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Health promotionin hospitals:

Evidence and qualitymanagement

Edited by: Oliver Groene & Mila Garcia-Barbero

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Health Promotion inHospitals: Evidence an

Quality Management

Country Systems, Policies and ServicesDivision of Country Support

WHO Regional Office for Europe

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Edited by : Oliver Groene and Mila Garcia-Barbero

World Health Organization 2005

All rights reserved. The Regional Office for Europe oOrganization welcomes requests for permission to repro publications, in part or in full.

The designations employed and the presentation of the matedo not imply the expression of any opinion whatsoever on Health Organization concerning the legal status of any couarea or of its authorities or concerning the delimitatio

ABSTRACT

More than a decade ago the WHO Health Promotiwas initiated in order to support hospitals towards emphasis on health promotion and disease preventdiagnostic and curative services alone. Twenty hos

European countries participated in the European pto 1997. Since then, the International Network of HHospitals has steadily expanded and now covers 2national or regional networks and more than 700 pBut, what has been achieved with regard to the imp promotion services at both hospital and network leevidence base for health promotion and has this faof health promotion services in hospitals? And howquality of health promotion activities in hospitals?This volume addresses some of these key is promotion evaluation and quality management anhelp health professionals and managers to assesshealth promotion activities in hospitals.

KeywordsHOSPITALS standardsHEALTH PROMOTION standardsQUALITY OF HEALTH CAREPROGRAM EVALUATIONEUROPE

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CONTENTS

Introduction (Mila Garcia-Barbero)...........................................

Health promotion in hospitals - From principles toimplementation (Oliver Groene) ...............................................

Health promotion: definition and concept...............Why hospitals for health promotion? ..................... Evolution of the International Network of Health P Hospitals..................................................................

Evidence base and quality management..................

The way forward.....................................................Evidence for health promotion in hospitals (Hanne Tnnesen,Anne Mette Fugleholm & Svend Juul Jrgensen) .....................

Evidence-based health promotion in hospitals........Concepts used .........................................................

Policy of health promotion in hospitals................... Health promotion for hospital staff ........................ Evidence for general health promotion ................... Recommendations with regard to hospital tasks .....

Systematic intervention and patient education ....... Evidence for specific prevention.............................

Conclusion...............................................................

Eighteen core strategies for Health Promoting Hospitals (JrgeM. Pelikan, Christina Dietscher, Karl Krajic, Peter Nowak).....

Introduction ............................................................

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New health promotion services for hospital patient

Promoting health of staff ........................................ Promoting the health of the population in the comm An overview of the 18 strategies for health promot

Putting health promoting policy into action............

Development of standards for disease prevention and healthpromotion (Anne Mette Fugleholm, Svend Juul Jrgensen, LillMller & Oliver Groene)...........................................................

Underlying principles for work on HPH.................Standards for Health Promotion .............................

International principles for the development of stanStandards and evidence...........................................

Existing standards in the area of disease prevention promotion................................................................

Process for the development of standards ...............Conclusion...............................................................

Implementing the Health Promoting Hospitals Strategy throughcombined application of the EFQM Excellence Model and the

Balanced Scorecard (Elimar Brandt, Werner Schmidt, Ralf Dziewas & Oliver Groene) ........................................................

Introduction ............................................................

From health promoting values to health promotion Implementing the HPH concept in the organizationculture of the hospital .............................................

The Addition Model ...............................................The Integration Model ............................................The WHO HPH/EFQM/BSC Pilot Project in the Im Diakonie Group ...................................................... Application of the EFQM Excellence Model .........

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Conclusion...............................................................

List of contributors....................................................................

Annex 1: Ottawa Charter for Health Promotion FirstInternational Conference on Health Promotion, Ottawa, Canad17-21 November 1986 ...............................................................

Annex 2: The Vienna Recommendations on Health PromotingHospitals ....................................................................................

Annex 3: Standards for Health Promotion in Hospitals ............

Annex 4: Acronyms and abbreviations used..............................

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Introduction (Mila Garcia-Barbero)

More than a decade ago, the WHO Health Pro(HPH) project was initiated in order to support hos placing greater emphasis on health promotion and rather than on diagnostic and curative services alonPromoting Hospitals strategy focuses on meeting tand social needs of a growing number of chronicalthe elderly; on meeting the needs of hospital staff, physical and psychological stress; and on meeting public and the environment.

Twenty hospitals in eleven European countrieEuropean pilot project from 1993 to 1997. Since thInternational Network of Health Promoting Hospitexpanded and now covers 25 Member States, 36 nnetworks and more than 700 partner hospitals.

But, what has been achieved with regard to thhealth promotion services at both hospital and netwthe scope of health promotion activities in hospital principles laid out in the Ottawa Charter for Healthinto practice? Is there an evidence base for health pthis facilitated the expansion of health promotion shospitals? Is health promotion a service anyway? H

promotion relate to quality management? And howthe quality of health promotion activities in hospitThis volume provides a review of the backgr

Promoting Hospitals project and addresses some health promotion evaluation and quality managem

Chapter 1 gives an overview on the principlhealth promotion in hospital, summarizes tdevelopment of the Health Promoting Hospitals ma range of issues on the evaluation and implem promotion activities in hospitals.

Chapter 2 presents a summary of the evidencespecific and for general health promotion activitiesindicating the level of evidence for major health pr

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Chapter 3 offers many conceptual innovations

the strategic importance of health promotion in ho18 core strategies for health promotion in hospitalsChapter 4 describes the importance of using q

assess health promotion in hospitals and describes five standards developed to support implementatio promotion activities.

Chapter 5 finally offers valuable insights in thof health promotion activities in hospitals through application of the European Foundation for Qualit(EFQM) excellence model with the Balanced Scor

This book is intended to help health professionmanagers to assess and implement health promotiohospitals. We hope that the principles, evidence, stquality standards presented in this volume supportapplication and thus help hospitals ensuring safe, h

effective health care.

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Health promotion in hospitals - Fromprinciples to implementation (OliverGroene)

Health promotion: definition and concept

Health promotion measures focus on both indicontextual factors that shape the actions of individ prevent and reduce ill health and improve wellbeincontext not only refers to the traditional, objectiveview of the absence of infirmity or disease but to aadds mental resources and social well-being to phyHealth promotion goes beyond health education an prevention, in as far as it is based on the concept ostresses the analysis and development of the health

individuals [3].The scope of disease preventionhas been defined

Promotion Glossary as measures not only to prevof disease, such as risk factor reduction, but also toand reduce its consequences once established [4].defines the scope of health educationas comprising cconstructed opportunities for learning involving socommunication designed to improve health literacimproving knowledge and developing life skills wto individual and community health. Health prom broader concept in the WHO Ottawa Charter as thenabling people to increase control over, and impr[5].

In practice, these terms are frequently used comeasures for the implementation may overlap; howmajor conceptual differences with regard to the fochealth promotion actions (Figure 1).

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Figure 1: Strategies for health promotion [6]

Whereas the medical approach is directed at pfactors (e.g. high blood pressure, immunization sta behavioural approach is directed at lifestyle factor physical inactivity) and the socio-environmental aat general conditions (such as unemployment, low poverty). Health promotion consequently includes beyond medical approaches directed at curing indi

Based on the notion of health as a positive conCharter put forward the idea that health is created people within the settings of their everyday life; wwork, play and love. This settings approach to hefounded on the experience of community and orgadevelopment, led to a number of initiatives such asCities, Health Promoting Schools, and Health Prometc. in order to improve peoples health where theytheir time: in organizations [7,8].

