Health Promotion at the Community Level: New Advance

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Edited by: Neil Bracht

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  • Front Matter
  • Back Matter
  • Subject Index
  • Part I: Advances in the Theory and Practice of Community Health Promotion

    Part II: Cross-National Experiences: Issues in Developing and Sustaining Community Health Programs

  • Dedication

    Go in search of people. Begin with what they know. Build on what they have.

    —Old Chinese proverb

    Copyright

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    Foreword

    A modern, international movement termed health promotion has emerged out of the historical need for a fundamental change in strategy to achieve and maintain health. During the initial era of public health, concern about communicable diseases appropriately dominated thinking. That led to the “cleanup” campaigns of the 19th century and, later, to the discovery of microbiologic agents of disease and the development of means for their control. Breaking the chain of infection became the focus of attention, later supplemented by strengthening people's resistance: sewage disposal, water treatment, pasteurization of milk, food protection, and avoidance of crowding. These actions, directed at preventing the spread of infectious agents and bolstered by immunizations against specific diseases, proved remarkably effective against the major health problems of the day.

    But another day has brought new health problems, a new system responsible for their origin, and a new set of requirements for their control. The current major problems, mainly the chronic diseases of middle and later life, arise out of conditions to which people are exposed when they enter modern industrialized life and out of their response to those conditions: plenty of calories, especially in the form of fats; lessened demands for physical exertion and heightened demands on the psyche; easy access to tobacco and excessive amounts of alcohol; and motor vehicle transport. Interaction of people with that new milieu constitutes the system that has generated present-day epidemics such as cardiovascular disease, cancer, chronic respiratory disease, cirrhosis, trauma, and diabetes.

    Again, scientific progress has disclosed enough about the nature of the current human-environment-disease system for the social organization of health advance. Breaking the chain of infection and building human resistance to it will no longer suffice. It has become necessary (a) to establish health-protective social policies concerning those aspects of life in industrialized societies that seriously jeopardize health and (b) to help people cope with such conditions of life so long as they exist.

    In former times, social action against principal health problems consisted largely of erecting physical barriers to the transmission of disease agents and providing immunizations. It also included attention to the medical needs of mothers and children. Education of people concerning personal hygiene, such as hand washing and sputum control, and other aspects of health played some role. The situation, however, induced action mainly toward environmental protection.

    Now recognition has grown that people's behavior in their present milieu and the conditions of life that influence behavior, rather than direct physical exposure to biological disease agents, constitute the major health issue. The social environment—especially access and encouragement to indulge in tobacco, excessive alcohol, and calories and too little physical exercise—has become more significant for health nowadays than physical environmental hazards. That is the reason for the profound shift in health strategy.

    Progress in the new situation has been under way for some time. Exercise is trendy in some circles and seat belt use is up, but not all signs are favorable. Obesity continues at a high level and even appears to be increasing. Some segments of the population lag seriously in overcoming behavior that is adverse to health. For example, people with low educational levels continue to smoke cigarettes, and their children also become addicted to nicotine. Teen smoking is once again on the increase.

    Corresponding to the generally positive behavior changes, along with some medical advances, coronary heart disease mortality has fallen sharply, and the lung cancer epidemic has reached its peak among men. People have started learning, as individuals, to cope with the conditions of life that induce these and other principal diseases. More important for the long term, they have initiated social changes to create a more healthful milieu in which to live. Thus television advertising of cigarettes has been banned in the United States, and smoking is prohibited in many places. Some states have increased taxes on tobacco products as a measure against their use. Progress internationally is well documented in Part II of this revised edition.

    Health promotion is thus advancing worldwide. This book is designed to guide professionals in both the health and community organization fields as well as interested citizens in their actions to improve community health. The book's significance lies in its potential to accelerate favorable trends and commence additional ones. A far cry from earlier efforts aimed directly at influencing individuals to adopt healthier patterns, the emphasis here is on the community. As editor, Neil Bracht has sought deliberately to bring together what has been learned in recent years about community organization processes and community intervention strategies and demonstrate the applicability of this knowledge to the health field.

