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    'Staff publications' is the digital repository of Wageningen University & Research

    'Staff publications' contains references to publications authored by Wageningen University staff from 1976 onward.

    Publications authored by the staff of the Research Institutes are available from 1995 onwards.

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Understanding healthful eating from a salutogenic perspective
Swan, E.C. - \ 2016
Wageningen University. Promotor(en): Maria Koelen; Gerrit Jan Hiddink, co-promotor(en): Laura Bouwman; Noelle Aarts. - Wageningen : Wageningen University - ISBN 9789462576957 - 111
extension - foods - health - health education - health foods - health policy - pathogenesis - voorlichting - voedingsmiddelen - gezondheid - gezondheidseducatie - gezondheidsvoedsel - gezondheidsbeleid - pathogenese

The biomedical model of health orients towards pathogenesis, the study of disease origins and causes. The starting point is to understand determinants of ill-health, and health is defined in this model as the absence of disease. When applied to nutrition research, the underlying assumption is that eating is a physiological act, and that eating supports physical health. This risk-oriented, pathogenic view also underlies the search for determinants of unhealthful eating. However, there is such an emphasis on finding risk factors, that the biomedical model overlooks the fact that individuals also possess, or have access to, factors that support healthful eating. As a result, very little is known on factors that enable healthful eating and how these factors can be used to complement current health promotion strategies. The overall aim of this research was to contribute to a better understanding of healthful eating in the context of everyday life. We applied a complementary research framework, the salutogenic model of health, to 1) map factors underlying the development of sense of coherence (SOC); 2) study which of these factors are predictors for healthy eating; 3) unravel how people develop healthful eating practices in everyday life; and 4) integrate this understanding and provide building blocks for nutrition promotion. This research employed a mixed research design, using cross-sectional survey research and in-depth interviews.

Chapter 2 explored the possibilities of applying the salutogenic framework as a complementary approach to biomedical-oriented nutrition research and practice. Nutrition research takes a mostly biomedical-oriented approach to better understand risk factors that determine unhealthful eating. Though relevant for curative medicine, such an approach limits the evidence base for health promotion, which is guided by the principles that personal and social resources are preconditions for health and well-being. Moreover, biomedical-oriented nutrition promotion takes a reductionist approach and studies and enacts upon individual or the external environment separately. Disjointedly studying and enacting upon people and context may be easier, yet it does not do justice to reality and limits the relevance and applicability in everyday eating situations. The salutogenic model of health can provide complementary knowledge on what is already known through biomedical approaches. It guides the study of the dynamics between people and their environment and how health develops from this interaction. Since salutogenesis guides the study of health as an interplay between physical, mental, and social factors, it is more in line with how people experience eating in their everyday lives. In the study described in chapter 3, we examined individual, social, and physical-environmental factors that underlie SOC. Dutch adults (n=781) participated in a cross-sectional study examining the relationship between SOC and a set of individual, social- and physical-environmental factors. The main findings indicate that high SOC was significantly (p<.05) associated with a diverse set of factors including lower doctor oriented multidimensional health locus of control (MHLC); higher satisfaction with weight; higher situational self-efficacy for healthy eating; lower perceived social discouragement for healthy eating; higher perceived levels of neighborhood collective efficacy; and higher perceived neighborhood affordability, accessibility and availability of healthy foods. Non-significant factors (p≥.05) included gender; employment status; education level; cohabitation; BMI; nutrition knowledge; internally oriented MHLC; chance oriented MHLC; and perceived social support for healthy eating. These findings are relevant since they can inform the design of nutrition interventions that target factors that strengthen SOC and provide building blocks for a healthier life orientation. Next, the study in chapter 4 aimed to determine a set of individual, social and physical-environmental factors that predict healthy eating practices in a cross-sectional study of Dutch adults. Data were analyzed from participants (n=703) that completed the study’s survey and logistic regression analysis was performed to test the association of survey factors on the outcome variable high dietary score. In the multivariate logistic regression model, five factors contributed significantly (p<.05) to the predictive ability of the overall model: being female; cohabitation; a strong sense of coherence; flexible restraint of eating; and self-efficacy for healthy eating. Non-significant factors (p≥.05) in the multivariate logistic regression model included age; employment status; net monthly household income; education level; nutrition knowledge; internally oriented MHLC; perceived social support and discouragement for healthy eating; perceived neighborhood collective efficacy and perceived neighborhood affordability, availability and accessibility of healthy foods. Findings complement what is already known of the factors that relate to poor eating practices. This can provide nutrition promotion with a more comprehensive understanding of the factors that both support and hinder healthy eating practices.

Lastly, the qualitative study described in chapter 5 examined a group of healthy eaters and explored life experiences and coping strategies that foster healthful eating through narrative inquiry. The study was undertaken with seventeen Dutch women (aged 36- 54 years) in the highest quartile of dietary quality index scores. The main findings showed that life experiences gave rise to coping strategies that enabled healthful eating. Childhood experiences included: accustomed to non-processed foods and positive child-parent interactions. Adulthood experiences included: regained stability and structure in stressful life events and forged positive experiences with food. Coping strategies included: organizing eating in an uncomplicated manner; creativity in the kitchen; valuing good food with good company; approaching eating with critical self-awareness; and applying craftiness and fortitude during difficult moments. The findings suggest that there is an interplay between life experiences and coping strategies, and this mechanism underpins healthful eating. Findings offer potential entry points for nutrition promotion to foster healthful eating.

When integrating the research findings in chapter 6, we found that healthful eating results from three composite factors: balance and stability, sense of agency, and sensitivity to the dynamics of everyday life. Firstly, healthful eating results from balance and stability in life, represented by a strong SOC, which characterizes a balanced mixture of giving meaning to eating as an integral part of life, comprehending its importance to oneself, and having competencies to manage its organization in the everyday social context. In the life course, healthful eating also results from the ability to regain stability and structure in stressful life events and craftiness and fortitude during difficult moments. Healthful eating is also rooted in a sense of agency (the feeling of being in control of one’s own actions), with regards to the ability to take action related to eating and life in general. This sense of agency is enabled through flexibility, lower doctor oriented MHLC, applying creativity in the kitchen, and approaching eating with critical self-awareness. Thirdly, healthful eating results from a sensitivity to the dynamics of everyday life, with regards to the how people deal with and navigate through everyday challenging situations by applying individual- and context-bound factors including situational self-efficacy, organizing eating in an uncomplicated manner, valuing good food with good company, and perceiving less social discouragement for healthy eating from family and friends.

Few of the factors associated with SOC and healthful eating converged with risk factors for unhealthful eating found in previous studies, including coping, self-efficacy, restraint of eating, and living situation. Our findings show that the set of factors related to the origins of health substantially diverged from the set of factors related to the origins of disease. From this, we conclude that the “origins of health” differ from the “origins of disease”. Hence, factors that foster and support healthful eating are not simply the reversed version of the factors known to increase the risk of unhealthful food choices. This implies that a different set of factors should inform health promoting strategies, in addition to the factors informing strategies targeting the prevention of diet-related illnesses.

The new insights brought forth in this research provide building blocks for salutogenic-oriented nutrition promotion. 1) Strategies should take a more holistic orientation to food and eating, emphasizing a balance between physical, social, and mental health. Similarly, dietary guidelines should emphasis more than what and how much to eat for physical health and also consider the social and mental dimensions.

