHO.

The country of Taiwan, or the "Republic of China", as it is referred to by the Taiwanese government, comprises 86 islands in the south-eastern sea of China totaling 14,000 square miles (36,000 square kilometers). The total population is about 22 million with a population density of 601 persons per square kilometer. The capital Taipei City represents the bustling center of the island with nearly 12% of the people living here. With the crude birth rate declining, Taiwan’s population of those over 65 years of age has grown to 8% in 1997. Taiwan has undergone remarkable economic development over the last 50 years. The per capita national income has increased ten-fold from 1976 to 1997, from US$ 1,041 to US$ 12,074.

With the betterment of living standards and the upgrading of the quality of health and medical care, life expectancy has been greatly prolonged, from 53.38 years in 1951 to 71.91 in 1997 for men, and from 56.33 years to 77.79 years for women. Also, the causes of death have changed from infectious diseases to chronic diseases, such as cancer (leading death cause), cerebrovascular diseases, heart disease, diabetes mellitus, etc. Of these diseases, cancer and diabetes have rapidly increased. Cerebrovascular diseases (since 1981) and heart diseases (since 1992) have slightly declined. With regard to health behaviors, currently about 30% of the population are smoking in Taiwan. 55% of the men and 3% of the women are smokers. These rates have slightly decreased since 1992. In addition, Taiwan is experiencing some of the effects of "Westernization" similar to other emerging countries, with the diet including more high-fat foods, especially in the cities. Another health issue of increasing concern in Taiwan is the air pollution.

Comprehensive health promotion efforts

The Department of Health of the Executive Yuan (the Cabinet) published a report on public health in Taiwan in October of 1998. The report highlights the comprehensive health promotion efforts of the Department, which fall into the following 15 areas: genetic health, family planning, health of mothers, infants and children, promotion of the health of adults and the elderly, vision promotion, oral health, occupational health, cancer control, control of tobacco hazards, control of betel nuts hazards, health education, nutrition education, injury prevention and control, comprehensive primary health care, and promotion of health-related fitness.

Tobacco control is one of the major priorities of these efforts. The "Tobacco Hazards Prevention Act", which came into effect in September of 1997, addresses the banning or restriction of advertisement and sales promotion of cigarettes, warning labels against smoking, labeling of nicotine and tar contents, restriction on smoking areas, and prohibition of juniors from smoking. Specific to the area of Taiwan, betel nut chewing has become a major concern in health care circles due to the carcinogenicity of betel nuts. 88% of oral cancer patients also have the habit of betel nut chewing. Previously, mostly practiced by laborers of lower social economic status, betel nut chewing has now spread across occupations to the younger and more educated people leading to an increase of the mortality from oral cancer from 1.25 per 100,000 population in 1976 to 5.38 in 1997.

The rising incidence of diabetes has been countered with a number of measures including the development of guidelines on the prevention, control, and treatment of diabetes, the establishment of health promotion centers for diabetic patients at 39 hospitals, and the involvement of the mass media to alert the public to the importance of diabetes prevention and control.

Health promotion is also gradually finding a place in the worksite. Hypertension screenings and fitness promotion have been encouraged by the Department of Health. The Taiwan Power Company (TPC), the largest enterprise in Taiwan, initiated the first formal workplace health promotion program in collaboration with the Departments of Physical Education and Health Education Health of National Taiwan Normal University. An initial experimental study of 250 employees at TPC headquarters included a fitness workshop and 12-week long intervention activities. The results showed improvements in cardiorespiratory endurance, muscular strength, and flexibility. TPC has continued the activity programs and expanded the workshops to other sites on the island. The TPC physical activity intervention has served as a model for other companies to learn from.

New focus: physical activity promotion

A major thrust to advance healthy lifestyles has come from the physical education and fitness field. The promotion of health-related fitness is now considered an important measure for the prevention of chronic diseases and improvement of quality of health. Physical activity programs have been implemented in different settings. Besides the workplace (see above), the school and the community setting have been targeted as a priority. The "Fitness Passport" program has been running on an experimental basis in about 200 schools since last September to measure health-related fitness of students and develop standards. The Ministry of Education hopes that by the year 2001 half of all primary and high school students will own the Passport as part of the strategy for fitness and physical activity promotion among students. Then by the year 2002, with the necessary revisions of the Passport, all students in this nation will be expected to own a personal Fitness Passport.

Only two years ago, the National Council on Physical Fitness and Sports was created as a cabinet-level council under the Executive Yuan. In its strategic plan for the 21st century, the Council emphasizes the need for an increased focus on physical activity and sport for all, instead of primarily targeting performance-related fitness of elite athletes. The National Society of Physical Education has joined this effort, and the two organizations recently teamed up to host a high-profile, international conference focusing on this topic (see IIHP Newsflashes for more details). Some of the major health challenges facing Taiwan may magnify in the near future with changing lifestyles and economic development. However, the Taiwanese government has recognized the need for health promotion initiatives and is well-positioned for the 21st century to create a healthier society.