    In so doing, he gives recognition to the fact that although individuals act in ways that affect health, the community largely determines individuals' actions. Hence, the focus here is on communitywide health promotion. Norms are established at the community level and transmitted to individuals as strong guidance. Realizing that relationship and building health promotion strategy clearly geared to it should help overcome the lingering resistance to health promotion as “blaming the victim.” Social action is needed for health promotion. It must be directed principally at the social situations that influence people's health-related behavior rather than at the physical environment that impinges on health without the intermediary of individual behavior. The task of perfecting the physical environment for health is by no means complete, but the new health environment now requires greater attention to such social forces as the extensive advertising of alcohol, widespread portrayal of alcohol use in films and television as “the thing to do,” inadequate constraint of driving while intoxicated, and low taxes on alcoholic beverages. These circumstances exert a profound effect on health.

    This volume offers substantial help to those interested in the community approach to health promotion. It reflects the considerable knowledge gained in the past 10 years. It outlines principles and practical advice concerning important aspects of organizing for communitywide health promotion, such as how to use local media while operating within budget constraints, patterns of academic-community relationships, participation of local health professionals, implications of worksite health promotion experience for other organized groups, involving people in evaluation, and institutionalization of efforts initiated from outside the community. These and other issues addressed here immediately confront those who undertake health promotion in the community. Programs in underserved communities are insightfully described to indicate the special problems in those segments of the population.

    This new edition makes a valuable contribution to the field.

    LesterBreslow M.D., M.P.H.Center for Health Promotion UCLA School of Public Health

    Acknowledgments

    Community health promotion has advanced greatly over the past two decades and is energetically approaching a “third generation” of research and development. The advances reported in this second edition owe much to the pioneering work of the “first generation” of community health promoters: those researchers, funding agencies, and community groups responsible for earlier intervention trials and projects. The researchers, many of whom made contributions to the first edition of this book, provided an important foundation for the growth and dissemination of the health promotion movement seen today. The lessons of these earlier studies, when coupled with the current insights of more comprehensive community health and social initiatives, provide for a growing science of community behavioral and environmental risk reduction. Equally important is our understanding of the key indicators of successful community participation that have evolved from these more recent experiences.

    The results of community intervention trials and studies are mixed, and they present challenges to the funding and design of new initiatives. Although puzzling, these challenges have not deterred the authors of this volume in their attempts to improve global health, equity, and community development. These contributors share a positive view of advances both made and yet to be clarified. I deeply appreciate their sustained interest in, and contributions to, this publication “partnership.”

    The global nature of the health promotion movement offers a far richer base for understanding the common strategies and principles of community health promotion. Part II of this second edition is almost entirely a report on selected international studies and developments. I am indebted to my former Minnesota colleague, Dr. Maurice Mittelmark, for encouraging a “course correction” away from the mostly North American approach of the first edition. No one scientific approach or model can embrace the richness of cross-national experimentation and development one now observes. Dr. Mittelmark, now of the University of Bergen, adeptly captures this diversity in the lead chapter for this book. He reviews the work, findings, and approaches of many studies worldwide. Both Dr. Mittelmark's and my own association with the World Health Organization's health promotion and Healthy Cities movements have enriched our understanding of broader health and social development opportunities. Dr. Mittelmark was a major editorial adviser for Part II of this book, and I am most appreciative of his overall commitment to the work of the second edition.

    I was particularly fortunate to have had the opportunity to personally observe the work of recent studies in Canada focused on the dissemination process of health intervention strategies. Several provinces in collaboration with “Health Canada” are undertaking important investigations of successful dissemination approaches. A special thanks to volunteers and colleagues on Prince Edward Island for sharing their promising approach to community empowerment and sustainability.

    Dr. Beti Thompson's pioneering contribution, in the first edition, on social change in the community (updated here) is now enlarged with her lead chapter for Part II of the book, which explores strategic planning for durability of health promotion efforts. Among the original authors, she was first to politely suggest that the time for a second edition was overdue. Our ongoing dialogue has been immensely helpful in the development of this “new advances” edition. I am, of course, thankful to Dr. Terry Pahacek, who first suggested that a book such as this would be useful to the field and did much to support the work of the first edition.

    Closer to home, I have continued to be the beneficiary of an ongoing association with outstanding colleagues and scholars in the Division of Epidemiology at the University of Minnesota. I especially want to thank Dr. Russell Luepker, Chair of the division, for his long-standing support of my work. His national and international contributions to the science of community health promotion and epidemiology are well known. His earlier first edition contribution (with Dr. Lennart Rastam) on physician involvement in community studies has led to a rich and widely available literature on the critical nature of physician roles in health promotion. Dr. John Finnegan has been a close working research colleague who has made unique contributions to understanding the ties between media campaigns and the community organization components of community trials. His insights, including new web page protocols for community implementation, have been extremely useful to me and research colleagues elsewhere. To many other faculty in “Epi” I express my thanks for being able to share so directly in the exceptional quality of your research, including innovative training programs for future community health professionals.