2) Nutrition promotion should develop strategies to support a healthful orientation to life. Through strengthening SOC, people can become more capable of coping with any situation or challenge, independent of whatever is happening in life. Nutrition promotion should also strengthen more general health promotion factors including mindfulness, critical thinking, and stress management because these skills support adaptive behavior when life circumstances change. 3) Strategies should facilitate health-directed learning processes through positive interactions and experiences with food. For instance, strategies that support health-directed learning processes should improve food-related procedural knowledge such as food literacy and cooking skills. They should also include socially-embedded learning experiences involving the selection, purchase, and preparation of healthful food; encourage positive parent-child interactions at the dinner table; and recommend that people cook regularly with partners, family or friends.

Twenty years of capacity building. Evolution of Salutogenic Training: The ETC 'Healthy Learning' Process
Pavlekovic, G. ; Pluemer, K.D. ; Vaandrager, L. - \ 2011
Zagreb, Croatia : European Training Consortium in Public Health and Health Promotion (ETC-PHHP) and Andrija Štampar School of Public Health, School of Medicine, University of Zagreb - ISBN 9789536255474 - 172
gezondheidsbevordering - gezondheidseducatie - volksgezondheid - opleiding - capaciteitsopbouw - europa - geschiedenis - health promotion - health education - public health - training - capacity building - europe - history
Wij moeten de spreekkamer uit : voedingsaspecten in de huisartspraktijk
Binsbergen, J.J. van; Groot, C.P.G.M. de; Bakx, C. van; Wayenburg, C.A.M. van - \ 2010
VoedingsMagazine 23 (2010)3. - ISSN 0922-8012 - p. 24 - 26.
overgewicht - kinderen - huisartsen - preventie - gezondheidseducatie - samenwerking - voedingseducatie - voeding en gezondheid - overweight - children - general practitioners - prevention - health education - cooperation - nutrition education - nutrition and health
Het aantal kinderen met overgewicht is aanzienlijk. 'Huisartsen vinden het doorgaans niet hun taak om de kinderen en hun ouders aan te spreken over dat onderwerp', zegt de huisarts dr. Carel Bakx. Maar ze willen wel graag- samen met andere professionals- een gezonde leefstijl bevorderen. 'Iedereen is van goede wil maar er is geen samenwerking. Dat komt omdat niemand de regie neemt.' Bakx en collega's hebben voor en collectieve aanpak gekozen. 'Wij moeten ons meer buiten de praktijk laten zien.'
Water en olie, dat mengt niet vanzelf : onderzoek naar theoriegebruik bij leefstijlcampagnes
Wevers, A. ; Renes, R.J. ; Woerkum, C.M.J. van - \ 2008
[S.l.] : ZonMw - ISBN 9789085852292 - 99
levensstijl - campagnes - ziektebestrijding - gezondheidseducatie - gezondheidsbevordering - informatieverspreiding - efficiëntie - theorie - onderzoek - kwalitatieve analyse - kwantitatieve analyse - volksgezondheid - nederland - kwalitatieve methoden - kwantitatieve methoden - lifestyle - campaigns - disease control - health education - health promotion - diffusion of information - efficiency - theory - research - qualitative analysis - quantitative analysis - public health - netherlands - qualitative methods - quantitative methods
Televisie voor dik en dun : onderzoek naar de effecten van een Entertainment-Education programma
Mutsaers, K. ; Woerkum, C.M.J. van; Renes, R.J. - \ 2006
Wageningen : Communicatiemanagement, Wageningen Universiteit - ISBN 9085851033 - 174
gezondheidseducatie - gezondheidsbevordering - vertier - methodologie - televisie - uitstrooien - efficiëntie - publiek - psychologie - motivatie - menselijk gedrag - gewichtscontrole - Nederland - health education - health promotion - methodology - television - broadcasting - entertainment - weight control - efficiency - audiences - psychology - motivation - human behaviour - Netherlands
The combat for gender equality in education : rural livelihood pathways in the context of HIV/AIDS
Kakuru, D. - \ 2006
Wageningen University. Promotor(en): Martin Mulder, co-promotor(en): Margreet van der Burg; Arjen Wals. - [S.l.] : S.n. - ISBN 9085045096 - 235
primair onderwijs - gezondheidseducatie - man-vrouwrelaties - platteland - afrika - acquired immune deficiency syndrome - hiv-infecties - plattelandsgemeenschappen - uganda - geslacht (gender) - gelijke behandeling van de vrouw - primary education - health education - hiv infections - acquired immune deficiency syndrome - gender relations - rural communities - rural areas - africa - uganda - gender - female equality
Nutrition Communication in Dutch General practice: integration of the patients' perspective and the family doctors' perspective
Dillen, S.M.E. van - \ 2005
Wageningen University. Promotor(en): Gerrit Jan Hiddink; Cees van Woerkum, co-promotor(en): Maria Koelen. - Wageningen : Grafisch Service Centrum - ISBN 9085042488 - 180
gezondheidsbevordering - gezondheidseducatie - communicatie - huisartsen - patiënten - ziekten - hart- en vaatziekten - suikerziekte - nederland - voedingseducatie - voedingsinformatie - diëten - health promotion - health education - communication - general practitioners - patients - diseases - cardiovascular diseases - nutrition education - nutrition information - diets - diabetes - netherlands
Health Education and Health Promotion
Koelen, M.A. ; Ban, A.W. van den - \ 2004
Wageningen : Wageningen Academic Publishers - ISBN 9076998442 - 285
gezondheidseducatie - gezondheidsbevordering - studieboeken - health education - health promotion - textbooks
This book is a comprehensive resource for theory, research and action in health education and health promotion. The authors describe strategies and actions for health education and health promotion based on theories for understanding, predicting and changing behavioural, social and environmental determinants of health. The book also offers a conceptual framework for planning, evaluation and research and discusses ethical issues in health promotion.
Mum to mum : an evaluation of a community based health promotion programme for first-time mothers in the Netherlands
Hanrahan-Cahuzak, M.H. - \ 2002
Wageningen University. Promotor(en): C.M.J. van Woerkum; C.M.H. Hosman; M.A. Koelen. - S.l. : S.n. - ISBN 9789058086389 - 175
gezondheidsbevordering - gezondheidseducatie - sociaal welzijn - moeders - ziektepreventie - voorlichting - zuigelingen - gezondheidszorg - nederland - baby's - health promotion - health education - health care - disease prevention - extension - social welfare - mothers - infants - netherlands - babies

Background This study evaluated the Dutch Mothers Inform Mothers (MIM) programme. In that programme a visiting mother meets with a first-time mother in her home on a monthly basis to discuss the caring and rearing of her infant. The first-time mothers went also to the well-baby clinics in their locality where they discussed topics in the areas of psychosocial, cognitive and physical development, language, play and safety. The programme lasted for 18 months.

Aim/objectives To evaluate the MIM programme with the view to:

- provide information and, where appropriate, recommendations concerning the positioning of the programme in the Dutch public infant health services;

- integrate appropriate theoretical perspectives into the MIM programme;

- determine outcomes in relation to maternal mental health, maternal and infant general health, maternal competence with parenting and satisfaction with the well-baby clinic.

Study design/ A literature review on parenting support programme focused on infant health.

Instruments A cohort-study using a pre-test - post-test design with one experimental and two control groups. This was used to develop and test a model for the programme and to determine its effects. The mothers' progress was followed for 15 months, which covers the period of infancy. (After 15 months is the toddler period). Validated instruments were used to gather information.

- An infant food consumption survey using 24 hour recall and questions on feeding practices (breast feeding or feeding bottle). For maternal fat consumption a popular questionnaire of the National Food Centre was used.

Timing The pre-tests for mental health, social support and breastfeeding were administrated when the infants were approximately 6 weeks old (T1). Infant temperament, maternal and infant general health, maternal competence with parenting and satisfaction with the well-baby clinic were measured at 10 months, as was the nutritional survey. The post-tests were administrated when the infants were approximately 15 months old (T3).

