Health Assets for Young People's Wellbeing

INDEX

Agenda

Presentation of the book: ‘Health Assets in a Global

Context’

Abstracts or presentations of some conferences

Participants

Organizing committee & Technical Secretariat

Agenda

Health Assets in a Global Context: Theory Methods Action

A series of events to translate the asset model into policy research and practice

Symposium 1: Health Assets for Young People’s Wellbeing

Seville1, Spain 28-30 April 2010

Agenda

Wednesday 28 April 2010

14:00 - 15:00 Lunch

17:00 - 17.45 Registration and coffee / tea

17:45 - 18:15

Opening Plenary Welcome • Carmen Moreno, Symposium co-organizer • Fiona Brooks, University of Hertfordshire, England • Rosa Ramirez, Ministry of Health and Social Policy and Spanish European

Presidency • Erio Ziglio, WHO European Office for Investment in Health and

Development, Venice • Pedro J. Paul, University of Seville

18:15 - 18:30

Short Introduction: Assets for Health and Development – Why Assets? Why Now?

• Dr Erio Ziglio, WHO European Office for Investment in Health and Development, Venice

18:30 - 19:00 Keynote 1: Assets for Health and Development – individual level resilience

• Dr Harry Burns – Chief Medical Officer, Scotland

19:45

Departure by bus to the Centre of Town • 20:15 Private guided visit to Reales Alcázares of Seville

(http://www.patronato-alcazarsevilla.es/index.php) • 21:30 Welcome ‘Tapas and Drinks’ inside Reales Alcázares private gardens • 23:00 Return by bus to Hotel Al-Andalus

1 The conference venue will be in the hotel where all the attendees will be hosted:

Hotel Al-Andalus Palace (http://www.hoteles-silken.com/hotel-al-andalus-palace-sevilla/en/) Avenida de la Palmera s/n, esquina Paraná Sevilla 41012 - Spain

Thursday 29 April 2010 (8:30 - 17:30)

8:00 - 8:30 Arrival and coffee/tea

8:30 - 9:00

Overview of the Agenda, Goals of the Symposium

• Introduction of Participants • Introduction to the Book: Health Assets in a Global Context:

Theory, Methods, Action Antony Morgan, Associate Director, National Institute of Health and Clinical Excellence (NICE), England Erio Ziglio, Head, WHO European Office for Investment in Health and Development, Italy

9:00 - 10:45 Session 1: The Meaning of Wellbeing

9:00 - 9:05 Chairs: Professor Fiona Brooks, University of Hertfordshire and Professor Carmen Moreno, University of Seville.

9:05 - 9:30 • Listening to Young People – DVD representing young people’s

views from Austria, Canada, England, Mexico, Romania and Spain

9:30 - 9.50 • Measuring wellbeing, some problems and possibilities – Dr Virginia

Morrow, Institute of Education, England.

9:50 - 10.10 • What is it to be well? - Mr Tom Hennell, North West Regional

Government, England 10:10 - 10:45 Facilitated Debate: Ms Cathy Herman, Independent Consultant, England

10:45 - 11:15 Coffee/tea break

11:15 - 11:45 What has the Asset Model got to offer the health equity agenda? Antony Morgan

11:45 - 13:00 Session 2: The Salutogenic Perspective

11:45 - 12:05 Chair: Dr. Jesús Palacios, University of Seville, Spain Presentation: Professor Bengt Lindstrom and Dr Monika Eriksson, Folkhälsan Research Centre, Finland

12:05 - 12:15 Respondents (5 Minutes each)

• Dr Fiona Adshead, Department of Health, England • Mr Mariano Hernán, Andalucian School of Public Health, Spain.

12:15 - 13:00 Facilitated Debate Ms Cathy Herman

13:00 - 14:15 Lunch

14:15 - 15:30 Session 3: Resilience as a Health Asset

14:15 - 14:35 Chair: Águeda Parra, University of Seville, Spain Presentation: Professor Ingrid Schoon, University of London, England


• Dr Anja Bauman, WHO Regional Office for Europe, Copenhagen • Dr. Jesús Jiménez, University of Seville, Spain


15:30 - 16:00 Coffee /Tea Break

16:00 - 17:15 Session 4: The link between biology and social structure

16:00 - 16:20 Chair: Dr. Mar González, University of Seville, Spain Presentation: Professor Mike Kelly, NICE, England


• Dr Harry Burns, Chief Medical Officer for Scotland • Ms Maggie Davies, Executive Director, HAPI


17:15 - 17:45 Keynote: Relevance of promoting risk and protective framework for promoting equity in young people Presenter: Professor Alfredo Oliva, University of Seville, Spain

19:30 Departure by bus to the Abades Restaurant (in the traditional district of Triana: (http://www.abadestriana.com/en/)

Gala Dinner at 20.30

Friday, 30 April 2010 (8:45am - 16:45pm)

8:30 - 8.50 Linking Symposium 1 to EU Spanish Presidency and Introduction to Day 2

• Dr Begoña Merino, Ministry of Health, Madrid, Spain • Dr Erio Ziglio and Mr Antony Morgan

8:50 - 10.45 Session 5: Evidence: Exploring Risk and Protective Factors using the WHO Health Behaviour in School Aged Children Study

8:50 - 9:00 Presenter: Dr Pernille Due, Deputy International Coordinator, University Southern Denmark, Copenhagen.

9:00 - 10:15

HBSC Presenters: Positive Health (Dr Veronika Ottova, Germany); Risk Behaviour (Ms Margreet de Looze, The Netherlands); Family Culture (Dr Carmen Moreno, Spain); Social Inequalities (Dr Pernille Due, Denmark); Resilience (Professor Yossi Harel-Fisch, Israel); Internal and External Assets (Professor Adriana Baban, Romania)

10:15 - 10:45 Facilitated Debate: Ms Cathy Herman

10:45 - 11:30 Coffee / tea break (including Spanish dance performance by Young Students of Conservatorio, School of Dance: http://www.juntadeandalucia.es/averroes/conservatoriodanzasevilla/index2.html)

11:30 - ... Young People’s ‘Mural of Wellbeing’ begins…’The things that make us feel happy’

11:40 - 13:15 Session 6: Action: Introduction for Asset Mapping

11:40 - 12:00 Chair: Dr. Victoria Hidalgo. University of Seville, Spain Presenter: Dr Deborah Puntenney, NorthWestern University, Chicago, USA

12:00 - 12:45

Health Assets in a Global Context – Panel Discussion

• Dr Alok Mukhopadhyay, CEO, VHAI, India • Dr David Houeto, CREDEPSA, West Africa • Ms Cristina Franceschini, PAHO (Central and Latin America) • Professor Alfred Rutten, Friedrich-Alexander University (Germany) • Dr Margarida Gaspar De Matos, FMH Universidade Técnica de

Lisboa (Portugal) • Dr Peter Makara, University of Debrecen (Hungary)


13:15 - 14:30 Lunch

14:30 - 15:45 Session 7: Evaluation: Developing evidence based guidance for wellbeing in secondary education: implications for the asset model

14:30 - 14:50 Chair: Carmen Granado, University of Huelva, Spain Presenter: Professor Mike Kelly, NICE, England

14:50 - 15:00

Respondents (5 Minutes each) • Professor Marcia Hills, University of British Columbia, Canada • Dr Tessa Moore, London Borough of Richmond upon Thames,

England


15:45 - 16:00 Coffee / tea break

16:00 - 16:30 Young Peoples Panel: So what do you think?

Chair: Professor Fiona Brooks and Carmen Moreno,

16:30 – 16:45 Closing Remarks and Next Steps

Erio Ziglio and Antony Morgan

Presentation of the

book:

‘Health Assets in a

Global Context’

Antony Morgan, National Institute for Health and Clinical Excellence (NICE), London, UK and

University of Hertfordshire, England; Maggie Davies, Department of Health, London, England;

and, Erio Ziglio WHO Regional Office for Europe, European Office for Investment for Health

and Development, Venice, Italy (Eds.)

q

Health Assets in a Global ContextM

organ · Davies · Ziglio Eds.

1

› springer.com

isbn 978-1-4419-5920-1

1 23

Health Assets in a Global Context

Antony MorganMaggie DaviesErio ZiglioEditors

Theory, Methods, Action

As global health inequities continue to widen, poli-cymakers are redoubling their efforts to address them. Yet the effectiveness and quality of these programs vary considerably, sometimes resulting in the reverse of expected outcomes. While local political issues or cultural conflicts may play a part in these situations, an important new book points to a universal factor: the prevailing deficit model of assessing health needs, which puts disadvantaged communities on the defensive while ignoring their potential strengths.

The asset model proposed in Health Assets in a Global Context offers a necessary complement to the problem-focused framework by assessing multiple levels of health-promoting aspects in pop-ulations, and promoting joint solutions between communities and outside agencies. The book pro-vides not only rationales and methodologies (e.g., measuring resilience and similar elusive qualities) but also concrete examples of asset-based initiatives in use across the world on the individual and com-munity levels, including:

• Strengthening the assets of disadvantaged women (Germany).

• Sustainable community-based development programs (India).

• Using parental assets to control child malaria (West Africa).

• Asset/evidence-based health promotion in the schools (Romania).

• Evaluating asset-based programs (Latin America). • Using social capital to promote health equity

(Australia).

Health Assets in a Global Context offers a new, positive lens for viewing the world’s most resistant public health crises, making it fundamental reading for researchers and graduate students in public health, especially those involved in health promo-tion, health disparities, social determinants of health, and global health.

MorganDaviesZiglioEditorsHealth Assets in a Global ContextTheory, Methods, Action

HEALTH ASSETS IN A GLOBAL CONTEXT: THEORY METHODS ACTION

Acknowledgements

Preface

Contents

Part 1: Conceptualising the notion of health assets

1. Revitalising the Public Health Evidence Base: An Asset Model Antony Morgan, Erio Ziglio

2. A Salutogenic Approach to Tackling Health Inequalities Bengt Lindström, Monica Eriksson

3. A Theoretical Model of Assets: The Link Between Biology and the Social Structure

Michael P. Kelly 4. Asset Mapping in Communities

John McKnight 5. Assets Based Interventions: Evaluating and Synthesizing Evidence of the

Effectiveness of the Assets Based Approach to Health Promotion.

Marcia Hills, Simon Carroll, Sylvie Desjardins.

Part 2: Building an evidence base on assets and health

6. Resilience as an Asset for Healthy Development Mel Bartley, Ingrid Schoon, Richard Mitchell, David Blane

7. How to Assess Resilience: Reflections on a Measurement Model

Nora Wille, Ulrike Ravens-Sieberer 8. Measuring Children’s Well-Being: Some Problems and Possibilities

Virginia Morrow, Berry Mayall 9. The Relationship Between Health Assets, Social Capital and Cohesive Communities

Ichiro Kawachi

Part 3: Health Assets in Action

10. Community Empowerment and Health Improvement Jennie Popay

11. Strengthening the Assets of Women Living in Disadvantaged Situations: The

German Experience

Alfred Rütten, Karim Abu-Omar, Sabine Seidenstücker, Sabine Mayer 12. Sustainable Community Based Health and Development Programs in Rural India

Alok Mukhopadhyay, Anjali Gupta 13. The Application and Evaluation of an Assets-Based Model in Latin America and the

Caribbean: the Experience With the Healthy Settings Approach

Maria Cristina Franceschini, Marilyn Rice, Cristina Raquel Caballero Garcia 14. Parents and Communities’ Assets to Control Under-Five Child Malaria in Rural

Benin, West Africa.

David Houéto, Alain Deccache

Part 4: Health Assets and Public Policy

15. Strengthening Asset Focused Policy Making in Hungary

Péter Makara, Zsófia Németh, Ágnes Taller 16. How Forms of Social Capital can be an Asset for Promoting Health Equity

Fran Baum 17. Internal and External Assets and Romanian Adolescents’ Health: An Evidence-

Based Approach to Health Promoting Schools Policy Adriana Baban, Catrinel Craciun

18. Bringing it all Together - The Salutogenic Response to Some of the Most Pertinent

Public Health Dilemmas

Monica Eriksson, Bengt Lindström

Conclusion

Health Assets in a Global Context: Theory, Methods, Action Antony Morgan, Maggie Davies, Erio Ziglio, editors

As global health inequities continue to widen, policymakers are redoubling their

efforts to address them. Yet the effectiveness and quality of these programs vary

considerably, sometimes resulting in the reverse of expected outcomes. While local

political issues or cultural conflicts may play a part in these situations, an important

new book points to a universal factor: the prevailing deficit model of assessing health

needs, which puts disadvantaged communities on the defensive while ignoring their

potential strengths.

The asset model proposed in Health Assets in a Global Context offers a necessary

complement to the problem-focused framework by assessing multiple levels of health-

promoting aspects in populations, and promoting joint solutions between communities

and outside agencies. The book provides not only rationales and methodologies (e.g.,

measuring resilience and similar elusive qualities) but also concrete examples of

asset-based initiatives in use across the world on the individual and community levels,

including:





• Evaluating asset-based programs (Latin America).

• Using social capital to promote health equity (Australia).

Health Assets in a Global Context offers a new, positive lens for viewing the world’s

most resistant public health crises, making it fundamental reading for researchers and

graduate students in public health, especially those involved in health promotion,

health disparities, social determinants of health, and global health.

Preface

Very few people argue with the need to address the social determinants of health. The

Commission on the Social Determinants of Health (CSDH) affirms that the conditions

in which people grow, live work and age have a powerful influence on health. The

Commission’s holistic view of these determinants calls for sustained action, globally,

nationally and locally to overcome the unequal distribution of power, income, goods

and services which often lead to unfair access to health care, schools and education

and an individual’s chance of leading a flourishing life (CDSH, 2008).

Asset based approaches offer one means of contributing to these goals by recognizing

that traditional epidemiological risk factors approaches to health development such as

programmes on smoking cessation, healthy eating and physical activity are

insufficient on their own to ensure the health and well-being of populations. In

particular, many of the solutions to addressing the social determinants of health rely

on the ability of professionals to recognize that individuals, communities and

populations have significant potential to be a ‘health resource’ rather than just a

consumer of health care services. The Asset Model described by Morgan and Ziglio

(see chapter 1) provides a framework for establishing fresh insights into how best to

collect and collate scientific evidence to demonstrate the benefits of the asset

approach for population health and how to harness the sorts of effective practice that

strengthen community capacities, promote independence and autonomy. They also

have the potential to secure sustainable and cost containment approaches to health and

development..

There are two things that should be noted about the asset approach as described in this

book. Firstly, it is not in itself a new concept or approach - but aims to add value to

other existing concepts and ideas by bringing them together in such away as to

promote a more systematic approach to assembling and applying knowledge for

health solutions. Secondly, it would be naïve to think that the asset approach could

exist in isolation from the more predominant deficit tradition to health promotion.

There will always be some situations where individuals, communities or broader

populations are exposed to health threats or increased exposure to known health risks

and therefore need the immediate attention of health professionals and access to

services. However the identification and strengthening of health assets should be a

key component of a country’s overall development strategy, because they can act as a

buffer or resilience factor to disease risk exposure and importantly can produce health

as a positive entity with a focus on quality of life and wellbeing. It is possible to

identify health promoting / protecting assets from across all the domains of health

determinants including our genetic endowments, social circumstances, environmental

conditions, behavioural choices and health services. An inventory of health and

development assets would, as a minimum, include family and friendship (supportive)

networks, intergenerational solidarity, community cohesion, environmental resources

necessary for promoting physical, mental and social health, employment security and

opportunities for voluntary service, affinity groups (e.g. mutual aid), religious

tolerance and harmony, life long learning, safe and pleasant housing, political

democracy and participation opportunities, social justice and enhancing equity.

The overarching aim of this book is to stimulate researchers, policy makers and

practitioners to think differently about how they approach their goal of improving the

health of populations particularly to minimise the risks of exacerbating or widening

health inequities. It brings together the work of a number of well known authors who

have been working in fields that have direct relevance to the asset model. The 18

chapters included in it provide illustrations as how asset based approaches can be

brought to fruition. Of course, it presents only a starting point for further work,

particularly in research – but hopefully its immediate impact can be to change the

mindsets of those in decision making positions to think of the ‘glass half full, not half

empty’ scenario.

We introduce each chapter here, to highlight how they can help us advance the asset

approach to ensure it can demonstrate its potential to contribute to the production of

health and reduction of health inequities through science and practice

The Chapters

Chapter 1 provides the overarching framework for the rest of the contributions to the

book. It sets out the rationale for asset based approaches and provides a systematic

way of thinking about how to build an evidence base which can identifies the most

important assets for health; help us understand the potential cumulative effect of a

range of different assets; and clarify their relative importance over the more well

established determinants of health such as absolute and relative poverty. It also

provides insights in to the sorts of practices that are conducive to the approach. The

chapter highlights a number of existing concepts which can be helpful in developing

this evidence base and together help to bring the asset model to life. Salutogenesis is

introduced as a concept which can help us to think outside of the deficit, disease

orientated approach to health and health services as by its very definition asks what

creates health, what helps us to manage and understand the world we live in. By doing

so it immediately highlights some of the key assets necessary for the development of

health and wellbeing. Lindstrom and Eriksson explore the potential of this concept in

more detail in chapters 2 and 18. The very well known concepts of resilience and

social capital are also included in the model as ones with potential to identify a set of

indicators for monitoring and evaluating the impact of investing in programmes which

emphasis the positive rather than negative. Specifically, in this context, the asset

model demonstrates how social capital can be applied for health benefit – offsetting

some of its criticisms concerning its ‘darkside’ (Portes, 1996). Chapters by Bartley,

Kawachi and Baum (6, 9 and 16 respectively) all elaborate the potential for these

concepts to contribute to the model.

Another important idea intrinsic to the model is that of asset mapping – this technique

seeks to build capacity within local communities by making the most of the existing

competencies of individuals, the resources of organisations and institutions and the

collective ability of groups take control of their own health(see Chapter 4 by

McKnight). The model also identifies the need to develop new indicators and

evaluation techniques that can take account of the asset approach and ultimately

demonstrate the benefits of investing in it. (See chapters 5 and 7).

The concept of lifecourse is also important to the model – as the potential for health

assets to be offset by all those risks that individuals and communities inevitably face

during the life experience, can be understood if we assess those assets that can be

accrued at different life stages. Chapters 8 by Morrow and 17 by Baban illustrate the

importance of applying the approach to young people’s health and development.

Of course, none of the ideas, concepts or techniques mentioned above can be brought

to practical value unless researchers, practitioners and policy makers embrace positive

approaches to health and importantly foci on health and wellbeing rather than disease

and dying. One of the reasons why politicians at least might favour the latter is on the

surface it is easier count death and measure progress against it. The asset model

provides an opportunity to make more explicit the concepts of wellbeing and its

associated precursors and to demonstrate how they can be measured.. The asset model

challenges all professionals involved in the health development to re-think their

strategies for promoting health and to balance their activities between the asset and

more familiar needs based approach – more thoughtful investments might then just

about bring the longer term gains required to promote the best health we can and help

us manage the limited resources available in our health systems.

Lindstrom and Eriksson (Chapter 2) consider the theoretical and empirical work

relating to the salutogenic framework. This framework focuses on positive health, in

contrast with the traditional disease-orientated approach.

Salutogenesis centres on two core concepts: Generalised Resistance Resources (GRR)

and the Sense of Coherence (SOC). The GRRs are biological, material and psycho

social factors that make it easier for people to perceive their lives as consistent and

structured. ‘The GRRs lead to life experiences that promote a strong sense of

coherence-a way of perceiving life and an ability to successfully manage the infinite

number of complex stressors encountered in the discourse of life.’

The authors review a range of other concepts and their relationship with

salutuogensis. These include hardiness, theories on welfare and quality of life, learned

resourcefulness, resilience and theories relating to social and cultural contexts. The

review indicates that salutogenesis draws a range of other related concepts.

The SOC questionnaire has been used to understand and test the role of SOC in

explaining health outcomes. SOC has been shown to be strongly related to health,

especially mental health. Lindstrom and Eriksson state that SOC, although not the

same as health, ‘is an important disposition for people’s development and

maintenance of their health’.

