Published on March 11, 2014
Focus on public health campaigns for older people ______________________________________ Introduction The increase in life expectancy is a positive step forward for medicine and public health. One reason for increasing longevity is the capacity for medicine to cure infectious diseases. As a result, there has been a shift in focus to chronic conditions such as arthritis, hypertension, heart disease, cancer and dementia. Many of conditions of later life can be prevented, delayed, or controlled through health promotion and the risks associated with the conditions can be reduced through changing behaviours. A public health campaign is an effort to persuade a defined public to engage in behaviours that will improve health or refrain from behaviours that are unhealthy (Springston, 2005). Public health campaigns can contribute by raising awareness of conditions and their risk factors and educating people as to how lifestyle changes can prevent or delay the onset of chronic conditions. This edition of the CARDI “Focus on” series examines public health campaigns as they relate to older people in both the Republic of Ireland (ROI) and Northern Ireland (NI). It examines what the role of government is and the key elements that make public health campaigns work. March 2013
2 March 2013 Key findings Public health campaigns seek to promote public health through education and raising awareness as well as promoting better health through changing behaviours (Health Development Agency, 2004). A US literature review of ten years of health communications found that if well-executed, health campaigns can have small-to-moderate effects on health knowledge, beliefs, and attitudes, and can also be effective in changing behaviours (Noar, 2006). Elements of successful public health campaigns include targeting to the specific audience, providing accurate information through clear, unambiguous messages and providing additional services in support of the campaign (Health Development Agency, 2004). Healthy ageing and maintaining independence in old age require a life-course approach. Governments can serve as a driving force to galvanise key stakeholders as well as older people themselves in bringing about a fundamental change on public health issues. Public health campaigns Public health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole (World Health Organization, 2013). Public health campaigns seek to promote public health in two main ways. The first is through health education and raising awareness about particular conditions and their impact. The second is through a campaign designed to change behaviours, such as promoting physical activity as a means to improve health and wellbeing. A literature review conducted in 2006 on public health campaigns in mass media found that targeted, well-executed health campaigns can have small-to-moderate effects on health knowledge, beliefs, and attitudes, and can also be effective in changing behaviours (Noar, 2006). Public health campaigns to change health-related behaviour may range from a simple, face-to-face consultation between a doctor and patient to a complex programme, often involving the use of mass media such as television or radio advertising (Health Development Agency, 2004). Such campaigns can also be used to build a better understanding of conditions like dementia which have a stigma attached to them due to misconceptions. The NI Life and Times Survey in 2010 included a module of questions exploring attitudes and knowledge of dementia. The results, presented in Figure 1, showed a good understanding of dementia in NI, but also indicated that misconceptions remain.
3 March 2013 Figure 1 Perception and understanding of dementia in NI Source: (McManus & Devlin, 2011) Issues are selected for public health campaigns as a result of public health planning. In public health, planning can be initiated and led by a variety of public health agencies or by other health-interested organisations. In theory, public health planning and decisions on what should be selected for a public health campaign are based on several factors: 1. Data analysis concerning the burden of disease 2. Distribution of available resources 3. Resource utilisation and health outcomes (GALE Cengage Learning, 2003). Figure 2 overleaf shows the development of “Open your eyes”, the Health Service Executive campaign on the issue of elder abuse in ROI. The genesis of the campaign was a submission to the Minister for Health and Children on the issue by the National Council for the Elderly. This developed into an exploratory study published in 1998 and the establishment of a working group on the issue in 1999. The exploratory study cited a “growing body of literature and research” highlighting the extent of the problem of elder abuse (O'Loughlin & Duggan, 1998). When the working group reported in 2002, one of the recommendations was the establishment of a national implementation group. In 2007, the National Elder Abuse Steering Committee was established, tasked among other things with the development of a public health campaign.
4 March 2013 Figure 2: Development of elder abuse public health campaign in ROI Source: Health Service Executive (2011) Campaigns for older people The table overleaf presents some examples of public health campaigns related to older people in ROI and NI. Public health campaigns are usually launched and supported by governments as they can provide the necessary resources and support. Governments can also fund voluntary or community sector organisations to operate public health campaigns. It is also possible that campaigns can be run privately by NGOs. While government campaigns tend to be supported by public services, private campaigns tend to be lobbying for services to be put in place, e.g. the “Can’t heat or eat” campaign in NI.e social support accelerates and improves patient recovery from conditions such as cancer, cerebrovascular disease and cardiovascular disease (Seeman, 2000). A positive social environment can also be as helpful to a patient diagnosed with a chronic disease as information or instrumental support (Arora et al., 2007).