- A qualitative study was carried out to gain insights in the way MIM co-ordinators perceive visiting mothers and visa versa.

Study population Total number of mothers was 346. In control group 1 (no MIM but using the

same well-baby clinics as the experimental mothers) N = 221, control group II (no MIM and not the same well-baby clinics), experimental group (MIM plus attending well-baby clinic) N = 42.

Results The visiting mothers visit on average two first-time mothers. This is very not enough for developing expertise as a visiting mother. The workload of co-ordinators was on average 25 visiting mothers / 50% FTE. Some mothers needing the programme were not accommodated due to illness of the programme's co-ordinator, absence of MIM co-ordinator, or because the caseload of visiting mothers are the co-ordinator were felt to be to high.

    • A first attempt was made to develop a theoretical framework for the MIM using maternal and infant characteristics together with social support factors. The boundaries of the model were set by Bronfenbrenner's theory on human ecology. Social support and infant temperament are important factors when caring and rearing a child. These factors are present in the maternal and infant health and maternal competence models. Partners' support with caring and household activities is especially important when a baby arrives. The factor lack of support is also present on numerous occasions.

Unexpected was the importance of the factor life events during pregnancy and complicated delivery, which remained so in the development of maternal general health, even after 15 months.

    • MIM had no impact on maternal mental and general health, although maternal general health scores of the experimental mothers increased over time and those of the control mothers decreased. MIM also had no impact on infant general health. The administration of the last inoculation of the Mumps, Measles and Rubella vaccines coincided with the post-test. This may have influenced the infant health score. MIM had a significant impact on maternal competence with parenting. The lower score for maternal competence for MIM mothers measured at baseline had disappeared by T3 relative to the two control groups. The most important influence on maternal competence with parenting seems to be infant temperament. Satisfaction with the well-baby clinic increased over time for all groups. Participation in the MIM programme was not significant in the final longitudinal model, but was significant at baseline and T3. This means that there was no further deterioration in satisfaction with the well-baby clinic of MIM mothers relative to the other two groups in the last six months of the study.

Given that lack of support has an important relationship with maternal mental health in T1, T3 and longitudinal regression models, it means that the factors identified by this regression indirectly contribute to the mother's state of mind.

Conclusions The evaluation has shown positive programme effects, but these effects need to be improved for the programme to be cost-effective. The programme is instrumental in enhancing the quality of health promotion activities of well-baby clinic members; it plays a role in the quality assurance process and it has an effect on enhancing mothers' competence with parenting. There are no indications that MIM had an influence on the mediating variables. This may be influenced by the fact that variables not included in the study, such as maternal attitudes, locus of control, or self-efficacy, play a role in the theoretical MIM model. Making healthy choices the easy choices through MIM is a strategy for helping people to accept responsibility for healthiness of their own lives, recognising health as a resource to be protected and actively enhanced. In line with the nurses' scope of practice their role as facilitator and coach could be strengthened, giving more responsibilities to the visiting mothers and making MIM a truly community based and community-led programme.

Stap naar hechtere samenwerking tussen Nederland en Zuid-Afrika. Wageningse aio's op studiereis naar Zuid-Afrika
Gaag, M. van der; Lieshout, M. van; Melse, A. ; Olthof, M. ; Tiemersma, E. ; Vissers, M. - \ 2000
Voeding Nu 2 (2000)2. - ISSN 1389-7608 - p. 28 - 29.
voedselhygiëne - voedingstoestand - voedingsstoffentekorten - samenwerking - universitaire onderwijsprogramma's - universiteiten - praktijkonderwijs - onderzoekers - zuid-afrika - nederland - voedingsleer - gezondheidseducatie - gezondheidszorg - epidemieën - epidemiologie - wetenschappelijke medewerkers - intellectuelen - food hygiene - nutritional state - nutrient deficiencies - cooperation - college programs - universities - practical education - research workers - south africa - netherlands - nutrition knowledge - health education - health care - epidemics - epidemiology - academic workers - intellectuals
Het doel van de studiereis was om kennis uit te wisselen tussen de Nederlandse onderzoekers in opleiding en hun Zuid-Afrikaanse collegae, op het gebied van voeding, gezondheid en epidemiologie
Voedingsvoorlichting in beweging: op zoek naar effectiviteit
Hiddink, G.J. - \ 2000
Wageningen : Wageningen Universiteit - 40
voedselwetenschappen - voeding - gezondheidseducatie - volksgezondheid - gezondheid - food sciences - nutrition - health education - public health - health
The turtle and the peacock : collaboration for prosocial change : the entertainment - education strategy on television
Bouman, M. - \ 1999
Agricultural University. Promotor(en): C.M.J. van Woerkum, co-promotor(en): G.J. Kok; E.M. Rogers. - S.l. : Bouman - ISBN 9789054859956 - 279
gezondheidseducatie - gezondheidsbevordering - gezondheid - communicatie - televisie - vertier - zepen - samenwerking - onderwijs - health education - health promotion - health - communication - television - entertainment - soaps - cooperation - education

In the early eighties, a popular prime time drama serial Zeg eens A was being broadcast in the Netherlands. Health communication professionals who saw this series regarded it as an interesting setting in which to introduce and deal with health communication messages (see for example Bouman, 1984). At that time, however, collaborating with scriptwriters of popular television programmes was a problematic issue, due to the fact that health organizations had great reservations about using a popular medium like a tabloid, a gossip magazine, a soap opera or other drama series to communicate serious health messages (Dekker, 1985 personal conversation). Apart from their unfamiliarity with popular culture, health organizations feared losing their respectable image and, as a possible ultimate consequence, their funding. Although understandable, this showed an explicit tension between the goals of health communication and the goals of public relations and fundraising. Health communication professionals however saw that the messages of health organizations have to compete with thousands of other communication messages. If the attention of the target audience is to be caught and held, and more especially if that audience is not spontaneously interested in health messages, it is no longer sufficient to rely solely on the rationality of the message: other, more emotionally appealing and popular communication methods must also be brought into play. Some health organizations acknowledged this, but did not yet accept its consequences. Zeg eens A became the most popular Dutch drama serial of the eighties, but never carried a purposively designed and eloquently interwoven health message1.

As time went by, the climate for using entertainment television for health communication purposes changed however, and worldwide a number of ways were found to incorporate health promotion messages into popular television entertainment. This approach is now known as the entertainment-education (E&E) strategy (Coleman & Meyer, 1989). In the Netherlands also, some challenging experiments were carried out in the late eighties, such as the drama series Familie Oudenrijn in 1987 (Verbeek, 1990), the Way of Life Show in 1988 (Nederlandse Hartstichting, 1988; Bouman, 1989) and Villa Borghese in 1991 (Bouman & Wieberdink, 1993).

The first experiments with E&E television programmes initiated a lively discussion and debate about norms and values in the Dutch health communication field. This provided an impetus for the creation of new and experimental ways of reaching the so-called 'hard to reach' groups. Because of the many still unanswered questions, research in the field of the entertainment-education strategy is both necessary and rewarding.

In the next four sections, some matters that need to be explicated will be touched upon. Section 1.1 defines some concepts frequently used in this thesis. Section 1.2 lists the research questions of the thesis. Section 1.3 gives a short overview of the health communication field, divided into organizations, health communication professionals and health communication strategies. Section 1.4 briefly describes the field of television in the Netherlands. Section 1.5 gives an overview of the thesis chapters, and section 1.6 summarizes this chapter.

