Women are vulnerable to diseases associated with risk behaviours, such as smoking, alcohol or drug abuse, unhealthy eating habits, physical inactivity and unprotected sexual intercourse. Some women are also vulnerable to violence, and many do not take advantage of screening and early detection programs that could reduce the risk of death from breast or cervical cancer. For each of these risks -- smoking, alcohol abuse, drug abuse, pour nutrition, physical inactivity, sexually transmitted diseases, domestic violence, breast cancer and cervical cancer -- women can take concrete steps that will reduce the risk and improve their health.
For the past 30 some years, jurisdictions all over the world have been working to develop health promotion programs that encourage people to reduce risk and adopt healthier behaviours. In that time, what have we learned? What works? Which approaches are most likely to help women make healthier choices?
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A. The Project
In 1999, the Ontario Women's Health Council commissioned the University Health Network Women's Health Program to conduct an extensive critical appraisal of the published literature on public policy, health promotion and prevention. The goal was to identify the strategies and mechanisms most likely to influence health risk behaviour among people in Ontario, especially women.
Researchers reviewed literature on programs designed to reduce smoking, alcohol, drug use, sexually transmitted diseases and violence against women, and on programs designed to encourage better nutrition, more physical activity and regular screening for breast and cervical cancer.
They also visited web sites and talked to people with extensive experience running health promotion programs. When the research was
complete, the project team organized a workshop to review the key findings from the health behaviour literature and to develop policy
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B. The Findings
i. Critical Success Factor: Social Support for Behaviour Change
"Health promotion seems to work best for all when it not only supports and promotes individual efforts but when it also capitalizes upon and enhances the value of social support, relationships, partnerships, formal and informal networks, for the exchange of ideas, information, practical help, resources and access to services."
P. Gillies, Keynote Address 2nd Nordic Health Promotion Research Conference (1998)
The literature confirms the importance of social support and healthy public policy in effective health promotion programs. While interventions that focus on the individual individually can work with motivated, educated people who have more financial resources, effective health promotion programs - particularly those aimed at women -- must take into account broader social, economic, and interpersonal issues.
Behaviour change initiatives must find a balance between helping individuals do what they can to promote their health and working at a broader societal level to guarantee that people will live in healthier circumstances.
For example, efforts to persuade young women not to smoke are more effective when they are supported by public policies that encourage smoke-free schools and other public places, prohibit the sale of cigarettes to minors, and price cigarettes above a certain level. Programs designed to reduce drinking among college students are more effective when universities ban events that encourage students to drink too much (e.g., free drink events, reduced prices for alcohol).
The same kind of comprehensive approach also works to promote better nutrition and more physical activity. For example, it is easier for
women to eat well and be more active when healthy food is readily available in school and work cafeterias, when there are ready opportunities to be physically active, and when the people around them encourage and model a healthier lifestyle.
Broad social strategies can also be used effectively to counter the problem of violence against women. Public policies that strive to improve the image of women, condemn violence against women and children, and provide care and shelter for those who are abused have the potential to help break the cycle of violence.
ii. Risk-Specific Strategies
Organizations committed to promoting women's health and helping them make healthier choices should be aware that, according to the
literature, certain strategies work better than others, depending on the risk.
For example, efforts to discourage young women from smoking or abusing alcohol and drugs should focus on social learning and social influence strategies. Girls need strong parental and societal role models to avoid the peer pressure to engage in risk behaviour. Effective health prevention initiatives use multiple strategies including mass communication and diffusion, empowerment, skills development, community development and health policy.
In promoting healthy eating, interventions based on general principles of health promotion such as environmental control, mass communication and policy development were found to play a critical role. The programs that combine individual, social and environmental change to promote better nutrition have been most successful.
Because most of the population is sedentary and not motivated to exercise, it is extremely difficult to persuade women to become more physically active. The interventions that are most effective are those that take into account the type of activities that women prefer and provide social support for those activities.
A woman's ability to practice safer sex is heavily dependent on her sense of self-esteem as well as her social network. The interventions that have been most effective are those that include strategies designed to increase women's autonomy, provide life skills training and change social norms. They are also more likely to succeed when the target community is actively involved in planning and delivering the program. Health professionals can and should play a key role in reducing the harm caused by sexually transmitted diseases by being more aware of the risks and encouraging women to have the screening and treatment they need.
Interventions that are successful in reducing violence toward women focus on primary prevention, including education and policies designed to change the community's attitude toward violence and programs designed to help women be more autonomous. They also involve a wide range of health and social service providers and governments who, together, can provide support for people who are victims of violence, and advocate for better legal protection.
Effective breast and cervical cancer intervention programs focus on ensuring women have the knowledge and attitudes to seek out screening programs (i.e., predisposing factors) as well as removing any barriers to screening (i.e., limited hours of operation), providing positive cues for screening (i.e., contacting women when it's time for their routine screens) and providing a supportive environment (i.e., enabling factors), including physician encouragement, adequate facilities, and skills. As noted above, successful interventions are directed not only at women, but at physicians. Community-based approaches with a mass media component appear to be the most effective way to increase screening rates among "hard to reach" women. An active recall system established in primary care physician offices -- a strategy that has proved effective in other provinces -- could be adapted to Ontario.
iii. Recommendations for Healthy Public Policy
In general, the field of health promotion lacks well-conducted evaluative research. Much of the literature describes health promotion
developments and activities, focusing on process rather than outcome. Despite the evidence supporting the value of health advocacy and
community development in supporting behaviour change, most health promotion initiatives still focus on individual lifestyle issues. While
traditional health promotion strategies can help reduce some health risk behaviours, they do not address the broader determinants of health or the effect those determinants have on women.