The settings approach acknowledges that behaonly possible and stable if they are integrated into correspond with concurrent habits and existing culPromotion interventions in organizations thereforeaddress changing individuals but also underlying ncultures.

The Ottawa Charter identifies five priority act promotion:

Build healthy public policy: health promotion polic but complementary approaches, including legislatiotaxation and organization change. Health promotionidentification of obstacles to the adoption of healthynon-health sectors and the development of ways to

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Create supportive environments for health: the prot

and build environments and the conservation of nat be addressed in any health promotion strategy. Strengthen community action for health: Communi

on existing human and material resources to enhancsupport, and to develop flexible systems for strengt participation in, and direction of, health matters. Thcontinuous access to information and learning oppowell as funding support.

Develop personal skills: Enabling people to learn (t

prepare themselves for all stages and to cope with cinjuries is essential. This has to be facilitated in schcommunity settings.

Re-orient health services: the role of the health sectincreasingly in a health promotion direction, beyon providing clinical and curative services. Reorientatalso requires stronger attention to health research, a professional education and training.

The following section will explain the need fohealth services and expand on some of the ideas seOttawa Charter.

Why hospitals for health promotion?

The impact of health services on health

Many health professionals presume that healthalways been the core business of medicine in gene particular. This view may be challenged for a varie

Although the history goes back further, the firhospitals were built during the 12th century and woriented, cloister-affiliated institutions providing selderly, psychologically deviant and others in needwere the accommodation, nourishment and the isodiseases, not the treatment of disease.

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Table 1: Historical evolution of hospitals [10]:Time Role of hospital Characteristics7 th century Health care Byzantine empire, Greek

theories of diseases10 th to 17 th century

Nursing, spiritual care Hospitals attached to relifoundations

11 th century Isolation of infectiousdiseases

Nursing of infectious such as leprosy

17 th century Health care for poor

people

Philanthropic and stat

Late 19 th century

Medical care Medical care and surgermortality

Early 20 th century

Surgical centres Technological transformhospitals, entry of midpatients; expansion ofdepartments

1950s Hospital-centredhealth systems

Large hospitals, temptechnology

1970s District general

hospitals

Rise of district genera

local, secondary and thospitals1990s Acute care hospital Active short-stay care1990s Ambulatory surgical

centresExpansion of day admexpansion of minimalsurgery

Until the late 19th century hospitals were not ahealth was created, but rather a place to die [11]. Tthe development of the science of medicine, suppostate philosophy and humanism. Since then, the pocare to improve health has made rapid improvemedevelopment of aseptic and antiseptic techniques, anaesthesia, greater surgical knowledge and skills, blood transfusion, coronary artery bypass surgery, pharmaceuticals, transplantation techniques and msurgery [12].

However, parallel to the advances in hospital pquestions have been raised with regard to the contrcare to the health of the population and the effectivservices. Various accounts have been made discardhealth care for the reduction of infectious diseasesdecline in infant mortality, reductions in the majorresulting increase in life expectancy [13].

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Although controversy is still continuing on de

McKeown demonstrated compellingly how reductthe United Kingdom, which were thought to be relaccomplishments of medical care, were in fact relaimprovements in hygiene and nutrition [14,15,16,1 perspective was brought in by Ivan Illich and Rickargued that medical care is more a cause of death, According to Illich, medicine has the potential to cas good, as reflected in his concept of iatrogenesis[18]criticized the medical professions of their sick-macontended that health care institutions performed toriginal purpose. Carlson argued along the same lithat the limited effectiveness of medicine will furthfuture [19]. Recently, these perspectives gained a lwith the report of the Institute of Medicine, To erestimates that in the USA about 100,000 deaths in are due to medical errors [20].

A more operational perspective was brought inDonabedian and others who, being well aware of t population impact of health care, focused on stratequality of health care services [21,22,23]. Althoughave been made with the outcomes movement andassessment, the definition of quality as doing the rit well, still raises fundamental questions and poinimprovements in the provision of health care servi

The Health Promoting Hospitals network link perspectives above. It is driven by the strong perceservices need to be more targeted towards the needonly to their organs or physiological parameters, inmore substantial and lasting impact on health. At tHPH philosophy is now based on strong evidence incorporate health promotion as a core principle inQuality strategies already applied in clinical settin

management of health care organizations are appli promotion as well. Before addressing this issue furfollowing paragraphs provide the rationale for andof health promotion services in hospitals.

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Health promotion activities in hospitals

Given the scope of possible health promotion hospitals, the WHO HPH movement focuses on fothe health of patients, promoting the health of stafforganization to a health promoting setting, and proof the community in the catchment area of the hosareas are reflected in the definition of a health prom

Ahealth promoting hospital does not only provide hcomprehensive medical and nursing services, but also didentity that embraces the aims of health promotion, de promoting organizational structure and culture, includinroles for patients and all members of staff, develops its promoting physical environment, and actively cooperatcommunity [25].

There is a large scope and public health impac promotion strategies in health care settings [26]. H between 40% and 70% of the national health care typically employ about 1% to 3% of the working pworking places, most of which are occupied by wocharacterized by certain physical, chemical, biolog psychosocial risk factors. Paradoxically, in hospitathat aim to restore health the acknowledgement oendanger the health of their staff is poorly develop promotion programmes can improve the health of absenteeism rates, and improve productivity and q

Health professionals in hospitals can also haveon influencing the behaviour of patients and relativresponsive to health advice in situations of experieThis is of particular importance for two reasons: fiof chronic diseases (e.g. diabetes, cardiovascular dincreasing in Europe and throughout the world [30hospital treatments today not only prevent prematuimprove the quality of life of patients. In order to mquality, the patients own behavior after discharge support from relatives are important variables [31]Programmes can encourage healthy behavior, prevmaintain quality of life of patients.

Hospitals also typically produce high amountshazardous substances Introducing Health Promoti

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cooperation with other institutions and professiona

the highest possible coordination of care. Furthermteaching institutions hospital produce, accumulate lot of knowledge and they can have an impact on tstructures and influence professional practice elsewTable 2: Example of health promotion projects/activities in hospitals

Evolution of the International Network of Health Promoting Hospitals

In order to support the introduction of health p programmes in hospitals, the WHO Regional Officthe first international consultations in 1988. In the the WHO model project Health and Hospital wahospital Rudolfstiftung in Vienna, Austria, as a par

After this phase of consultation and experimenmovement went into its developmental phase, beininitiation of the European Pilot Hospital Project byOffice for Europe in 1993. This phase, which laste1997, involved intensive monitoring of the develop20 partner hospitals from 11 European Countries.

Subsequent to the closing of this pilot phase, nregional networks were developed and the networkconsolidation phase. Since then, national and regioan important role in encouraging the cooperation aexperience between hospitals of a region or a counidentification of areas of common interest, the sha

d h d l f l i

Patients Brief interventions for smoking

cessation Introduction of a patient charter Patient satisfaction measurement

Staff Healthy nutrition Introduction of inter

team-work Education on lifting

prevent back painOrganization Conflict and change management Health promotion mission

statement Introduction of Total Quality

Management

Community Reduction of waste

ecological risks Use of hospital data

population health pr Safe driving ways f

cars

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thematic network exists, bringing together psychia

allowing the exchange of ideas and strategies in thThe International Network of Health Promotin

a network of networks linking all national/regionasupports the exchange of ideas and strategies implcultures and health care systems, developing knowissues and enlarging the vision. As of May 2005, tHPH Network comprises 25 Member States, 35 nanetworks and more than 700 hospitals.Figure 2: overview of the distribution of HPH in the WHO Europea

Region. [32, 33, 34].