Definitions
The subject of this thesis is collaboration for prosocial change; the entertainment-education strategy on television. The concepts in the title of this thesis are defined as follows:

  1. In this thesis, collaboration refers to two different professional fields working together to design and produce a television programme in which entertainment and education are combined. The two professional fields concerned are the field of health communication and that of television production. In a wider sense these represent national health organizations on the one hand and broadcasting companies and independent production companies on the other; in a narrower sense they are the health communication professionals and television professionals working within these respective organizations.
  2. The term prosocial denotes 'that which is socially desirable'. From a critical theory perspective, questions can be raised about what is socially desirable (see also Chapter 2, section 2.4.). In this thesis, health is the object of prosocial change. Health is defined by the World Health Organization (WHO) as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity' (WHO, 1986). The goals of prosocial and health communication, as referred to in this thesis, are directly derived from policy papers as formulated and formalized by national governments, and indirectly by international organizations, such as the WHO.
  3. In this thesis, change agencies are national health organizations. National health organizations as change agencies are defined here as either government related agencies or non-governmental organizations (NGOs) and the change agents are health communication professionals who work within these organizations. Health communication is regarded here as an essential element of the wider concept of health promotion. Some of the researched projects in this thesis also concern broader health related issues, such as environmental communication or road safety, but the term 'health communication' will be used as an overall concept for all forms of prosocial communication with which this thesis deals.
  4. Entertainment-education (E&E) strategy refers to the combination of entertainment and education in order to promote prosocial change. In Chapter 2 the definition of the entertainment-education strategy will be elaborated. The E&E strategy can be applied to different popular media: theatre, music, film, radio, television, etc. This thesis focuses on the use of the E&E strategy in television.

Research questions
Television entertainment as a potential vehicle for health promotion is regarded as a challenging concept. A study into the use of the E&E strategy in television refers to such questions as: 'What are the characteristics of television programmes in which education has been or can be combined with entertainment?' 'How effective is the E&E strategy?' 'Which facilitating or hindering factors play a role in the collaboration between health communication and television professionals when making an E&E television programme?' 'Is it possible to develop a working model that helps practitioners to decide if and how an entertainment-education programme can be designed and produced successfully?' These - and other - questions have led to the central research question, which is twofold:

  • A) What are the characteristics of entertainment-education (E&E) television programmes which are purposively designed to enhance prosocial behaviour, and what is known about their effects and conditions for success?
  • B) How do health communication and television professionals collaborate in the design and implementation of an E&E television programme and what recommendations can be made for the management of E&E collaboration in the future?

Anderson and Meyer (1988) indicate that the motives of a researcher to investigate a certain topic can be epistemological in nature, but the results and implications of the research can be ideological and economic. In this study all these components play a part. As E&E practice is ahead of E&E theory, the aim of this research is to transpose the experiences of E&E practice into a theoretical framework and to add new concepts to the discourse of E&E communication professionals. In order to answer the questions posed in this thesis, the following research has been undertaken:

  • A review of the literature on the theory and practice of health communication, mass media (television) and the entertainment-education strategy;
  • An analysis of the quantitative data of Dutch E&E research;
  • An analysis of E&E television programmes worldwide;
  • A review of the literature on television production and collaboration;
  • An in-depth qualitative study into the collaboration process between health communication professionals (N=18) and television professionals (N=12) on twelve Dutch E&E television programmes.
  • As the E&E strategy is not yet widely known, let alone implemented in Dutch health communication and television practice, a rather broad scope has been chosen in this thesis. The disadvantage of this is that not all related subjects can be given an exhaustive treatment. The advantage, however, is that a solid basis is created for further analysis and research.

Epilogue I

Conclusions and lessons learned (Summary part I)
The purpose of this section is to summarize some of the experiences and lessons of the E&E television programmes studied here in order to assist the design of E&E television programmes in the future and to answer the first part of the central research question in this thesis:

A)What are the characteristics of entertainment-education (E&E) television programmes which are purposively designed to enhance prosocial behaviour, and what is known about their effects and conditions for success?

Characteristics
Entertainment-education (E&E) television programmes which are purposively designed to enhance prosocial behaviour are not just regular television programmes. In order to be effective, the design of E&E television programmes (drama, comedy and soaps, or quizzes, gameshows and talkshows/magazines) should be based on the principles of vicarious learning and social modelling. The actual modelling and observational learning process is governed according to Bandura (1986) by four interrelated subprocesses: attention, retention, production and motivation (see Chapter 2, section 2.3.5). Based on these four processes, combined with the research results of the design and effects of E&E television programmes worldwide, the following characteristics can be identified as important for the design and success of E&E television programmes:

Attention process
First, the socially desirable television model must catch the attention of the audience (observer). In entertainment-education television, this is achieved by using a popular programme genre. Other variables, such as the perceived credibility and attractiveness of the model, also come into play. It is important to use spokespersons (show host, stars, actors) that the audience will trust and believe. Entertainment-education television must be of high quality, using skilled and talented professionals. The production quality has to meet or exceed media standards. It is important to keep entertainment in the foreground and education in the background. First the audience has to get involved in the programme, later messages can be introduced and incorporated. It is important to cater for both the head and the heart and to be dramatic and moving. Although different kinds of programme formats have been used in E&E television studies, varying from talk and gameshows and variety shows to popular soap and drama series, realistic social drama is especially successful in involving people emotionally. There is much inconsistancy about the effectiveness of humour. Studies concluded that in order to be an effective aid to learning, humour must be at least meaningfully related to the material to be learned. The humour should coincide perfectly with the critical learning opportunity.

Retention process
In order to reproduce the behaviour without the presence of the model, it is necessary to retain the image and verbal symbols that are provided. Retention of modelled information is enhanced when viewers perceive the model and the circumstances to be similar to themselves and significant in their lives. The programme has to involve a variety of problems which are eventually solved to the benefit of positive role modelling characters.

It is necessary to present role models who exchange ideas and opinions about the prosocial issue involved. In this way, different segments of the population will be able to identify with the issue at hand. Vicarious learning can best take place when viewers identify with and relate to these role models and when viewers recognize issues as relevant for their daily lives. This way, television programmes can serve as touchstones for experiences which viewers have and which they see reflected in the programme. The programme has to be realistic, set in todays world, include events in different settings (urban and rural), and depict characters who are regarded by the viewers as 'people like us'.

Depicting lifelike situations and portraying social models who are 'people like us' is an essential part of E&E television programming to create the circumstances necessary for social learning and to enhance a feeling of involvement. A realistic programme does not mean that every detail must conform to reality, but that it has a contemporary setting, that it concerns itself with secular action (human action described in exclusively human terms) and that it is socially extended, which means that it deals with the lives and experiences of ordinary people. With reference to the latter, to avoid feelings of embarassment or stigmatization, it is advised to depict positive role models with a slightly higher aspiration level. Domestic productions with outdoor scenes at well known sites, using colloquial language, make E&E television more realistic.

The essence of the entertainment-education strategy is to use television characters as models of behaviour and to encourage audience members to talk each other into practising the desirable behaviour they see portrayed. Entertainment-education programmes are designed to stimulate and enhance parasocial interaction between viewers and television personalities and characters and encourage talking with neighbours, family and friends about what they have seen on television. Memorable images and the acting out of prosocial behaviour are remembered better and longer than dialogues and lectures about such behaviour. E&E television programmes have to link in with what is already part of public awareness. The influence is problably greater when a message evokes recognition and then adds an idea or concrete information to that, rather than when it is contradictory to the prevailing opinion. It is important that E&E television programmes address their objectives by associating them with pre-existing human values and dramatizing how specific role models learn to actualize these values in their lives by practising the prosocial behaviour.