    Disseminating the theory and science of community health promotion has been a special contribution of the many staff members and professionals in the Minnesota Department of Health. I appreciate the numerous opportunities for collaboration with the department, and I especially thank Lee Kingsbury, senior planner, who is pioneering new linkages between managed care and public health (see Chapter 12). The department's partnerships with a wide range of voluntary and public groups have provided expanded field laboratory settings for studying issues of implementation, citizen participation, and empowerment. This has also been true on my visits to many other Public Health Departments, in this country and abroad, where I have observed the unique features and challenges of community partnerships.

    Many of the opportunities I have had to observe and learn have come from invitations to consult on a number of long-term studies funded by the National Heart, Lung, and Blood Institute (NHLBI), National Cancer Institute (NCI), and Centers for Disease Control (CDC), among others. Particularly useful in this regard were the Community Intervention Trial for Smoking Cessation (COMMIT) and American Stop Smoking Intervention for Cancer Prevention (ASSIST) projects of NCI and the Rapid Early Action for Coronary Treatment (REACT) project of NHLBI. The scientific and professional staff of the NIH Institutes who have supported my participation in these and related studies are too numerous to mention, but clearly, I owe much to many. This sentiment of appreciation applies equally to staff members of several foundations (e.g., Kaiser, Robert Wood Johnson, and California Wellness) who have made significant investments in the community-based health movement. I have also benefited from my association with the Society of Public Health Education (SOPHE).

    It is my hope that those leaders of governmental and private organizations who have invested substantially in community-based health studies will remember that positive outcomes often take longer than anticipated. This has been shown in one of the original community-based studies—the North Karelia Project in Finland. Also, let's not forget that sometimes we learn as much from mixed or negative results as we do from positive ones. Federal and state legislative groups, along with their counterparts in the foundations, need to stay the course in funding important but unfinished research agendas. Future investments in community development for health will help us better determine the “right mix” of actions required to effectively mobilize communities and improve social and health conditions.

    As I mentioned in the acknowledgment to the first edition, many insights, both about the science and art of community work, continue to come from the volunteer community groups and leaders I have collaborated with over the years. Equally valuable are the insights and hindsight of the numerous community organizers and project field directors who have given of their time in training and evaluative feedback sessions, sharing their perspectives on what works, what doesn't, and why. The accumulated wisdom of these groups has too rarely been captured in the subject literature. What I have learned from them I have integrated into the content of this book (especially in Chapter 4). As I now devote more of my professional career effort to community health development, consultation, and training over the next few years, I anticipate even more productive exchanges with the above-mentioned groups.

    Finally, I wish to thank my wife and family for their support throughout this process.

    NeilBrachtUniversity of Minnesota

    Introduction

    This book is about ways to improve the health of communities. There is a new urgency to the complex and important work of advancing community health promotion activities and policies. Population groups around the world are experiencing sharp declines in earlier achieved health gains. Life expectancy in Eastern Europe is declining. In Russia, for example, life expectancy in men declined from 64 years in 1989 to 57.2 years in 1996. In Zimbabwe, largely because of deaths from AIDS, life expectancy, now age 61, is projected to be age 49 by the end of this century. The 1998 International AIDS Conference in Geneva labeled AIDS a “runaway epidemic.” Africa has 90% of all AIDS deaths in the world, and thousands of children are being left to care for themselves. By the year 2000, the World Health Organization estimates that 16 million women worldwide will be infected with HIV. The social and economic costs of coronary disease continue despite much knowledge of modifiable risk factors. The second International Heart Health Conference in Barcelona (1995) predicted a rise to 20 million cardiovascular deaths by the year 2005, with 13 million of these in developing countries and Eastern Europe.

    All of these statistics and trends are troubling enough, but when coupled with the negative health indicators from more industrialized/Western countries, the call for bold new investments in health promotion programs, training, and research becomes more pressing. In the United States, nearly half of the 3 to 5 million migrant and seasonal farmworkers have positive tuberculosis skin tests. Hispanic women of Mexican and Puerto Rican origin are at significantly higher risk of AIDS and cervical cancer than the general U.S. population (Suarez & Siefert, 1998). Latinas are among the youngest and fastest growing minority group in the United States, and they must be a high priority for prevention work, along with other high-risk groups. Substance abuse and cigarette smoking among young people are at unacceptable levels, not to mention increased violence on streets and in schools. Twenty-five percent of 12th graders in U.S. schools smoke regularly. New data show an increase in smoking among African American and Hispanic youth (America's Children, 1998). Revised estimates of the number of overweight or obese Americans are now at 97 million. A recent study (Ebrahim, 1998) found that the prevalence of alcohol use by pregnant women increased from 9.5% to 15.3% from 1992 to 1995. Refugee health and mental health problems continue to be a serious concern in the United States and in other countries as well (Dhooper & Tran, 1998).