Dr. Jwo is a professor at the Department of Physical Education of National Taiwan Normal University and can be reached at t08002@cc.ntnu.edu.tw (e-mail) or (011886)-2-23634240 (fax). Wolf Kirsten is the Manager of the International Institute for Health Promotion at American University

A recent study (published in the Journal of Epidemiology in 1999; 28: 824-828) on the effect of passive smoking on lung cancer of non-smoking wives, underlined the significance of addressing the smoking habits of Korean men. Only few studies have investigated the effect of passive smoking in East Asia, where the prevalence of smoking is among the highest in the world. The effects of spousal smoking were investigated in 160,130 Korean women by conducting medical examinations between 1992 and 1994 and documenting lung cancer incidences from 1994 to 1997. At baseline, 53.9% of husbands were smokers and 23.3% were ex-smokers, while 1.1% of wives were current smokers and 0.6% were ex-smokers. During 3.5 years of follow-up, 79 cases of lung cancer occurred among non-smoking wives. Wives of heavy smokers were found to have a higher risk of developing cancer (dose-response relationship).

Lung cancer mortality is the most rapidly increasing cause of death among Koreans. Rates increased from 2.1 per 100,000 in 1980 to 28.0 per 100,000 in 1996 among men, and from 1.4 per 100,000 in 1980 to 6.9 per 100,000 in 1996 among women. This increase is persistent in men and women despite the fact that only few women smoke. The prevalence of smoking among adult men is 72%. In spite of a slight recent decline in smoking rates, tobacco control remains a high public health priority in Korea to avert an emerging epidemic of smoking-related disease.

For more information, please contact Sun Ja Hee of the Department of Epidemiology and Disease Control, Graduate School of Health Science and Management at Yonsei University in Seoul, Korea.(email) jsunha@yumc.yonsei.ac.kr or 82-2-365-5118 (fax).

Organizers and speakers assemble on stage at the 
closing ceremony of the Millennium Conference

Physical Activity Conference in Taiwan

The National Council on Physical Fitness and Sports and the National Society of Physical Education co-hosted "The Millennium Conference on Exercise and Quality of Life", which was held in Taipei City from January 24-26, 2000. The conference attracted around 300 physical educators, coaches, fitness professionals, academicians, and government officials from Taiwan. A number of international speakers presented on their areas of expertise: 

• Ming Li (Georgia Southern University. USA) – Modern technology, quality of life and physical activity 
• Jessie Jones (California State University Fullerton, USA) – Aging and physical activity 
• Allen Jones (University of Northern Colorado, USA) – Physical activity using the transtheoretical model 
• Toshio Saeki (Japan) – Advantages of exercise on social intercourse 
• Akio Kataoka (Japan) – Philosophical discussion of the conditions of quality of life 
• Victor Matsudo (Celafiscs, Brazil) – Physical activity : passport for health (AGITA) 
• Bob Karch (American University, USA) – Workplace health promotion and physical activity 
• Wolf Kirsten (American University, USA) – Global perspective of health promotion and quality of life.

The conference almost exclusively focused on the health-related benefits of physical activity and how these benefits can be brought to the general population through effective programs. This central topic reflects a recent shift in focus of the fitness and physical education associated government agencies and academic institutions from performance-related to health-related physical fitness. As many other emerging countries, Taiwan is facing an enormous challenge to fight chronic diseases, often precipitated by inactivity. The government is actively striving towards a new policy orientation, and the Millennium Conference was a major step in the direction of gathering the necessary information and discussing the next strategic steps.

Health Promotion Conference in Saudi Arabia Postponed

Unfortunately, the health promotion conference in Jeddah, Saudi Arabia planned for May 5-7, 2000 has been postponed due to unforeseen circumstances. Global Perspectives will keep you up-to-date about new dates or a different location in the region.

IIHP Committees Update

The chair of the Global Fitness Testing committee, Dieter Lagerstrøm (IPN, Germany) has taken the initiative to advance the immense task of finding agreement on a common test battery assessing health-related fitness. The committee members have been asked to provide their widely-used protocols and answer the following questions: 

1. Is there agreement that the test, which was discussed in past IIHP Meetings, should focus on testing an individual’s fitness level compared to a sex- and age related mean ("normal") instead of testing the max? Looking at health-related fitness testing is the key. 
2. Are the tests, test batteries, and the test parameters in the group session during the last IIHP meeting in Brazil acceptable or what should be changed? 
3. Is the strategy to set up a Global Fitness Test, which can be used with and without high-tech equipment the right strategy? Looking at the needs in both developed and developing countries is a very important point. 
4. What possibilities do you have to collect data if we have an agreement for the Global Fitness Test rather fast? 
5. What ideas do you have regarding working methods within the group (e.g., communication process), how to progress, and set a time schedule for optimal efficiency?

Additional information and updates on the other committees will follow in upcoming issues of Global Perspectives.

Conference Dates

2nd Conference on "Health Status of Central and Eastern European Populations After Transition", Warsaw, June 5-7, 2000.

5th Global Conference on Health Promotion: "Health Promotion – Bridging the Equity Gap" hosted by WHO, PAHO, and the Ministry of Health of Mexico. Mexico City, June 5-9, 2000.

The First International Conference on "Exercise & Nutrition for Better Health and Chronic Diseases" hosted by the Chinese Sports Science Society (CSSS) and organized by the Chinese Sports Medicine Society (CSMS) and Institute of Sports Medicine of Beijing Medical University. Beijing, China, June 11-16 , 2000.

The 2000 Pre-Olympic Congress hosted by the International Council of Sports Science and Physical Education (ICSSPE), Sports Medicine Australia, and the Australian Council of Health, Physical Education and Recreation. Brisbane, Australia, September 7-13, 2000.

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe.  It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations.  More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation.  Email the IIHP at iihpaa@american.edu.  The IIHP website is http://www.healthy.american.edu/iihp.html.

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