Production process
The third subprocess that influences the degree of modelling is called the production process. This process addresses the ability of the individual to replicate the observed behaviour, or the translation of retained symbols into guides for future behaviour. In order to reproduce the modelled behaviour it is important to tell audiences what they can do now, referring them to sites (e.g. address, telephone, Internet page) for answers on questions or to services or service providers that are familiar, available and ready. Some ways to do this are: (1) by using several 'reality reminders' epitomizing appropriate behaviour; (2) by 'advising' viewers how to deal with specific situations; and (3) by introducing epilogues to programmes to summarize the main educational points and to provide specific information about the services and infrastructure needed for viewers to convert an intention, motivated by the television programme, into action. Direct messages work best, especially with hard to reach audiences. Researchers report that respondents with lower levels of education gained more from factual information and knowledge about health issues than from more subtle messages conveying particular attitudes from which they were sometimes unable to draw appropriate inferences. Respondents with higher levels of education, however, gained most from the inferential messages tackling prejudice and attitudes. This confirms that different audiences demand different kind of message frames. Clear cut factual information and practical advice seems to meet especially the needs of the less well educated, while implicit contextual information suits more highly educated audiences. It is also suggested that a more direct approach may be more successful in addressing issues where attitude change is likely to be particularly difficult. It is important to focus on so-called 'personal efficacy', or the extent to which people think that they have the skills to change their behaviour. Focusing on imparting skills to handle different situations seems to offer a better prospect for changing behaviour than emphasising the damaging effects for health. Another approach which does not place too heavy an emphasis on the transfer of information and does not become too serious, is to depict how ordinary people deal with dilemmas in everyday life: how they share emotions, exchange ideas and arguments about a certain issue and how they make their final choice for one or the other behaviour.

Message framing based on a 'consumer approach' supports and empowers lay people, in contrast to a 'medical approach', which underlines and supports the central role of the educated health care professional. Message framing according to a 'look after yourself' approach focuses on individual lifestyle determinants of health problems, and an 'environmental approach' stresses the socio-economic determinants and conditions of health problems.

Motivation and reinforcement process
The most important and decisive subprocess is motivation and reinforcement. An individual may observe, retain and have the ability to translate the retained symbols into specific behaviour, yet not do so unless favourable incentives are introduced. Motivational processes address incentives to exhibit modelled behaviour, including direct and vicarious rewards. There are three types of modelling characters with whom the audience needs to identify closely in order to vicariously experience the rewards (or punishment) for practising the promoted behaviour: (1) those who support the prosocial behaviour (positive role models), (2) those who reject it (negative role models), and (3) those who move from antisocial to prosocial behaviour (transition models). In entertainment-education television programmes, the observer or viewer learns vicariously by watching a television model being visibly rewarded or punished immediately after the model engages in prosocial or antisocial behaviour. These rewards or punishments must be realistic and can vary from subtle gestures to more explicit moral statements.

Effects
In general we can say that, from a social marketing perspective, the use of entertainment television formats has been very beneficial. Most programmes gratified both the need for entertainment and education and attracted a huge public, in ways that cannot be achieved by straight-forward didactic approaches. The programmes had favourable prime time slots which are never given to more conventional health education television formats. The most reported impact of E&E television programmes was at the level of exposure and awareness. Several results have also been reported in affecting knowledge, attitude and even in some cases a change of behaviour regarding the prosocial issue. The strength of E&E television programmes lies especially in social modelling, social reinforcement and interpersonal communication. Some E&E television programmes were also successful in triggering and mobilizing local communities (collective efficacy). While the direct effects of most E&E programmes were modest, the indirect effects via the encouragement of peer comunication can be substantial. Effects occur through the social psychological processes of social modelling, parasocial interaction and efficacy building which take place particularly when audience members discuss the content of an E&E message in peer communication. Although generally E&E television proved successful in raising the attention of the audience in respect of the prosocial issue and in communicating the message as intended, clearly failure has to be accepted in certain areas. The entertainment education strategy is not free of problems. Viewers did not always identify with the intended characters and it was sometimes difficult to find the right balance between entertainment and education. In addition, many summative research designs had methodological limitations.

Entertainment-education by itself can sometimes bring about social change, and under certain conditions (in combination with other sources of influence) it can create a climate for social change.

There are several contextual differences between non-western and western countries that may explain why some E&E televison projects are more successful than others, such as differences in infrastructure, available audiences, novelty and timing and other societal factors.

Conditions for success
As indicated earlier, the entertainment-education strategy is based on a social marketing approach, implying a strong focus on the social adoptability of prosocial messages and a consumer orientation. In order to position the 'product' and to be responsive to consumer needs, pre-production research and 'product testing' (formative research) is of utmost importance. Various techniques of social marketing are used in the design of entertainment messages (e.g. formative evaluation, audience segmentation, needs assessment, product development, pre-testing).

Research-based knowledge about the characteristics, needs and preferences of the target audiences can substantively inform and support the design of entertainment-education programmes. This may be done by having the scripts of E&E television programmes read by representatives of the target audience, by inviting audience representatives to participate in the design process, or by organizing focus groups to get actual information and feedback from the specific target group. In order to achieve realistic portrayals, visiting the sites and neigbourhoods where the target audience lives and talking with them about their day to day problems and experiences have proved to be of considerable value. In particular, establishing whether there are any rumours, myths or misinformation around the issue involved is helpful in designing the content of the programme and very helpful in choosing positive and negative role models. Besides improving the messages and materials, the process of audience analysis and pretesting also proves helpful in generating a sense of involvement in the collaboration process between television professionals and health communication professionals. Some researchers report that by attending the focus-group discussions and reflecting on the feedback from the potential audience, the collaboration partners came all the more to the realization that communication is a process, not a product.

This extensive formative research, however, demands more preparation time before and during the design of an E&E television programme than conventional television programmes. This calls for careful planning in advance and communicating with the television professionals in order to meet the demands of the production schedule. Effective implementation requires the creation of solid ground in order to optimize programme effects. The research shows that E&E television programmes that are part of a multi-media campaign and are combined with a variety of other promotional and educational activities to inform and influence target groups are the most effective. E&E television alone cannot cause change without the support of other socio-cultural and structural factors. The importance of providing adequate infrastructural services to support E&E is emphasized. In order to be effective E&E television programmes need to be well planned, researched and orchestrated, but even the most thorough planning, research and orchestration do not guarantee success. Enough time, adequate funding over a sustained period, applied by a dedicated staff of able people using strategies based on research, is also essential. Effective communication demands a high level of commitment and multidisciplinary teamwork. The way in which collaboration partners succeed in building a win-win relationship is important for success.

Epilogue II

Conclusions and Lessons Learned (Summary part II)
In this section, an overall view of the experiences and lessons of the E&E collaboration processes as studied in Part II of this thesis will be given, and an answer will be provided to the second part of the central research question of this thesis:

B)How do health communication and television professionals collaborate in the design and implementation of an E&E television programme and what recommendations can be made for the management of E&E collaboration in the future?

Characteristics
In general, the E&E collaboration between health communication and television professionals was experienced as complicated. Bourdieu's general theory of practice (see Chapter 6) may be of assistance in gaining more insight into the hows and whys of the complexities of the E&E collaboration process. The key concept in this theory is that of 'habitus'. The habitus is sometimes also described as a 'feel for the game', a 'practical sense' that inclines agents to act and react in specific situations in a manner that is not always consciously calculated, but nevertheless fits the rules of its 'field' (the 'territory' of the habitus). It is clear that health communication and television professionals belong to different fields and thus employ a different habitus. In collaborations, however, where fields more or less have to integrate in order to reach a common goal, like in E&E production, it is necessary that both parties attune (make 'congruent') their habitus to that of their collaboration partner.