These findings suggest that the real potential of a salutogensis approach relates to the

adoption of healthy public policies. Historically public health has operated in a risk

framework, while salutogenesis makes other solutions available for improving health.

Two themes have evolved within salutogenic research–resilience and sense of

coherence -that can now guide action that addresses social and mental wellbeing in a

post-modern world.

Kelly (Chapter 3) highlights the importance of complexity of understanding how to

create the optimum conditions for health by introducing the notion of the lifeworld.

This chapter explores the relationships between those assets that help to protect health

and those conditions which create vulnerabilities to ill health. It explains how these

are located in the lifeworlds of ordinary human experience and the health benefits and

disbenefits which accumulate over the life course. Kelly explains that the lifeworld

and lifecourse together are the bridge between social structure and individual human

biology. Together they constitute the focal point where society and biology intersect

and interact. The lifeworld and lifecourse are the mechanisms through which the

social determinants of health produce biological outcomes in individuals. Theorising

this vital causal link from the social to the biological and from society to individuals,

is essential for ensuring the success of the asset approach in practice. Assets and

vulnerabilities are the crucial mediating or intervening variables between the wider

determinants of health and the human body and it is those intervening variables that

produce individual differences in health. Researchers can help us to understand how

through the identification of key health assets these differences in health can be

minimised.

Asset mapping is introduced in Chapter 4 as a means of capturing the spirit and

energies of communities to assert their ownership on health development. McKnight

highlights how policy makers have tended to create hierarchical systems where a

small number of people are in charge of the mass production of standardised goods.

Clients/consumers in large numbers grow dependent on this cycle of production. Such

systems create dependency rather than empowerment. He argues that in creating maps

to reflect the way in which these systems work we have tended to neglect the notion

of “associated community”; where there is a dependence on consent, choice, care and

citizen power. Systems are seen to exploit need in individuals, whilst communities, in

contrast nurture existing skills and capacity. Systems identify with “the glass half

empty” approach, whilst communities with “the glass half full”. The service culture

produces “clients”, whilst the community culture produces “citizens”.

This chapter explores the nature of the relationship between systems, communities

and citizens, and looks at the shift, in developed society, from equal relationships

between citizens and communities to a relationship where systems are dominant. The

authors argue that the move towards an increasingly “consumerist society” has

marginalized the role of the citizen. In order to encourage and build healthy

communities we must recognise and appreciate the unique capabilities that

communities offer in developing, nurturing and caring for their citizens.

Hills and colleagues (Chapter 5) discuss the limitations of current evaluation

frameworks and methods for evaluation of an asset based approach. The challenges

that need to be addressed for developing the evidence base on effectiveness are

highlighted.

The authors assert that a new paradigm is required for evaluation of a health assets

based approach. The orthodox approach, based on the epidemiological discipline, has

limited utility for evaluating the effectiveness of community assets, capabilities, risks

and protective factors; and for the synthesis of evidence across studies.

There are major challenges for the evaluation of complex initiatives and programmes.

There is a need for greater theoretical and methodological precision, particularly with

respect to definition of health assets and their operationalisation through appropriate

indicators. A more integrated approach to process and outcomes evaluation, formative

and summative approaches is required. ‘Improvements in specific health assets need

to be seen as intermediate outcomes in a linked chain of progress towards improving

overall health and social outcomes.’ Participatory evaluation approaches need to be

adopted that provide greater understanding of the processes involved in implementing

programmes and their impact on the outcomes of the programme. Evaluators need to

have a more direct role in programme development: evaluation becomes ‘reflective

practice’.

Realist synthesis is applied to determine the effectiveness of a Canadian Community

Interventions Project. This provides an example of an alternative methodology that

enables the synthesis of evidence from different initiatives and programmes.

Programmes are viewed as the interaction between context, mechanism and outcomes.

Systematic review is concerned with understanding ‘families of mechanisms’ across

programmes. The ‘mechanisms’ operating in the Community Interventions Project are

illustrated, and relate to elements of collaborative planning, community organisation

and action, and transformational change. The authors indicate that evaluation of the

assets based approach is possible, but will required development of such innovative

methodologies.

Bartley et al. (Chapter 6) examine evidence relating to positive adjustment and

resilience as an asset which can promote health even in adverse conditions.

Studies show that individuals and families experiencing difficult conditions are more

likely to experience negative health consequences. However the processes by which

individuals and communities adapt have received less research attention.

Three models of resilience have been identified based on a review of evidence in this

field. These three models (compensatory, protective and challenge) are described.

A link has also been made between the study of resilience and research on the life

course processes involved in chronic diseases. This has highlighted the need to

examine the accumulation of both risks and resources or assets. Health assets are

shaped by the social and physical environment. Resilience is a set of conditions that

allow individual adaptation to different forms of adversity. Resilient practices and

processes may be viewed as health assets. Such processes need to be identified and

promoted by social and economic policies.

The authors discuss issues relating to resilience and freedom. Sen’s work indicates

that the ability to adapt in the face of adversity can increase an individuals perception

of their own freedom to lead a valued life ie resilience increases capability. ‘It is

important for the individual to have the freedom to pursue health itself, and therefore

to understand constraints on that freedom’: such as being forced by financial necessity

to accept stressful working conditions, and to live in polluted areas.

This means that policy should be concerned with enabling people to make healthy

choices while faced with these challenges; different policy responses will be required

to address different threats to freedom.

Bartley and colleagues consider a number of cases that show how health resilience

can be promoted in communities that are disadvantaged. For example analysis of

health inequalities in Europe, has shown that socially disadvantaged populations in

Southern European countries, possess a source of resilience in terms of a healthy diet.

Although these countries have clear income inequalities, these populations have long

life expectancy and less heath inequalities. More research is required to understand

diet as a source of health resilience but there are potentially important implications for

wider policies.

The authors explore how that process of modernisation may lower the economic

capability societies with detrimental health consequences. The role of women in the

nurture of children and families has added value in traditional economies. However

the changes in this role in modern societies (a shift between home and work) are not

fully understood and the authors assert that skills in the conduct of family

relationships as a major health asset are being neglected- there is loss of ‘free

emotional labour’ and …. ‘It is important to increase the capacities of both men and

women to choose a way of life they can sustain themselves in terms of both physical

and emotional self care’.

Bartley and colleagues argue that there are many aspects of human relationship that

function as health assets for individuals and communities. However they are only

acknowledged when they are lost. The assets based approach provides the potential

for recognising and understanding the processes necessary to development of these

capabilities in the modern context.

Wille and Ravens-Sieberer (Chapter 7) consider approaches to the measurement of

resilience. Research in resilience does not address pathological responses of

individuals to stress but investigates health protecting mechanisms ie the ability of

individuals to maintain good health despite considerable stressors.

Resilience research has aimed to identify protective factors or developmental assets

that can modify a child’s response to adversity. This understanding provides the basis

for designing prevention programmes that promote factors that buffer effects of

adversity.

Conceptually resilience is characterised by good outcomes despite of serious threats to

adaptation or development. Two conditions pertain: the presence of demonstrable risk

and competence in response. There is an interactive process involving a person’s

constitution as well as functional qualities of its environment.

There are certain conceptual challenges. For example there is some inconsistency in

how the term ‘protective’ is used. Certain authors only use ‘protective’ to factors that

operate in the presence of adversity-buffering the effect of risks, but it is also applied

more broadly.

From a salutogenic perspective there is a case for a population based approach for

supporting resilience among children and adolescents through direct amelioration as

well as buffering of protective factors. Large population based studies that assess a

variety of risks and resources can support the design of effective public health

interventions. Such studies are rare; however the BELLA study provides an important

example of a study that is focusing on mental health problems in children and

adolescents and associated risks and resources. The range of measures used to assess

risk factors and protective factors are described. The findings of analysis of

demonstrate the potential for guiding policy.

Morrow and Mayall (Chapter 8) explore the concept of children’s well-being, how it

is measured and how it is being researched. The authors indicate that the concept of

well-being is not well defined, yet it has become part of public, political and policy

discourse particularly in the UK. Given the emphasis of wellbeing in the asset model,

this chapter provides important reflections the issues involved in assessing the how

best it should be conceptualized and measured.

A number of important questions are raised, including whether other European

countries would simply refer to ‘children’s welfare’; and whether the focus on well-

being is ‘inherently individualistic’, and detracts from a concern for welfare and

responsibilities of governments towards children.

The authors conclude with a number of suggestions. Care needs to be taken with

conceptualisation of complex concepts such as ‘well-being’. There remains a ‘danger

that a focus on well-being is ultimately an individualistic, subjective approach that

risks depoliticising children’s lives’. Caution is required when reporting research

relating to children, as there is a risk of over-simplification through international

comparisons. Both qualitative and quantitative approaches should be used. Children

and young people should be involved in the conceptualisation of well-being. There

should be greater understanding of UN Convention on the Rights of the Child in

moving towards a ‘genuinely rights-based approach to monitoring children’s everyday

lives’ that confronts the low social status of children in western societies.

Kawachi (Chapter 9) summaries the nature of the knowledge base concerning social

cohesion as a community level asset and determinant of health- covering theories of

causation, measurement approaches, empirical evidence and also the potential of

social capital as a public health intervention.

Social cohesion is clearly related to an assets based model of health- enhancing the

capacity of communities to preserve and maintain. Residents of cohesive communities

can access and mobilise to protect their health consist of norms, trust, and the exercise

of sanctions. These assets are translated into improved health status through a number

of social processes- socialisation, informal social control, and collective efficacy.

Recent reviews of the empirical evidence linking community cohesion to health

outcomes. Studies indicate a link between community cohesion and physical health

outcomes (including self rated health) and health related behaviours. The evidence on

mental health is more sparse and mixed. The majority of studies have been conducted

in developed countries. Community cohesion (as a health asset) appears to be more

salient in societies characterised by the deficient provision of material infrastructure.

There is debate about the value of investing in social cohesion as a public health

improvement strategy. Social cohesion is not a panacea for population and can

sometimes have negative consequences. For example strong social networks may

demand conformity and restrict individual freedoms. Kwat identifies a number of

principles that should guide investment in building social capital. Broader structural

interventions (such as job creation and improved working conditions) aimed at

boosting the capacity of individuals and communities to organisation should be

considered along side building social capital locally. Attention needs to be given to

the type of social capital; building bridging social capital rather than bonding social

capital. For example the linking of unemployed youth to employed adults can provide

access to role models and mentoring. The distribution of costs and benefits should be

assessed to avoid unintended consequences. For example women may

disproportionately be expected to provide support. There is also a need for

governments to be actively involved in building social capital, voluntary efforts are

insufficient.

Popay (Chapter 10) focuses on activities concerned with enabling communities to

have greater control over decisions that affect their lives with the aim to improve

population health and or reduce health inequalities.

The author provides definitions of community development, community

empowerment and community engagement and involvement. A theoretical framework

is presented that defines a number of interlinked pathways between activities aimed at

increasing community engagement and/or empowerment and health outcomes

including both improved population health and reduced health inequalities. In theory

different pathways to health outcomes will be operating at different levels of

empowerment and/or engagement. Activities involved in giving communities more

power and control over decisions that affect their livers the more likely there are to be

positive impacts on service quality, social capital, socio economic circumstances,

community empowerment and ultimately on population health and health inequalities.

Popay states that community engagement and development have a long history both

in the UK and internationally. Current UK policy across many different areas view

engagement and empowerment as the means to finding local solutions and a pre

requisite for success and sustainability.

There is substantial evidence that can inform good practice. Evidence highlights that

there are a range of barriers to effective community development which relate to a

lack of both community and organisational capacity.

Popay discusses the challenges and limitations relating to the evidence base and

provides a comprehensive set of issues that need to be addressed in conducting

evaluations. Given the diversity of the evidence based, there is a strong case for

constructing a review of evidence that tests theoretical models of the pathways

between different approaches to community empowerment and engagement (and

specific methods) and the varied outcomes.

Rutten (Chapter 11), Mukhopadhyay (Chapter 12), Franceschini (Chapter 13) and

Houeto (Chapter 14) all provide examples of the issues involved in the development,

implementation and evaluation of asset approaches to community health in different

country contexts. The experiences from Germany, India, Latin America and the

Caribbean and West Africa, demonstrate the commonalities and differences of

applying the model in different circumstances.

Rutten et al., (Chapter 11) uses the concepts of asset mapping and indicator

development to improve the opportunities for women living in difficult life situations

in Germany to engage in physical activity or ‘movement’ as they define it. It

demonstrates how the model can be used to challenge power structures within

communities to overcome how professionals in positions of power can work with

representatives from the community to achieve their health goals. Importantly they

describe a process that could be replicated in different country contexts to help

overcome some of the barriers that local communities face in try to have their voices

heard by professionals in positions of power. They also highlight how the processes

important to the success of community focussed initiatives can be captures by mixed

method approaches to evaluation and use of indicators that represent the assets

necessary for improving the opportunities for health and access to facilities and

services.

Chapter 12 focuses on sustainable community based health and development

programmes in rural India.. it introduces the Khoj project, a community based

development programme which exemplifies the power of the asset approach to change

the life circumstances of people living in poorer circumstances. Mukhopadhyay and

Gupta describe their experience of strengthening the capacities of local communities

in remote rural parts of India. The project is set within the broader context of Indian

state’s commitment to achieve “health for all”. The overall vision of Khoj is to create

an enabling climate for the sociopolitical development of communities living in

difficult terrains of the country. The chapter highlights the successes of a non

government group through implementation of a range of cross cutting interventions

aiming to bring about a holistic change in the lives of the communities by uplifting

their socioeconomic and health status. The Khoj projects emphasizes that there is no

concept of recipients, as the community is involved in managing the development of

the project including efforts access and obtain the resources needed. The chapter

outlines the broader context within in which the project takes place with a brief

description of the health sector in India and highlights the features of the community

centric sustainable strategies of Khoj that brought about improvements in the overall

well being of the population.

Chapter 13 by Franceschini and colleagues use the settings approach to highlight

what can be achieved in Latin American countries (LAC) where policies and

interventions to tackle poverty and inequalities in health have tended to focus on

disease prevention and treatment. The authors argue that to create sustainable

strategies it is more beneficial to follow a “settings approach”, based on the belief that

determinants of poverty and equity, and their influence on health, can be tackled

through activities, which embrace and work with existing community networks and

infrastructures. This may include the creation of appropriate public policies and laws

and places particular emphasis on the importance of working with regional and local

governments.

This chapter looks at the Healthy Municipalities and Communities movement,

developed in the 1990’s, whose aim was to look at underlying living conditions and

build on existing assets. The focus is deliberately shifted from a focus on illness and

disease to tackling the determinants of health. The chapter concludes by highlighting

the constraints of traditional evaluation methods in their ability to record and assess

the significance and impact of “asset building” in projects. Participatory evaluation

techniques, it is proposed, may be an effective methodology to engage people in a

joint reflection and learning process

Houeto and Deccache (Chapter 14) provide an example from Benin, West Africa of

how parental and community assets can help to control under five child malaria. This

chapter reviews the issues around the burden of malaria in the region and details the

successful facets of a community-led, assets based, anti-malarial project.

Chapters 15 to 18 (Makara, Baum, Baban and Eriksson respectively) consider the

asset model through the policy lens and the range of issues that need be addressed by

those in positions of power to ensure that appropriate attention is given to the

approach.

Chapter 15 (Makara et al) reflects on the Hungarian experience of adopting assets

based approaches and the timeliness of adopting the asset approach as the country

faces the challenges of the social and health impact of the economic and financial

crisis. A greater focus on assets based approaches could help unlock some of the

existing barriers to effective action on health inequities. The chapter highlights that

Hungary has a history of asset approach in local communities. However, if an asset

approach is to be realised, a number of things need to be in place to ensure that the

aims and objectives of the New Hungary Development Plan (NHDP) can be reached.

This chapter sets out the lessons learnt from the past and highlights the critical

conditions for policy to assure they take account of the country’s assets at the

national, regional and local level.

In chapter 16, Baum examines the role of social capital in bringing about equity

based policies that are central to achiving healthy populations. This involves a review

of theories and evidence on the relationship between different forms of social capital

(bonding, bridging and linking), equity and health outcomes.

Baum explores in detail how health inequities are created through social and

economic structures, opportunities and networks, and psychosocial and behavioural

mechanisms, and how social capital can play a role in making the outcomes more

equitable. ‘A high social capital society has high social and civic participation with

bonded, bridging and linking networks which produce co-operation and trust among

the citizens and a desire to provide a fair go, for all members of the community’.

But there is an issue of direction of causality. Wilkinson’s work indicates that equity

of income distribution in a population leads to a society with these high social capital

attributes However Baum points out that it is possible to assume that high social

capital society will result in more equitable health outcomes and that social capital is

easier to generate in more equitable societies. A virtuous cycle can be established.

The role of governments in creating and supporting social capital, and how social

capital can effect political processes, is also examined. Linking social capital implies

can be paraticularly important in bringing about redistributive and progressive

policies. A number of historical and contemporary examples are cited that

demonstrate how movements of solidity and democratization can impact on equity.

that there is a sense of obligation from powerful institutions in society towards the

less powerful.

Thus a crucial public policy question is what are the conditions under which a society

demonstrates higher degrees of linking social capital and solidarity? How can these

attributes be fostered especially in an age in which economic globalisation stresses the

value of individual autonomy.

Baum concludes that further research on social capital and its relationship to health

equity that is more strongly informed by political economy theory will be important

for better understanding of its role as a health asset.

Chapter 17 by Baban and Craciun focuses on the assets required for the health and

wellbeing of adolescents living in Romania. They use data from the Romanian Health

Behaviour in School Aged Children survey to examine how ‘internal and external

assets’ relate to the mental health and health behaviour of this group of young people.

In particular they investigate the relationship between school social capital and mental

health and consider the implications for health promoting school based policies. The

authors argue that the assets based model for health provides a useful frame-work,

demonstrating how school health promotion should focus on building internal and

external resources, helping young people to become active agents in the promotion of

their own mental well being and health behaviour. Results demonstrate that changes

in family structure, parenting patterns and the easy availability of unhealthy lifestyle

options means that the contemporary role played by school in the health education of

teenagers has assumed greater importance than in the past. Gender differences also

emerged from the study, with boys demonstrating more internal and external

resources than girls. Data such as this can be useful in developing national school

policy, promoting student centred methods that help increase self efficacy and self

esteem.

Eriksson and Lindstrom in the final chapter 18 assess the potential of the

salutogenic approach as the basis for tackling public health challenges. The

salutogenic approach focuses on assets for health and the processes that can promote

health.

Salutogenic theory is conceptually and empirically sound. The application of the

sense of coherence scale (SOC) demonstrates the evidence potential as for research

and practice.

Potentially the salutogenic approach embraces a number of concepts that are

concerned with assets for promoting health. The sense of coherence has similarities,

as well as differences with a range of other concepts including resilience, hardiness,

self efficacy, empowerment and habitus and cultural capital.

There is potential to integrate the sense of coherence as an indicator within the health

indicator system. It is important that SOC as a health indicator is assessed on a

population level, and the authors propose introducing a new concept RALY –

Resource Adjusted Life Year as a measure to include in vital statistics –applied on a

general population level. The inclusion of SOC as a health indicator is important for

the deeper integration of the salutogenic perspective on healthy public policy-a policy

development approach that ‘gives people the possibility to live the life they want to

live’. The salutogenic model can also provide a comprehensive cross sectoral

framework and coherence for policy making.

The salutogenic framework is also important for public health and health promotion

research. The authors introduce a model that draws on a number of theories and brings

together ‘research on risk factors for vulnerability and adversities, protective factors

for survival and good health outcomes with salutary factors promoting health and

Quality of life’.

References

Commission on the Social Determinants of Health (CSDH) (2008). Closing the gap in

a generation – health equity through action on the social determinants of health.

Final report of the Commission on the Social Determinants of Health. Geneva:.