35

708

25

National/Regional Networks

Member states

Hospitals

In the past, the projects carried out within the

characterized by a more traditional focus on healthinterventions for patients and to a lesser extent for the HPH projects is now enlarging, addressing alsocommunity issues such as a change of organizationenvironmental issues [35].

A future challenge of HPH is still to link organ promoting activities with continuous quality impro programmes, making use of the apparent similarition continuous process and development involvem

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monitoring and measurement, and to incorporate th

health promotion into the organizational structure Johnsen & Baum pointed out that there is still

until health promotion is anchored to the organizatstructure [36]. Based on a review of the literature aof health promoting hospitals projects in Australiagrouped in a typology with four dimensions (TableTable 3: Typology of HPH activities

Type ImplicationDoing a healthpromotion project

No re-orientation of the whole organizatiroles. This may be a starting point for heapromotion activities when no support frommanagement is available.

Delegating healthpromotion to a specificdivision, department or staff

A specific department deals with health pbut activities are not integrated in the oveorganization. Hospitals falling within thisbe in a developmental phase.

Being a health

promotion setting

Health promotion is considered a cross-se

issue in hospital decision-making. The hobecome a health promoting setting, althouresources are applied to impact in the com

Being a healthpromotion setting andimproving the health of the community

The hospital is a health promoting settingresponsibility for, and improves communi

Although the authors are aware of the difficulthealth promoting setting with visible community ithat the settings approach to health promotion ithan introducing a variety of opportunities for indihospital to change their behaviour. Their argumenwith our observations of activities in the InternatioHealth Promoting Hospitals. We found that many hintroduced selected health promotion activities; hoof extending and incorporating these activities at a been slow.

The preceding paragraphs illustrated that, alth perceive the hospital as a health promoting settingdegrees to which hospitals actually have an impacthealth, potentially harm individuals seeking cure ause of the knowledge available to improve health. d t i t f h lth li t id th h lth

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improve the health of their patients and can have a

impact, in particular for patients with chronic condIn addition, the health promotion strategy inclstaff health, which is not only important for the dirhealth professionals, but also for the link between satisfaction and patient outcome and satisfaction.

Various strategies of health promotion exist anin one form or another in some of them, e.g. patienindividual risk assessment. However, the main shosystematic implementation and quality assurance oactivities in hospitals. The question of how health can be implemented and their quality assessed willsubsequent section.

Evidence base and quality managementOne of the factors for the further advancement

strong evidence base, since the lack of evidence, c prevailing cost pressures in almost any health caremake health promotion programmes an easy choic[37]. Tools for implementation represent another faexperience show that despite of good evidence, thevariations in clinical practice.

Evidence-based health promotion?

Focusing on evidence in Health Promotion haissue [38, 39]. One key publication in the field hasthe International Union for Health Promotion and European Commission [40]. Parts of this work deaHealth Promotion in the Health Care Sector [41]. a major issue at the recent 5th Global Conference oPromotion 2000 in Mexico [42] and at the 9th InteConference on Health Promoting Hospitals in Cop[43].

1 Abstracts of the conference are available at the web oJournal of Integrated Care,http://www.ijic.org(2001, 1, 3, si l di f hi d f f

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With a certain delay, the call for evidence in h

follows the development of the evidence-based meand many indeed demand the application of the saand criteria to the evaluation of health promotion (that have proven to provide evidence in clinical m

As defined in the WHO Health Promotion Glo promotion evaluation is an assessment of the extent to promotion actions achieve a valued outcome. Assesand outcomes differ in health promotion as compa

medicine (Table 4).Table 4: Clinical trials vs. HP interventions.

Clinical Trial Health PromInterv

Context anddesign of intervention

physiological interventionrandomization, blinding andplacebo control possibleunit is individual under controlled conditions(efficacy evaluation )

behavioural interandomization, placebo controlimpossible

unit is individuaorganization or community in esituation ( effecevaluation )

Provider health professionalsimplement intervention inclinical trial

often various prinstitutions invo

Addresseeparticipants with health

problems hoping for relief

participants not

aware of health

Time framefor outcome

aims to cure disease, endpoint is end of treatment or when intervention istechnically stable

aims to preventhealth, outcomeyears, decades ooffspring

Although experimental designs and quantitativcan also be applied to health promotion interventiothose related to staff and patients, the importance omethods also has to be considered for the evaluatiointerventions on broader organizational, policy or [45].

in Vienna, WHO Collaborating Centre for Hospitals an(http://www hph-hc cc/)

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With the current focus of health system and ho

outcomes, qualitative methods are frequently consonly weak evidence. In fact, the long-term benefit promotion interventions makes it necessary to distdifferent levels of health promotion outcomes, beyclinical parameters and in health status. In the cont promotion participation, partnership, empowermendirected to the creation of supportive environmentaspects that need to be evaluated, and many propo promotion indeed recommend different levels of a

Don Nutbeam suggests distinguishing outcomehealth promotion outcomes, intermediate outcomesocial outcomes [51]:

Health promotion outcomesrefer to modificationssocial and environmental factors to improve pethe determinants of health (e.g. health literacy, action, healthy public policy and organizationa

Intermediate outcomesrefer to changes in the det(e.g. lifestyles, access to health services, reductrisks);

Health and social outcomesrefer to subjective (seassessments such as Nottingham Health ProfileEUROQOL) and objective measures (weight, c blood pressure measurement, biochemical test,in health and in social status (e.g. equity).

The HPH movement has provided many good promotion interventions that hospitals can carry ouinterventions have been evaluated in the literature effective and cost-effective as described in the chafor Health Promotion in this volume. Some may diview of health promotion activities that were evalucontrolled designs, and argue that our understandinthese activities.

Assessment of activities in Health Promoting Hospitals?

Currently, the quality of health promoting actihospitals of the International HPH network is not sassessed. Hospitals becoming members of the Inte

endorse the f ndamental principles and s

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- belong to the National/Regional HPH N

countries where such networks exist (howithout such networks apply directly to coordinating institution); and

- comply with the rules and regulations esinternational and national/regional levels

Hospitals in the International Network furtherthemselves to become a smoke-free hospital and to projects/activities addressing health issues of staff,community, or improving organizational routines wimpact on health. A web-based database has been register projects and activities, providing informatindicators of the hospital and on health promotion

At the international level, attempts have been develop evaluation systems for health promotion. Fifth Annual Workshop of National and Regional Coordinators in 1998 and 1999 addressed the issueso far, evaluations, if any, were mostly carried out only a few strategies of quality assurance were applevel and most coordinators experienced great proband applying evaluation schemes. There are differapproaches at national and regional network levelsthem are well developed yet [53].

A previous review in 1998 identified existing

problems in the evaluation of HPH [54]. Among thtools applied was the Hospital Accreditation Schemfrom the Healthy Hospital Award in the United Kiwere formally accredited as Health Promoting Hosapplication, standardized self-audit survey and extvalidate the survey and interview staff and patients

A similar system was installed in the German of two peer-reviews from hospitals and one site-vi

representative of the network to the applicant hospassessors decided on the acceptance in the networkGerman experience shows that, due to the financiavisits are difficult to carry out. The German Netwoon adapting the excellence model of the European Quality Management and the Balanced Scorecard

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structure and culture. A report on the process of th

available in the present volume.In 1994, the Polish Network started a self-assemonitor the improvement of individual hospital pehowever, its application was not continued due to vreliability issues of the tool. The Danish Network December 2000 to initiate the establishment of a sof this work is also presented in this volume.