In the E&E collaboration processes under study, health communication and television professionals experienced a lot of incongruency because they had different interpretations of the habitus the collaboration required. Television professionals talked about 'viewers' and 'viewers satisfaction', and health communication professionals about 'target groups' and 'behaviour change'. With regard to programme content, television professionals looked at potential topics in terms of visualization and gaining the attention of the audience, seeing these as goals in themselves. Health communication professionals were interested in the topics' potential for vicarious social learning and influencing audiences' awareness, attitude and behaviour. What was an end in itself for television professionals was a means for health communication professionals. Consequently, both wanted to obtain and maintain steering power during the whole E&E collaboration process. Health communication professionals wanted to work along the principles of behaviour change theories and to have influence on all programme aspects: content, form, angle, context. Television professionals, however, expected a clear division of tasks: health communication professionals to deliver and to take care of the content of the message, and television professionals to design the format in which the health message could be best televisualized. So it appears that instead of creating common ground (or habitus), both fields first just employed their own habitus. Then almost automatically the question arose as to whose habitus was the strongest and could force the other to comply with its rules.

According to Bourdieu, in order to be accepted by a field (to be 'consecrated'), one must possess the habitus which predisposes one to enter that field. Without full recognition of the habitus, a field will always reject or try to exclude new 'players'. Although television organizations often took the initiative for the E&E collaboration, and in that sense were the requesting party with regard to health organizations, practice showed reversed positions. Besides paying an entrance fee (delivering economic, cultural and/or social capital), health communication professionals were more or less forced (not always conciously) to incorporate the televison field's habitus in order to be 'consecrated' and allowed to 'play along'. For health communication professionals, especially when they were newcomers to the television field, this proved to be a complex and demanding task that often made them feel they were drifting away from their own field. In their eyes, working along the television professionals' frame of reference caused an asymmetry of power. This was not what they had in mind when they started the collaboration. Moreover, this acquisition of the habitus of the television field jeopardized their relations with their own organization. By 'going native', they put not only the backing of their organization at risk, but also its symbolic capital (fear of misrepresenting their health message, losing their respectable image, damaging their networks). Health communication professionals, knowing this, became hesitant to assimilate the television field's habitus, and experienced difficulties in shifting between the two fields.

Differences in field mechanisms also played a significant role in the complexity of the collaboration. According to Bourdieu, the field with the greatest economic and commercial interests will (try to) dominate other fields. Ultimately, the competition for high viewing rates always determined the way the E&E television programme was designed. In this case, the television field dominated the health communication field. Health communication professionals had to prove that an effective E&E television programme could not be made without their professional input and expertise with regard to behaviour change. That burden of proof was additionally complicated by the fact that the collaboration motives of national health organizations ranged from raising money, creating publicity and selling products to influencing behaviour change. In cases where behaviour change was not an aim, specific behaviour change expertise indeed was not needed. Television professionals in such situations could just follow their own knowledge and expertise. To design E&E television programmes, however, their knowledge and expertise are not sufficient, and there is a requirement for the specific expertise of health communication professionals about the way the programme can be attuned to the goal of prosocial behaviour change, and therefore the merging of professional cultures becomes inevitable. Because of all this, combining entertainment and education in the television field means working within a high risk context.

Conditions for success
The nature of the habitus will in almost all cases militate against fields easily merging and working together in harmony. Specific measures have to be taken to stimulate the fusion of one habitus with the other and to build an E&E collaborationship based on symmetry of power. What is required is a joint frame of reference which incorporates elements of the habitus of both professional fields. Both partners have to acquire a new 'E&E habitus' that materializes in an E&E television programme with specific genre features and working principles, and which is consecrated by both constituting fields. The next important question is how both types of professional can be convinced of the advantages of collaborating on common ground. The answer to this question is not yet fully clear, but engaging in some informed speculation may provide a few clues. When health organizations experience the asymmetry of power in the collaboration as a crucial factor hindering success, they may find ways to exert their power to exclude: 'if the television field does not collaborate on our terms, they cannot have our money or expertise'. This will certainly help health communication professionals to gain self-esteem, and maybe even stimulate the expansion of their habitus. It would be an antagonistic strategy however, which in the long run probably would result in unwanted adverse effects on the power balance.

The designing of new incentives to create a joint frame of reference can be expected to have more, and positive, effects. Probably the best incentive will be the attraction of a new television genre which is both challenging and promising. Health organizations as well as television organizations, therefore, are recommended to invest in establishing the features for this genre and to stimulate the formation of capital relevant to an 'E&E habitus'. Cultural, social and symbolic capital can be formed by establishing professional standards and by achieving success. Cultural and social capital originate where a body of knowledge and expertise is acknowledged and distributed by a core network of professionals. Symbolic capital is ultimately confirmed by success. In order to achieve this, a substantial investment is inevitably required from both fields: health organizations must become more television literate, television organizations must combine commercial interest with social accountability, and both must move from a production-centred to a truly audience-centred attitude.

Constructing a healthy balance : action and research ingredients to facilitate the process of health promotion
Vaandrager, H.W. - \ 1995
Agricultural University. Promotor(en): C.M.J. van Woerkum; J.R. Ashton; M.A. Koelen. - S.l. : Vaandrager - ISBN 9789054854326 - 245
gezondheidseducatie - voedingseducatie - voedingsinformatie - voedselhygiëne - voedingstoestand - consumptiepatronen - voedsel - voedingsmiddelen - consumenteninformatie - consumenten - onderzoek - vraag - europa - health education - nutrition education - nutrition information - food hygiene - nutritional state - consumption patterns - food - foods - consumer information - consumers - research - demand - europe
There is a strong consensus that nutrition issues in Europe play an important role in public health. During the last half century Western diets have become unbalanced. They now contain too much fat, too much sugar and salt, and not enough fibre. The best diet to reduce the risk of heart disease is one which protects against obesity, diabetes, common cancers and other western diseases, and also promotes general good health. Nutrition education, or transfer of information, is known to be a relatively unsuccessful strategy to improve diets because only modest correlations have been found between knowledge about diet and eating behaviour. What people buy and eat depends on individual, social, cultural, economic and environmental factors, In short, food choice is a complex process. Information supply on its own is insufficient as a strategy to promote healthy eating. Public health professionals in five European cities (Eindhoven, Horsens, Liverpool, Rennes and Valencia) decided to start a joint project trying to use the health promotion approach as an alternative strategy. This so-called SUPER project is analysed in this doctoral dissertation, because it could give many insights in the health promotion approach. The three main research questions are:

(1) Is the health promotion approach suitable for promoting healthy nutrition?
(2) What factors contribute to success or failure in developing a health promotion approach aimed at improving public nutrition?
(3) Is the knowledge gained by this multiple case study suitable for other cities and other topics?

The main objective of this doctoral dissertation is the development of strategies for facilitating processes of local, national and international collaboration in the field of nutrition. In The Netherlands the SUPER project was financially supported by the Dutch 'Praeventiefonds'. The European network is financially supported by the European Commission (BIOMED).

In chapter I the discussion focuses on existing strategies to promote healthy eating which have not been very successful. It is argued that the starting-points for health promotion are fundamentally different from health education. Health promotion uses a broader perspective, is more context specific, is partly unpredictable and requires flexibility for practice as well as for research. A basic principle of health promotion is a shift from interventions imposed from the 'top' to facilitation of an ongoing process, creating a physical and social environment which enables individuals to interact and gain more control over enviromnental factors and thus their own health.