World Health Organisation

Portes, A. and Landolt, P. (1996). The downside of social capital. The American

Prospect 26 18-21

Abstracts or

presentations of some

conferences

Health Assets for Young People’s Wellbeing



Symposium 1: Health Assets for Young People’s Wellbeing

Seville, Spain 28-30 April 2010

Introduction to Symposium The Symposium is being organised by the University of Seville (Spain) and the University of

Hertfordshire (England) who are working to together with the WHO Health Behaviour in School

Aged Children (HBSC) collaborative study (www.hbsc.org) to produce an evidence base which

can help us understand the benefits of investing in positive approaches to health and wellbeing,

specifically in relation to young people. Recommendations from the Symposium will be fed in

to the final report of the EU Spanish Presidency which is taking place in first semester of 2010.

The Symposium draws on a new book ‘Health Assets in a Global Context: Theory Methods

Action’ to be published in September 2010. Many of the contributors to the book are

participating in the event to share their experience of working with asset based approaches in

many different country contexts. Health Assets in a Global Context offers a new, positive lens

for viewing the world’s most resistant public health crises. The asset model proposed in Health

Assets in a Global Context offers a necessary complement to the problem-focused framework by

assessing multiple levels of health-promoting aspects in populations, and promoting joint

solutions between communities and outside agencies. The book provides not only rationales

and methodologies (e.g., measuring resilience and similar elusive concepts) but also concrete

examples of asset-based initiatives in use across the world on the individual and community

levels, including:






• Evaluating asset-based programs (Latin America).

• Using social capital to promote health equity (Australia).

Health Assets in a Global Context presents an opportunity unlock some of the difficulties

associated with the effectiveness and quality of programs set up to tackle health inequities.

While local political issues or cultural conflicts may play a part in these situations, the book

recognizes that the prevailing deficit model of assessing health needs, putting disadvantaged

communities on the defensive, may be part of the problem and that asset based approaches

which release the potential strengths of communities maybe part of the solution.

The first symposium in the series focuses on young people’s wellbeing. A key facet of the asset

model recognizes that the more opportunities young people have in childhood and adolescence to

experience and accumulate the positive effects of a range of health assets (usually residing in the

social context of their lives) that outweigh negative risk factors, the more likely they are to achieve

and sustain health and mental well-being in later life.

The overall goal of the Symposium is to contribute to the advancement of asset based

approaches to young people’s wellbeing by highlighting the actions required by researchers,

policy makers and practitioners to make it a reality. In so doing, it will start the process of

building a case for why investments in the approach can have benefits across a wide range of

health and development outcomes in many different contexts.

The Symposium has been organized into a number of keynote speeches and sessions focusing

on the central ideas and themes of the asset model as presented in the forthcoming publication.


Each session will have a Chair, Respondents and include time for facilitated debate. The debate

will hopefully focus on one or more of the following issues:

• The underpinning values associated with the theme being discussed.

• The relative importance of the theme to promoting wellbeing amongst young people.

• The potential for contributing to the health inequity agenda

• The transferability of the theme / idea to different cultural contexts

• The implications for policy research and practice.

It is hoped that the outcomes of the Symposium will be able to support the Spanish EU

Presidency by making specific recommendations about:

• The types of research questions that will support the development of a more systematic

evidence base on asset approaches to young people’s wellbeing

• The prerequisites for effective asset based practice.

• how to stimulate those working in decision making positions to think differently about

how they devise, monitor and evaluate health programmes which aim to promote

young people’s wellbeing and to reduce health inequities.

The Main Sessions were these debates will take place are:

Session 1: The Meaning of Wellbeing

Session 2: The Salutogenic Perspective

Session 3: Resilience as a Health Asset

Session 4: The Link between Biology and Social Structure

Session 5: Evidence: Exploring Risk and Protective Factors using the WHO Health Behaviour in

School Aged Children Study

Session 6 Action: Action: Introduction to Asset Mapping

Session 7: Evaluation: Developing evidence based guidance for wellbeing in secondary

education: implications for the asset model.

Enjoy the Symposium!!


Biography

Harry Burns graduated in medicine from the University of Glasgow in 1974. He worked as a surgeon

for 15 years and developed an interest in health inequalities while working in Glasgow Royal

Infirmary, a university hospital in one of the poorest areas of the UK. He has been Medical Director

of the Royal Infirmary, Director of Public Health for the City of Glasgow and, for the past 4 years,

Chief Medical Officer for Scotland and Director of Health Improvement and Health Protection for the

Scottish Government

Abstract

“Assets for Health and Development: the creation of individual resilience”

Evidence from many studies suggests that adverse social conditions erode the capacity to develop

health through prolonged activation of a range of host defence systems such as the stress response.

An understanding of the mechanisms by which these responses are activated is necessary if we are

to target public policy effectively. Recent insights from developmental biology suggest that the

capacity for health is determined to a large extent in the early years of life. This presentation with

describe some of the evidence for the importance of early years in creating health and discuss some

of the policy implications of this work.

1

Measuring wellMeasuring well--being, some being, some problems and possibilitiesproblems and possibilities

Ginny Morrow (and Berry Ginny Morrow (and Berry MayallMayall))Institute of Education, University of LondonInstitute of Education, University of London

UNICEF report (2007)UNICEF report (2007)

Child poverty in perspective: An overview of child wellChild poverty in perspective: An overview of child well--being in rich countries. A comprehensive assessment of being in rich countries. A comprehensive assessment of the lives and wellthe lives and well--being of children and adolescents in being of children and adolescents in the economically advanced nationsthe economically advanced nations6 dimensions of well6 dimensions of well--being: material wellbeing: material well--being; health being; health and safety; education; peer and family relationships; and safety; education; peer and family relationships; behavioursbehaviours and risks; and young people’s subjective and risks; and young people’s subjective sense of wellsense of well--being. being. 40 sets of indicators relating to children’s lives and 40 sets of indicators relating to children’s lives and children’s rightschildren’s rightsUK finds itself ‘in the bottom third of the rankings for five UK finds itself ‘in the bottom third of the rankings for five of the six dimensions reviewed’of the six dimensions reviewed’

2

1. What is well1. What is well--being?being?

WHO 1946: health as a ‘state of complete physical, WHO 1946: health as a ‘state of complete physical, mental and social wellmental and social well--being and not merely the absence being and not merely the absence of disease or infirmity’.of disease or infirmity’.Linked to public health and health promotionLinked to public health and health promotionBut no clear definition But no clear definition –– increasingly used, detached increasingly used, detached from health, in New from health, in New LabourLabour policy documents. Pervasive. policy documents. Pervasive. Happiness/positive emotions. Happiness/positive emotions. InterdisciplinarityInterdisciplinarity. A . A problem for economists?problem for economists?IndividualisedIndividualised. responses (therapeutic) . responses (therapeutic) → → medicalisationmedicalisationof individual children’s problems (of individual children’s problems (CoppockCoppock, , EcclestoneEcclestone))Is it a way of not talking about ‘welfare’ & responsibilities Is it a way of not talking about ‘welfare’ & responsibilities of states? of states?

Some problems Some problems

DevelopmentallyDevelopmentally--based assumptionsbased assumptionsCulturally loaded Culturally loaded Choice of indicators appears selectiveChoice of indicators appears selectiveLinguistic mattersLinguistic matters

3

RelationshipsRelationships

Proportion of children in lone/step familiesProportion of children in lone/step familiesEating main meal with parent(s) (Finland)Eating main meal with parent(s) (Finland)Time parent(s) spend ‘talking to you’Time parent(s) spend ‘talking to you’‘Kind and helpful’ friends? ‘Kind and helpful’ friends? Example: Example:

“The report presents a sad picture of “The report presents a sad picture of relationships with friends, which are so important relationships with friends, which are so important to children”to children”Not much more than 40% of the UK's 11, 13 and Not much more than 40% of the UK's 11, 13 and 1515--yearyear--olds find their peers "kind and helpful", olds find their peers "kind and helpful", which is the worst score of all the developed which is the worst score of all the developed countries” (Guardian 14 Feb 2007).countries” (Guardian 14 Feb 2007).Classmate support: Most of the Classmate support: Most of the pupils in my class(pupils in my class(eses) ) are kind and helpful/are kind and helpful/ Agree a lot/agree a bit/neither Agree a lot/agree a bit/neither agree or disagree/disagree a bit/disagree a lot (WHO agree or disagree/disagree a bit/disagree a lot (WHO HBSC questionnaire)HBSC questionnaire)

4

3. UN CRC and rights3. UN CRC and rights--talktalk

Selective reading of UN CRC Selective reading of UN CRC -- focus on focus on provision rightsprovision rights‘takes note of the child’s right to be heard and to ‘takes note of the child’s right to be heard and to this end incorporates a dimension that is based this end incorporates a dimension that is based solely on children’s own subjective sense of their solely on children’s own subjective sense of their own wellown well--being [sic]’ (p40) being [sic]’ (p40) EnnewEnnew: the right to be properly researched. : the right to be properly researched. Article 17: and the Oslo Challenge (1999)Article 17: and the Oslo Challenge (1999)

Encourage the mass media to disseminate Encourage the mass media to disseminate information and material of social and cultural information and material of social and cultural benefit to the child (UN CRC Art 17 (a))benefit to the child (UN CRC Art 17 (a))To work ethically and professionally to sound To work ethically and professionally to sound media practices and to develop and promote media practices and to develop and promote media codes of ethics in order to avoid media codes of ethics in order to avoid sensationalism, stereotyping (including by sensationalism, stereotyping (including by gender) or undervaluing of children and their gender) or undervaluing of children and their rights (Oslo Challenge, MAGIC 1999)rights (Oslo Challenge, MAGIC 1999)

5

DiscussionDiscussion

Is the comparison (competition) between Is the comparison (competition) between countries helpful? countries helpful? Can we compare welfare states with neoCan we compare welfare states with neo--liberal societies re: children?liberal societies re: children?Adult preoccupations vs. children’s Adult preoccupations vs. children’s experiences/wellexperiences/well--beingbeingCan it be done as crossCan it be done as cross--cultural cultural comparative level?comparative level?

ConclusionsConclusions

Media reports Media reports –– impact on children.impact on children.Children’s wellChildren’s well--being rarely discussed in being rarely discussed in context of adults’ wellcontext of adults’ well--being,being,Or in understandings of structural, political Or in understandings of structural, political and economic constraints on children’s and economic constraints on children’s lives.lives.

6

SuggestionsSuggestions

Care needed in defining ‘wellCare needed in defining ‘well--being’being’Caution in reporting research relating to Caution in reporting research relating to childrenchildrenInvolving children in defining wellInvolving children in defining well--being being could enhance researchcould enhance researchCombine approaches Combine approaches –– surveys and insurveys and in--depth researchdepth researchGreater understanding needed of UN CRCGreater understanding needed of UN CRC

What it is to be well? Tom Hennell; Department of Health North West Introduction Until recently, there had been two rival disciplines claiming predominance in exploring a systematic understanding of ‘wellbeing’. Traditionally, Liberal Economics has regarded total wellbeing as definable in terms of the accumulation of economic welfare – potentially measurable by such proxies as Gross Value Added. However, following the 1978 Alma-Ata declaration, the field of Public Health has also stated an interest – in defining ‘health’ as ‘complete physical, mental and social wellbeing’; and in the last 20 years many of the systematic tools of econometrics have been applied to health services data; with the intention of creating a quantifiable assessment of population health and wellbeing as a framework for national health policy. But both of the claims of liberal economics, and those of public health have recently been subject to serious critiques. The critics come from a range of politico-economic standpoints, but they draw extensively on one another’s work; and they share the perspective that both the liberal economic and public health approaches, fail to take systematic account of issues of sustainability and reciprocal obligation. Hence, it is argued that the policy formulations of liberal economists are increasingly failing to function in a social environment of weakened recognition of inter-generational obligations; while it has also been argued that key public health goals – such as reduction in health inequalities – have proved resistant to current policy formulations, specifically due to a weakened recognition of inter-community obligations. The critics have maintained that, if the metrics adopted by the dominant disciplines had indeed provided robust quantifiable indicators of wellbeing, then their policy prescriptions would not have failed; however, alternative quantifications of wellbeing – incorporating the missing elements of sustainability and reciprocal obligation – have yet to command widespread acceptance. We report on the application of the analytical approach of data reduction to three large-scale surveys of health and wellbeing in general adult populations: the ‘Health Survey for England’ of 2006 and 2008; and also the North West Mental Wellbeing Survey of 2009. Data reduction – specifically the technique known as Factor Analysis or Principal Component Analysis – has been widely used in behavioural psychology and social marketing as a means to extract underlying common characteristics from within a mass of collected data items. Our intention has bee both to provide a means to compare and visualise social characteristics in different surveys against a consistent dimension of ‘being well’; but also more ambitiously, to propose an understanding of how ‘being well’ functions as a social characteristic; and how it relates to individual, social and reciprocal attributes.

Deficits and Assets Implicit in the formulation of the Alma-Ata declaration is as understanding of health as an ideal state; with the corollary that the life-course tends to consist of serial exposures to health risks, leading over time to an accumulation of health deficits, to which health systems respond with therapeutic interventions combined with strategies for condition management. Eventually, however, health deficits exceed the technical resources of therapy or management, leading to rapid loss of wellbeing, and death. The function of Public Health in this systematic understanding, has been primarily seen as the ‘upsteam’ identification and reduction of exposure to health risks. Overall, in this analysis, continued wellbeing is seen as a health outcome; and, though levels of wellbeing may be assessed by aggregating characteristics of wellness, as an ideal state it cannot be consistently measured. Our visualisations of extracted survey data do not, however, support this way of thinking. In particular, we found that higher quantifications of ‘being well’ to be associated with some characteristics that are conventionally considered as health risks; so, for example, being ‘overweight’ (but not obese) we found consistently to be more associated with being well than was being ‘normal’ weight; while we were also surprised to find that regular drinking of alcohol was associated with much higher levels of ‘being well’ than was total abstention from alcohol (and this remains the case, even when the data is adjusted for those who have given up alcohol for health reasons). The highest levels of ‘being well’ are found in those who have acquired the capability of being able to drink regularly, without drinking to excess. Drinking alcohol appears to function both as a health risk, and as a health asset; the balance of effect being related less to how much is drunk, and more to the reasons for drinking. This suggests an alternative understanding of the life course, as an accumulation of the capabilities and confidence for controlling health states; an understanding that is consistent with our observation that ‘being well’ tends to increase with age up till around 60. Overall, in this analysis, ‘being well’ is better seen as a health input; such that persons who are relatively well may be enabled to become ill better, and recover from illness (or manage their condition) sooner, Getting Ill better Fortunately, the hypothesis that persons who are well tend to get ill better, is empirically testable on the 2006 Health Survey; in that we can see that – standardising for age and condition severity, persons who are relatively unwell appear systematically inhibited from reporting themselves as becoming ill; while those who are unwell and report illness, appear systematically inhibited from reporting themselves as being able to manage their condition. Becoming ill is – in a 21st century culture – a complex, confusing and threatening process. And the same is also true, for recovering from, or managing, illness conditions. For those who are less well, the threats represented by illness tend to be greater, and the potential benefits from access to treatment and support tend to be less apparent. But consistently deferring becoming ill, must necessarily increase the risk of early death or severe disability.

Dimensions of Being Well Although our analysis concentrates on health effects, it is clear that the health domain is not the only, or indeed the primary, field in which ‘being well’ interacts with quality of lilfe. We also see interactions in the domains of ‘liveable neighbourhoods’, ‘workable employment’, and ‘accessible skills’. This implies that ‘being well’ – as we are using the term- has a wider field of application than is provided by established metrics of mental wellbeing; (e.g. the Warwick Edinburgh Mental Wellbeing scale). Being well in the analyses that we have undertaken, relates not only to acquired capability in personal feelings and functions, but also to the accumulation of social and reciprocal capabilities relating each individual in their social context of choice. We propose that these relationships can be shown diagrammatically as a “carousel”, in which “Being Well” forms a common vertical axis while domain specific dimensions of advantage/disadvantage radiate outwards. Within each domain we appear to find a common pattern of differential dynamic potential. Those who are relatively well are those who are most able to perceive how dynamic change may be to their advantage/disadvantage, and who have a higher degree of control over their opportunities for change. For example, those who are well, are most likely to find a job; and if they lose one job, to find another. We also find inter-relationships between domains; having a job is strongly related to reporting good health, which is then strongly related to being well qualified. The core underlying quality that differentiates “being well” appears to be that of acquired individual and social confidence and resilience; those have acquires higher levels of confidence appear able to exercise more control over their changing social opportunities – those who have not acquired such confidence can find themselves constrained within inter-related domains of disadvantage – educational, workplace, health and neighbourhood/household – and systematically inhibited from being able to control their circumstances in fulfilment of their aspirations.

Carousel of Being Well and domains of advantage/disadvantage

1

What it is to be well?What it is to be well?What it is to be well?What it is to be well?

Health Assets for Young People’s Wellbeing Health Assets for Young People’s Wellbeing Health Assets for Young People’s Wellbeing Health Assets for Young People’s Wellbeing

Symposium 1: SevilleSymposium 1: SevilleSymposium 1: SevilleSymposium 1: Seville

29292929thththth April 2010April 2010April 2010April 2010

Tom Tom Tom Tom HennellHennellHennellHennell

Regional Analyst Regional Analyst Regional Analyst Regional Analyst

Department of Health North WestDepartment of Health North WestDepartment of Health North WestDepartment of Health North West

[email protected]@[email protected]@dh.gsi.gov.uk

44 (0)161 952 455944 (0)161 952 455944 (0)161 952 455944 (0)161 952 4559

North West Government Office Region

Total Population

6.9 million

Life expectancy at

birth: 18 months

less than the

England average,

for both males and

females

2

The context: a debate on ‘being well’• Liberal Economics approach: ‘being well’ is about the accumulation and

distribution of economic welfare.– Proxied by the aggregated monetary value of traded goods and services– Readily quantifiable and modelled by econometric techniques – Gross Domestic

Product, Gross Value Added– Relating to the market economy; hence a discourse of the ‘right’

• Public Health approach: ‘being well’ is about the accumulation and distribution of good health; WHO definition as ‘complete physical, mental and social wellbeing’– Proxied by life expectancy, hospitalisation rates, disability rates, self-reported ‘health in

general’– Quantified indicators readily analysable through econometric techniques; modelled in

England, Scotland and Wales through successive NHS resource allocation formulae– Relating to the actions of public agencies ; hence a discourse of the ‘left’

• Social Dynamics approaches : ‘being well’ is about establishing and sustaining status and reciprocal obligation within the domains of household, neighbourhood, workplace and nation. Two current flavours in current UK discourse (with much cross-fertilisation) : – an internal critique of the ‘right’, to do with changing family structures, time

preference and consequent generational inequity;– an internal critique of the ‘left’, focussing on social justice and inequity of economic

power– So far, instruments are yet to establish recognition as quantifiable at the individual level;

and hence not amenable to econometric techniques : ‘life satisfaction’, ‘happiness’

Three Population Health Surveys

• Health Survey for England: 2006 and 2008 – 14,142 adults (16+) in 2006, 15,102 in 2008– Approx 1,000 items of information recorded for each respondent– Focus on social capital (2006), physical activity and fitness (2008)– Structured samples of household population, weighted for non-

response– (children under 16 were surveyed; but collecting different questions,

and according to different protocols)

• North West Mental Wellbeing Survey 2009– Questions asked of 18,500 adults – Approx 230 items of information recorded for each respondent– Focus on questions assessing mental wellbeing (WEMWBS) and

quality of life (EQ5D)– Structured samples of household population, weighted for non-

response

• Concentrating on younger adults: (< 35 HSE, < 40 NWMWBS)

3

Issues on ‘being well’

• Can ‘being well’ be quantified?

• Can relationships of wellbeing be visualised?

• What conclusions may be suggested on the nature of ‘being well’

• How does ‘being well’ relate to ‘becoming ill’

• How much does it matter?

Wellbeing and ‘being well’: three approaches

1. Being well as “not being ill”; the response of the person in the street,– if so, not separately quantified at all.

2. Being well as an ideal state of “complete physical, mental and social wellbeing”; analysed in terms of protection against loss, and promotion of recovery,

– if so, a fluid concept whose quantification may be expected to vary according to the balance of domains within which questions may be framed.

