Bjarne Bruun Jensen

Complexity-oriented approaches built on complexity theories are not widely used in health promotion research. The field of health promotion faces significant difficulties in explaining and addressing unforeseen impacts and side effects due to the widespread tendency to implement health promotion initiatives that are considered best practices. It is important to theoretically embrace the fact that we operate in a complex world and that we, therefore, need to redefine our approaches by acknowledging the complexities involved in promoting health. In this theoretical paper, we propose a set of four complexity-oriented principles for health promotion research based on Niklas Luhmann’s systems theory: (1) direct transfer of health knowledge and health competencies is impossible; (2) all individuals and social entities are fundamentally different from each other; (3) the individual’s sense of health-related meaning determines what is deemed relevant; and (4) it is essential for communication to meet expectations if it is to be observed. The set of principles presented in this article can be applied to research projects intended to explore and address challenges related to complexity in health promotion settings. It can be used as a lens through which to observe health promotion practice. If health promotion research wants to address the field that we have defined for ourselves as extremely complex and unaddressed by anyone else, we need to embrace approaches that actually do this—by providing health promotion research with a formal framework appropriate to its existing main purposes and concerns.

Project SoL was a 19-month (September 2012 to April 2014) community-based multi-component intervention based on the supersetting approach that was designed to promote healthier eating and physical activity among children and their families. The aim of this study was to examine the effects of a multi-component intervention (level 1) and a mass media intervention alone (level 2) compared to a control area (level 3) on food sales. The design was quasi-experimental. Weekly sales data for all Coop supermarkets in the intervention and control areas were analysed via longitudinal linear mixed-effects analyses. Significant increases in the sales of fish (total) (29%; p = 0.003), canned fish (31%; p = 0.025) and oatmeal (31%; p = 0.003) were found for the level 1 intervention area compared to the control area. In the level 2 intervention area, significant increases in the sales of vegetables (total) (17%; p = 0.038), fresh vegetables (20%; p = 0.01), dried fruit (51%; p = 0.022), oatmeal (19%; p = 0.008) and wholegrain pasta (58%; p = 0.0007) were found compared to the control area. The sales of canned fish increased by 30% in the level 1 area compared to the level 2 area (p = 0.025). This study demonstrated significant increases in the sales of healthy foods, both in the areas with multi-component and mass media interventions alone compared to the control area.

The chapter addresses the health of children and young people in the school setting with a special focus on experiences from Health Promoting Schools (HPS) and selected health promotion projects in schools. On the basis of brief definitions of the salutogenic orientation and the health promoting school model, comparisons will be conducted with regard to key concepts and principles of the two approaches to children’s health. A brief literature overview on the use of salutogenic concepts in relation to schools and health-promoting schools also is presented and discussed.

Project SoL is implemented over a period of four years with the aim to promote healthy eating and physical activity among children aged 3–8 years by targeting the families in a Danish municipality based on the multi-component, supersetting strategy. Interventions are implemented in childcare centres, schools and supermarkets in three local communities as well as in local mass media and social media during a 19 months period in the Municipality of Bornholm. The matching Municipality of Odsherred serves as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper gives an account of the design used for the summative and formative evaluation based on a realistic evaluation and a mixed methods approach combining qualitative and quantitative methods. Summative studies are conducted on changes of health behaviours among the involved families and within the municipalities in general, changes in community awareness of the project, changes in purchase patterns, changes in overweight and obesity among the targeted children and changes in knowledge and preferences among children due to sensory education workshops. The formative research comprises studies on children’s perceptions of health, perceptions of staff at supermarkets and media professionals on their roles in supporting the health promotion agenda, and motivations and barriers of community stakeholders to engage in health promotion at community level. The paper discusses operational issues and lessons learnt related to studying complex community interventions, cross-disciplinarily, interfaces between practice and research and research capacity strengthening; and suggests areas for future research. The development and implementation of the intervention and its theoretical foundation is described in a separate paper.