In chapter 2 food consumption patterns, prevalence of nutrition related diseases and nutrition policy in the countries participating in the project are presented. The countries can be divided in two comparable groups for general diet characteristics, diet related diseases as well as for the development of nutrition policy. The first group includes Denmark, the Netherlands and the United Kingdom, the second group includes Spain and France. The latter has a higher consumption of fruit and vegetables whereas the first group has a higher consumption of fat and sugar. There is also a clear gradient of coronary heart disease mortality across Europe ranging from high in the North to low in the South. Since the United Kingdom, Denmark and the Netherlands have higher rates of cardiovascular disease they have been more active in the field of developing nutrition policies. Slow development of nutrition policies in Spain and France is also related to the fact that the Spanish, and especially the French are very proud of their diet and are quite convinced that their diet is healthy. For a nutrition policy on a national level two factors seem to be important: (1) a sound supply of food stuffs and (2) promotion of healthy eating habits. The first factor is well taken care of in the five countries whereas the second leaves much to be desired. It seems desirable to find a better balance between the individual choice strategy and the structural change strategy.

The answer to the seemingly simple question 'why do individuals and population groups eat what they do?' is difficult because the choice of food involves a multitude of factors. As illustrated in chapter 3, various models of food choice have been proposed in the course of time. Some have emphasized internal motivation, other have concentrated on environmental factors. Food choice is discussed from several disciplines such as anthropology, social psychology, nutrition science and sensory research. Each of these theoretical insights, viewpoints and models have contributed to an understanding of the factors which shape food choices, at the same time leaving many questions unanswered. Furthermore, since food choice behaviour is a dynamic process these insights are constantly developing.

Without taking the broader context into account health education has been criticized as 'victim-blaming'. This led to a shift in thinking about health which is comparable to the shift in thinking in the field of agricultural extension. Many present-day viewpoints in this field are similar to those in the field of health promotion. This is described in chapter 4 and it is explained how this has resulted in the choice for the systems perspective. From this perspective, change in one sector usually implies that adjustments or responses also have to occur in other parts of the system. Not only change of individuals, but change of all actors in the food and health system is required. Community participation and intersectoral collaboration are perceived to be important elements of health promotion. A variety of interpretations of these concepts exists. The interpretation of these concepts has clear consequences for the choice of success factors. The more facilitative the approach becomes, the more one is interested in process indicators. For the SUPER project participation has been understood as active sharing of information among the different subsectors in the food and health system. Active sharing of information was viewed as an important prerequisite for facilitating change.

The use of the health promotion approach in the field of nutrition was new for all participating cities. A continuous learning process throughout the project resulted in redefining goals, research and philosophy with time. In chapter 5 and 6 it is shown how these learning experiences have influenced the project and research methodology. It is explained that action and research are strongly related and that the project was not designed to test hypotheses. Step by step actions have been taken, adapted and improved.

Chapter 5 describes the project methodology of the SUPER project. In each city two project areas were selected (a deprived area and a wealthy area). Intersectoral steering groups were set up consisting of people who worked and lived in the project areas, and who were able to plan nutrition promotion activities which were suitable for the local situation and which the local inhabitants believed to have a potential impact. The original idea behind the project was to organize activities in supermarkets, but the project broadened out to other settings such as health centres, schools, libraries and neighbourhood centres. The programme in each city was based on the same principles but differed in detail because of local and cultural differences.

Chapter 6 explains the research methodology of the SUPER project. During the development of the project it became clear that measuring a possible change in nutrition behaviour (a behaviourial endpoint) as a result of the activities, was an extremely complex undertaking. Furthermore, although the effect on nutritional behaviour is a valued outcome, collective work with the community on the issues related to nutrition can be seen as equally important. Studying participation processes and formative evaluation therefore achieved more emphasis after the first phase of the project. The effectiveness, feasibility and comparability of the project was evaluated in the course of three years. Research to guide and support the project was carried out on

(1) individual level (knowledge, attitudes, behaviour);
(2) enviromnental level (local possibilities to buy healthy food or to obtain information about healthy nutrition);
(3) community level (social networking, including the quality of participation from the different participants and conditions for cooperation); and
(4) the level of the project as a whole (incorporation in the structure).

Chapter 7 reports project development, implementation and evaluation of the project in Eindhoven. In chapter 8 the course of the projects in the other cities is described. Networks and the activities initiated in the five project cities have been incorporated into the local structures so that the health promotion approach in the field of nutrition has become a structural approach. Intersectoral collaboration resulted in complementary approaches including creating supportive environments, organizational change and social and individual development. The interactive character and the importance of linking to local possibilities have resulted in independency of the projects, i.e. projects do not only rely on outside funding and outside human resources. Furthermore, practical tools for health promotion programmes have been developed. There has also been a positive change in
environmental factors (both physical and social) which influence public nutrition. Examples of these changes are the willingness of supermarket managers to continue with activities, repetition of successful nutrition promotion activities in different community settings and schools paying more regular attention to nutrition education. Most importantly, the actors within the local nutrition and health systems are communicating with each other. Interest, curiosity and awareness has been created and those involved have experienced ways of working together effectively. By means of encounters and discussions, mutual dependencies have become clear, thereby creating possibilities for negotiation. Overall, the project was successful in establishing a sustainable basis for continuation and there is enough reason to believe that in the end individual behaviour will also change in the positive direction.

Chapter 9 details the results of the project as a whole. It is concluded that experiences of the five case studies taught that it is possible to stimulate and facilitate an ongoing process in the field of nutrition that creates a social foundation for improvements in health. Four success factors are mentioned: (1) reflection and flexibility; (2) cultural change; (3) visibility and transparency; and (4) the role of a community organizer.

Reanalysing the situation and reflecting on what had been successful or disappointing, appeared to be an important success factor for continuation. Cultural change refers to the learning process of both professionals as well as community members and their new role models. Visibility is important for four aspects of health promotion in practice: (1) visibility of process and outcomes (output); (2) visibility of activities (input); (3) visibility of possibilities and contribution of the actors involved; and (4) visibility of health promotion principles, procedures and approach.

All four function as incentives for action and continuation. A community organizer is important for facilitating the networking process itself.

Based on the results it is recommended that local, regional and national governments need to create situations in which actors of the food and health system recognize their interdependence and feel responsible for improving public nutrition. Educational material is necessary, but it is stressed that it is important to make more use of what is available and to try and improve connections to existing questions or questions which are raised through the interaction and participation process.

Tales of logic : a self-presentational view on health-related behaviour
Koelen, M.A. - \ 1988
Agricultural University. Promotor(en): N.G. Röling, co-promotor(en): G.J. Kok. - S.l. : Koelen - 129
communicatietheorie - cybernetica - gezondheidseducatie - informatie - communication theory - cybernetics - health education - information

This dissertation questions the informational approach to health education. Many health education programmes are conducted with the implicit assumption that providing individuals with relevant information about the consequences of unhealthy behaviour will lead to a healthier way of life. Evaluations of health education programmes show, however, that rational cognitive appeals often do not seem to possess enough power to motivate people to change their behaviour. This study examines the extent to which health-related behaviour can be explained by the wish to be accepted by others.

Two theories are described: attribution theory and self-presentation theory. In attribution theory it is assumed that individuals are logical information processors. By means of 'naive scientific' analysis of available information, the individual tries to obtain a veridical view of reality. Self-presentation theory assumes that individuals are motivated to create an impression on significant others that will lead to approval and avoid disapproval, by means of, for example, overt behaviours such as expressed opinions and dressing. The results of two experiments show that individuals use attribution statements for self-presentaional goals. When an actor perceives that others cannot easily repudiate a boosted self-presentation, the actor tries and succeeds to impress on others by self-enhancing attributions. When others do have access to possible repudiating information, actors' attribution statements are accurate.