– ‘Wellbeing’ metrics typically constructed by aggregation: ‘Adding Up’

3. Being well as an acquired and mutual capacity for being better able to gain from social opportunities, and being able to recover sooner from setbacks; potentially transferable from one social domain to another,

– if so, the extent of being well may be solid and consistently quantified, if a technique can be found to extract the underlying common factor of improved functioning within any population survey (so long as the topics covered are wide-ranging enough).

– ‘Being well’ metric quantified by data reduction: ‘Boiling Down’

• I am here using ‘Wellbeing’ to refer to values calibrated from specific survey instruments; and ‘being well’ to refer to an extracted underlying factor

4

Data Reduction on Health Surveys• Lengen, C; Blasius, J (2007) Constructing a Swiss health space model of

self-perceived health.Social Science and Medicine, 65, 1, 80-94.

• Technique of Categorical Principal Component Analysis (CATPCA)– Over 40 input characteristics, 2 extracted summary dimensions

– About half questions overlap in all three surveys: age, sex, ethnicity, education, marital status, economic activity, household type, alcohol use, smoking, physical activity, general health, Multiple Deprivation quintile, components of EQ5D; but the overlap includes most questions with a high statistical communality (variance accounted for)

– In all three surveys, the two extracted dimensions account for slightly less than 20% of overall individual level variance

– Rotated to align with ‘ageing’ in the horizontal dimension; resulting in a counterpart ‘being well’ alignment of the vertical dimension

Health Survey for England 2008: summary plot of ageing and being well

16-24

25-34

35-4445-5455-64

65-74

75+

>>> weighted ageing >>>

>>>

wei

ghte

d be

ing

wel

l >>

>

5

Health Survey for England 2008: General Health Questionnaire (GHQ12) grouped score s

ghq 1-3

ghq 4+

16-24

25-3435-4445-54

55-6465-74

75+

ghq 0


>>>

wei

ghte

d b

eing

wel

l >>

>Health Survey for England 2008:

Components of EQ5D: none, moderate, extreme


>>>

wei

ght

ed b

eing

wel

l >>

>

anxiety/depression

mobility

pain

selfcare

usual activities

Health Survey for England 2008: Body Mass Index, for persons under 35

underweight

normal weight overweight

obese


>>>

wei

ghte

d be

ing

wel

l >>

>

North West Mental Wellbeing Survey 2009: Warwick Edinburgh Mental Wellbeing Scale; age < 40


>>>

wei

ghte

d be

ing

wel

l >>

>

6

Health Survey for England 2008: Recreational activity level; age < 35

inactive

lightmoderate

vigorous


>>>

wei

ghte

d be

ing

wel

l >>

>Health Survey for England 2008:

Smoking and Quitting, for persons under 35

current smoker

recent quit

quit 5+ yrs

never smoker


>>>

wei

ghte

d b

eing

wel

l >>

>

Health Survey for England 2008: Frequency of alcohol consumption; age < 35

stopped for health reasons

drinks dailydrinks weekly

occasional drinker

never drinker stopped drinker


>>>

wei

ghte

d be

ing

wel

l >>

>

Health Survey for England 2008: Alcohol consumed on heaviest day; age < 35

did not drink

light

moderate

binge


>>>

wei

ghte

d be

ing

wel

l >>

>

7

Health Survey for England 2008: Individual economic status; age < 35

looking after home and family

ft student

employed

unemployed

long term sick


>>>

wei

ghte

d be

ing

wel

l >>

>

Health Survey for England 2008: Highest qualification attained; age < 35

degree

A level

O level/CSE

no qualfication

ft student


>>>

wei

ghte

d be

ing

wel

l >>

>

Health Survey for England 2008: Household type; age < 35

lone parent

lone adult

two adults

small family

large family

multi adult


>>>

wei

ghte

d be

ing

wel

l >>

>

Health Survey for England 2008: Marital Status; age < 35

single

married

cohabiting

separated/divorced


>>>

wei

ghte

d be

ing

wel

l >>

>

8

NW Regional Wellbeing Survey 2009: life changing events in past 12 months ; age < 40

redundancy

bereavement

going to university

engaged

married

divorce

birth of child

move house


>>>

wei

ghte

d be

ing

wel

l >>

>NW Regional Wellbeing Survey 2009:

Participation in local groups ; age < 40

Parents’/School Association

Arts Religious Youth

Sports

None


>>>

wei

ghte

d be

ing

wel

l >>

>

The nature of ‘being well”• ‘Being well’ increases with age up to mid 60s.

– Suggests it functions as an acquired social capacity, rather than as an ideal state

– Different populations acquire ‘being well’ at different rates

• Indicators of positive mental health and social resilience align more closely with ‘being well’ than do indicators of physical health

• Through acquiring and maintaining the capacity to manage health behaviours, health risks can also function as health assets (e.g. alcohol)

• ‘Being well’ has a wider field of application than conventional indicators of positive mental wellbeing; and appears to function in three domains:

– Personal: individual feeling and functioning (how confident can I be, that I can do a job?)

– Social: functioning of individual in their social environment (how confident can I be that there a job that I can do?)

– Reciprocal: the quality of response within a social environment to the functioning of the individual (how confident will others be that I can do the job?)

9

well notill well ill

64% 16%

unwell notill unwell ill

10% 10% >>>> becoming ill >>>>

>>

bei

ng w

ell >

>Proportion of adults in each category

Proportion of adults in each categoryaged under 35

well notill well ill72% 5%

unwell notill unwell ill17% 6%

>>>> becoming ill >>>>

>>

bei

ng w

ell >

>

10

Conundrums from the Health Survey for England

• If respondents have been diagnosed with a clinical condition, do they differ in their ability and propensity to construct illness; and is any difference socially patterned?

• If respondents report a chronic illness, do they differ in their ability and propensity to construct effective management of their condition; and is any difference socially patterned?

Odds of reporting diabetic illness, for those with a doctor diagnosis of diabetes; adjusted for age, gender and general heal th.

Adults in the Health Survey for England 2006

0

0.5

1

1.5

2

2.5

3

well notill well ill unwell ill unwell notill

wellness and illness category

Odd

s R

atio

com

pare

d to

'wel

l not

ill'

Becoming ill better

11

Adults reporting chronic musculo-skeletal illness ( first) in HSE 2006odds of reporting illness as "limiting" - adjusted f or age and self assessed pain

0

0.5

1

1.5

2

2.5

3

3.5

best second third fourth worst

quintiles of wellness

Odd

s of

repo

rtin

g ill

ness

as

"lim

iting

“ com

pare

with

mos

t wel

lRecover from, and manage, illness sooner

well notill well ill


>>>>> becoming ill >>>>>

>>

bei

ng w

ell >

>

Poor wellbeing and inhibitions against becoming ‘ill’ and ‘not ill’

12

Dimensions of Being Well• “Being well” is not the same as simply “not becoming ill”. We

propose a common underlying dimension of wellbeing; related to dimensions of: employment status, education, health and household/neighbourhood characteristics.

• These characteristics interact with one another; overall “being well” is both an aggregate of these interactions, and a determinant in each separate dimension or ‘domain’.

• Within each dimension, being “unwell” is strongly associated with inhibition against benefiting from the social opportunities associated with that dimension; with a consequent lower degree of perceived control, and lower levels of social confidence.

– Consequently, those who are “unwell” and “notill” tend to be systematically inhibited against recognising their unwellness as relating to a long-term illness or clinical condition; and hence may be unable to access resources for managing that condition.

– But; those who are “unwell” and “ill” tend to be systematically inhibited against attaining control over the management of their condition, such as to overcome or transcend consequent limitations.

Four domains of Being Well

well workless well inwork

unwell workless unwell inwork

>>> employment status of household >>>

bein

g w

ellwell notill well ill


>>>>> becoming ill >>>>>

bein

g w

ell

well nohouse well housed

unwell nohouse unwell housed

>>>> household and neighbourhood >>>>

bein

g w

ell well noqual well qualified

unwell noqual unwell qualified

>>>> education >>>>

bein

g w

ell

household & housing education & training

health and illness work & participation

13

Carousel of Being Well and domains of advantage/disadvantage

Components of ‘not good’ health

Quantified explanation of individual ratings of health as ‘not good’ for adults (16+) in the Health Survey for England, using multi-stage logistic regression:

• Individual factors = 76%– Prior morbidity and individual variation = 65%

– Age (10 year intervals) and Sex = 9%

• Systematic factors = 24%– Health deficit risk factors = 8%

– Cohorts of birth and residence = 8%

– Health and wellbeing asset factors = 8%

14

A third, a third, a thirdSystematic differences in the health of populations appear to be

perpetuated through three mechanisms (which seem to have roughly equal degrees of effect; although inter-relationships make quantification uncertain)

• Differences in biomedical health risk factors: (e.g. obesity, smoking, excess alcohol, poor diet, low levels of education)– Policy response in prevention strategies– Deficit approach: ‘ how not to do the things that are bad for you’

• Differences in cohort risk factors: (where and when born, where and how lived since)– Policy response in screening and early diagnosis

• Differences in positive wellbeing; individual, social and reciprocal: (Everyone may expect to become ill at some time; but those with high levels of wellbeing, have the capacity to recognise their illness better, access services easier, recover sooner, and manage their condition fuller.)– Policy response in promotion of ways to wellbeing, healthy

workplaces and social environments, community development– Asset approach: ‘what will enable you to do what you aspire to do’

Nine varieties of savings: as user experiences

1. Reduce the range of spells covered for treatment: (rationing)

2. Impose a time/money cost penalty to user presentation (waiting times)

3. Reduce proportion of each illness spell covered (early discharge)

4. Reduce duplication and increase cross-boundary working

5. Reduce non-treatment overhead costs

6. Reconfigure treatment delivery to reduce resource intensity

7. Reduce representation with the same condition

8. Reduce inappropriate presentation/non-presentation

9. Reduce primary illness generation

15

Nine varieties of savings: as user experiences

1. Reduce the range of spells covered for treatment: (rationing)

2. Impose a time/money cost penalty to user presentation (waiting times)

3. Reduce proportion of each illness spell covered (early discharge)

4. Reduce duplication and increase cross-boundary working

5. Reduce non-treatment overhead costs

6. Reconfigure treatment delivery to reduce resource intensity

7. Reduce representation with the same condition

8. Reduce inappropriate presentation/non-presentation

9. Reduce primary illness generation

Cost

shifting

Efficiency

saving

Getting

ill better

NW mental wellbeing survey 2009: components of EQ5D (excluded)


>>

>

wei

ghte

d be

ing

wel

l >

>>

mobility

self-care

usual activities

pain/discomfort

anxiety/depression

Health Survey for England 2006: test on components of EQ5D

>>>>> weighted ageing >>>>

>>

>>

wei

ghte

d be

ing

wel

l >>

>>

mobility

self care

usual activities

pain/discomfort

anxiety/depression

SUMMARYHealth Assets for Young People’s Wellbeing:

THE SALUTOGENIC PERSPECTIVE

Bengt Lindström and Monica Eriksson, Folkhälsan Research Centre, Helsinki, Finland

The salutogenesis was the first model and theory systematically exploring health in termsof a development towards the health end of the health – unhealthy (ease/dis-ease)continuum(Antonovsky 1979, 1987). It was later connected to health promotion(Antonovsky 1996). Now thirty years later we have convincing evidence that healthpromotion is effective if run the salutogenic way (Eriksson 2007, Eriksson and Lindström2005, 2006, 2007, 2008) and including quality of life (QoL) (Lindström 1994).

There are in fact three things that have to be in place to make health promotion effective:- Health promotion (HP) according to the WHO Ottawa Charter (OC), - the salutogenesis (SAL) as the process and - quality of life (QoL) as the outcome

HP(OC) = SAL+QoL

The only necessary addition is to build in human rights as a fundament making the value of the human being as an active participating subject a rule. For children and young people this means an active use of the child convention as the value base (UN CRC)

HP(OC) = SAL + QoL

UN CRC

The evidence of salutogenic research over the life span shows there is a small but rather insignificant advantage for the male. Maybe the world as a systemis constructed for the male? However, if the Salutogenesis is implemented we can demonstrate itdoes reduce inequity. There is a special issue regardingyoung people. Because of developmental issues in puberty there are periods where the female have significantly lower SOC, just as self esteem is affectedin the same direction.

In cultural context we see the salutogenic framework works in all cultures as far as we know. Today it has been tried out in more than 50 languages on all continents of the globe.

We stand with good scientific evidence on the effectiveness of the salutogenesis. People and systems that adapt this develop a population that live longer, is more prone to choose positive health behaviour, if encountering illness or acute or chronic illness they manage better, they endure stress better. Further they perceive they have a better health, good quality of life and mental health.

The problem as we see it salutogenesis is not being implemented to the extent it should be.

References:Antonovsky A. Health, Stress and Coping. San Francisco: Jossey-Bass; 1979.Antonovsky A. Unraveling the Mystery of Health. How people manage stress and stay well. San Francisco: Jossey-Bass; 1987.Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996;11(1):11-18.Eriksson M. Unravelling the Mystery of Salutogenesis. The evidence base of the salutogenicresearch as measured by Antonovsky's Sense of Coherence Scale. Doctoral thesis. Folkhälsan Research Centre, Health Promotion Research Programme, Research Report 2007:1. Turku; 2007.Eriksson M, Lindström B. Validity of Antonovsky's Sense of Coherence Scale - a systematic review. J Epidemiol Community Health 2005;59(6):460-466.Eriksson M, Lindström B. Antonovsky's Sense of Coherence Scale and the relation with health - a systematic review. J Epidemiol Community Health 2006;60:376-381.Eriksson M, Lindström B. Antonovsky's sense of coherence scale and its relation with quality of life: A systematic review. Journal of Epidemiology & Community Health 2007;61(11):938-944.Lindström B. The Essence of Existence. On the quality of life of children in the Nordic countries - Theory and practice in public health. [Doctoral thesis.]. Göteborg: Nordic School of Public Health; 1994.

Health Assets for Young People’s WellbeingThe Salutogenic Perspective

Monica Eriksson, PhD

Folkhälsan Research Centre, Helsinki, Finland

[email protected]

mailto:[email protected]

mailto:[email protected]

Disposition• Salutogenesis

• SOC & GRRs

• Research synthesis

• SOC and adolescents health

• New research areas

• The salutogenic umbrella

• Health promotion towards life promotion

How to manage the everyday stress?

It depends on

The Sense of Coherence and Generalized Resistance Resources

Conceptually, salutogenesis is defined as ...

”the process of movement toward the health end of a health ease/ dis-ease continuum.”

Antonovsky A. The salutogenic approach to aging. Lecture held in Berkeley, January 21, 1993. © Monica Eriksson 2010

Sense of Coherence

... is a global life orientation – a way of viewing life as coherent, structured, manageable and meaningful.

... is a confidence to be able to identify internal and external resources, use and reuse them in a health promoting manner.

... is a way of thinking, being and taking action as a human being.

© Monica Eriksson 2010

Generalized Resistance Resources

Material (money, housing…)

Biological/mental (self-esteem, intelligence …)

Emotional (contact with your feelings, social relations …)

Physical (heredity, healthy orientation …)

Existential (beliefs, religion, meaning of life …)

Meaningful activities


(Antonovsky 1979, 1987)


Development of a strong SOC

Contact with inner feelings (Antonovsky 1979, 1987)

Intimate relationships (Antonovsky 1979, 1987)

Social support(Antonovsky 1979, 1987; Shawn et al. 2007)

Meaningful activities (Antonovsky 1979, 1987)

Existential issues (Antonovsky 1979, 1987)

Load balance (Sagy & Antonovsky 1996)

Participated in shaping the outcomes

(Sagy & Antonovsky 1996)

Consistency (Sagy & Antonovsky 1996)

Good childhood conditions(Antonovsky 1979, 1987)

Family conflict and neighbourhood cohesion

(Shawn et al. 2007)

Psychoemotional rather than socioeconomical factors

The Key ...

it is not only about the resources at disposal but the ability and flexibility to use them in a health promoting manner.


Individual

Group

Society

About 450 papers 2004-2009

Thematic reviews

SOC & age

SOC & working life

SOC & adolescent health

SOC & health behaviour

Research synthesis (thesis)

based on about 500 papers and

doctoral thesis (1992-2003)

Review protocols

Inclusion and exclusion

criteria

Analysis of drop outs

Personal communication with

authors

⁺

SOC and AGE

0

20

40

60

80

100

120

140

160

180

15 21 23 37 39 41 44 46 48 50 69 75 78 80 81

SOC

Mean age

Mean SOC by Mean Agebased on 15-81-year-aged general populations

(16 studies using SOC-13, 1993-2003)

0

20

40

60

80

100

120

140

160

180

18 19 20 23 36 37 43 48 50 55 60 67 76 77 81

SOC

Mean age

Mean SOC by Mean Agebased on 18-81-year-aged general populations

(15 studies using SOC-29, 1994-2008)

Eriksson M, Lindström B. Life is more than survival: Exploring the links between Antonovsky’ssalutogenic theory and the concept of resilience, some conceptual considerations. In: Celinski MJ, GowKM (eds.) Continuity versus creative response to challenge; The primacy of resilience and resourcefulness in life and therapy. Accepted March, 2010. Do not yet refer!

© Monica Eriksson 2009© Monica Eriksson 2009


… the stronger the SOC the fewer the symptoms of mental illnesses… protects against anxiety, depression, burnout and hopelessness… is strongly and positively related to health resources such as optimism, hardiness, control, and coping ... Parents’ SOC has an impact on childrens’ health ... SOC predicts good health and QoL

(Eriksson 2007)

Generally - A strong SOC

SOC and health behaviour

The stronger the SOC the healthier behaviour in general

A person with a strong SOC has a lower level of alcohol

consumption, less use of tobacco and drugs, exercise

more frequently and makes healthier food selection

Andersen S, Berg JE. Addiction Research & Theory 2001;9(3):239-251; Ullrich-Kleinmanns et al.

Suchttherapie 2008;9(1):12-21; Bergh H, Baigi A, Fridlund B, et al. Public Health 2006;120:229-236; von

Ah D, Ebert S, Ngamvitroj A, et al. Tobacco Induced Diseases 2005;3(1):27-40; Hassmén P, Koivula N,

Uutela A. Prev Med 2000;30:17-25; Lindmark U, Stegmayr B, Nilsson B, et al. Nutr J

2005;4(9):doi:10.1186/1475-2891-4-9; Myrin B, Lagerström M. Scand J Caring Sci 2006;20:339-346.

SOC and Adolescents healthKoushede V. et al. J Adolescents health 2009;45:149-155

Aim: Examine the association between headache, SOC and medicine use

Sample: Danish students (grade 7 and 9) N = 1393 response rate = 93 %

Results: Adolescent with weak SOC used medicine to cope with headache to a greater extent than adolescents with a strong SOC


Ray C, Suominen S, Roos E. J Epidemiol Community Health 2009; 2009;63(12):1005-1009.

Finnish children aged 10-11 years and their parents

(n = 772 child-parents pairs)

• less irregular meal pattern

• more frequent intake of nutrient dense foods

• less frequent intake of energy rich foods

Parent’s SOC and children’s food intake pattern

An association between a stronger parental SOC and children’s food intake pattern


SOC AND ORAL HEALTHStronger SOC was associated with more

frequent toothbrushing behaviours among

Iranian adolescents (Dorri et al. 2010)

Brazilian mothers’ SOC was an important psychosocial determinant of the oral health status among preschool children (Bonanato K et al. 2009)

Strong support for an association between SOC and more favourable oral health-related behaviours among South-African adolescents (Ayo-Yusuf et al. 2009)


SalutogenesisAn assets approach

Hardiness

(Kobasa)Learned resourcefulness

(Rosenbaum)

Sense of coherence

(Antonovsky)

Self-efficacy

(Bandura)

Cultural capital

(Bourdieu)

Social capital

(Putnam)

Coping

(Lazarus)

Empowerment

(Freire)

Resilience

(Werner)

Will to meaning

(Frankl)

Locus of control

(Rotter)

Wellbeing

(Becker)Quality of Life

(Lindström)

Learned optimism

(Seligman)

Connectedness

(Blum)

Ecological system theory

(Bronfenbrenner)

Flourishing

(Keyes)

Interdiciplinarity

(Klein)

Learned hopefulness

(Zimmerman)

Action competence

(Bruun Jensen)

Eriksson M, Lindström B. In: Morgan A, Davies M, Ziglio E. (Eds.) International health and development: Investing in assets of individuals, communities and organisations.: Springer; 2010.


is the process of enabling individuals, groups or societies to increase control over, and to improve their physical, mental, social and spiritual health.