    What all of these negative indicators of health status have in common is that they are largely amenable to health promotion and/or preventive community action. Communities and their governmental entities can mobilize to successfully reduce social, behavioral, and environmental risks to health. For example, high blood lead levels among U.S. children have decreased significantly over the past two decades as a result of concerted social action. This book's chapters and case studies point to numerous other successful projects that promote health and prevent unnecessary illness. Much can be learned from a worldwide sharing of health promotion experience, and each author of this edition lists lessons learned in his or her specific content area. The general strategies and approaches required to successfully confront the deterioration of global health status are well-known. They were succinctly outlined in the first International Health Conference on Health Promotion (Ottawa Charter, 1986) and in subsequent conferences (Adelaide, 1988; Sundsvall, Sweden, 1991; Jakarta, 1997). These include five primary strategies:

    • Build healthy public policy.
    • Create supportive environments.
    • Strengthen community action.
    • Develop personal skills.
    • Reorient health services.

    With these overall strategies and guides as background, the chapters of this volume add the tested science and practice skills content required for effective and accountable community health promotion. The authors demonstrate in considerable detail how health promotion programs are implemented and evaluated and how the lives of citizens and the community they live in can be improved. This is a book about both the art and science of community-based health work, and it will be useful to laypersons and professionals alike. At the heart of any successful community health effort is capacity building and local empowerment. This book also provides tangible suggestions for assisting citizens, governmental agencies, and voluntary health groups to collaborate and advocate for healthy community policies. Such policies will be sustained only if the political will and vision remain strong and are periodically reinforced.

    The last decade of research and development has considerably advanced the science of what Lester Breslow, in the Foreword, refers to as “a modern, international movement [that] emerged out of the historical need for a fundamental change in strategy to achieve and maintain health.” The vitality of future population-based health and social improvements will demand continuing attention to discover what works, what doesn't, and why. Our understanding is improving, and more remains to be learned both nationally and internationally. In this second edition, the contributing authors share their “lessons learned” from diverse health promotion experiences and point out areas requiring further study and/or adjustment in community implementation.

    The growth of the movement will be further enhanced through the refinement of community organization processes enabling local citizens and groups to participate fully in actions to promote healthy communities. Green (1990) stated it best in the first edition: “community development puts the control over the determinants of health where it belongs—with the people.” Empowerment theory is emphasized in Chapter 4 and is a recurring theme in many chapters and case studies within the book.

    One “threat” to community empowerment comes from externally designed research protocols that include little, if any, community input. Mittelmark's (1990) earlier chapter contribution on “Balancing the Requirements of Research and the Needs of Communities” has helped to sensitize a generation of health promotion practitioners to the negotiations required in community work. In fact, more participatory evaluation initiatives between researchers and community representatives are now being reported in the literature. This is a welcome advance. Beti Thompson and Carol Winner enlarge this dialectic of community versus research interests (see this edition's Chapter 7, on the durability of health promotion) when they discuss the tension between scientific integrity and broad public health dissemination of partially tested interventions.

    As indicated earlier, this revised edition has been expanded to better integrate the international dimension(s) of health promotion. Part II of the book reports on recent health promotion programs and health policy developments from several continents. Although not exhaustive, these selective experiences provide the reader with a broader perspective and richness to the work of health promotion and community involvement. In sum, these new chapters are a potent reminder of the importance of culture, geography, and politics in shaping health and healthy environments.

    In the lead chapter to the book, Maurice B. Mittelmark summarizes the wide range of definitions and approaches to health promotion and critically examines the mixed scientific results from numerous large-scale community-based studies. His past research in North America, current work in Europe, and frequent interchange with the World Health Organization uniquely qualify him for this daunting task. Part I of the book provides for the core theory and practice principles of community-based health promotion. It builds on the foundation content that readers found most useful from the first edition; this foundation is now updated and linked with three new case studies that immediately follow the conceptual and theory content of Chapters 2, 3, and 4. Case study authors bring a rich background of experience in both quantitative and qualitative research designs, practical field operations, and proven results in fostering community participation.