Other countries in the WHO European Region past similar schemes consisting of site-visits, peer assessment, and surveys. Outside Europe, the MinThailand conducted a survey comparing 17 HealthHospitals with 23 non-HPH [55]. A questionnaire items were constructed for a self-assessment of HPimplementation according to the following dimensand administration, b) Resource allocation and Hudevelopment, c) Supportive environment, d) Healtstaff, e) Health promotion of patients and families,health promotion. Many methodological issues nee before a valid comparison can be made; however, many innovative ideas that may be elaborated in th

At the time of the review, approaches of othernetworks in the WHO European Region were still [56, 57]. Although it is not the intention of WHO t performance and rank hospitals with regard to heaabsence of systematic assessments of health promohinders the direct improvement of activities.

The way forwardAlthough a lot of progress has been made in th

idea of health promotion has only slowly been intrPerhaps one of the main factors explaining this wastrategies and tools for implementation. The know presented in this volume will, without any doubt, aof implementation and make sure that health promimportance within the hospital setting. There is nostronger evidence for many health promotion interpatients staff and the community Likewise tools

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health promotion. The evidence of health promotiostrategies and quality tools, that will allow better imhealth promotion in hospitals in the future, will befollowing chapters.

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promotion.Health Promotion International, Vol.40. The Evidence of Health Promotion Effectiveness:

Health in a New Europe. A report for the Europeathe International Union for Health Promotion and One: Core Document. Part Two: Evidence Boo

41. McKee M. Settings 3: health promotion in the hThe evidence of health promotion effectiveness: Shealth in a new Europe. Luxembourg, European C123-133.

42. 5th Global Conference on Health Promotion.Mexichttp://www.who.int/hpr

43. 9th International Conference of HPH htt // h i t/h lth h /

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44. Health Promotion Glossary.Geneva, World Healt1998. (http://www.who.int/hpr/NPH/docs; hp_gloss

45. Thorogood M & Coombes Y (ed.). Evaluating healt Practice and methods. Oxford, Oxford University

46. Green LW.Evaluation and measurement: some dileducation. American Journal of Public Health, Vol.161.

47. Rootman I, Goodstadt M, McQueen et al. (ed.) Eva Health Promotion: Principles and Perspectives.CopRegional Office for Europe, 2000.

48. McQueen DV. Perspectives on health promotion: t practice and the emergence of complexity. Health Pr International,Vol. 15, 2000, 95-97.

49. McQueen DV.Strengthening the evidence base for promotion. A report on evidence for the Fifth Glo Health Promotion.Mexico City, 5-9 June 2000.

50. McDonald G.Where next for evaluation? Health P International , Vol. 11, 1996, 3:171-173.

51. Nutbeam D.Evaluating health promotion - progres solutions. Health Promotion International , 1998; 13

52. WHO Health Promoting Hospitals Database:http://data.euro.who.int/hph/ 53. Report on the Fourth Workshop of National/Re

Promoting Hospitals Network Coordinators. CoRegional Office for Europe (EUR/ICP/DLVT 0http://www.euro.who.int/healthpromohosp/pub

54. Report on the Fifth Workshop of National/RegiPromoting Hospitals Network Coordinators. . CRegional Office for Europe (EUR/ICP/DLVT 0http://www.euro.who.int/healthpromohosp/pub55. Auamkul N et al. Result of a self-assessment of He Hospitals Implementation in Thailand .2002.http://www.anamai.moph.go.th/newsletter/Presd.pdf

56. Groene O. Managerial experiences of Health P Networks. In: Health Promoting Hospitals Newslet1998http://www.univie.ac.at/hph/

57. Annual Reports on Progress of National and Regio Promoting Hospitals Networks. http://www.euro.who.int/healthpromohosp/pub

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Evidence for health promotion in hospitals

(Hanne Tnnesen, Anne Mette Fugleholm & Svend Juul Jrgensen)

Health Promoting Hospitals have committed tintegrate health promotion in daily activities and toRecommendations, which advocate encouraging pinvolving all professionals, fostering patients` righhealthy environment within hospitals. Thus, healthhospitals includes interventions and actions. In order toeffective and efficient implementation of health prstandards and guidelines are needed just as for othThe evidence base for a wide range of interventionin the following sections.

Evidence-based health promotion in hospitals

While curative medicine is delivered to symwho seek health care, health promotion and prevenwill often attempt to modify individuals lives, andon the highest level of randomized evidence that manoeuvre will do more good than harm [1].

Practice guidelines are considered valid if whlead to the health gains and the costs predicted for must be based on evidence from trials using valid is usually categorized as:

- 1a: Evidence from meta-analysis of randomize- 1b: Evidence from at least one randomized con- 2a: Evidence from at least one controlled study

randomization;- 2b: Evidence from at least one other type of qu

study; - 3: Evidence from descriptive studies, such as c

correlation studies and case-control studies;- 4: Evidence from expert committee reports or o

experience of respected authorities, or both. Health promotion should be based on a high le

i l l 1 1b 2 h ibl W k

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used for describing good clinical practice in healthhospitals, but whenever category 1a to 2a is absentconsidered relevant to establish new evidence.

Clinical trials in the spectre of health promotiosame criteria for quality as other randomized trialsAppropriateness of inclusion and exclusion criteriaallocation, blinding of patients and health professiobjective or blind method of data collection, valid data analysis, completeness and length of follow uof outcome measures and statistical power of resul

The large group of qualitative studies are oudefinition. They describe the opinions and fe persons, and they are based upon the spinterpretation and competences, and the concreteimportant for an implementation process and mahypothesis, but the results can seldom be generquantitative research and qualitative studies is a in exploring new areas for investigation and imple

Concepts used In public health, disease prevention is usually

primary disease prevention which prevents diseasesecondary prevention which detects disease at an e prevents disease from developing, and c) tertiary p

rehabilitation which prevents aggravation or recursecures maintenance of functional level.Traditionally, hospitals primarily take care of

secondary or tertiary prevention whereas the primasocial institutions take care of primary prevention.increasingly recognized that also hospitals can plain primary prevention.

When integrating health promotion in clinical more sense to use a classification that distinguishe pathways in ordinary clinical practice, staff and th

- Patients: General health promotion which sall patients and which addresses all patient health promotion vis--vis defined patient g

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characterized through their belonging to cegroups or otherwise.

- Staff: General health promotion aiming at awork environment. Training in the field of health promotion.

- Community: Cooperation with relevant struorganizations. Information on health promoservices for citizens.

General health promotionaddresses general detehealth and disease (including tobacco, alcohol, nutactivity and psychosocial issues). One example of intervention, which involves activities aiming to in behaviour (alcohol consumption, smoking etc.). Liincludes counselling, recommendations and empowto enhance their competence and their capability.

Specific health promotionaddresses conditions thsignificant for specific patient groups. Examples o prevention of complications in diabetes patients, e patients, cardiac rehabilitation etc. An important erelated health promotion is strengthening the patiemanage his/her condition.