Project SoL was implemented over a period of four years from 2012–2015 with the aim to promote healthy eating and physical activity among families with children aged 3–8 years, living in selected communities in two Danish municipalities. This was done by applying the supersetting approach to implement complex multi-component interventions in a participatory, coordinated, and integrated manner in childcare centres, schools, and supermarkets in three local communities, as well as in local media during a 19-month period in the Regional Municipality of Bornholm, which served as the intervention site. The matching municipality of Odsherred served as a control site based on its similarity to Bornholm regarding several socio-demographic and health indicators. The present paper describes the design of Project SoL as well as the processes of developing and implementing its complex interventions. Moreover, the theoretical and conceptual framework of the project is described together with its organisational structure, concrete activities, and sustainability measures. The paper discusses some of the key lessons learned related to participatory development and the implementation of a multi-component intervention. The paper concludes that coordinated and integrated health promotion activities that are implemented together with multiple stakeholders and across multiple settings in the local community are much more powerful than individual activities carried out in single settings. The supersetting approach was a useful conceptual framework for developing and implementing a complex multi-component health promotion intervention and for fostering ownership and sustainability of the intervention in the local community. The research and evaluation approach of the project is described in a separate paper (Part 2).

Background: Based on widespread critique of the moralizing paradigm that has long characterized much of the work conducted within the field of health promotion, Steno Health Promotion Research has developed a comprehensive health promotion approach consisting of five principles that constitute the framework for a new intervention paradigm. The five principles are: (1) A broad and positive health concept; (2) Participation and involvement; (3) Action and action competence; (4) A settings perspective and (5) Equity in health. Objectives: To describe a comprehensive health promotion approach consisting of five principles; to present research and development projects based on this set of principles; and to discuss experiences and results from implementing the health promotion principles in healthcare practices. Results and conclusion: The principle approach enables consolidation of hitherto disparate approaches into a single comprehensive approach. The principles have turned out to be productive and effective “management tools” that have led to new discoveries, but also helped to identify limitations.

Background: The prevalence of obesity among children is increasing, but treating obesity is difficult and has poor outcomes. We assessed the 4-year impact of a school-based educational intervention on physical activity, body mass index (BMI) and the prevalence of overweight and obesity. Methods: A 6-year cluster-randomised study was used to evaluate an intervention programme for children in primary school in 2006–08. The intervention promoted healthy eating habits and physical activity in the school setting through the investigation, vision, action and change educational methodology that involves children as active participants in healthy change. BMI and physical activity were measured in 2006, 2008, 2010 and 2012. Multilevel mixed-effects linear regression was used to assess change in BMI over time. Results: The effect of the intervention was maintained 4 years after completion. Average increase in BMI was greater in the control than in the intervention group (3.85 ± 2.82 vs. 2.79 ± 2.37); the mean difference was 1.06 (95% confidence interval: 0.14–1.97). In the intervention group, the prevalence of overweight and obesity decreased (1.4 and 3.7%, respectively). In the control group, the prevalence of overweight increased (9.4%) and the prevalence of obesity decreased (1.6%). The control group spent more time in sedentary activities. No differences were observed in physical activities. Conclusions: Control of weight gain was sustained 4-years after an educational intervention during the first 2 years of primary school. Future interventions to prevent obesity should build on principles viewing children as active agents of healthy change. Trial registration: ClinicalTrials.gov NCT01156805.