    In Chapter 2, Beti Thompson and Susan Kinne review past and current theories of social change. A wide range of individual, organizational, community, and environmental change theories are analyzed and synthesized. She discusses the lack of empirical attention paid to studying changes in norms and values and how this is tied to the lack of an integrated theoretical explanation of community change. Suggestions for improved community measures are made. A successful cancer prevention screening project from North Carolina is used to illustrate the use of a theory-driven intervention.

    In Chapter 3, models and methods for conducting a comprehensive community needs assessment and resource(s) analysis are presented by Chris Rissel, a colleague from Australia. Again, this builds on the earlier first edition chapter but reflects more of a “community strengths” perspective. A case study (conducted by the research team from the University of Vermont Health Promotion Center) on community capacity building in Florida follows. Themes of empowerment, durability, and accurate needs assessments emanate from this rich case history.

    In Chapter 4, the applied process of mobilizing citizens and organizations to empower communities for effective health and social improvement is detailed. This is an updated version of the five-stage community organization model presented in the first edition (Bracht and Kingsbury, Chapter 3) but with an enlarged focus on empowerment theory (Rissel), coalition building, and advocacy. The chapter discusses optional organizational structures in building successful citizen involvement in community and health development. References to a substantial number of other works and community participation experiences are provided. A rural case study using the five-stage community organization model follows the chapter, explicating the principles of community mobilization and intervention.

    Most would agree that mass media campaigns can be an important aspect of successful community health intervention projects for social change. Increased experience with message design, marketing, and the phasing of campaign interventions provides new lessons for using local and regional media channels. John R. Finnegan Jr. and his colleague K. Viswanath review these recent innovations, which include more interactive media possibilities. Web site educational programs for professionals and community leaders are also mentioned. The implications for public health practice are changing dramatically, and this chapter provides an essential framework for improving the use of media, especially in reaching low socioeconomic and low literacy groups.

    Part I of the book concludes with an updated chapter by Phyllis L. Pirie on the challenges and approaches to evaluating health promotion programs. This readily understood content should be useful to a diverse audience of researchers, professionals, community citizens, and students but especially to those new to health promotion activities. Formative, process, and outcome evaluation measures are highlighted.

    As mentioned above, Part II of the book focuses more specifically on international developments. Issues of durability, centralization versus decentralization, infrastructure support, and broad intersectoral approaches are common themes among these varied reports. This section of the book begins with a discussion by Beti Thompson and Carol Winner of the durability of community intervention programs, a topic of increasing cross-national interest. The content on durability is new and brings a much-needed framework for examining this important dimension of local and national health promotion programming. Too many public agencies and nongovernmental organizations ignore this aspect of planning and policy resource development. Though limited, recent evidence as presented in this chapter suggests that when durability planning is integrated into a community-based project or governmental initiative, ongoing actions and policies can continue. Community groups and partnerships often want programs to continue and have the motivation to secure resources for long-term impact. Following descriptions of health promotion programs in Africa (Knut-Inge Klepp and colleagues), Asia (Rhonda Galbally and colleagues), Latin America (Abel Arvizu Whittemore and Janet R. Buelow), and Nordic and related countries of Europe (John G. Maeland and Bo J.A. Haglund), Part II concludes with the discussion of an emerging development in the United States. This development relates to achieving community health goals through collaborations between traditional public health agencies and private medical care groups, especially large managed care systems. Lee Kingsbury provides some early insights into the promise and barriers of such arrangements and lists some of the early lessons learned. These emerging partnerships, which are unique to the entrepreneurial aspects of the American health system, may well have broader applications for public-private interactions elsewhere.

    Finally, it should be obvious to all who engage in the work of improving communities that communities, however defined, are undergoing tremendous changes. Individuals and families are buffeted by social, economic, and environmental forces that weaken ties of mutual support. Social disconnectedness increases the opportunities for violence and discrimination. The ravages of war and famine continue to dislocate and alienate large numbers of people worldwide. Inequality of education and income deprive many of their fullest potential. These conditions, as well as the alarming deterioration of health status mentioned at the beginning of this Introduction, must receive critical and sustained attention now. This book can help to foster the work yet to be done to achieve healthy communities and healthy nations.