Policy of health promotion in hospitalsHospitals are a special type of workplace with

that are exposed both physically and mentally in cclinical tasks. In spite of work environment regulaexposures and risk situations cannot be avoided. Tnecessary for hospitals to have a health promotion

On the basis of existing knowledge of the impfactors for treatment and prognosis, all hospitals sh policy, counselling services, education and suppor promotion as an integrated part of the individual pwell as for the staff.Effect of a health promotion policy in hospitals is bdescriptive studies, exclusively, giving a low level

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Health promotion for hospital staff

Those working in the health care sector can plrole in promoting health, either through providing can be done to achieve a healthy environment or thauthority to act as advocates for public health policadvice to individual patients or citizens [3].

Learning and teaching in methods used in hea patient education should build on evidence [4]. Thlifestyle habits of health care staff, their attitudes ainfluence the way they handle prevention issues.

Staff who are smokers generally underestimatsmoking as a risk factor, whereas non-smokers in soverestimate this risk factor. Thus smokers are less patients on lifestyle issues in general and the samefeel that they have too little training in this field [5smokers do not convey through their behaviour thethey are supposed to communicate to the patients; disparity between their behaviour and their knowlechoose to stop smoking or ignore their knowledge advice for patients.

Interestingly, staff that stops smoking initiate mamong patients with improved effect. Special comimportant way of improving the integration in the The figure below shows the results of an implemen

smoking cessation among medical patients admitteThe implementation rates are given for spontaneocounselling in the emergency department, for the uspecialist nurses in three successive periods, each patients [6]. Specialized staff offer more systematismoking cessation than other staff.

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Figure 1: Smoking cessation among patients

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spont. staff spec.

Missing

Offering

Counselling

Effect of role models and education of staff is based high level of evidence.

Evidence for general health promotionThere is documentation for the effect of health

relation to lifestyle factors.

Tobacco Tobacco causes a wide range of diseases. Smo

all occurrences of ischaemic heart disease, explaincancer, 75% of chronic obstructive lung disease (s6 % of hip fracture. Not only do diseases occur mosmokers, they also occur at a younger age compareDanish figures show, for instance, that among patiinfarction, smokers are admitted 10 years earlier th

[7]. And population studies show that there are twiadmissions among smokers as among non-smokerA great number of hospital admissions are rela

lifestyles. Tobacco related diseases cause 30% of aordinary medical ward [9]. And in addition, tobacc

l f h d i i S ki l i fl

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of treatment. It is well documented that medical trhypertension, radiation treatment of cancers of thetreatment of arteriosclerosis and wounds are muchsmokers than in non-smokers. Smoking influencesand plays a role in the prolongation of hospital stayinfections.

Patients long term condition and prognosisinfluenced. There is documentation that patients wfollowing myocardial infarction diminish the risk the following two years by 50%. Unplanned readmconsiderable expenditure for the health care sectoralmost twice as many readmissions as non-smokerthat the average rate of readmission amounts to be27%; patients with ischaemic heart disease, smokeand lung cancer have a particular high rate of read

Smoking cessation has a well-documented eff

and health [12]. Many studies show a dose-responexposure to tobacco (duration of smoking habit anand the occurrence of disease. Similarly, there is drelationship between how long a person has been sreduced risk of disease. Recent studies document tcessation at the age of 65 has a positive effect on hmorbidity [13], however, a reduction of the amounno decisive role [14].

In short, documentation shows that smoking cessat- reduces or removes lung diseases such as c

expectorate in healthy smokers;- normalizes future loss of lung function in p

established chronic lung disease;- reduces by half the risk of cancers after 5 y

scale smokers do, however, have an increascancer for the rest of their lives);

- leads to an immediate drop in the risk of cainfarction;

- reduces by half the risk of another infarctiowithin the years following acute myocardia

- reduces the risk of arteriosclerosis and relatd th i k f t i d lti

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- reduces the risk of giving birth to a prematuundertaken during the first 3 to 4 months o

- reduces the risk of late complications in padiabetes;

- improves the delayed healing process of wohealing.

The evidence is based upon descriptive studies of smrandomized clinical studies of stop smoking, giving aevidence.

Alcohol

Large scale alcohol consumption adds to the ras pneumonia, infections, diarrhoea and malabsorpof cancer, non-alcoholic liver disease, hypertensiodiabetes, fluid and electrolyte imbalances. Patientsintake are more often admitted to hospital; about 2

10% of the women admitted to hospital consume ainternationally recommended limits.Patients alcohol consumption also influences

treatment and care. The mechanisms include reducfunction, sub clinical or clinical cardiac dysfunctioimbalance, delayed healing of wound and slow tissturnover, myopathy, and increased stress-response prolongation of hospital stay for the patients [15].

There is evidence that cessation and to some dalcohol consumption leads to:

- fewer admissions with alcohol related disocirrhosis of the liver and Pancreatitis;

- fewer admissions due to poisoning, alcohol psychosis;

- fewer infections (especially pneumonia and

- improved wound and bone healing;- improved heart function and blood pressure- improved outcome for several non-alcoholi

other effects).

The evidence is based upon descriptive studies of alc

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studies of voluntary excessive alcohol intake, giving evidence. High alcohol consumption causes a wide range of nearly all organs, see the figure below.

Figure 2: Alcohol related damages

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Physical activity

Lack of physical activity is associated with increastype 2 diabetes, overweight, high blood fat levels, development of metabolic syndrome.There is evidence that regular physical activity [16

- reduces the risk of developing cardiovasculgeneral and ischaemic heart disease in part

- reduces the risk of developing type 2 diabe- reduces mortality in middle-aged and elder

sexes;- strengthens the development of bone densit

related drop in bone mineral content and prdevelopment of osteoporosis;

- prevents hypertension and reduces hyperten- prevents overweight;- prevents depression, reduces tension and in

respect;- prevents loss of muscle mass in elderly pat

the risk of falls.

Physical training is an important element in sev programmes, e.g. cardiac rehabilitation, rehabilitatobstructive lung disease, surgical rehabilitation, psrehabilitation etc.

Physical training for patients with myocardial the risk of another infarction by 25% in the first this also an important element in mobilization of patrheumatoid arthritis and patients with arthritis, andthat exercise in the form of walks may put off the tintervention for patients who are waiting for knee The evidence is based upon descriptive studies of phyrandomized clinical studies, giving a high level of ev

Nutrition

In the European population, overweight is the health problem. The increasing prevalence of overgrowing number of persons with diabetes, cardiov

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encountered by hospitals is under-nourishment. Stualmost 30 % of hospital patients are undernourishethe same time, studies show that patients food intstay often amounts to only 60% of their actual nee

There is documentation that undernourished pincreased morbidity and mortality than well-nourissame time, there is documentation that systematic nutrition status and proper nutritional therapy durithe risk of wound infection and lead to shorter hoscontribute to more rapid convalescence [18]. There is enutritional interventions in relation to undernouris

- improve lung functions and walking distanchronic lung disease;

- increase weight and muscle mass in patient- increase physical activity and reduces mort

patients;- reduce mortality in patients with acute rena

The evidence is based upon several randomized clinic giving a high level of evidence.

Recommendations with regard to hospitaltasks

There is international consensus that patients srecommendations, guidance and support with rega promotion in hospitals. Health promotion secures tare identified and that the patient has knowledge othese conditions, recommendations for changes ancarrying out these changes. Evidence exists for theinterventions, which should be implemented in gen practice:

Tobacco:

- identification of smokers and establishing ahistory;

- oral and written information to patients on and health benefits, and the possibility of s

- advice and recommendations with regard to

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- establishing smoking cessation services or smoking cessation counselling as part of tre

Alcohol:

- identification of patients with harmful and consumption according to ICD-10 criteria;

- oral and written information to patients on and health benefits and the possibilities of or reducing consumption;

- recommendations for large scale consumerconsumption;- offering brief interventions (for harmful intalcohol unit (for dependent intake).