This could be reached by creating environments and societies characterized of clear structures and empowering environments where people see themselves as active participating subjects who are able to identify their internal and external resources, use and reuse them to realize aspirations, to satisfy needs, to perceive meaningfulness and to change or cope with the environment in a health promoting manner.”

© Monica Eriksson, 2010Eriksson M, Lindström B. J Epidemiol Community Health 2007;61(11):938-944

Life promotion ...

Health in the River of Life

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“ Life promotion is the process of enabling individuals, groups or societies to increase

control over, and to improve their physical, mental, social and spiritual health. This could

be reached by creating environments and societies characterized of clear structures and

empowering environments where people see themselves as active participating subjects

who are able to identify their internal and external resources, use and reuse them to realize

aspirations, to satisfy needs, to perceive meaningfulness and to change or cope with the

environment in a health promoting manner.”

J Epidemiol Community Health 2007;61(11):938-944

- www.salutogenesis.fi

Health Promotion Research

FOLKHÄLSAN RESEARCH CENTREHEALTH PROMOTION RESEARCH PROGRAMME

Helsinki, Finland

www.salutogenesis.fi

WHO Symposium

Health Assets in a Global Context

28-30 April 2010, Seville

Resilience as an asset for healthy development

Ingrid Schoon, Institute of Education, University of London

Abstract

One of the greatest threats to health and wellbeing are precarious living conditions and the

experience of poverty. However not all individuals experiencing, or growing up in conditions

of serious adversity, such as severe family disruption or persisting poverty develop

adjustment or health problems later on. The recognition of individual differences in

response to risk exposure is indicated by the notion of resilience, which describes the

practices and processes by which some individuals – or communities – adapt to adversity

and even thrive against the odds. The aim of this paper is to explore the notion of resilience,

and its usefulness for the study of social inequalities in health and wellbeing. To gain a

better understanding of the multiple, interlinked influences on health and well-being a

developmental-contextual model of resilience is introduced, and the dynamic interactions

between a developing individual in a changing context are conceptualised, taking into

account causation, selection, and cumulative processes in life course development.

Furthermore, findings from the ESRC Priority Network on human capability and resilience

will be presented, identifying key factors that make it possible for individuals to do well in

the face of adversity.

Resilience as an asset for healthy development

What enables young people to strive and to develop into well-balanced and healthy adults?

This paper addresses the antecedents, pathways, and outcomes of transitions through

childhood and into independent adulthood. The particular focus lies on children growing up

in circumstances of relative social disadvantage, characterised by lack of material resources

and poor housing conditions. There is now consistent evidence to suggest that serious harm

to physical and mental health and well-being can be caused by the experience of poverty

and adverse life events (Duncan & Brooks-Gunn, 1997; McLoyd, 1998). Socio-economic

disadvantage and material hardship experienced early in life greatly increase the risk of

developing adjustment problems later on, such as educational failure, behaviour problems,

psychological distress, or poor health. On the other hand, there is also evidence that not

everyone is affected in the same way. Some individuals seem to be able to ‘beat the odds’

and to do well despite the experience of adversity. This phenomenon of ‘beating the odds’,

of striving in the face of adversity, has also become known by the concept of resilience

(Garmezy, 1991; Luthar, 2003; Rutter, 1987; Werner & Smith, 1992). The observation of

positive outcomes in the face of adversity has lead to a paradigm shift away from a

pathogenic or deficit model towards a focus on adaptive functioning and developmental

processes leading to health and well-being instead of adjustment problems or disease

(Antonovsky, 1979).

In the following I will explore the notion of resilience, and its usefulness for the study of

social inequalities, the intergenerational transmission of advantage and disadvantage, and

possible ways of breaking a cycle of disadvantage. In this context the notion of

developmental health refers to a range of outcomes, such as physical, mental, psycho-

emotional health, literacy and academic competence (Keating & Hertzman, 1999).

Developmental health is influenced by individual, social and wider contextual determinants,

such as characteristics of neighborhoods and institutions. Many of these determinants are

not disease-specific, but may be associated with multiple health outcomes throughout the

life course. To gain a better understanding of the multiple, interlinked influences a

developmental-contextual systems model (Bronfenbrenner, 1989; Lerner, 2002) is

introduced that takes into account interactions between a changing individual and a

changing social context. This metatheory includes several assumptions regarding the

multiple levels of organizations engaged in human development, ranging from biology and

dispositions to relationships, social institutions, culture and history, which are fused into an

integrated system.

Based on such a dynamic systems notion of resilience a ‘short list’ of commonly observed

correlates of resilience (Masten, 1999), as well as a taxonomy of developmental assets

(Scales & Leffert, 1999) have been identified, highlighting the core elements of positive

human development comprising assets within the individual, their families, and the wider

community. Furthermore, the developmental assets approach is designed to have practical

significance for the mobilization of communities.

The assets approach is based on the assumption of cumulative or additive impact: the more

assets, the better, where increases in assets is associated with increases in positive

developmental outcomes, such as increased academic achievement, leadership, prosocial

behavior, delay of gratification. Although the asset approach has a ‘universal’ resonance,

there is evidence to suggest that some assets are particularly beneficial to a particular risk

or thriving behavior. There is however, relative little understanding of how assets interact

with specific risk situations, or how they are acquired or maintained over time. Asset lists

are primarily descriptive, based on evidence regarding characteristics that matter for

positive human development. Furthermore, they do not consider indicators of poverty or

hardship. Moving beyond a descriptive approach, alternative models of resilience emphasise

the interactive relationship between protective factors and risk exposure, and take into

consideration the severity and timing of risk exposure (Rutter, 2006). Children and young

people growing up in poverty are generally less likely to have access to asset building

resources, as poorer families are more likely to live in places where facilities and services

have been stripped away and are often unable to access even essential services such as

health care and education (Townsend & Gordon, 2002). Evidence from work conducted for

the ESRC funded Network on human capability and resilience has nonetheless identified

various processes and mechanisms that allow young people growing up in poverty to build

and maintain crucial resources and developmental assets that enable them to thrive even in

the face of adversity. Beyond individual characteristics and those of the family environment,

experiences in the wider social context, such as in school, in the work place, within one’s

neighbourhood, or in contact with institutions and services are all contributing to the

development and maintenance of competencies and health resources (Bartley, 2006;

Schoon, 2006). Examples of our findings will be presented and discussed in view of their

implications for policy and practice.

References

Antonovsky, A. (1979). Health, stress and coping (1st ed.). San Francisco: Jossey-Bass Publishers.

Bartley, M. (Ed.). (2006). Capability and resilience: Beating the odds. London: University College

London. Department of Epidemiology and Public Health.

Bronfenbrenner, U. (1989). Ecological systems theory. In R. Vasta (Ed.), Six theories of child

development: Revised formulations and current issues (pp. 187-250). Greenwich, CT: JAI

Press.

Duncan, G. J., & Brooks-Gunn, J. (1997). Consequences of growing up poor. New York: Russell Sage

Foundation Press.

Garmezy, N. (1991). Resiliency and vulnerability to adverse developmental outcomes associated with

poverty. American Behavioral Scientist, 34(4), 416-430.

Keating, D. P., & Hertzman, C. (1999). Developmental health and the wealth of nations. New York:

Guilford Press.

Lerner, R. M. (2002). Concepts and theories of human development (3rd ed.). Mahwah, NJ: Lawrence

Erlbaum Associates Inc.

Luthar, S. S. (Ed.). (2003). Resilience and vulnerability: Adaptation in the context of childhood

adversities. Cambridge, U.K., New York: Cambridge University Press.

Masten, A. (1999). Resilience comes of age: Reflections on the past and outlook for the next

generation of research. In M. D. Glantz & J. L. Johnson (Eds.), Resilience and development :

Positive life adaptations (pp. 281-296). New York: Kluwer Academic.

McLoyd, V. C. (1998). Socioeconomic disadvantage and child development. American Psychologist,

53(2), 185-204.

Rutter, M. (1987). Psychosocial resilience and protective mechanisms. American Journal of

Orthopsychiatry, 57(3), 316-331.

Rutter, M. (2006). Implications of resilience concepts for scientific understanding. Annals of the New

York Academy of Science, 1094(1), 1-12.

Scales, P. C., & Leffert, N. (1999). Developmental assets: A synthesis of the scientific research on

adolescent development. Minneapolis, MN: Search Institute.

Schoon, I. (2006). Risk and resilience. Adaptations in changing times. Cambridge: Cambridge

University Press.

Townsend, P., & Gordon, D. (Eds.). (2002). World poverty: New policies to defeat an old enemy.

Bristol: Policy Press.

Werner, E. E., & Smith, R. S. (1992). Overcoming the odds: High risk children from birth to adulthood.

Ithaca: Cornell University Press.

A theoretical model of assets: the links between biology and the social

structure.

Michael P. Kelly

This chapter explores three problems in order to develop an account of health

assets. First, it considers the epistemological problem of the way to cross disciplinary

boundaries successfully and in ways which maintain disciplinary integrity, especially

between biology, psychology, sociology and economics in order to construct

meaningful accounts of the ways in which social structures determine health,

positively and negatively. Second, it considers the ontological problem of linking

subjectivity and the material world, in concepts such as the lifeworld and the life

course, which it will be argued offer the bridge between the disciplines and the

mechanism for the social determination of health. Third, the chapter considers the

empirical problem of the link between community health assts and individual assets.

A model of health assets will be developed using these three elements. The chapter

will focus on the translation of complex philosophical and theoretical ideas into

meaningful and usable indicators for health and disease.

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RelevanceRelevance of of promotingpromoting riskrisk and and protectiveprotective factorsfactors forfor promotingpromoting

developmentdevelopment and and equalityequality in in youngyoung peoplepeople

Alfredo OlivaAlfredo OlivaDepartamento Departamento de de

Psicología Evolutiva y de Psicología Evolutiva y de la Educaciónla Educación

Universidad de SevillaUniversidad de Sevilla

The starting point The starting point

Negative image of Negative image of adolescenceadolescence

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Consequences of Consequences of negative image of negative image of

adolescenceadolescence

Negative ConsequencesNegative Consequences

Social support for punitive lawsSocial support for punitive lawsReduction or suppression of Reduction or suppression of adolescents’ rightsadolescents’ rightsIncrease of intergenerational conflicts Increase of intergenerational conflicts at home / schoolat home / school

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Positive Positive consequencesconsequencesHighHigh sensibilizationsensibilization toto somesomeadolescentadolescent problemsproblems ((sustancesustance abuse, abuse, bullyingbullying, , riskrisk takingtaking behaviorsbehaviors, etc.), etc.)

IncreasesIncreases in in investmentinvestment in in interventionintervention and and researchresearch focusedfocused in in thesethese problemsproblems

DEFICIT MODEL

Beyond the deficit: Beyond the deficit: Building a model of Competence or Building a model of Competence or

Positive Youth DevelopmentPositive Youth Development

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4

AdolescentAdolescent positive positive developmentdevelopment StudyStudy: 1st : 1st phasephase

GoalGoal

To build a model of adolescent positive development from the point of view of experts in adolescence .

AdolescentAdolescent positive positive developmentdevelopment StudyStudy: 1st : 1st phasephase

MethodMethodNominal Group: 12 professionals with

expertise in adolescence (psiquiatrics, psychologist, teachers)

Delphi Technique: 30 professionals (3 rounds)

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5

ResultsResults

MORAL1.Social commitment2.Responsibility3.Prosociability4.Justice5. Equality (gender, social..)6. Respect for diversity

SOCIAL1. Asertivity2. Relational skills3. Conflict resolution skills4.Communicattion skills

COGNITIVE1.Crítical Intelligence2. Analitycal intelligence 3.Creativity4. Planning5. Decision making

MODEL OF ADOLESCENT POSITIVE DEVELOPMENT

EMOTIONAL1. Empathy2.Emotional Intelligence (Emotional attention & clarity, Mood repair)3. Frustration Tollerance

PERSONAL STRENGHTSPERSONAL STRENGHTS1.Self-esteem2. Self-efficacy3 Self-control4.Autonomy5.Optimism and sense of humor6. Iniciative

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6

¿¿WhichWhich are are thethe familyfamily, , schoolschool and and neihgborhoodneihgborhoodassetsassets thatthat promotepromoteadolescentadolescent positive positive developmentdevelopment??

AdolescentAdolescent Positive Positive DevelopmentDevelopmentStudyStudy: 2nd : 2nd phasephase

GOALSGOALS

1. To validate our theoretical model

2. To analyze developmental assets and risks in the family, the school and the neighborhood

3. To elaborate and validate instruments to assess competences and assets related to positive develoment

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7

METHODMETHOD

Sample

- 20 Secundary Schools selected in Andalucía

- 2400 students from 12 to 17 years

MethodMethod

InstrumentsInstruments� Competencies : 11 scales - 170 items-� Adjustment (YSR) 101 items� Life-style: 16 questions� Family: parenting style (41 items) and marital

conflict (13 items)� School: students perception of the climate and

functioning of the center� (30 items)� Neighborhood: students perceptions of their

neighborhood (22 items)

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8

RESULTSRESULTS

OurOur empiricalempirical modelmodel (EFA)(EFA)1. Personal Strenghts (51%):

Self-esteem, Optimism, Life-satisfaction, Self-efficacy,

Emotional Clarity and Mood repair

2. Socio-Emocional (moral) Competencies (14%):

Empathy, Emotional Attention, Personal values

(responsibility, honesty, integrity), Social values (social

committment, justice & equality, prosociality), Peer

attachment, Social skills

3. Academic Competencies (12%):

Motivation to school, Committment to learning, Grades,

Study time

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The competenciesThe competencies

Personal Personal strenghtsstrenghts byby sex and sex and ageage

0 10 20 30 40 50 60 70 80 90 100110 120130

16-17 years

14-15 years

12-13 yearsgirls

boys

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Personal strenghts by parent Personal strenghts by parent education leveleducation level

90

92

94

96

98

100

102

104

106

Bajo Medio Alto

Personal strenghts by family SESPersonal strenghts by family SES

90

92

94

96

98

100

102

104

106

Bajo Medio Alto

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Academic Competencies Academic Competencies by sex and ageby sex and age

0 10 20 30 40 50 60 70 80 90 100110120130

16-17 years

14-15 years

12-13 yearsgirls

boys

Academic Competencies by Academic Competencies by parents education levelparents education level

90

92

94

96

98

100

102

104

106

Low Medium High

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12

Academic competencies by Academic competencies by family SESfamily SES

90

92

94

96

98

100

102

104

106

Low Medium High

SocioSocio--emocional competencies by emocional competencies by sex and agesex and age

0 10 20 30 40 50 60 70 80 90 100110120130

16-17 years

14-15 years

12-13 yearsgirls

boys

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Adjustment Adjustment ( The problems)( The problems)

Internalizing problems Internalizing problems by sex and ageby sex and age

0 1 2 3 4 5 6 7 8 9 10 11 12

16-17 years

14-15 years

12-13 yearsgirls

boys

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InternalizingInternalizing ProblemsProblems byby parentparenteducationeducation levellevel

0123456789

101112

Bajo Medio Alto

Internalizing Problems by Internalizing Problems by family SES family SES

0123456789

101112

Low Medium High

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Problemas externalizantes según Problemas externalizantes según sexo y edadsexo y edad

0 1 2 3 4 5 6 7 8 9 10 11 12

16-17 Años

14-15 Años

12-13 AñosChica

Chico

Externalizing Problems by parent Externalizing Problems by parent education leveleducation level

0123456789

101112

Bajo Medio Alto

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Sustance use by sex and ageSustance use by sex and age

0 1 2 3 4

16-17 years

14-15 years

12-13 yearsgirls

boys

CompetenciesCompetencies , , ajustmentajustment , sex , sex and and ageage

Girls presented higher socioemotional and academic competencies and lower personal strenghts. They also showed more internalizing and extrernalizing problems than boysBoys presented higher personal strenghts and lower academic and socioemotional competencies, and more internal and external adjustment than girls.

Gender health inequalities

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CompetenciesCompetencies, , adjustmentadjustment and and ageage

�� SustanceSustance use use increasesincreases withwith ageage�� InternalizingInternalizing and and externalizingexternalizing problemsproblems

increaseincrease and personal and personal competenciescompetenciesdecreasedecrease withwith ageage….….ButBut onlyonly in in girlsgirls

�� AcademicAcademic competenciescompetencies decreasedecrease in in boysboys

Gender inequalitites increase

during adolescence

TheThe assetsassets

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FamilyFamily assetsassets & & competenciescompetencies//problemsproblems

AffectionAffection//CommunicCommunic.. .10** .10** --.12***.12***

AutonomyAutonomy GrantingGranting .20***.20*** .01.01

BehavioralBehavioral ControlControl .07**.07** --.01.01

SelfSelf--disclosuredisclosure .12***.12*** --.08**.08**

Positive Positive HumourHumour .10***.10*** --.03.03

PsychologicalPsychological Control Control --.04.04 .21***.21***

Marital Marital ConflictConflict --.08**.08** .13***.13***

Competencies Problems

R2= .27 R2= .18

Demograph. Variables were partiating out in first step

SchoolSchool assetsassets & & competenciescompetencies//problemsproblems

GoodGood schoolschool climateclimate .01.01 --.13*** .13*** (Peer (Peer relationsrelations and y and y securitysecurity))

AttachmentAttachment toto schoolschool .23***.23*** --.14***.14***((belongingbelonging, , satisfactsatisfact., ., supportsupport))

Clear Clear valuesvalues and rulesand rules .23***.23*** .04.04((LímitsLímits, rules, , rules, promotedpromoted valuesvalues))

EmpowermentEmpowerment & & opportunitiesopportunities .01.01 .01.01((PercepcionPercepcion of of influenceinfluence/ / activitiesactivities…)…)


R2= .21 R2= .10

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NeighborhoodNeighborhood assetsassets and competen./and competen./problemsproblems

EmpowermentEmpowerment .10***.10*** --.12***.12***

AttachmentAttachment .13*** .13*** --.02.02

SecuritySecurity .07***.07*** --.16***.16***

Social ControlSocial Control .17***.17*** .02.02

YouthYouth ActivitiesActivities AvailAvail.. .00.00 .02.02

ServicesServices//InfrastructuresInfrastructures .10***.10*** .06***.06***


R2= .19 R2= .11

TheThe importanceimportance of of youthyouth activitiesactivitiesParticipation in youth activities Participation in youth activities was associated to competencies was associated to competencies and adjustmentand adjustmentBut avalilability of activities was But avalilability of activities was not related.not related.

Availabiliy is impotant but is not Availabiliy is impotant but is not enough. Is necessary to promote enough. Is necessary to promote participation, specially among girls, participation, specially among girls, older adolescent and from low SES older adolescent and from low SES familiesfamilies

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AssetsAssets & & competenciescompetencies//AdjustmentAdjustment

SexSex .06***.06*** .22***.22***AgeAge --.01.01 .07***.07***SESSES .06***.06*** .01.01ParentsParents EducationEducation .10***.10*** --.07**.07**FamilyFamily AssetsAssets .37***.37*** --.25***.25***SchoolSchool AssetsAssets .19***.19*** --.05*.05*NeighborhNeighborh. . AssetsAssets .14***.14*** --.08***.08***

Competencies ProblemsR2= .34 R2= .14

- Assets showed stronger relationships with

competencies than with problems.

- Family assets were the most influential ones.

According to Positive According to Positive Development modelDevelopment model

No problems No problems ≠≠ Good HealthGood Health

COMPETENCE MALADJUST-

MENT

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Mental Health TipologyMental Health Tipology

�� FlourishingFlourishing : High competencies well adjusted: High competencies well adjusted�� Flourishing maladjustedFlourishing maladjusted�� OrdinaryOrdinary: medium competencies well adjusted: medium competencies well adjusted�� Ordinary maladjustedOrdinary maladjusted�� LanguishingLanguishing: low competencies well adjusted: low competencies well adjusted�� Languishing maladjustedLanguishing maladjusted

Mental Mental HealthHealth and and AssetsAssets

60 65 70 75 80 85 90 95 100 105 110

Flourishing

Flourishing

maladj.