    NeilBrachtUniversity of Minnesota
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    About the Editor

    Neil Bracht, M.A., M.P.H., is a private consultant in the field of community health promotion and Professor Emeritus in the Schools of Public Health and Social Work at the University of Minnesota. He is a nationally recognized expert on the application of community organization theory to community-based health and social development programs. His research on citizen participation, coalition building, and project sustainability has been published widely. He conducts workshops on effective public-private partnerships that aim to reduce or prevent social and behavioral risks associated with heart disease, drug abuse, teen pregnancy, AIDS, and other preventable diseases. For the past 10 years, he has been a consultant to the National Cancer Institute's community-based smoking control projects throughout the United States and Canada. He is a frequent presenter at professional and scientific meetings both nationally and internationally.

    In 1990, Professor Bracht was the recipient of the Swedish Medical Research Council's Distinguished Fellowship and was previously a visiting professor of health promotion at Karolin-ska University in Stockholm. He also served as consultant to the World Health Organization's Health Cities Project (Copenhagen) and was the keynote speaker at the European Healthy Cities Conference in Pecs, Hungary.

    Professor Bracht received his undergraduate degree in psychology from Loyola University (Chicago) and his graduate degree in social work from the School of Social Service Administration at the University of Chicago. His graduate public health degree (Medical Care Administration) is from the School of Public Health at the University of Michigan, Ann Arbor.

    About the Contributors

    Chris Borthwick, LL.B., is Manager of the Development Unit of the Victorian Health Promotion Foundation (VicHealth) in Melbourne, Australia. His publications include Health Promotion for People With Disabilities; The Prevention of Disability; Severe Communication Impairment, Facilitated Communication and Disclosures of Abuse; Re-inventing the Wheelchair, and “Children in State Institutions: The Mental Health Legislation,” in Disability, Human Rights and Law Reform.

    Janet R. Buelow, Ph.D., M.P.H., M.S.N., R.N., is Associate Professor of Health Services Administration in the School of Business, University of South Dakota, Vermillion. A former fellow of the American Association for the Advancement of Science (AAAS) assigned to the United States Agency for International Development (USAID), she has also engaged in consulting assignments in Latin America, Eastern Europe, Central Asia, and Southeast Asia. Her speciality is aging and long-term care administration. She has published in Health Marketing Quarterly, Home Health Care Services Quarterly, Journal of Aging and Health, Journal of Applied Gerontology, Journal of Long Term Care Administration, and New Directions for Program Evaluation.

    Ralph D'Agostino Jr., Ph.D., is Assistant Professor of Public Health Sciences in the Biostatistics Section at Wake Forest University School of Medicine. His research interests include observational and longitudinal studies and missing data. He is the author or coauthor on more than 45 journal articles, abstracts, and book chapters. He serves as Program Chair for the Epidemiology Section of the American Statistical Association and as an Associate Editor for the American Journal of Epidemiology.

    Anne L. Dorwaldt, M.A., is a Health Education Coordinator with the Office of Health Promotion Research, University of Vermont, Burlington, Vermont.

    John R. Finnegan Jr., Ph.D., is Associate Professor of Epidemiology at the University of Minnesota School of Public Health. He has 18 years of experience in the design, implementation, and evaluation of public health campaigns in the prevention of heart disease, cancer, and youth alcohol use. As a former media professional, he has specialized in the use of mass media in prevention and health promotion. His recent projects have included the Minnesota Heart Health Program, the Cancer and Diet Intervention Project, Project Northland, and the Rapid Early Action for Coronary Treatment (REACT) Study.

    Jean Forster, Ph.D., M.P.H., is Associate Professor in the School of Public Health, University of Minnesota. Her research interests center around the potential of public health policy to reduce the population prevalence of chronic disease risk factors. Her recent research has focused on the prevention of tobacco use by youth and the reduction of youth access to tobacco. She is the principal investigator of a National Cancer Institute grant to evaluate the effects of local policy change on youth access to tobacco and adolescent smoking rates and an NCI grant to investigate community strategies to reduce the social availability of tobacco to youth.

    Rhonda Galbally, Dip. Ed., D.Sc. Hon, is the founding Chief Executive Officer of the Victorian Health Promotion Foundation (VicHealth) in Melbourne, Australia. She has worked extensively with the World Health Organization to develop guidelines and training. Her work in the health care sector focuses on the integration of health promotion strategies into primary health care programs, development of organizational health capacity at the local level, financing models for health promoiotn, MCH health promotion, and women's health.