5 March 2013 Table 1 Sample public health campaigns for older people on the island of Ireland Issue Details Elder abuse in NI What: Comic Relief funded a campaign, “Uniting against elder abuse”. The aim was to provide independent advocacy for frail older people and people with dementia and raise awareness of the problem of elder abuse. When: The campaign ran from 2009 to 2011. Who: Operated by Age NI and the Alzheimer’s Society in NI. Impact: The review of the campaign published in 2011 suggested that more could be done to raise awareness of the issue among the general public, especially as there had been high-profile media coverage of elder abuse in NI (Age NI / Alzheimers Society, 2011). Fuel poverty in ROI What: “Keeping well and warm” is a public health campaign developed by an inter-departmental / agency working group on energy affordability in 2008, aimed at reducing deaths and illnesses related to fuel poverty in ROI each winter. When: Launched in 2008 and is currently ongoing. Who: www.wellandwarm.ie is a website hosted by the Sustainable Energy Authority of Ireland in conjunction with several partners including Age Action. The website gives information on keeping warm, energy efficiency and financial and support services. Impact: 19.4% of all households in ROI were fuel poor in 2008. There has been an overall decrease in mortality due to fuel poverty for all ages and, in particular, older age groups (The Irish Examiner, 2012). Physical activity in NI What: “Get a life, get active” is a dedicated campaign for promoting physical activity, “Get a life, get active”, including a website, radio and television advertising. For older adults, the campaign suggests activities such as walking, cycling, dancing and swimming for increased mobility and muscle strength, managing weight and building balance. When: Campaign first launched in June 1999 and is ongoing. Who: The Public Health Agency in NI. Impact: Following Phase 2 of the campaign, 63% of people surveyed reported having seen elements of the campaign, with the television element being the most frequently recalled. 23% of respondents reported being more active during the campaign period.
6 March 2013 What makes public health campaigns work? An NHS Health Development Agency health briefing on the effectiveness of public health campaigns presents evidence on the key elements for success of campaigns in changing health behaviour. The characteristics include: Targeted and tailored campaigns in terms of age and gender. Providing basic, accurate information through clear, unambiguous messages. Joining up services with other community provisions (e.g. providing transport links from community centres to clinics). Working with community members as advocates of appropriate services. Addressing peer norms and social pressure (Health Development Agency, 2004). It is important that public health campaigns are designed with their target audience in mind, and that they utilise the most effective means of communication for that target audience. Older people have consistently cited word of mouth sources such as GPs or family and friends as the preferred mode of information provision. It has also been noted that informal sources of information are particularly important for the older population (McDaid, 2012). The success of public health campaigns is dependent on many factors. In the area of health, high levels of public spending and improved services can lead to better outcomes, but success also requires better engagement and participation from people themselves (Halpern & Bates, 2004). Non-governmental organisations such as charities have an important role to play in raising awareness of public health issues or challenging stereotypes when it comes to conditions such as dementia. Any public health campaign should ensure that key stakeholders are involved in shaping the message and providing support services. (Alzheimer's Disease International / World Health Organization, 2012). Monitoring and evaluation being built into a campaign can also increase the chances of success. This can lead to evolution of the messages or means of communication in response to the reaction of the target audience so the campaign is always relevant and using the right way of getting its message across (Alzheimer's Disease International / World Health Organization, 2012). It can be difficult to assess the actual impact that a public health campaign may have on the area of health it is designed to address. An assessment of the ACTIVE for LIFE campaign in England found mixed results on the impact of the advertising. In a nationally representative sample of 3,189 adults aged 16-74 years, 38% were aware of the main advertising images when asked 6-8 months after the main television advertisement. The proportion of participants knowledgeable about moderate physical activity recommendations increased significantly following the campaign, but there was no evidence that the ACTIVE for LIFE campaign actually improved the levels of physical activity among the sample (Hillsdon et al., 2001). A successful campaign will likely be as a result of many different factors working together – a media campaign, provision of support services, involvement of key stakeholder groups or changes in behaviour of healthcare professionals. Smoking rates have decreased significantly in the past decade in both ROI and