Physical activity:

- identification of patients with a need for co physical activity;

- counselling on exercise in accordance with

guidelines, and follow-up and counselling isubsequent contacts with the department;- establishing systematic training programme

patients (heart and lung patients, diabetes, soverweight and underweight).

Nutrition:

- identification of undernourished patients anof under-nourishment;

- initiation of relevant nutrition treatment anobservation of body weight and food intake patients stay in hospital;

- communication of information on discharghome care, general practitioner);

- identification of overweight patients and scdiabetes and other complications;

- counselling on diet and physical training;- establishing of systematic training program

patients;- secure follow up in the primary health care

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Systematic intervention and patient education

The aim of health counselling is to support the process of change with regard to lifestyle. Health con theories of behavioural change [20]. The theori phases and processes that people go through when behaviour. The model describes behavioural chang process. Most people go through the process severfinally change behaviour.Health counselling consists of a dialogue with the on:

- the patients knowledge of the influence ofalcohol on health and the significance of cefor disease, treatment and health;

- the patients ideas, emotions and attitudes wconsumption under consideration;

- the patients previous experiences when tryhabits;

- recognition of the patients emotions with rconsumption;- acceptance of the patients choice with rega

and;- setting realistic goals for the outcome of th

correspond to the phase of change that the through.

There is evidence that health counselling may blifestyle changes [21]. Since 1996, the Bispebjerg (Copenhagen, Denmark) has been trying to develointervention with regard to alcohol and tobacco, wcounselling for all patients including outpatients, e patients and acutely admitted patients.

The intervention is based on clinical guidelinesinterdisciplinary groups of health care staff from redepartments in the hospital. These clinical guidelinwith international guidelines concerning the treatmalcohol-related disease in hospitals. The tobacco inin the routine audits performed in all clinical deparare given below:

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Table 1: Tobacco-related indicators for routine audit

No Indicators for systematic intervention withregard to tobacco

1 Have the smoking habits been documentedmedical record?

2 Does the patient smoke daily?3 Has information been giving about the influ

on tobacco related to the patients symptomtreatment and prognosis?

4 Has intervention been initiated according toclinical guidelines?

5 Has motivational counselling been perform6 Has the patient been admitted to the clinic

smoking cessation?

It is recommended that following screening fo(tobacco, alcohol, nutrition and physical activity), is offered systematically to all patients and that reloffered by way of follow up.

Evidence for specific prevention Specific prevention concerns prevention activ

specific groups of patients. Patient education and r programmes are examples of this. Rehabilitation pto support the individuals own ability to manage dof the clinical guidelines for several patient groupssupplementary aspect, but as part of treatment [22]education and rehabilitation programmes include ce.g. counselling on smoking cessation, stopping orintake, physical activity, nutrition, psychosocial sueducation and optimizing the medical (or surgical treatment.Heart patients

Ischaemic heart disease is one of the biggest dhospital sector and is the source of large, and ever

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of heart patients primarily concerned physical train background of the scientific results achieved over years, the concept of heart rehabilitation has been the following elements:

- physical training;- lifestyle intervention and risk factor contro

of eating habits, smoking cessation, alcohomoderate physical training and preventive

- patient education;- psychosocial care;- medical treatment of symptoms;- systematic control and follow up.

Results from international, controlled studies sheart rehabilitation may provide significant health 25] in the form of:

- reduction of the number of admissions, bot

overall cardiac admissions;- maintenance of the patients functional leve- improvement of the patients health related- improvement of overall risk factor control

change and enhanced medical compliance.

There is a high level of evidence for the value of cardrehabilitation.

Chronic lung patients Chronic obstructive lung disease (COPD) is a

occurring disease and is the cause of 20 to 25 % ofmedical departments in Europe. COPD is one of thresource demanding diseases in Denmark. Over thmany different lung rehabilitation programmes havand tested, and there is now documentation that thlead to [26, 27]:

- alleviation of breathing difficulty;- increase in the distance that the patient is ab- improved physical capacity;- improved functional level in everyday life;- improved quality of life;

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- improved ability to cope with disease and adisease;

- fewer admissions.

It is still not clear what the optimum structure, duration of COPD rehabilitation programmes is, hagreement that as a minimum the following elemeincluded:

- smoking cessation assistance;- physical training/training in the home;- physiotherapy;- nutritional counselling;- psychosocial support;- patient education.

There is a moderate to high level of evidence for rehabilitation after lung disease.

Asthma patients Asthma is a widespread disease, which occurs

adult population and in 5 to 10% of school childrecountries. Over the past 30 to 40 years, a large numstudies have been carried out in order to throw lighvarious education programmes. The programmes h both in the hospital sector and in general practice. evidence has been summarized in several reviews [29] study, which conclude that there is documentawho take part in asthma education programmes fotraining of skills achieve considerable effects, such

- fewer admissions;- fewer emergency ward visits;- less absence from work;- fewer asthma attacks at night;- improvement of the patients general capac- improved medical compliance;- improved quality of life.

It is still not clear what the optimum structure, duration of education programmes for asthma patie

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There is a high level of evidence for the value of among asthma patients.

Diabetes patients

Type 1-diabetes occurs in all age groups. Lessoccurrence of type 2-diabetes than about type 1-dioccurrence of type 2-diabetes is increasing rapidlyincrease in overweight/obesity it is seen in younge persons. With regard to both types of diabetes the health risk is development of late complications (rcardiovascular disease increased 3 to 5 times) and diabetic eye disease, renal disorder and nervous dinephropathy and neuropathy).

A number of randomized and controlled studiout with regard to both type 1 and type 2 diabetes.show that interventions with regard to one or sever

can lead to late complications are effective [30, 31should address [32]:- near normalization of blood sugar;- near normalization of blood pressure and b- smoking cessation;- psychosocial support;- counselling on nutrition, including alcohol,

activity.

There is a high level of evidence for the value of diabrehabilitation.

Osteoporosis patients

There is an increase in the prevalence of osteowestern world, among other things because of an i

number of elderly persons. The risk of osteoporosiincreases considerably with age and is especially fThe three most frequent osteoporosis-related fractudifferent age groups. Fracture in or near the wrist ifrom the age of 55, back problems from the age ofor around the hip from the age of 75.

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There is evidence that increased calcium intakincrease bone mineral content. There is no agreemwomen may benefit from calcium intake after the there are studies that indicate that calcium intake aD, reduce the number of fractures in elderly men a

Physical activity and an active lifestyle increacontent along with enhanced muscle strength and mcoordination, which contributes to reduction of the[34]. Smoking increases the risk of osteoporosis infemale smokers have an earlier menopause than noenhanced oestradiol metabolism. In the same way men constitutes a significant risk factor for the devosteoporosis because of poor nutrition and reduced production.Thus primary prevention should address:

- smoking cessation;- reduction or cessation of alcohol consumpt- motivation for physical activity.

Furthermore there is evidence that hip protectonumber of fractures by 67% among elderly personThus hip protectors are an important element of th programmes for frail elderly persons who are pronosteoporosis [35].