Ordinary

Ordinary

maladj.

Languishing

Languishing

maladj.

Neighborhood

School

Family

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FlourishingFlourishing AdolescentsAdolescents

BoysBoys & & girlsgirls, , highhigh parentparent educationeducation levellevel, , and and highhigh SES, SES, earlyearly adolescentsadolescents, , manymanyfamilyfamily, , schoolschool and and neighborhoodneighborhood assetsassets. . TheyThey devoteddevoted lessless time time toto watchwatch TV, TV, toto use use PC and PC and toto playplay video video gamesgamesTheyThey werewere involvedinvolved in in manymany activitiesactivities and and theythey sleptslept more more hourshours..

PredictionPrediction of of internalizinginternalizing problemsproblems ((GirlsGirls))

AffectionAffection --.12**.12**PsychologPsycholog. control. control .13**.13**GoodGood SchoolSchool climateclimate --.11**.11**Peer Peer attachmentattachment --.19**.19**SelfSelf--esteemesteem --.29**.29**EmpathyEmpathy .09*.09*EmotionalEmotional clarityclarity//repairrepair --.12**.12**AttentionAttention toto emotionsemotions .26**.26**

Internalizing Problems

R2= .35

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CONCLUSIONSCONCLUSIONS

Family is very important for Family is very important for childrenchildren

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When parents are missing….When parents are missing….

AuthoritativeAuthoritative parentsparents are are stillstill thethe mainmainassetsassets forfor a a healthyhealthy adolescentadolescent

developmentdevelopment

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No blaming parents but supporting them

Parent Education Program

PayPay attentionattention toto gendergender inequalitiesinequalitiesbecausebecause theythey increaseincrease fromfrom earlyearly toto late late adolescenceadolescence

Parental Parental psychologicalpsychological control control shouldshould bebereplacedreplaced byby behavioralbehavioral control control oror selfself--disclosuredisclosure

EmotionalEmotional clarityclarity & control, and & control, and moodmood repairrepairshouldshould bebe promotedpromoted amongamong girlsgirls

ThereThere are are alsoalso importante social importante social inequilitesinequilitesin in competenciescompetencies and and adjustmentadjustment

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InvolvementInvolvement in in activitiesactivities shouldshould bebepromotedpromoted ((girlsgirls, , lowlow SES SES youthyouth))

Security and social control in Security and social control in thetheneighborhoodneighborhood are are importantimportant forforpreventingpreventing adolescentadolescent maladjustmentmaladjustment

AttachmentAttachment toto schoolschool, , clarityclarity in rules in rules and and valuesvalues and and goodgood schoolschool climateclimate are are keykey developmentaldevelopmental assetsassets

Empowerment (at home, school, Empowerment (at home, school, or neighboorhod) is an important or neighboorhod) is an important

asset, but…..asset, but…..

Is possible to empower when the social representation of adolescence is so negative?

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WhichWhich adolescenceadolescence do do wewe wantwant toto promotepromote??

A A generationgeneration withwith no no problemsproblems isisnotnot a a generationgeneration sufficientlysufficiently wellwellpreparedprepared toto faceface futurefuture challengeschallenges

Muchas graciasMuchas gracias

“Youth Resiliency” - An evidence-based positive social psychology framework to reduce adolescent risk behaviors by enhancing well-being:

Implications for research, policy and programs

Yossi Harel-Fisch Bar Ilan University, Israel

Findings of the regional youth health behavior surveys carried out during the past decade in the middle east have clearly identified four main modifiable determinants of adolescent risk behaviors, bullying, injuries, low mental states, truancy and school-failure. The effects of these determinants are consistent across all negative behavioral and health outcomes and across all sub-populations. The surprise, however, was that all four determinants are not the usual "risk factors" targeted in most traditional prevention programs, but rather, four protective (resilience) factors that in their absence, the children are at higher risk. In other words, the major behavioral, health and social negative outcomes are not merely consequences of exposure to negative risk factors in the social environment, but rather, they are caused by the absence of vital protective and resilience factors that aught to be there for a child to be able to grow healthy and develop constructive patterns of behavior and conduct. The four highest-priority determinants of well-being on which “Youth Resiliency” is focused are:

(1) Significant Adults: • Daily involvement of significant adults in the child's life in a way that

creates the experience of unconditional love, acceptance, support, guidance and setting clear boundaries – parents, teachers, mentors, instructors and youth counselors.

(2) Positive school experience (school climate): • Experiences creating feelings of belongingness, safety, growth,

interest, capability, joy of creation, success and appreciation. • Establishment of a "safe-zone" in which behavioral boundaries, mutual

respect and caring become internalized and kept. • Implementation of effective tools to treat children with challenging

patterns of problem behaviors or conduct – focusing of identification and harnessing of their respective strengths or talents and abilities.

• Improvement of nurturing and effective leadership of teachers creating daily positive experiences in class.

(3) A sense of self worth: • Experiences that create a feeling of significantly contributing,

appreciated, needed, expressing talents, successfulness – by volunteering or carrying out tasks in the community or at school.

(4) Social connectedness: • Experiencing close, meaningful and supportive friendships, accepted

by peers, and not feeling lonely or socially rejected. • Maintaining a balanced social life with relationships that are positive

and constructive while avoiding negative social influences.

On the bases of the empirical findings and insights, and with use of conceptual frameworks such as positive social psychology, social capital, and socialization theories, we have developed "Youth Resiliency" as a new innovative evidence-based and scientifically sound approach aimed at reducing youth violence, injuries, risk behaviors and truancy, by focusing primarily on the enhancement of the highest priority determinants of well-being. During the past 6 years we have implemented this model in over 55 Arab and Jewish schools in Israel as a long-term intervention program using a built-in scientific monitoring and evaluation system. Findings of the evaluation indicate significant improvements on all behavioral and mental outcomes. From a conceptual point of view, a relatively new framework is emerging. One that is bringing together models used in psychology (i.e., positive psychology), social welfare (i.e., social-economic indicators of childhood well-being), sociology (i.e., social capital and social support) and public health (i.e. positive indicators of health and the asset approach). The emerging framework is a positive social psychology approach to the field of psychosocial factors in health. A framework that is proving to be vital for the continuous development of the field of childhood and adolescent health promotion.

Details of presenter: Margreet de Looze, PhD candidate, Utrecht University, the Netherlands. Title: Key assets in adolescent multiple risk behaviour: The role of parents and peers. Abstract: Risk behaviours such as smoking tobacco, drinking alcohol, using cannabis and engaging in early sexual intercourse are highly prevalent among young people across Europe (Currie et al., 2008). The co-occurrence of these behaviours is high. In Europe, 20 percent of young people engage in multiple risk behaviour (De Looze et al., submitted). As they have been related to various adverse health outcomes, we wanted to identify key assets that keep young people from engagement in (multiple) risk behaviour. We predicted multiple risk behaviour from a variety of variables in the Dutch HBSC 2005 dataset. Two of the strongest predictors of multiple risk behaviour were parental knowledge on their children’s whereabouts and time spent with peers. Whereas parental knowledge on their children’s whereabouts was negatively related to adolescent multiple risk behaviour, time spent with peers was positively related. Both factors mediated the relationship between educational level and multiple risk behaviour, indicating that adolescents in lower educational levels experience less parental monitoring and higher levels of peer involvement, which are in turn related to higher levels of engagement in multiple risk behaviour. Our findings should be understood in the light of the normative transition from childhood to adulthood that adolescents undergo. From a developmental perspective, distancing oneself from one’s parents, being highly involved with peers and engaging in multiple risk behaviour are part of the functional process of youth to accomplish the developmental tasks of adolescence (e.g. establishing one’s identity and acquiring autonomy). The health inequity across educational levels with respect to multiple risk behaviour may be explained by the fact that adolescents in lower educational levels distance themselves from their parents and get involved with peers (and consequently with multiple risk behaviour) at an earlier age compared to adolescents in higher educational levels. They may go through this process earlier because they enter the labour market (and therewith start an adult life) at an earlier age. The fact that they have a shorter period to go through the transition from childhood to adulthood may prompt them to break away from their parents, engage with peers and risk behaviours earlier and more intensely. Key considerations that are important in developing an evidence base for asset based approaches: With respect to policy implications, increasing parents’ knowledge of their children’s whereabouts may be an important topic for prevention and intervention programmes. Although they may feel that their influence becomes much smaller as children become adolescents and although some adolescents pretend to be adults already, parents are clearly still one of the main actors that influence their adolescent child's behaviour. Keeping track of what is going on the life of their child is crucial when it comes to multiple risk behaviour.

(Short) biography / associated readings: Barnes, GM, Hoffman, JH, Welte, JW, Farrell, MP & Dintcheff, BA (2007)

Adolescents’ time use: effects on substance use, delinquency and sexual activity. Journal of Youth and Adolescence, 36, 679-710.

Currie, C. et al. (eds) (2008) Inequalities in young people's health: international report from the HBSC 2006/06 survey, (Health Policy for Children and Adolescents, No.5). WHO Regional Office for Europe, Copenhagen.

Engels, RCME & Ter Bogt, T (2001). Influences of risk behaviours in the quality of peer relations in adolescence. Journal of Youth and Adolescence, 30, 675-695.

Richter, M & Leppin, A (2007) Socioeconomic inequalities in health. Trends in socio- economic differences in tobacco smoking among German schoolchikldren, 1994-2002. European Journal of Public Health, 17, 565-571.

Schrijvers CTM, Schoemaker CG (2008) Playing with your health. Lifestyle and mental health in the Dutch youth population. Bilthoven: RIVM.

Stattin, H., & Kerr, M. (2000). Parental monitoring: A reinterpretation. Child Development, 71, 1072-1085.

Willoughby, T, Chalmers, H & Busseri, MA (2004). Where is the syndrome? Examining co-occurrence among multiple problem behaviours in adolescence. Journal of Consulting and Clinical Psychology, 72, 1022-1037.

1

Key assets in adolescent multiple risk behaviour:

The role of parents and peers

Margreet de Looze, Tom ter Bogt, Saskia van Dorsselaer,

Zeena Harakeh & Wilma Vollebergh

Risk behaviours

• Alcohol, tobacco, cannabis, sex

• High prevalence among adolescents

across countries

2

Multiple risk behaviour

• Frequent co-occurrence of different types

of risk behaviours � can be measured as a latent factor

in all European countries (De Looze et al., submitted)

• About 1/5 of European youth engage excessively in

various risk behavours simultaneously (De Looze et al.,

submitted)

Key assets that support young people to not engage (excessively) in (multiple) risk behavior

Factors involved:

• Socio-demographic factors (age, gender, educational level, ethnicity)

• Family factors (family structure, FAS, quality of communication with parents, parental knowledge about adolescent’s whereabouts, rules on alcohol drinking)

• Peer factors (time spent with peers, number of friends, classmates’ engagement in risk behaviours)

• School factors (experiencing school as fun, feeling pressured by school work, truancy, good school performance, bullying)

• Mental health factors (happiness, psychosomatic complaints, conduct, hyperactivity, emotional and peer problems)

3

Family factors

• Incomplete vs. complete family (ORs up to 2)

• Prosperity of the family / FAS

• Religious

• Quality communication with mother (ORs up to 3)

• Knowledge of parents on adolescent’s

whereabouts (ORs up to 6)

• Rules on alcohol drinking (ORs up to 30!) – not

only for alcohol, but for all RBs

�� Parental involvement is very important

Peer factors

• Time spent with friends (ORs up to 12)

• Number of friends

• Communication with friends

• Risk behaviours of classmates (ORs around 3)

� Peer involvement also very important, but in a different

direction…

4

Parent & Peers

• Parental involvement = protective factor

• Peer involvement = risk factor

Adolescence: Transition from childhood to adulthood

�Distancing oneself from parents and high involvement

with peers are developmentally functional

BUT even though adolescents distance themselves from

their parents � parental monitoring and setting rules

continues to have a large effect

Implications for policy making:

Focus on the role of parents!

“Be aware of your child’s whereabouts!”

• Upcoming campaign in the Netherlands

5

Applicable to different cultural contexts?

• Yes!

�Little parental monitoring related to adolescent

(multiple) risk behaviour:

- Israel (Walsh, Harel-Fisch & Fogel-Grinvald, 2010)

- USA (Barnes et al., 2007; Dick et al., 2007; Simons-

Morton, Chen, Abroms & Haynie, 2004)

- Other countries, research

Health inequity

• Do adolescents with different SES engage in multiple

risk behaviour to similar extents?

• Do parents of children with different SES monitor their

children more or less compared to parents of children

with high SES?

• Are children with low SES more involved with their peers

compared to children with high SES?

6

Health inequity

• Recent research: use educational level as an indicator of

adolescent SES � is a more proximal indicator than family

SES and is highly predictive of adolescents’ future SES

• In the Netherlands: Youth in lower educational levels engage

more in (multiple) risk behaviour than youth in higher

educational levels

Source: Schrijvers CTM, Schoemaker CG (2008) Playing with your health. Lifestyle and mental health in the Dutch youth population.

Bilthoven: RIVM.

Applicable to different cultural contexts?

• Not all countries have an educational system with

different levels (e.g. separating vocational training from

theory-based education).

• In those countries that do have different educational

levels in secondary education: more MRB in lower levels

�Norway (Friestad & Klepp, 2006)

�Sweden (Hagquist, Sundh & Eriksson, 2007)

�Germany (Richter & Leppin, 2007)

�Netherlands (current study)

7

Explaining differences in MRB across educ. level

• Can a distant relationship with parents and high peer

involvement explain the effect of educational level on

multiple risk behaviour?

educationallevel

Distance fromparents

High peerinvolvement

Multiple riskbehaviour

alc

.75

can.90

tob

.91

sex

.77

-.17

-.24

.24

.52

.-.11

Can we blame the parents..?

• Distancing oneself from parents and high involvement

with peers are developmentally functional

• Youth in lower educational levels / vocational training

enter the labour market earlier

�Enter adulthood earlier

�Have a shorter (and potentially more intense) transition

period

• It may not be the parents, but the adolescents who

need more distance

� However, monitoring is still necessary, even though

they may pretend to be adults already

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Conclusion

• Distant parent relations and close peer relations as

� functionally developmental tasks in adolescence

�Risk factors for MRB

• Is parental monitoring a key asset to support young

people to deal with risk behaviours in a healthy way?

• Yes: adolescents want parents to be involved in their

lives, even though they sometimes prove the opposite

• Especially for adolescents in vocational training / lower

educational levels: shorter period between childhood

and adulthood � parents should be extra aware

Thank you!

The hierarchy of social assets for life satisfaction in English and Spanish

young people

Fran Rivera

Carmen Moreno

Antony Morgan

Aims and Objectives:

To investigate the relative importance of a range of ‘social assets’ on the life

satisfaction of young people growing up in England and Spain by:

1 analysing the differences between countries in the perceived quality of a range of

relationships in different social contexts (family, peer, school, neighbourhood),

taking account of their socio-economic status.

2 studying the differences in the weight of these relationships and how these

compare across the two countries, independently of socio-economic status. ic

status on adolescents’ life satisfaction in Spain and England.

Method:

The sample consisted of 5,333 15 years old, of whom 3,624 were Spanish and 1,709,

English. The socio-demographic variables considered were gender and family

affluence scale (a proxy for socio-economic status). The social relationship variables

were family (communication with parents, parental affection, parental monitoring and

family life activities), peers (communication with friends of the same sex and opposite

sex, to have been involved in any episode of bullying, and to have been bullied), school

(liking the school, classmates’ support and teacher’s support) and neighborhood

(perceived support and wellbeing from the neighborhood). Life satisfaction was

measured by Cantril’s scale.

The chi squared test was used to proove significance for each variable in each country

simple. A general linear regression model was used to assess the role of each variable

in life satisfaction in separate models for Spain and England (partial square etha and

the standardized coefficients were used to determine the weight of each variable in

explaning levels of life satisfaction).

Results:

Family context: no statistical differences were found between England and Spain in:

communication with father, communication with mother, father’s affection, mother’s

affection and frequency of family life activities. However, significant differences were

found in parental monitoring - Spanish adolescents were more likely to report that their

mother or father knew more about their lives than English adolescents.

Peer context, no statistical differences were found between England and Spain in:

communication with same sex friends and reported frequency of being bullied.

However, there were significant differences in communication between friends of the

opposite sex and between the frequency of reports of having bullied others.

School context, no statistical differences were found between England and Spain in

teacher’s support. However, the differences in liking school and classmates’ support

were significant. Spanish adolescents were both more likely to claim that they liked

school and that they felt that their classmates supported them.

Neighbourhood sense of belonging: Spanish adolescents were significantly more likely

to report a feeling of belonging in their neighbourhood as measured by the trust

neighbours watching out for one another.

It is important to note that there were significant differences in FAS between England

and Spain. In England there were a lower proportion of families with lower affluence

(for example, only 6,7% of English adolescents compared with 28,10% of Spanish

adolescents).

Results from the general linear model show that both the variable types and their

relative importance in explaining life satisfaction is very similar for both countries. In

particular, in both countries the positive relationships with mothers is central to their life

satisfaction of adolescents (in both countries, communication with the mother and

maternal affection occupy the top two places in the hierarchy). Some aspects of peer

relationships, school and relationships with fathers are also important and common

across the two countries..

However, there are some differences between the two countries that are worth noting.

In England, family affluence is a much stronger predictor of life satisfaction along with

being bullied, whereas in Spain these are not so important.

The results presented here are useful in classifying a hierarchy of health assets that

are important in the lives of adolescents living in 2 different country contexts. By

inference the results can be used to understand the relative importance of different

assets and thus better understand how, sometimes, when an asset fails, another can

help to improve life satisfaction in adolescence.

Abstract Title Evidence: Exploring Risk and Protective Factors using the WHO Health Behaviour in School-Aged Children Study – Positive Health Authors Ottova, V., Wille, N., Ravens-Sieberer, U., & the Positive Health Focus Group HBSC Summary Introduction Within the changing morbidity, mental health problems have emerged as a growing public health problem. An estimated 10-20% of children and adolescents today suffer from some form of mental health problem. Mental health problems comprise a wide range of disorders, often have a poor prognosis, high burden, and a strong impact on individual health and well-being. The strong focus on mental “ill” health, however, has hindered the consideration of positive mental health of individuals which can be regarded as an important resource and has important implications for improving health. Methods Information was gathered from two surveys: the BELLA study, the mental health module of the German National Health Interview and Examination Survey among Children and Adolescents (KiGGS) containing data from 2.863 families with children between 7-17 years of age; and data from the Health Behaviour in School-aged Children (HBSC) Study, comprising data of 204.534 school-children 11, 13 and 15 years of age. Relevant findings on risk and protective factors for mental health in children are presented. Results Within the BELLA study, risk and protective factors were studied in detail. In-depth analyses revealed that the number of high resources available was associated with mental health problems. Likewise, the higher the number of risks present, the greater the percentage of children with (probable or possible) mental health problems. Interestingly, when risk factors were absent, no significant association could be found between availability of resources and mental health problems. In the presence of one or two risks, the results showed that with increasing availability of resources (from low to medium to high), the percentage of mental health problems (both probable and possible mental health problems) decreased. When 3 risks are present, this trend is somewhat less distinct, and totally disappears when four or more risks are present (again no association). Within the HBSC study, 56% of children reported no noticeable health problems, however 44% reported either suffering from multiple health complaints, poor or fair health, low life satisfaction or a combination of these. Particularly older pupils and girls reported poorer health outcomes. In the fifteen countries which used the Kidscreen-10 index (suitable for use as a mental health indicator), those children who reported multiple health complaints also had lower Kidscreen values. Conclusions Protective factors are particularly important in the presence of risk factors and it could be shown that when no risk factors were present, there was no significant association between availability of resources and presence of mental health problems. The findings also highlight the importance of differentiating between various subgroups (by age, gender, country, socioeconomic status, etc.). Contextual factors and national indicators can provide further information helping to understand cross-national differences, especially in terms of health promotion and prevention activities. In this sense, health monitoring, trends analyses and cross-national differences in psychological, social and physical well-being are important in drawing attention to the rising burden of mental health problems. Contact Veronika Ottova, MPH University Medical Center Hamburg-Eppendorf Center for Obstetrics and Pediatrics Department of Psychosomatics in Children and Adolescents Martinistr. 52, W29 D-20246 Hamburg Tel. +49-40-7410 57376 Email: [email protected]

Asset-Based Community Development Deborah Puntenney, representing John McKnight, both of the Asset-Based Community Development

Institute at Northwestern University

The work of the Asset-Based Community Development Institute (ABCD) originated in the 1960s with a focus on institutional change as the necessary element in creating communities where residents could thrive. That is, the work emphasized how improving modern systems and methods—in schools, the criminal justice system, health care, and government, for example—could improve people's well-being—particularly those with lower incomes or those who had been marginalized in some way from the mainstream. But this focus quickly changed when staff realized that the "institutional assumption," or the idea that hospitals produced health, schools produced wisdom, legal systems created justice, and social service systems produced well-being, etc., was simply incorrect. Instead, the focus shifted to identifying the positive conditions of a good life, and an examination of the critical determinants of health, wisdom, justice, community, knowledge, and economic well-being. The evidence supported the proposition that these determinants could be found in individual behavior, social relationships, the physical environment, and economic status. Thus, the typical "map" of a community as a list of possible institutional interventions targeting the various deficiencies and pathologies characterizing a particular place seemed irrelevant, and a new sort of community map emerged. This new map—the asset map—focused on people, their collective relationships, and the contexts in which they live their lives, and emphasized people as the primary agents in the production of their own well being. Community assets of six types were ultimately identified:

• Individuals and their skills, abilities, interests, and experiences. • Associations, where individuals come together for a common purpose. • Institutions, where resources and expertise are concentrated. • Physical infrastructure, that provides the environmental context in which people live. • Local economy, that generates the financial resources to support community members. • Local culture, the ways people do things and the meanings they attach to their world.