7 March 2013 NI, but in addition to media campaigns, there have also been the ban on smoking in public places, tax increases, new quit smoking therapies and other measures. Thus it can be difficult to evaluate what the successful decrease in smoking rates results from. As a result, it is important that monitoring and evaluation of campaigns are built into the objectives, to ensure that success can be measured and lessons can be learned for other campaigns in the future. An examination of the proportion of the decline in coronary heart disease deaths in ROI attributable to (a) medical and surgical treatments, and (b) changes in major cardiovascular risk factors was conducted in 2006. The changes in risk factors such as smoking, cholesterol and blood pressure were the result of public health initiatives. Between 1985 and 2000, coronary heart disease mortality rates in ROI fell by 47% in the 25-84 age group. According to the research, 43.6% of the observed decrease in mortality was attributed to treatment effects and 48.1% to favourable population risk factor trends, i.e. the elements that public health campaigns can influence (Bennett, et al., 2006). In ROI, the overall prevalence of smoking in June 2003 was 28.3%. This reduced to 21.9% by June 2012 as a result of the ban on smoking in public places and extensive public health campaigning (Office of Tobacco Control, 2012). Road deaths have been the subject of extensive public health campaigns in both NI and ROI, involving mass media advertising, changes to drink driving and speeding laws, the introduction of penalty points and targeted police campaigns. This has led to significant success in reducing road fatalities. There were 365 road deaths in ROI in 2006, but this had reduced to 162 in 2012 (An Garda Síochána, 2012). Road traffic fatalities on NI roads have seen a huge decrease as a result of extensive public health campaigning. In 1972, there were 372 fatalities. There were 171 fatalities in the year 2000 and this had reduced to 59 by 2011 (Police Service of Northern Ireland, 2012). The approach used in success public health campaigns for heart disease and road traffic deaths could be applied to further campaigns for older people across the island of Ireland, in areas such as falls. In order to achieve that success, public health interventions should be comprehensive, address the multiple factors that influence the particular health problem and strike a balance between efforts directed at the individual and the social-environmental context in which people live (Eriksen, 2005).
8 March 2013 The role of government The role of government in the area of public health is a contentious issue. One view is that bans on smoking public places or junk food advertising is an unnecessary government intrusion into the personal lives as citizens. On the other hand, the argument is that only the state can alter the environment that shapes people’s decisions and behaviour (Jochelson, 2006). In addition to supporting public health campaigns through funding of charities and other stakeholders, governments in NI and ROI can work to change how ageing is viewed in a public health sense. It has been noted that there is a view of ageing which focuses health concerns on clinical medical care, whereas a focus on social, economic, political and environmental factors could contribute to more healthy ageing (Popejoy, 2012). In devising public health campaigns for older people, policymakers in Ireland, North and South should ensure that as well as emphasising health diets, exercise and other behavioural changes, campaigns are accompanied by a drive to bring more opportunities for social interaction, increased access to support programmes and access to quality healthcare for older people. Adshead & Thorpe (2007) argue that unless people themselves are engaged in public health, supporting a cultural shift towards a health promoting society, it is unlikely that the necessary sustainable impact on challenges such as obesity, diabetes and other chronic diseases will be achieved (Adshead & Thorpe, 2007). Thus the role of government in public health campaigns may be as a driving force to galvanise key stakeholders, the voluntary and community sector, and older people themselves in bringing about a fundamental change on public health issues. Case study: Mind your mind, Australia Alzheimer’s Australia launched “Mind your mind” in 2005 with government funding. The aim was to educate people in Australia about what they can do reduce their risk of dementia. The campaign was based around seven “signposts” to dementia risk reduction, addressing physical, mental and social activity, cardiovascular risk factors, diet, smoking and alcohol, and prevention of head injuries. “Mind your mind” utilised several different means to get the message across, including community education sessions, training for staff to deliver the sessions, a range of printed resources, promotion in the media, a mobile app and a dedicated website. Evaluation of the campaign indicated a high level of satisfaction with their interaction with “Mind your Mind”, increased knowledge about dementia risk factors, and increased intention to modify their behaviour to address risk factors (Alzheimer's Disease International / World Health Organization, 2012). “Mind your mind” was replaced in 2012 by a new campaign, “Your brain matters”, which focuses on the brain, body and heart in reducing dementia risk. The three strands are keeping the brain active, being fit and healthy and looking after the heart (Alzheimer’s Australia, 2012).