There is a low to moderate high level of evidenc

rehabilitation among these patients.Patients with cancer

A reduction of the occurrence of cancer is a prhealth care plans in most countries whereas rehabi patients has not been considered equally. It is estimof newly diagnosed cancer patients need rehabilitaIt is necessary to initiate further knowledge in this interventions should address:

- psychosocial support and counselling;- physical training/relaxation;- nutrition guidance;- smoking cessation;

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- communication of knowledge to patients an

There is a low level of evidence for cancer rehabilitat

Stroke

Stroke is a serious condition in so far as 40% oduring the first year after onset of the disease, and not able to return to their own homes.

Many factors increase the risk of stroke: smoklack of physical activity, increased blood fat levelsdiabetes, irregular heartbeat. The risk increases wievidence that patients participating in rehabilitatiocomprehensive interdisciplinary treatment throughthe disease may achieve [41]:

- a reduction of mortality of 25%-50%;- a reduced need for residential homes of 40%

- improved functional level.Furthermore prevention includes counselling o

cessation, stop drinking or reduction of alcohol coregulation of blood fat levels, optimization of bloofunction as well as anticoagulant therapy.

Thus, it is recommended that patients with strospecial stroke units where rehabilitation may be in

acute phase [38].There is a high level of evidence for rehabilitation aft

Patients with psychiatric disorders

A large proportion of psychiatric patients is smother substance abuse problems.

Treatment with psychoactive medicine leads tweight gain in many patients and therefore there isintervention with regard to nutrition and physical aactivity in psychiatric patients has a documented pcourse of treatment. Thus, prevention should be inpsychiatric patient pathways in the same way as in

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Work has been carried out concerning documeevaluation of various ways of organizing treatmenAssertive Community Treatment teams. There is eAssertive Community Treatment Teams that addrelarge use of inpatient days may reduce the cost of hincrease the number who are in contact with the treimprove user satisfaction among patients and relat positive effect with regard to a number of social pahomelessness or not having an independent home recommended that outreach psychosis teams be int

for the treatment of patients with long-term psychoThere is a high to moderate level of evidence for psycrehabilitation.

Surgical patients

A varying number of patients that undergo sursuffer from long-term and complicated conditions.of complications can be related to the diagnosis andisease, type of intervention and the organization, competence, use of clinical guidelines etc. In recenacquired new knowledge on the significance of thelifestyle habits with regard to tobacco, alcohol, nutin connection with intervention. There is now evid prevention initiatives can reduce the number of cosignificance of increased risk of complications due

mentioned factors should form part of overall indiAs in the case of intervention with regard to medicchronic disorders, qualitative intervention should celements, i.e. tobacco, alcohol, physical activity, n psychosocial support, medical (including surgical optimization and patient education [41].

Against the backdrop of available evidence, thof Health has established general recommendationwith regard to tobacco and alcohol in connection wintervention [16]. Early mobilization and nutritiondescribed as significant elements of the postoperat

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Smoking Altogether smokers have three times as many

the form of poor healing of wounds and other tissulung complications in connection with surgical intto non-smokers.

The first international intervention study fromthat complications in surgical patients, who stop sm before the intervention, are reduced from 52% to 1average length of stay is reduced from 13 days to 1Figure 3: Complications in surgery after health promotion interventi

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Hip or knee replacement

Intervention

Control

New Danish figures furthermore show that ceweeks prior to surgical intervention reduces compldegree [44].

Alcohol

Excessive alcohol consumption is linked to inrisk, which increases with consumption so that themany complications in patients who consume five

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day. Complications are due to alcohol-induced orgreversible to a wide extent if no alcohol is consum

Thus there is evidence that preoperative alcohfour weeks reduces complications following colorehalf, as illustrated in the figure below [45].Figure 4: Complications after colorectal resection

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Colorectal resection

Intervention

Control

Nutrition

There is evidence that nutritional intervention patients [18] reduces complications in connection intervention by 10% and reduces the frequency of increases muscle strength in surgical patients.

There is also evidence that resumption of foodimmediately after intervention considerably reduce[46, 47].

Physical activity

Early mobilization and increased physical actisurgery has turned out to be significant and is part

f h bili i i i i h

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intervention reduces weight loss and the fatigue ofsurgery [48].

Preventive intervention that should be offered - identification of risk factors;- dialogue with the patient to clarify the role

and the patients own responsibility and opinfluencing their own situation;

- evidence-based offer of intervention and fo

Intervention with regard to surgical patients is high motivation for changes in lifestyle prior to su by surprisingly high compliance [44,46,47]. Patienshould include the high postoperative morbidity refactors, and the evidence based programme shouldtime before surgery.

The level of evidence is high to moderate with re prevention and rehabilitation in relation to surgery.

Conclusion Evidence supports the recommendation of clin

the hospitals preventive intervention in relation tospecific conditions, for which clinical health prominfluence on further development. Clinical guideliestablished that describe evidence in accordance w

health promotion developed by the Health Promot Network.Hospitals have tradition and expertise in healt

research and practice and should prioritize further developing health promotion programmes. The healone cannot bring about major changes in health bsector can play an important role in identifying im problems and drawing the attention of society and those problems.References

1. Sacket DL.The arrogance of preventive medicine. CMAJ365.

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2. Eccles M, Freemantle N, Mason J. North England evidenc guidelines development project: Methods of developing gu

efficient drug use in primary care. BMJ. 1998, 316:1232-13. McKee Martin. In:The evidence for health promotion eff for the European Commission by the International Union f Promotion and Education.Brussels, 2000.4. ABC of learning and teaching in medicine.BMJ. 2003, 32270,328-330,385-387, 437-440, 492-494, 443-445, 591706, 753-755, 810-812, 870-873, 921-923.5. Willaing I, Iversen L, Jrgensen T.What do hospital staffmean for knowledge, attitude and counselling practice rela

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9. Jensen JK.Smoking and admission to a department of ina county hospital . Ugeskr Laeger. 1999 Dec 6; 161(49):6abstract).10. Evangelista LS et al.Usefulness of a history of tobaccoin predicting multiple heart failure readmissions among veCardiol. Vol. 86, 2000, 12:1339-1342.11. Sicras MA et al.The evaluation of hospital readmissionmedicine service.Med Clin. Vol. 101, 1993,19:732-735.12. Fiore MC, Bailey WC, Choen SJ et al.Treating tobacco udependence. Clinical practice guideline.Rockville, MD, UHealth and Human Services, Public Health Services, 2013. Doll R, Peto R et al.Mortality in relation to smoking: 40observations on male British doctors. BMJ. 1994, 309:90114. Mller AM, Villebro M, Pedersen T, Tnnesen H. Effect smoking intervention on postoperative complications: a rancontrolled trial.Lancet. 2002, 159:114 117.15.Smoking & Alcohol and Operations Prevention and H(systematic review).Danish Board of Health. Vol. 20. 20016. Physical Activity and Health, Systematic Review of liteand Health Promotion. Danish Board of Health..Vol. 19, 17. Heys SD, Walker LG, Smith I, Eremin O. Enteral nutritio supplementation with key nutrients in patients with criticalcancer: a meta-analysis of randomized controlled clinical tVol. 229. 1999, 4:467-477.18 ESPEN id li f i i l i d h

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Eighteen core strategies for Health

Promoting Hospitals (Jrgen M. Pelikan,Christina Dietscher, Karl Krajic, PeterNowak) 2

IntroductionBased on the Ottawa Charter [1], the WHO-Re

Europe initiated three strands of support for reorietowards health promotion:- conceptual development [2]; Budapest decl

recommendations [4];- implementation experiences through the W

Health and Hospital in Vienna [5] and the Ehospital project [6, 7]; and

- networking and media (business meetings, international conferences since 1993, worknational and regional networks, data base, wCollaborating Centre for Health PromotionHealth Care, WHO Collaborating Centre foHealth Promotion in Hospitals [8,9].