In shifting to this new focus, two things happened. First, it became necessary to reorient people's thinking, to retrain them to see community assets rather than community needs and deficiencies. The ABCD metaphor—the glass half full rather than the glass half empty—clearly represents this perspective. Rather than looking at what is problematic in the empty part of the glass, the asset map intentionally focuses on what is present in the full part of the glass–the assets in all six categories. And the process of asset mapping is intentional; in order to overcome our training to see only needs and deficits, we need to go through the discovery process to locate and understand the gifts and assets present in every individual and every community. Second, it became important to distinguish between two worthwhile types of community tools, (a) the institutional/systems tool, and (b) the associational/community tool. From the ABCD perspective, institutions are important assets, but have, over time, taken on community roles for which they are fundamentally unsuited. In other words, the institutional "tool" is being used for jobs in which the associational "tool" of the community would be a better fit.

The difference between these tools is important. Institutions and systems are structured in a hierarchical fashion that concentrates authority and decision-making in just a few people at the top of the structure. The control and efficiency this allows is useful and appropriate in some contexts, for example, we all want the automobile industry to produce lots of vehicles of uniform quality; we all want competent air traffic controllers making decisions in a highly structured environment. But

these efficiencies tend to produce systems that encroach on community space in their quest for more consumers of the institutional product. Associations are structured very differently. Associations are comprised of people who come together in self-appointed groups for recreational purposes, mutual support, or community problem solving. Because these groups are not structured for authority, control, and efficient production, associations represent a much better "tool" for accomplishing objectives in community space. Associations can be responsive to community needs and provide the venue for each member to offer his or her "gifts" in the resolution of community issues. Associations are a context in which care is manifested and shared, one person to another, contrary to institutional space, in which products and services are delivered by the system to the customer or client. Asset-based community development reclaims the associational space that drives healthy communities and uses the power of civic engagement to define a new way of producing health and well being.

Institutional/Systems Structure Associational/Community Structure Applying these ideas to the question of the health and well being of young people sets up some interesting questions. First, are institutional/system tools or associational/community tools better able to deliver the supports and care that are necessary for young people to thrive? Second, are institutions/systems or associations/communities better able to provide the context in which young people are recognized for their gifts and talents, and where they can contribute to their own well being and to that of the community? It seems clear that this is a case where the institutional tool is the wrong choice for creating well being, and one in which the community tool can be more appropriately deployed. The most important reason the institutional tool cannot be used to build strong youth is that institutions are programmed to see and respond to deficiencies, needs, and problems, and when youth are approached in this manner, they may well become exactly what is expected of them. Instead, what youth require is support, care, and opportunities for meaningful participation that reflect their community's expectation that they grow into strong, contributing adults. Asset-based community development is not a rigid model or a set of specific steps that guarantee success. Instead it is a set of principles (asset-based, resident centered, locally focused), and practices (intentional mapping and mobilizing of local assets) that help reshape how communities function and redistribute community roles to the appropriate entities. As such, it is adaptable to different cultures, geographic regions, and political contexts with thoughtful consideration of how it complements local ways of being. Additionally, it has implications for policymaking, in that the primary objective of social welfare policies should be the removal of barriers to participation in all aspects of life, and the enhancement of opportunities for individuals and associations to launch their own enterprises and build their own economic and social well being.

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INDIAINDIAA TALE OF TWO NATIONSA TALE OF TWO NATIONS

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Health is not everything but everything else is

nothing without good health.

This applies to Individuals, Communities and to

the Nation. Recent outbreak of various

epidemics has shown that economic prosperity

of a Nation can get completely jeopardized if the

health concerns are not addressed adequately.

Therefore, in our future thinking, we need to

look at health as an investment and not as an

expenditure.

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33

State of India’s Health & Challenges State of India’s Health & Challenges Towards Establishing an Appropriate and Towards Establishing an Appropriate and Sustainable Health SystemSustainable Health System

� India’s health system is going through a transition

� While the economic development in India has been gaining momentumover the last decade, our health system is at crossroads today.

� Government initiatives in public health have recorded some noteworthysuccesses over time (eradication of small pox and guinea worm;substantial decline in the number of leprosy, polio and malaria cases,etc (NHP, 2002).

� Still our achievements in health outcomes are only moderate byInternational standards.

� India ranked 118 among 191 WHO member countries on overall healthperformance (WHO, 2000).

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The Indian Health Scenario The Indian Health Scenario

On the basis of the health status of the people, and the existing capacityof the healthcare delivery system, demographically the states of thecountry can be divided into four main groups:

Group States % of Pop.

I Kerala, TN. 9.1

II Mh., Kn., Pb., WB, AP, Gj., Hy 39.1

III Or, Rj, MP, Ch, UP 33.1

IV Am, Bh, Jh. 18.7

� 6 states with 11.4% of the population, have already achieved replacement levels of fertility (TFR-2.1);

� 11 states with a population of 60%, still have a TFR of over 3 (including, Bihar, MP, UP, Orissa & Rajasthan) .

3

55

Health and Social Health and Social Determinants of Vulnerable Determinants of Vulnerable CommunitiesCommunities

66

The “KHOJ” Initiative

4

77

The KHOJ InitiativeThe KHOJ Initiative

The “KHOJ” initiative was launched with the focus on thestrengths of panchayats to perform functions like

� To develop upon the knowledge, resources and aspirations ofcommunity.

� Preparing area plans and allocating resources.

� Marking the government health infrastructure accountable to thepanchayats.

� Empowering zila parishads to appoint (and dismiss) doctors.

� Involving and mobilizing community participation to meet health anddevelopment needs of the area

� An effective partnership was sought between government, NGOs andprivate sector to optimize and improve health status of people.

88

KHOJ Project Locations KHOJ Project Locations

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99

Process, Process, ProgrammesProgrammes and Outcomeand Outcome

VHAI identified 17 pockets in remote mountains, dessertsand areas inhabited by indigenous people to initiate KHOJproject. The process involved approach to

� Develop project based on community strengths and aspirations andlocal health traditions.

� Develop project according to local basic needs.

� Optimal utilization of the existing government infrastructures.

� Building local health and development skills and expertise.

� Sustainable initiatives, from financial as well as human resources.

� Ensuring health and development status of the people.

� Ensuring permanent capacity building of the community.

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Thrust Areas of WorkThrust Areas of Work

� Initial emphasis on provision of curative services.

� KHOJ health centre was established for indoor admissions with help from Panchayats.

� Health and relief camps organized for epidemic like situations like malaria, diarrhea, etc.

� To re-energize the Indian System of Medicine.

� Linkages developed for referral of complicated cases.

Health InterventionsHealth Interventions

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1111

Women and HealthWomen and Health

� At their initiation, MCH services were in poor shape in all KHOJprojects with high maternal deaths and high incidence of deliveries by untrained birth attendants and low. immunization coverage

� In 1999, most of the projects did not report a single maternal death.

� Traditional Birth Attendants provide safe deliveries in project areas.

� KHOJ adopted a holistic approach to reproductive health to initiateattitudinal change towards women’s basic rights.

� Priority placed on entire range of women’s health needs from girl childto reproductive age women.

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Health PromotionHealth Promotion

� Major focus on health promotion and disease prevention by improvedcommunication through MMs, VHWs and Youth club members.

� Efforts made to develop need based area specific communication strategy

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1313

Health Impact of Health Impact of KHOJKHOJ ProjectProject

�� Reduction in mortality due to Reduction in mortality due to communicable diseases.communicable diseases.

� Effective disease surveillance leading to prevention of epidemics.

� Reduction in health expenditure as quality health services made available at reasonable cost.

� Increased health awareness.

� Increased utilization of available govt health functionaries.

� Significant improvement in antenatal care, natal care and post natal care.

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Community OrganizationCommunity Organization

� Formation of social action groups to optimize government resources.

� Effective linkages developed with panchayats to assess local basic needs

� Initiation of non formal basic education centres for school dropouts.

� Capacity building involving vocational, income generation training & entrepreneurship development.

� Effective steps taken to organize people’s group in form of women’sgroups, youth groups and farmers group.

� Village health communities organized with people’s representativesdiscussions on future plans and strategies.

� Mobilization of village communities for improving their conditions.

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1515

Income Generation ProgrammesIncome Generation Programmes

� Vocational trainings: for skill enhancement and providing after training, marketing outlets.

� Promotion of local skills / crafts: to provide necessary support, including skill upgradation of artisans.

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Income Generation ProgrammesIncome Generation Programmes

� Entrepreneurship Development: to take advantage of numerousgovernment schemes available for the rural employed.

� Formation of Self Help Groups: to encourage periodic savings withcontribution of matching grants from the project.

� Livestock Improvement: through improving the breed with artificialinsemination and technical support.

� Environment, Water and Sanitation: involving villagers for villageenvironment, drinking water related activities, afforestation,preservation of natural resources, horticulture, etc.

Contd…

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1717

Collaboration with the GovernmentCollaboration with the Government

� Health: immunization programme, family planning programmes, health camps, workshops and referrals.

� Sanitation and Drinking Water: linkages with CAPART, DRDA, block offices and panchayats.

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Collaboration with the GovernmentCollaboration with the Government

� Direct benefits under various government schemes: Ayushmati, Vatsalya, old age pension, Rashtriya Parivar Yojana , Jawahar Rojgar Yojana, for maternity, adolescent girls, etc.

� Training of panchayat members.

� Recognition of the projects by state governments by handing over of Primary Health Centres (in Arunachal Pradesh, Orissa etc), training of animators (NLM) and direct financial support to projects for specific activities.

Contd…

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1919

SustainabilitySustainability

� Sustainable income generation programmes

� Emphasis on human resources development

� Strengthening local panchayats

� Developing linkages with government and other agencies

2020

In all these situations children and youth play an important and proactive role.Few examples…

Setting up Computer Training Centre in West Bengal

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2121

Providing Disaster Relief in Jammu and Kashmir

2222

Taking up Tobacco Control Initiative in Orissa

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2323

Promoting Herbal Garden in the Schools in Orissa

2424

Paths are made by walkingPaths are made by walking

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Parents and communities’ assets to control under five child malaria in rural Benin. David Houéto, Alain Deccache

Summary

Introduction : Malaria is the biggest threat in terms of morbidity and mortality in sub-Saharan Africa (SSA) and one of the main factor contributing to poverty in the region. One of its target populations are children under five years. Despite the fact that several actions are being put in place for already many decades, the Malaria issue has never had a little change and continues to challenge the whole of the actors engaged in the process of its control. It is in this context that we initiated an experiment to show the node of the failure of the various actions undertaken to date.

Context: At the time when we carried out the present experiment, Abuja Declaration to control Malaria had already failed. Countries in the region are struggling actually to control Malaria through the Millennium Development Goals (MDGs) n° 6. But as one said, “Globally, we are not doing a better job of reducing child mortality now than we were three decades ago…” So one can say, when considering the way health systems in the region are working, that there is no possibility to control Malaria.

In fact, according to many authors, Malaria in SSA is characterized by a particular context anchoring in a culture, socio-economic, and environment. Fever in Malaria is the main sign which entails particular perceptions and social representations from individuals in communities depending on each sub-region of SSA. So there is a need for a strong participation of the people in order to be able to control Malaria in SSA basing interventions on their assets.

Methods and results: How assets based policy has worked to improve Malaria control and reduce inequalities? Within a rural community in Benin (West Africa), we chose to plan to control Malaria by putting all the process in the hands of the members of that community. All the process lasted for 27 months. As health professionals, we were their referent, giving them the needed skills and knowledge to accomplish their mission. The community planned six activities to control Malaria: (1). Early home treatment of the child fever by mothers; (2). Use of impregnated mosquito nets (IMN); (3). Parents’ income improvement; (4). Setting up of a micro-insurance for health. (5). Environment cleanliness and creation of mosquito-free habitat; (6). Systematic schooling of children and adult literacy.

As the results, there were significant changes in terms of knowledge of Malaria transmission and prevention in children, parents practices of recourse to health centre in the case of child fever, community participation, competence to treat child fever adequately, skills to establish partnership with stakeholders, and communication through a positive interaction, expression from divergent point of view anchored in confidence. The prevalence of fever and other signs of malaria were significantly reduced, the recourse to the health facilities in the case of fever increased, but especially an early and adequate home treatment of fever. Consequently, there is reduction in severe cases of fever compare to the year before the intervention. Deaths caused by malaria were statistically significantly reduced.

The critical conditions required to ensure the effective implementation of assets based in malaria control policy at a community level are: (1). No action was taken without considering the local context of the intervention community; (2). The issue approached has priority for the intervention community; (3). Participation, giving really capacity to the community to take all the possible and suitable actions, according to the members community’s assets, for the fever control; (4). We (professionals), played a role of guiding the process mainly at the beginning

2

and the resource persons, enlightened actions under consideration by the community. We acted as a referent; (5). The use of several types and strategies of action concerns various aspects of the community’s life, without limiting ourselves to the health sector as the causes go beyond this sector alone; (6). Confidence in the community (their assets) had played a role of "motivator" that contributed to the development/increase of their self-esteem, implying an important motivation to make their own suggested actions successful. We call this process “The principle of the Crank”

New methodologies for constructing the evidence base on assets approaches to health and development. Speaking about interventions which ensure people’s health and wellbeing, and based on population’s assets, health professional must: (1). Take care that health interventions/programs lie within the framework of health and the global wellbeing of the populations concerned while aiming at the community control from the early beginning of their development. (2). Support the initiatives of community development which contribute to the improvement of the quality of life of the partner populations. (3). Take care of the development of the community competences and skills. This process reorients the role of health professionals and shows the importance of the multisectoral work that is centered on specific contexts with their own realities. These realities are not sufficiently perceived without the full participation of the members of community, using in consequence various strategies. All this leads to the sustainability of the action through the process of implementation and evaluation and contributes to the resolution of specific health problems and to the reduction of the social inequalities of health.

Conclusion: We showed through this community approach that it is possible to control Malaria basing programs on population’s assets. With this approach helps awakening its critical conscience, not only child fever, but to also contribute to the resolution of other problems and to the community development. Such an action would deserve to be taken back on a larger scale to examine more of the various methodological and operational outlines. Building capacities in health promotion in the region should come as a main priority for health systems in order for them to consider the bio-psychosocial vision of health instead of the one being used, the biomedical when planning health action.

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PAHO’S Healthy Municipalities, Cities and Communities (HMC) Strategy

The Pan American Health Organization (PAHO) developed and introduced The Healthy Municipalities, Cities and Communities (HMC) strategy in the 1990s to improve and promote local health and development in the hemisphere of the Americas. This strategy is being actively implemented in 18 of the 35 countries and 3 territories of the Americas.

Based on the notion that being healthy means having a good quality of life, the actions of the HMC strategy focus more on the underlying determinants of health than on their consequences in terms of diseases and illnesses. This strategy also focuses strongly on the notion that every community has assets and resources that, when strategically aligned around community-driven priorities, can lead to more effective change. This is achieved by facilitating joint action among local authorities, community members and key stakeholders, aimed at improving their living conditions and quality of life in the places where they live, work, study and play.

The HMC Strategy incorporates an assets-based approach by:

• Emphasizing capacity building through (1) community empowerment, education, and participation; (2) strengthening individual skills and fostering critical thinking among those involved in the initiative; and (3) supporting the development of leadership, agents of change, and advocates.

• Promoting action by communities, institutions, and intersectoral organizational structures for action through (1) the identification of community resources and assets (assets-mapping, community assessments, etc.); (2) and the definition of priorities, strategic planning and the development of a responsive and appropriate action plan.

• Fostering socio-political action by (1) guaranteeing formal commitment by local governments, (2) forming community-based, intersectoral committees, and (3) utilizing participatory, community-based methodologies.

PAHO’s Participatory Evaluation Initiative

It is evident that health promotion and assets-based approaches can greatly contribute to the development of programs and policies that support the preservation of health and the decrease of health inequities, rather than only the prevention of diseases. During the past few decades the implementation of the healthy settings approach in Latin America and the Caribbean (LAC) countries have greatly advanced the cause for health promotion in

Executive Summary:

The application and evaluation of an assets-based model in Latin America and the Caribbean: the experience with the healthy settings approach

Maria Cristina Franceschini1, Marilyn Rice1, Cristina Caballero1

2

the Region and have accumulated valuable experiences and information related to the process, outcomes, benefits and challenges of these approaches to community and population health. Nevertheless, practitioners in the field are often concerned that health promotion programs and policies will not be continued due to a perception on the part of decision makers and funders that there is a lack of success and effectiveness.

In an attempt to address this need, in 1999 PAHO established a Healthy Municipalities Evaluation Working Group formed by evaluation experts from leading institutions in the Americas working on issues related to health promotion, evaluation and local development. The Working Group was comprised of people from governmental, non-governmental and academic sectors from various countries in the hemisphere, including Argentina, Brazil, Canada, Chile, Colombia, Ecuador, and the United States. It developed a series of evaluation tools, among them, a Participatory Evaluation Guide for Healthy Municipalities, Cities and Communities (2005).

This Participatory Evaluation Guide for Healthy Municipalities, Cities and Communities provides guidance and tools to evaluate healthy settings and health promotion efforts using an evaluation framework that incorporates essential health promotion elements and assets such as intersectoral collaboration, social participation, capacity building, individual physical and material conditions, health determinants, and community capacity, among others. It aims to provide an alternative evaluation framework that reflects the underlying health promotion principles embedded in many long-term initiatives taking place in LAC countries while continually building on a community’s assets and capacities through continued participation.

Lessons learned

Over the past 3 years, the Participatory Evaluation guide has been introduced and applied to several LAC countries. Based on the experiences from Brazil, Dominican Republic, Honduras, Mexico, Peru, and Trinidad and Tobago, it was found that the main factors that affected the implementation of this evaluation strategy were ‘political context’ and ‘timing’. Election periods and political transitions often caused major delays (if not termination) of initiatives, shortage and/or change of personnel and funds, and great uncertainty about the future of the initiatives. The lengthy time period required to implement this strategy, as well as the necessity for intersectoral collaboration, also posed to be challenges.