Subsequently, self-presentation theory is applied to health-related behaviour. In two field studies the assumption of many anti-smoking campaigns that smoking adolescents are less capable to resist peer pressure than nonsmoking adolescents is questioned. Self-presentation theory appeared to contribute to a fuller understanding of the working of peer pressure. Peer pressure is related to lifestyles, and it should be conceived of as a twoway influence process, in which it is rewarding for both the individual and the group to act in accordance with existing group norms. Peer pressure is equally strong for smokers, intenders and non-smokers.

The results of the four studies show that behaviour often is guided more by self-presentational concerns than by concerns for cognitive consistency. The results of the studies can facilitate a more effective use of the influence of the social environment in health education.

Voeding in het basisonderwijs : welke basis hebben de kinderen? : een onderzoek naar opvattingen van schoolkinderen in Amersfoort over voedsel en voeding
Maaswaal, M. van; Roorda, L. - \ 1983
Wageningen : L.H. (Rapport / Vakgroep Humane Voeding. Landbouwhogeschool no. 83-12)
basisproducten - consumenteninformatie - consumenten - consumptiepatronen - vraag - lerarenopleidingen - basisonderwijs - voedsel - voedselhygiëne - voedingsmiddelen - gezondheid - gezondheidseducatie - hygiëne - kennis - voedingstoestand - primair onderwijs - onderzoek - schoolkinderen - onderwijzen - schoolvakken - commodities - consumer information - consumers - consumption patterns - demand - educational courses - elementary education - food - food hygiene - foods - health - health education - hygiene - knowledge - nutritional state - primary education - research - school children - teaching - subjects
Doelgroepsegmentatie in de primaire preventie van cardiovasculaire ziekten
Kok, F.J. - \ 1982
Landbouwhogeschool Wageningen. Promotor(en): A.W. van den Ban; J.G.A.J. Hautvast. - Wageningen : Kok - 103
vaatziekten - bloedstoornissen - hart- en vaatziekten - hart- en vaatstoornissen - mortaliteit - gezondheid - doodsoorzaken - preventieve geneeskunde - ziektepreventie - preventie - gezondheidseducatie - vascular diseases - blood disorders - cardiovascular diseases - cardiovascular disorders - mortality - health - causes of death - preventive medicine - disease prevention - prevention - health education
Profiles of target groups (target group segmentation) in the primary prevention of cardiovascular disease (CVD), can lead to an effective target group-directed approach in health education. Objectives in this thesis are: 1) To identify demographic and socioeconomic characteristics of such target groups. 2) To find personal and environmental determinants of preventive health behavior, which are useful as guidelines for intervention.

Segmentation was performed on the basis of health behavior regarding cardiovascular risk factors like inadequate nutrition habits, smoking, obesity, and physical inactivity. Using linear discriminant analysis we examined for each of these life-style habits, which of a series of characteristics discriminated between the target group and a preventive group. This multivariate technique yields the independent contribution of a determinant by controlling for confounding.

Data have been collected through a cross-sectional survey about knowledge, attitude and behavior regarding cardiovascular risk factors among the Dutch population in the age of 18 to 64 years. The study was carried out in 1978 by interviewing a national, stratified random sample of 889 men and 1,062 women. All participants were personally interviewed at their homes according to a partially structured questionnaire.

Chapter 1 describes determinants of health and cardiovascular risk, in particular the role of life-style. Also the use of primary prevention and target group segmentation are discussed.

In Chapter 2 we studied the interrelationship of different life-style habits. Although some risk habits were associated, the results did not suggest systematic clustering: a combination of three or four risk habits in one person did not occur more often than one would expect on the basis of probability. Because of the high prevalence of multiple risk habits and their cumulative effect on CVD risk, health education on a prudent life-style is still to be recommended. Segmentation identified as target group: men, with low level of education and occupation. Dissemination of knowledge and attitude change through audiovisual mass media can stimulate preventive health behavior.

In Chapter 3 those individuals are characterized with dietary habits that were thought to increase CVD risk. Comparison with a group with a desirable food consumption pattern by means of discriminant analysis indicated that the target group included more men, in the age of 18 to 44 years, from large families and in the lower socioeconomic strata. According to the target group's preference, nutrition education methods should include audiovisual mass media as well as group counseling or face-to-face instruction directed at young families. Educational objectives are: increasing knowledge (composition of food products and meals), stimulating motivation for change and learning personal skills (food selection and preparation of wholesome meals).

Chapter 4 deals with the dietary history recall method that evaluated the quality of the food consumption pattern. The questionnaire focussed on nutrients considered as important in a diet aiming at prevention of CVD: fats, polyunsaturated fats, simple carbohydrates, cholesterol, dietary fiber, and alcohol. To assess the preventive value of the diet, a food scoring system based on the criteria of a prudent diet was constructed. The rationale behind the scoring procedure was that frequent use of foods which are optimal from a preventive point of view leads to a high score.

The method was validated on quantitative seven-day-record data and seems to be applicable in nutrition education programs. For the analysis in Chapter 3 the upper 30 percent of the nutrition score distribution was labeled desirable and the lowest 30 percent as undesirable food consumption pattern.

In Chapter 5 results are presented of the relationship between body mass index (BMI) and sociodemographic and life-style characteristics. Because of the U-shaped relationship with overall mortality, BMI was introduced as continuous variable in a linear regression to avoid an arbitrarily chosen reference group.

In both sexes, a strong positive association was found with age and a negative one with level of education. Irrespective of own level of occupation and education women with high familial social class had a lower BMI. Sedentary living was positively related to overweight in women. Among men an inverse relationship was revealed for unemployment and a U-shaped pattern for smoking: non-smokers and heavy smokers had the highest BMI. No effects were identified for alcohol consumption and leisure time physical activity. An inventory of opinions relating to dietary habits and physical exercise may be useful for therapy.

The differences of smokers, who failed in one or more cessation attempts of at least one month and ex-smokers - those who quitted at least a year ago - are reported in Chapter 6. This contrast was studied because the increase of non-smokers in the Netherlands in the seventies was hardly the consequence of a rise in the number of ex- smokers.

The profile of the failing quitter could aid to give up the smoking habit successfully. Failing attempts were associated with men, younger age (18-34 year), a low educational level and divorced/widowed status. The fact that several univariate differences disappeared in a multivariate model, was in agreement with other findings of intercorrelation among smoking predictor variables e.g., tobacco consumption, number of inhalers, alcohol intake, skipping breakfast, obesity and leisure-time physical inactivity. These and other findings may be useful to design more effective smoking cessation programs.

In Chapter 7 we identified those individuals who did not exercise regularly in leisure time. Sixty minutes per week engaging in sports or its equivalents in cycling (75 min/week) or walking (90 min/week) were cut-off points in classifying active and inactive subjects. Inactivity was defined as limited or not regular practice of any activity. Those who regularly participated in at least two activities and exceeded the time limits were classified as active.

After adjustment for sedentary living, independent determinants of the target group were older age (55-64 yr), lower educational attainment and large families. Therefore programs promoting physical fitness, stimulating motivation, and encouraging social support, should address older people and large families.

Chapter 8 includes a general discussion and guidelines for health education. Sources of bias (selection, information, and confounding bias) that may affect the validity of the results, the choice of the contrasts for segmentation, and the importance of multivariate analysis are discussed.

Our study with its shortcomings is placed in a framework for planning of health education in solving health problems. For target group-directed educational programs, we gave guidelines for contents and methods and arguments to prefer a 'population-strategy' over a 'high-risk-strategy' in a prevention policy.

Finally we dealt with a topic of discussion in health education: to advise or to inform the public.

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