In 2001, WHO launched a working group to destrategic framework for health promoting hospitals presents a shortened and focused version of the maworking group Putting health promoting hospital In order to understand the relationship of hospitals promotion and the specific potential of hospitals to promotion, some aspects of the situation of hospitacharacteristics of health promotion need to be clari

The situation of hospitals is characterized by aincreasing pressure of their dynamic environmentschanging political and economic, professional and2 This paper is based on the discussions within the WHO WHPH Policy into Action. We want to thank the other worktheir valuable comments: Elimar Brandt, Carlo Favaretti, PGntert Oliver Grne (WHO Barcelona) Ann Kerr Eli

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expectations concerning the process and content ofTwo general tendencies can be distinguished withi

hospital reforms:- Strategic re-positioning of the hospital: The

the range and mix of services (i.e. the distin business and other services; balancing inpaservices or acute/chronic/rehabilitative serveducative elements; specialization of typesdepartments; and integration with primary services and intersectoral collaboration).

- Assuring and improving quality of servicessafety, appropriateness, effectiveness and eservices and improve satisfaction of stakehhospitals are increasingly introducing qualias TQM, EFQM, ISO, accreditation and puemphasis on evidence based medicine and

To be able to identify the specific contributions

promotion to such strategic re-positioning and quahospitals, we need to follow the definition in the OHealth promotion is the process of enabling peopcontrol over, and to improve, their health. Health as the absence of disease and positive health, and bin relation to body, mind and social status. Health interventions include the maintenance and improvit by protection or development of positive health

treatment and care.The term enabling from the Ottawa Charter rthat health has to be reproduced by the people themtherefore depends upon their abilities and orientatihand, and on opportunities and incentives in the sithey are living and acting on the other. Only in extcontrol of health be completely handed over to expcare and other systems). From this perspective foll

sense to invest not only in clinical interventions, binterventions to improve health: Educating personsmanagement (lifestyle approach) and developing sthe healthy choice the easy choice [10].

Following the Ottawa Charter, the term of ena

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through which people gain greater control over deaffecting their health [11]. Empowerment relates

social groups or communities and combines measustrengthening actors life skills and capacities (e.gneeds, present their concerns, devise strategies for decision-making) with measures creating supportivand social environmental conditions which impactProcesses to achieve both may be social, cultural, political.

The two terms are usually used in combinationthe comprehensive goal and the empowering meancould or should be reached. In the list of 7 guidingcriteria for health promotion, as defined by a WHOWorking Group on Health Promotion Evaluation (2001, p. 4) [12], empowering is the first, followed - participatory (involving all concerned in all sta- holistic (fostering physical, mental, social and - intersectoral involving the collaboration of age

sectors);- equitable (guided by a concern for equity and s- sustainable (bringing about changes that indivi

communities can maintain once initial funding- multistrategy (using a variety of approaches

development, organizational change, communilegislation, advocacy, education and communiccombination).

If health promotion is applied to improve qualiwidens the concept of outcomes and has implicatioand processes of hospitals. Following the more exp philosophy of hospitals, the outcome concept of howidened to include, in addition to clinical outcomerelated quality of life and patient satisfaction.

Health promotion underlines the psychologicaldimensions of health outcome and adds health litermeasurable outcome dimension of (educative) emp processes as far as services are concerned. By thhealth promotion introduces health impacts of the effects of hospitals to be observed, controlled and

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outcomes of services and impacts of the materialclinical and hotel hospital setting. This widening o

outcome also leads to a widening of the focus for qof the processes and underlying structures. The conthat is most relevant for distinguishing between di promotion strategies to be implemented in or by hohealth, can be summarized as service oriented strategie2 and 4, 5 in Table 1 below) vs. setting oriented strateg3, 6).Table 1: Six general health promotion strategies for each group

of stakeholders of the hospital (patients, staff, community)

Service oriented strategies includequality improve

existing clinical and hotel services (strategies 1, 2) introducingnew, primarily educative services with miterm health effects(strategies 4, 5). Strategies can beaccording to their orientation of treating or managi(strategies 2, 4) and strategies oriented at services improving positive health(strategies 1, 5). Concerninstrategies developing the hospital setting itself (strdistinguished from strategies of participation of thdeveloping the community setting (strategy 6) or othe community (e.g. workplaces or schools). By beimproving health gain and not just clinical outcomstrategies do not only apply to patients (and their rsomewhat modified way also to staff and membersthe hospital serves and is situated inresulting in 18 str

1. HP quality development of treatment & care, by empowermestakeholders for health promoting self care / self-repro

2. HP quality development of treatment & care, by empowermestakeholders for health promoting co-production

3. HP quality development for health promoting & empoweringhospital setting for stakeholders

4. Provision of specific HP services empowering illness

management (patient education) for stakeholders5. Provision of specific HP services empowering lifestyledevelopment (health education) for stakeholders

6. Provision of specific HP activities participation in healthpromoting & empowering community development for stakeholders

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The amount and quality of evidence that suppoeffectiveness and the amount of health gain that ca

reached is different for each of these strategies, bugood practice and evidence for each of them. For rdescription, the strategies are described for specifithey may overlap in reality.

Patient-oriented strategies

HP quality improvement strategies for acute hospital services

Empowerment of patients for health promoting self care/ self maintenance/ self reproduction in the hospital

Even if patients are not only understood as the objalso as co-producers of their health outcomes, we haccount that they can only fulfil their patient role itrinity of body, psyche, social status).

Depending on their condition, the patients contrib production ranges self-care of the patient, over prosupported care to intensive care (heart/lung machinfour criteria of the complex concept of health gainconcerns all three dimensions of health the physinutrition), the mental (e.g. enough privacy in the hsocial (e.g. possibilities for contacts with relatives,

In order to avoid hospitalization as far as possible, principle to allow for as much self-care as possiblemuch professional care as necessary. To make selfthe difficult conditions of partly severely ill individusual household environment, and subjected to theimperatives of the hospital organization, professioempowering as possible, and needs to take into accdifferences of patients. Empowerment again includand social dimensions, knowledge, skills and motican be seen as the specific contribution of health pThe effects of this strategy have not been systemat but examples of interventions that have been succeimplemented in specific hospitals are:

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- visiting and lay support services to support the of patients [5];

- patient information about general hospital featufind what; visiting hours) at hospital admission

- offers and options to encourage patient activitiresponsibility (e.g. exercise, culture activities, discussions, patient internet cafe);

- provide psychological assistance to cope with srelated to the hospital stay or to the patients di

Empowerment of patients for health promoting participation / cproduction in treatment and care

The core task of the modern acute care hospital is and therapeutic services for incidents of acute illnesevere type or with the need / opportunity for technand treatment) as well as acute episodes of chronicinpatients and outpatients.The second health promotion strategy relates to thtradition of quality assurance and quality improvemstarting with the education of professionals, and inswitching towards developing processes and structorganizations and larger systems. How can health contribute to the quality improvement of core procThe concept of empowerment stresses the necessittake control over their health which means in thehospital that patients are not only seen as objects oalso as co-produce