9 March 2013 Conclusion The fact that people are living longer is a major social and medical advance, but it brings public health challenges in terms of increasing incidence of chronic conditions. An older population means increased incidence of conditions such as dementia. Public health campaigns can help to influence behaviour in a way that improves the chances of living longer, healthier lives and not just adding extra years to life which may be spent in poor health. Lessons can be learned from successful public health campaigns in areas such as road deaths or reduced coronary heart disease mortality, and applied to health issues affecting older people such as falls. Bibliography Adshead, F., & Thorpe, A. (2007). The role of the Government in public health: a national perspective. Public Health , 121(11):835-9. Epub 2007 Sep 21. Age NI / Alzheimers Society. (2011). Evaluation of the Uniting Against Elder Abuse project. Belfast: Age NI / Alzheimers Society. Alzheimer’s Australia. (2012). The Your Brain Matters programme. Retrieved February 28, 2013, from www.yourbrainmatters.org.au. Alzheimer's Disease International / World Health Organization. (2012). Dementia: A Public Health Priority. Geneva: World Health Organization. Alzheimer's Disease International. (2011). World Alzheimer Report 2011: The benefits of early diagnosis and intervention. An Garda Síochána. (2012). Garda National Traffic Bureau Fatalities and other Traffic Statistics. Dublin: An Garda Síochána. Bauchner, H. (2002). Successful US paediatric public health campaigns. Archives of disease in childhood , October; 87(4): 290. Belfast Telegraph. (2012, December 7). Fewer households in fuel poverty. Retrieved February 26, 2013, from www.belfasttelegraph.co.uk. Bennett, K., Kabir, Z., Unal, B., Shelley, E., Critchley, J., Perry, I., et al. (2006). Explaining the recent decrease in coronary heart disease mortality rates in Ireland, 1985–2000. Journal of Epidemiology and Community Health , April; 60(4): 322–327. Department for Social Development. (2011). Warmer, Healthier Homes: A New Fuel Poverty Strategy for Northern Ireland. Department of Health. (2013). National Strategy on Dementia - Summary of Consultation Process. Dublin: Department of Health. Department of Health. (2011, November 7). Six out of ten people with dementia go undiagnosed – £2 million campaign launched to tackle dementia. Retrieved February 27, 2013, from mediacentre.dh.gov.uk.
10 March 2013 DHSS&PS. (2012). A fitter future for all. Framework for preventing and addressing overweight and obesity in Northern Ireland 2012-2022. Belfast: DHSS&PS. DHSS&PS. (2011). Improving Dementia Services in Northern Ireland. A Regional Strategy. Belfast: DHSS&PS. DHSS&PS. (2011). Physical activity guidelines for older adults (65+ years). DHSS&PS, Scottish Government, Welsh Government, Department of Health. Eriksen, M. (2005). Lessons Learned from Public Health Efforts and Their Relevance to Preventing Childhood Obesity. In L. C. Koplan JP, Preventing Childhood Obesity: Health in the Balance. Washington DC: National Academies Press. GALE Cengage Learning. (2003). Encyclopedia of Public Health . Macmillan Reference USA. Halpern, D., & Bates, C. (2004). Personal responsibility and changing behaviour: the state of knowledge and its implications for public policy. London: Cabinet Office, Prime Minister's Strategy Unit. Health Development Agency. (2004). The effectiveness of public health campaigns. London: Health Development Agency. Health Service Executive. (2011). HSE Elder Abuse Services 2010. Dublin: Health Service Executive. Hillsdon, M., Cavill, N., Nanchahal, K., Diamond, A., & White, I. (2001). National level promotion of physical activity: results from England's ACTIVE for LIFE campaign. Journal of epidemiology and community health , Oct;55(10):755-61. Jochelson, K. (2006). Nanny or steward? The role of government in public health. Public Health , Volume 120, Issue 12, December 2006, Pages 1149– 1155. McDaid, O. (2012). Caught in the Web. Mapping older people's information pathways to public service. Dublin: Older & Bolder. McManus, M., & Devlin, P. (2011). Dementia: Public knowledge and attitudes. Belfast: ARK NI. Noar, S. (2006). A 10-year retrospective of research in health mass media campaigns: where do we go from here? Journal of Health Communications , 11(1):21-42. Office of Tobacco Control. (2012). Ireland: Current trends in cigarette smoking. Dublin: Office of Tobacco Control. O'Loughlin, A., & Duggan, J. (1998). Abuse, Neglect and Mistreatment of Older People. Dublin: National Council on Ageing and Older People.
11 March 2013 Police Service of Northern Ireland. (2012). Road Traffic Fatalities on Northern Ireland Roads since 1931. Belfast: Police Service of Northern Ireland. Popejoy, M. (2012). The role of government and public health organizations in healthy ageing. Perspectives in public health , July 2012 Vo. 132 No. 4, p. 151. Springston, J. (2005). Public Health Campaign. In R. L. Heath, Encyclopedia of Public Relations . New York: Sage publications. Stein, C., & Moritz, I. (1999). A life course perspective of maintaining independence in older age. Geneva: World Health Organization. The Irish Examiner. (2012, February 7). Fears fuel poverty will cause more elderly to die . Retrieved March 19, 2013, from www.irishexaminer.com. World Health Organization. (2013, February 19). Public Health. Retrieved February 19, 2013, from www.who.int.
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