    Berta M. Geller, Ed.D., is Research Assistant Professor with the Office of Health Promotion Research and the Department of Family Practice and a member of the Vermont Cancer Center, University of Vermont, Burlington, Vermont.

    Bo J. A. Haglund, M.D., Ph.D., is Professor in Public Health Sciences and Director of the World Health Organization Collaborating Centre on Supportive Environments at the Karolinska Institute, Sundbyberg, Sweden. He has been a contributor to and editor of several books, including Community Intervention Strategies (1986), Youth Health Promotion: From Theory to Practice in School and Community (1991), Work for Health? (1991), and Creating Supportive Environments for Health: Stories From the Third International Conference on Health Promotion, Sundsval, Sweden (1996).

    Bridget H.-H. Hsu-Hage, M.S., Ph.D., is the Health Promotion Unit Convener of the Faculty of Medicine, Monash University. She is also the founder and president of the Chinese Health Foundation of Australia. With her medical students, she established the first health promotion home page on the Internet and initiated the Internet Journal of Health Promotion. She is a strong advocate for Asian women's health, especially diabetes in pregnancy.

    Lee Kingsbury, B.A., is a Community Health Planner in the Division of Community Health Services, Minnesota Department of Health in St. Paul. Her research interests include community organizing, community health planning, and public/private partnerships.

    Susan Kinne, Ph.D., is Staff Scientist at the Fred Hutchinson Cancer Research Center in Seattle, Washington.

    Knut-Inge Klepp, Ph.D., M.P.H., is Professor in Public Nutrition at the Institute for Nutrition Research, University of Oslo, Norway, and Adjunct Professor in International Health, Center for International Health, University of Bergen, Norway. His research interests center around health promotion among adolescents, reproductive health, and nutrition and food security issues.

    Gro Th. Lie, Dr. Psychol., is Associate Professor at the Research Centre for Health Promotion, University of Bergen, Norway. Her current research focus is on HIV prevention and coping strategies for people with AIDS.

    Catherine M. Lloyd, M.A., is Assistant Director of the Office of Health Promotion Research at the University of Vermont, Burlington, Vermont.

    John G. Maeland, M.D., Ph.D., is Professor in Health Promotion, School of Psychology, University of Bergen, Norway. His research interests include community-oriented health promotion, health and quality of life research, and psychosocial aspects of rehabilitation.

    Melkiory C. Masatu, M.D., M.Sc., is with the Center for Educational Development in Health, Arusha, Tanzania. He is currently a Ph.D. student at the University of Bergen, Norway. His research interests include health systems research, with a focus on adolescent use of health care services.

    Donna J. Sabina McVety, R.N., Ph.D., was Executive Director of the Lee County Breast Screening Program from December 1990 through June 1997. She is currently serving as volunteer Chairperson of Development for the Lee County Breast Screening Program, Fort Myers, Florida.

    Maurice B. Mittelmark, Ph.D., is Professor of Health Promotion, School of Psychology, University of Bergen, Norway. His research interests include community approaches to health promotion and the study of the near social environment's influence on physical and mental health. He is Director of the World Health Organization Collaborating Centre for Health Promotion, University of Bergen. He also directs an international master's degree program in health promotion in which students throughout Europe and Africa participate. His publications include “Realistic outcomes: Lessons From Community-Based Research and Demonstration Programs for the Prevention of Cardiovascular Diseases” (with Hunt, Heath, and Schmid in the Journal of Public Health Policy, 1993).

    Electra D. Paskett, M.S.P.H., Ph.D., is Associate Professor of Epidemiology and Social Sciences and Health Policy in the Department of Public Health Sicences at Wake Forest University School of Medicine. Her research interests include cancer prevention and screening studies and issues affecting cancer survivors. She is the author or coauthor of more than 46 articles, book chapters, or abstracts. She also serves as the chair of Cancer Control Committee of Cancer and Leukemia Group B.

    Cheryl L. Perry, Ph.D., is Professor in the Division of Epidemiology, School of Public Health, at the University of Minnesota. She has published over 125 articles in the peer-reviewed literature on health promotion and prevention programs with children and adolescents, including papers on health promotion and prevention theory, design, implementation, and outcomes. She is principal investigator of the University of Minnesota site of the Child and Adolescent Trial for Cardiovascular Health (CATCH), a 96-school trial to improve eating and exercise patterns of preadolescents; Project HRIDAY-CATCH, a 30-school study in New Delhi, India on cardiovascular health; and Project Northland, a 28-community trial to reduce alcohol use among adolescents.