On the other hand, experiences showed that this participatory evaluation strategy was an empowering and assets-building process by itself. This approach encouraged community participation, the development of personal skills and the understanding of the key assets that created supportive environments for health development. Having strong, sustained and dynamic leadership was central to the sustainability of a community-responsive evaluation initiative. Active commitment and engagement from institutions both at the local and national levels were key to the success of these initiatives, as well as the quality of the collaborative work among them. Overall, it was found that this evaluation process provided an invaluable opportunity to discuss and reflect on communities’ experiences, challenges, assets and potentials.

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Assets in action – The use of assets in promoting physical activity among women in difficult life situations

Alfred Rütten (University of Erlangen-Nuremberg, Germany)

1 Assets in “Movement as investment for health – th e BIG project” We adapted the “Assets for Health” approach to research in the field of physical activity promotion. The project “Movement as Investment for Health - Bewegung als Investition in Gesundheit” (BIG) - was funded by the German Prevention Research Program (2005-2008). It was the first project to prospectively use the “Assets for health” approach.

The overall goal of BIG was to increase physical activity among this group, by supporting the women to overcome the social, environmental, and economic factors known to inhibit physical activity. The project developed activities closely in line with the WHO Ottawa Charter for Health Promotion. These activities included the empowerment of people to control the determinants of their health, the development of healthy public policies at the community level, and the creation of supportive environments. The goals of the project were to improve community level connectedness, increase physical activity, and in so doing raise the physical, social, and mental health of the target population. The project evaluation considered determinants for the implementation of project activities, the reach of project activities, potential changes in health behaviour, potential health benefits, as well as the potential social and economical impact of the project implementation. The BIG project used the assets approach in the assessment phase of the project as well as in planning and implementation of activities. BIG also demonstrated how asset based models to intersectoral policy making in health promotion can improve the effectiveness of projects aiming to improve health and related outcomes.

In the meantime, the BIG approach to physical activity promotion has been transferred to several other municipalities in Germany. WHO named BIG a case study in the programmes “Assets for Health and Development” and “Tackling Obesity by Creating Healthy Residential Environments”. It is also online in WHO feature series “Voices from the frontline: Socio-economic determinants of health”.

1.1 Assets and movement BIG had two objectives: firstly, to make full use of potential effects of movement in health promotion, i.e. going beyond a bio-medical focus towards fundamental psychosocial and environmental functions; and secondly, the project aimed at developing adequate evaluation instruments for health promotion and adapting instruments to the context. Instead of aiming at behaviour change through readymade interventions, BIG established a co-operative planning group including researchers, women from the neighbourhood as well as policymakers, and local experts. This group decided about planning, implementation, and evaluation of activities. Acknowledging the educational, social, policy and environmental dimensions of movement, BIG implemented low fee exercise classes with childcare, improved access to sport facilities, education activities, and activities to improve organizational and political capacities.

1.2 Assets and social inequality National health survey data indicated that women with a low socio-economic status are the subpopulation group physically most inactive with a high prevalence of sedentary lifestyles, and thus high levels of associated conditions such as obesity. This can be linked to social inequality in health, like lack of social support, lack of community connectedness, or environmental determinants. Therefore, women with a low socio-economic status were chosen to represent the BIG target group. The women themselves suggested to use ‘women in difficult life situations’ as most appropriate term to describe low income or social welfare, low educational attainment, working shifts in unskilled occupations, unemployment, single parentship or ethnic minorities. 2 Assets assessment in BIG Following WHO, in general, the definition of a health asset was adapted to specific health behaviour, i.e. movement. An asset for movement was defined as “any factor (or resource), which enhances the ability of individuals, communities and populations to begin, maintain and sustain movement”. Within our theoretical framework, we operationalized assets for movement on the individual, organisational, and infrastructural level.

Focus groups and workshops were used to collect and map the potential assets already existing in the neighbourhood. Two separate focus group meetings were organised for women in difficult life situations, policymakers and local experts – representatives from the municipality (e.g. health sector, women affairs, social

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affairs, urban affairs, socio-cultural work and sports), and other institutions (e.g. NGOs or religious communities). Information was collected separately from women and experts to avoid bias towards experts’ perceived assets. Participants of both focus group meetings mapped and discussed overlapping assets at a subsequent workshop. The workshop marked the beginning of mapping a range of potential assets which could be used to improve the possibilities for increased physical activity amongst the target population. The focus groups were also able to identify specific organisations that could play a role in creating the right conditions for our study population to participate in physical activity. Infrastructural assets highlighted during the process ranged from parks and recreational facilities to community rooms, unused grounds in the neighbourhood, and exercise facilities of schools and sports clubs. 3 Utilization of assets in BIG planning and impleme ntation BIG utilized identified overlapping assets for movement in the development of interventions for the promotion of movement among women of the target group. Women’s participation in project work was accomplished by setting up a co-operative planning group. The group included women, policymakers, and local experts. Decisions regarding the planning, implementation, and sustaining of project activities were made by this group. Women in difficult life situations voiced their interests at group meetings, decided on actions that should be taken for the promotion of physical activity among them, organised – in cooperation with other stakeholders – the implementation of these actions, and participated in deciding on instruments for the evaluation and carrying out the evaluation of the project.

Meta-evaluation indicates that assets for movement were employed in the process of planning and implementing interventions for the promotion of movement. On the individual level, some of the most powerful supporters of the cooperative planning process were identified through the mapping of individual assets. Also, on the organisational level, a high impact of organisations that were identified through the mapping of assets can be assumed. On the infrastructural level, results indicate that identified assets were successfully employed and host interventions for the promotion of movement. Results, however, also provide examples for assets for movement that were mapped but disregarded, or did not function as an asset in the planning and implementation process 4 The policy impact of assets use Policy analysis was employed in BIG to understand some of the potential barriers and facilitators to improving the chances of local women living in difficult life situations to engage in physical activity. The policy analysis highlighted how a range of individual and organisational assets already identified in the assessment phase and integrated into planning and implementation were crucial to overcome political barriers which had been inhibiting women access to public sports facilities (cf. Rütten et al, 2009).

Asset based approaches to health promotion programmes can provide a useful means of overcoming some of the structural-political barriers to effective implementation. A systematic mapping of available assets and their subsequent use in collaborative planning and implementation processes may contribute to improved accessibility of public spaces for women in difficult life situations and more importantly lead policy makers and other key decision makers to think and act in ways which are more inclusive to the needs of the less well served parts of their population. The inclusion of different stakeholders out of the range of identified assets in participatory intersectoral policy-making processes for planning and implementation appear to be crucial for success and having a policy impact.

The BIG website, http://www.big-projekt.de

BIG at WHO, http://www.euro.who.int/socialdeterminants/socmarketing/20070813_2

Rütten, A., Abu-Omar, K., Frahsa, A., Morgan, A. (2009). Assets for policy-making in health promotion. A case study. Social Science and Medicine 69: 1667-1673.

Rütten, A., Abu-Omar, K., Levin, L., Morgan, A., Groce, N., Stuart, J. (2008). Research note: social catalysts in health promotion implementation. Journal of Epidemiology and Community Health 62: 560-565.

Participants



Symposium 1:


Seville, Spain

28-30 April 2010

Participants

Participant Organization Postal address Email address

Dr Fiona Adshead Deputy Chief Medical Officers (DCMO) in the Department's Health and Social Care Standards and Quality Group

22 Burnley Road. London SW9 0SJ. England. United Kingdom [email protected]

Ms Dory Aviñó Juan-Ulpiano

Psychologist. Alzira Public Health Center and Foundation for Research Hospital Dr. Peset

Avda Cataluña 21. 46020 Valencia. Spain [email protected]


Dr Adriana Baban Professor of Health Psychology. Babes-Bolyai University, Dept. of Psychology.

Republicii 37. Cluj-Napoca. Romania 400015 [email protected]

Dr Anja Baumann Technical Officer for Mental Health. World Health Organization Regional Office for Europe.

Scherfigsvej 8. 2100 Copenhagen. Denmark

[email protected]

Dr Fiona Brooks

Professor of Primary Health Care and programme lead for the CRIPACC adolescent and child health research group. University of Hertfordshire.

College Lane Campus. Hatfield AL10 9AB. United Kingdom [email protected]

Dr Harry Burns Chief Medical Officer for Scotland. Scottish Government. Health Directorate.

Room 1E17. St Andrew’s House, Regent Road. Edinburgh. EH1 3DG. Scotland. United Kingdom

PS/[email protected]

MS Pilar Campos Esteban Head of Health Promotion Service. Ministry of Health and Social Policy.

Paseo del Prado 18-20. 28014 Madrid. Spain [email protected]

MS Maggie Davis Executive Director. Health Action Partnership International (HAPI).

Tavistock House (Entrance D), Tavistock House, London, WC1H 9LG, England. United Kingdom

[email protected]

MSc Margreet de Looze PhD Student. Utrecht University Heidelberglaan 2, Willem C. Van Unnikgebouw, kamer 1518a. 3584 CS Utrecht. The Netherlands

[email protected]

Dr Pernille Due Research director. National Institute of Public Health. University of Southern Denmark.

Øster Farimagsgade 5A, 2nd floor. DK- 1353 Copenhagen. Denmark [email protected]

Dr Monica Eriksson Researcher. Folkhälsan Research Center Health - Promotion Research

Paasikivenkatu 4. 00250 Helsinki. Finland [email protected]


Ms Isabel Escalona

Chief of service health promotion and participation. General Secretariat of Public Health and Participation. Regional Ministry of Health. Junta de Andalucía.

Avda. de la Innovación, s/n Edif. Arena 1. 41020 Sevilla. Spain

[email protected]

Ms Christina Franceschini Technical officer. Pan American Health Organization (PAHO).

525 23rd ST NW. Washington DC, 20037. USA [email protected]

Dr John Freeman Professor. Faculty of Education. Duncan McArthur Hall. Queen’s University Kingston, Ontario K7L 3N6. Canada

[email protected]

Ms Irene Fuentes Caro

Technical officer. Service health promotion and participation. General Secretariat of Public Health and Participation. Regional Ministry of Health. Junta de Andalucía.

Avda. de la Innovación, s/n Edif. Arena 1. 41020 Sevilla. Spain [email protected]

Ms Irene García MSc Student. Department of Developmental and Educational Psychology. University of Seville.

Camilo José Cela, s/n. 41018 Sevilla. Spain

[email protected]

Mr Antonio Garrido Porras

Technical officer. Service health strategies and comprehensive plans. General Secretariat of Public Health and Participation. Regional Ministry of Health. Junta de Andalucía.


Dr Margarida Gaspar de Matos

Professor. Technical University of Lisbon (UTL). School of Human Kinetics (FMH).

Estrada da Costa Cruz Quebrada. 1499 Lisboa codex. Portugal [email protected]

Ms Begoña Gil Barcenilla

Pediatrician. Head of the Comprehensive Childhood Obesity Plan of Andalusia. Regional Ministry of Health. Junta de Andalucía.

Avda. de la Constitución, 18. 41071 Sevilla. Spain [email protected]


MSc Maria del Carmen Granado

Professor. PhD Student. Department of Developmental and Educational Psychology. University of Huelva.

Campus Universitario «El Carmen». Avda. de las Fuerzas Armadas, s/n. 21007 Huelva. Spain

[email protected]

Dr María del Mar González

Professor. Department of Developmental and Educational Psychology. University of Seville.


[email protected]

Dr Yossi Harel-Fisch

Director International Research Program on Adolescent Well-Being and Health, School of Education, Faculty of Social Sciences, Bar Ilan University

Ramat Gan 52900 Israel [email protected]

Mr Tom Hennell Senior Analyst, North West Public Health Group, Government Office for the North West. Department of Health North West.

13th Floor, City Tower, Piccadilly Plaza. Manchester M1 4BE. United Kingdom

[email protected]

Ms Catherine Herman Independent consultant. 25 Whittington road. London N22 8YS. England. United Kingdom [email protected]

MSc Mariano Hernán Professor of Health Promotion and Public Health. Andalusian School of Public Health.

Cuesta del Observatorio, 4. Campus Universitario de Cartuja s/n. Apdo. Correos 2070. 18080 Granada. Spain

[email protected]

MS Zaida Herrador Ortiz Technical Officer. Ministry of Health and Social Policy.

Paseo del Prado 18-20. 28014 Madrid. Spain

[email protected]

Dr Victoria Hidalgo Professor. Department of Developmental and Educational Psychology. University of Seville.

Camilo José Cela, s/n. 41018 Sevilla. Spain [email protected]

Dr Marcia Hills Professor. University of Victoria, British Columbia, Canada

PO Box 1700 STN CSC. Victoria British Columbia V8W 2Y2. Canada [email protected]


Dr David Houeto

Regional Adviser in Health Promotion, Coordinator of the EPIVAC International network, Preventive Medicine Agency (AMP, www.aamp.org).

07 BP 1411 Sainte-Rita. Cotonou 07. Benin. West Africa

[email protected]

MSc Antonia Jiménez-Iglesias

PhD Student. Research Fellow. Department of Developmental and Educational Psychology. University of Seville.


Dr Jesús Jiménez Professor. Department of Developmental and Educational Psychology. University of Seville.


Ms Nicola Kell Project Manager. Project John Ltd. 20 Bath Street, Barrow in Furness, Cumbria, LA14 1NE. United Kingdom

[email protected]

Dr Mike Kelly Professor. Centre of Public Health Excellence. National Institute for Health and Clinical Excellence (NICE)

MidCity Place. 71 High Holborn. London WC1V 6NA. England. United Kingdom [email protected]

Dr Ellen Klemera Research Fellow in Child & Adolescent Health team at CRIPACC. University of Hertfordshire.


Dr Bengt Lindstrom Professor, Research Director. Folkhälsan Research Center Health - Promotion Research.

Paasikivigatan 4. 00250 Helsinki. Finland

[email protected]

MSc Josefine Magnusson Research Fellow in Child & Adolescent Health team at CRIPACC. University of Hertfordshire.



Dr Peter Makara Associate Professor, Faculty of Public Health, University of Debrecen. Hüvösvölgyi 42.1021 Budapest.Hungary [email protected]

Dr Ramón Mendoza Professor. Department of Developmental and Educational Psychology. University of Huelva.


[email protected]

Dr Begoña Merino Merino Head of Health Promotion Area. Ministry of Health and Social Policy.


Dr Tessa Moore Head of School Effectiveness. London Borough of Richmond upon Thames, England

Civic Centre. 44 York Street. Twickenham Middlesex. TW1 3BZ

[email protected]

Dr Carmen Moreno Professor. Department of Developmental and Educational Psychology. University of Seville.


[email protected]

Mr Antony Morgan Associate Director. National Institute for Health and Clinical Excellence (NICE).

MidCity Place. 71 High Holborn. London WC1V 6NA. England. United Kingdom [email protected]

Dr Virginia Morrow Professor. Institute of Education. University of London.

20 Bedford Way. London WC1H OAL. England. United Kingdom [email protected]

Mr Alok Mukhopadhyay Chief Executive. Voluntary Health Association of India.

B-40, Qutab Institutional Area. New Delhi – 110016. India

[email protected]

MSc Victoria Muñoz-Tinoco

Professor. PhD Student. Department of Developmental and Educational Psychology. University of Seville.



Dr Alfredo Oliva Professor. Department of Developmental and Educational Psychology. University of Seville.


Ms Veronika Ottova

University Medical Center Hamburg-Eppendorf. Center for Obstetrics and Pediatrics. Department of Psychosomatics in Children and Adolescents.

Martinistr. 52, W29. 20246 Hamburg. Germany [email protected]

Dr Jesús Palacios Professor. Department of Developmental and Educational Psychology. University of Seville.


Dr Águeda Parra Professor. Department of Developmental and Educational Psychology. University of Seville.


Dr Pedro J. Paúl Vice-rector for Educational Planning. University of Seville.

San Fernando, 4. 41004 Sevilla. Spain. [email protected]

Dr Deborah Puntenney

Associate Director, Asset-Based Community Development Institute Research Assistant Professor, School of Education & Social Policy. Northwestern University.

2120 Campus Drive. Evanston, IL 60202. USA [email protected]

Ms Rosa Ramírez Fernández

Deputy Director for Health Promotion and Epidemiology. Ministry of Health and Social Policy.


Dr Pilar Ramos Research Fellow. Department of Developmental and Educational Psychology. University of Seville.



MSc Francisco Rivera

PhD Student. Associate Professor. Area de Metholodology. Department of Behavioural Sciences. Faculty of Education.


[email protected]

Mr Manuel Rodríguez

Chief Service Health Promotion and Comprehensive Plan. General Secretariat of Public Health and Participation. Regional Ministry of Health. Junta de Andalucía.


Dr Alfred Rütten Professor. University of Erlangen-Nuremberg.

Gebbertstr. 123. D-91058 Erlangen. Germany [email protected]

Ms María Santaolaya Cesteros

Technical Officer. Ministry of Health and Social Policy.


Dr Ingrid Schoon Professor. Institute of Education, University of London.

20 Bedford Way. London WC1H OAL. England. United Kingdom

[email protected]

Ms Cristina Torró

General Associate Director of Health Promotion and Participation. General Secretariat of Public Health and Participation. Regional Ministry of Health. Junta de Andalucía.


Ms Cara Zanotti HBSC Research Communications Officer. HBSC International Coordinating Centre.

St Leonards Land, Holyrood. Edinburgh. Scotland. United Kingdom [email protected]

Dr Erio Ziglio

Head. World Health Organization, Regional Office for Europe, European Office for Investment for Health and Development.

San Marco 2847. 30124 Venice. Italy [email protected] copy in also [email protected]


Group of Young People invited as respondents:

Becki-Joe Christie Trainee youth worker, Project John Ltd. England, United Kingdom [email protected]

Thomas Finill Erasmus of Mathematics England, United Kingdom [email protected]

Chiara Fioretti Erasmus of Psychology Italy [email protected]

Karen Leppien Leonardo of Law School Germany [email protected]

Marian Lueder Erasmus of Sports Science Germany [email protected]

Alice Naundorf Student of Psychology Germany [email protected]

Liz Penn Student of Science, with a major in Chemistry

Canada [email protected]

Tiago Ribeiro Erasmus of Business Studies Brasil [email protected]

Adolescents from Portaceli School. Sevilla, Spain: Asunción, Blanca, Carlos, Carolina, Jaime, Javier, Lola, María, Marta and Pedro.

Adolescents from Professional Dance Conservatory. Sevilla, Spain: Elena, Lucía, Rafaela, Isabel, Rocío, Jazmín, Belén, Beatriz, Macarena, María, Marta, Natacha, Lucía, María, Sara Elizabeth, Ana, Juliana, Ana Belén, Soledad, Sara, Ángela, Irene, Lidia, Celia, Elisabeth, María Isabel, Blanca, Rosana, María, Carmen, Mª del Rocío, Mª Jesús, Mª Jesús, Milagros, Joana, Lorena, Macarena, Concha, Patricia, Elena, Alba, Mirian, Almudena, Alba, Mercedes, Marta, Inés and Rocío. And teachers: Ana Lía de Paz, José Manuel Moreno, Esther Rivas, Beatriz Adarve.

Organizing committee

& Technical secretariat



Symposium 1:


Seville, Spain

28-30 April 2010

Organizing Committee

Carmen Moreno. University of Seville, Seville (Spain)

Antony Morgan. NICE / University of Hertfordshire (UK)

Fiona Brooks. University of Hertfordshire, England (UK)

Erio Ziglio. WHO, Venice (Italy)

Candace Currie. University of Edinburgh, Scotland (UK)

Begoña Merino. Ministry of Health and Social Policies, Madrid (Spain)

Technical Secretariat

Pilar Ramos. University of Seville, Seville (Spain)

Antonia Jiménez-Iglesias. University of Seville, Seville (Spain)

Francisco Rivera de los Santos. University of Huelva, Huelva (Spain)

Viktorija Ziabliceva. University of Hertfordshire, England (UK)

Ellen Klemera. University of Hertfordshire, England (UK)

Jo Magnusson. University of Hertfordshire, England (UK)

Cara Zanotti. University of Edinburgh, Scotland (UK).

Margreet de Looze. University of Utrecht, Utrecht (Neetherlands)

Laura de la Rosa. Viajes El Corte Inglés S.A., Seville (Spain)

Health Assets for Young People's Wellbeing

Documents