    Phyllis L. Pirie, Ph.D., is Professor in the Division of Epidemiology at the University of Minnesota. She directed the process evaluation of the Minnesota Heart Health Program and has taught evaluation to students in the Community Health Education program at the University of Minnesota School of Public Health for 10 years. She is also Director of the Data Collection and Support Services unit in the Division of Epidemiology, which conducts mail and telephone surveys and carries out data processing operations for research projects in the Division and the Academic Health Center.

    Chris Rissel, Ph.D., is an epidemiologist with the Needs Assessment and Health Outcomes Unit of the Central Sydney Area Health Service and Clinical Senior Lecturer with the Department of Public Health and Community Medicine at the University of Sydney. He specializes in research in tobacco control, community participation and empowerment, ethnic health and acculturation, and health outcomes.

    Julia Rushing is employed as a biostatistician at the Wake Forest University School of Medicine in the Department of Public Health Sciences. Her collaborations with researchers have led to over 25 coauthored papers in the areas of geriatrics, cancer, diabetes, and cardiovascular disease. She is a member of the American Statistical Association.

    Philip W. Setel, Ph.D., is Director of the Adult Morbidity and Mortality Project in Dar es Salaam, Tanzania. His main research focus has been in the area of reproductive health, particularly male sexuality and reproductive rights.

    Cathy Tatum, M.A., is Research Associate in the Department of Public Health Sciences at the Wake Forest University School of Medicine. She has worked on several research studies, including the ARIC study, the Polyp Prevention Trial, the Forsyth County Cancer Screening Study, and the Robeson County Outreach, Screening and Education Project. She is author or coauthor of four articles.

    Beti Thompson, Ph.D., M.P.H., is Assistant Professor at the University Washington School of Public Health and Community Medicine and an Assistant Member at the Fred Hutchinson Cancer Research Center in Seattle.

    Sara Veblen-Mortenson, M.S.W., M.P.H., is the Intervention Director for Project Northland: Partnerships for Community Action and has managed the development and implementation of the intervention components (school, youth, parent, and community) of the research since the beginning of the project in 1990. She has worked with adolescent health issues in school-based clinic and community settings for 10 years.

    Ramon Velez, M.D., M.Sc., is Professor of Medicine in the Section of Internal Medicine and Gerontology at the Wake Forest University School of Medicine and Director of Reynolds Health Center. He is author or coauthor of more than 25 articles and abstracts.

    K. Viswanath, Ph.D, is Associate Professor in the New School of Communication and the School of Public Health, Ohio State University, Columbus, Ohio.

    Abel Arvizu Whittemore, D.B.A., M.H.A., FACHE, is Chair of the Division of Health and Human Services at Walden University, Minneapolis, Minnesota. A former hospital chief executive officer, he has held visiting professorships in Bulgaria and Brazil. He also has served as a Yale/Mellon fellow in international health at Yale University and has engaged in consulting assignments in Latin America, Eastern Europe, Central Asia, and East Africa. His areas of expertise are in health administration and strategic management, and his most recent publication appeared in the Journal of Long Term Care Administration.

    Carol Winner, M.P.H., is Research Instructor with Georgetown University's National Center for Education in Maternal and Child Health, serving as the Director for the Division of Program and Policy Development. She served as the Director of Technical Assistance on the National Cancer Institute's American Stop Smoking Intervention Study (ASSIST) and has also been a Program Director with the American Lung Association and the Epilepsy Foundation.

    Mark Wolfson, Ph.D., is Associate Professor and Director of the Center for Community Research in the Section on Social Sciences and Health Policy, Department of Public Health Sciences, Wake Forest University School of Medicine. His research interests include alcohol and tobacco policy, managed care and population health, and the politics of community health. His recent publications include “Managed Care, Population Health, and Public Health” (in Research in the Sociology of Health Care, 1998), “Unintended Consequences and Professional Ethics: Criminalization of Alcohol and Tobacco Use by Youth and Young Adults” (in Addiction, 1997), and “Adolescent Smokers' Provision of Tobacco to Other Adolescents” {American Journal of Public Health, 1997). His book, The Fight Against Big Tobacco: The Movement, the State, and the Public's Health will be published in 1999.

    John K. Worden, Ph.D., is Research Professor with the Office of Health Promotion Research and the Department of Family Practice and is a member of the Vermont Cancer Center, University of Vermont, Burlington, Vermont.


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