Since stakeholders’ active engagement is essential for public health strategies to be effective, this review is focused on intervention designs and outcomes of school- and community-based noncommunicable disease (NCD) prevention interventions involving children and young people. The review process was based on the principles of scoping reviews. A systematic search was conducted in eight major databases in October 2015. Empirical studies published in English, French, Portuguese, and Spanish were considered. Five selection criteria were applied. Included in the review were (1) empirical studies describing (2) a health intervention focused on diet and/or physical activity, (3) based on children’s and young people’s involvement that included (4) a relationship between school and local community while (5) providing explicit information about the outcomes of the intervention. The search provided 3995 hits, of which 3253 were screened by title and abstract, leading to the full-text screening of 24 papers. Ultimately, 12 papers were included in the review. The included papers were analysed independently by at least two reviewers. Few relevant papers were identified because interventions are often either based on children’s involvement or are multi-setting, but rarely both. Children were involved through participation in needs assessments, health committees and advocacy. School-community collaboration ranged from shared activities, to joint interventions with common goals and activities. Most often, collaboration was school-initiated. Most papers provided a limited description of the outcomes. Positive effects were identified at the organisational level (policy, action plans, and healthy environments), in adult stakeholders (empowerment, healthy eating) and in children (knowledge, social norms, critical thinking, and health behaviour). Limitations related to the search and analytical methods are discussed. There are very few published studies on the effectiveness of interventions based on children’s involvement in school- and community-based NCD prevention programmes. However, interventions with these characteristics show potential benefits, and the merits of complex multi-setting approaches should be further explored through intervention-based studies assessing their effectiveness and identifying which components contribute to the observed outcomes.

The chapter compares the salutogenic orientation with the health promoting school approach and comparisons are made with regard to key concepts and principles of the two approaches to children’s health. A brief literature overview compares the usage of salutogenic concepts to the usage of overlapping concepts, such as self-efficacy, resilience and health literacy in relation to school health. Furthermore, main findings indicating links between schools and young people’s sense of coherence are presented. Finally, a number of projects using the health promoting school approach are described as examples of major interventions in the field and the evidence on health and behavioural outcomes are summarized. The main conclusion is that a closer merging of the salutogenic orientation and the health promoting school development is fruitful as the former has the potential to enrich the health promoting school development with an overall philosophy, and that intervention studies based on the health promoting school model have the potential to strengthen the intervention dimension of a salutogenic approach in schools.

Purpose: – The purpose of this paper is to examine how students’ participation in an integrated school food program was related to the development of components of food and health-related action competence (F & HRAC). These components were understood to be the knowledge, insight, motivation, ownership and social skills that made students able to take action regarding food and health in everyday life. Design/methodology/approach: – Research was undertaken as a single case study of the development of an integrated education and health program called LOMA-Local Food (LOMA) in a secondary school in Denmark. Qualitative methods were applied, including an action research component, where researcher and teachers examined how students developed action competence. The program was based on a whole school approach with the aim of improving F & HRAC. As a way to obtain this, students participated in planning, preparing, cooking and serving their own school food as integrated in curriculum. The study applied the Health Promoting Schools’ (HPS) conceptual framework and the I: nvestigation, V: ision, A: ction and C: hange (IVACE) approach. Findings: – Students who participated in LOMA educational activities became motivated for developing a food F & HRAC, which included components such as knowledge, insight, motivation, ownership, action experience, commitment, cooperation and critical thinking. Students developed practical skills related to food and health, when they were cooking healthy school food together with professionals and peers. The study also points to the importance of capacity building among teachers. The IVACE matrix is suggested as a relevant tool for monitoring forms of participation that contributes to students’ development of F & HRAC. Practical implications: – There were indications of how participation in LOMA contributed to students’ development of F & HRAC. The practical implication of this is that “setting” is very important for the success of food and health education initiatives. In this integrated approach the production kitchen and the dining hall are indispensable. Also the new organization of the school day and the introduction of a shared daily meal are important practical components for the improvement of the learning environment. The possibility of combining theory and practice seem conducive for students’ achievement of action competence. Social implications: – The current study is an example of how the IVACE matrix can be applied in order to plan, conduct and evaluate LOMA educational activities, which could be considered as a contribution to the HPS scientific community. It would be useful for other schools that intend to apply the LOMA approach. However, more research is needed, where teachers, students, staff and other stakeholders collaborate in an action research process. This could promote students’ health and support other initiatives regarding public health, sustainable development and democracy. Originality/value: – This research may have implications for the way that school food programs are developed and implemented if they are to make a contribution to students’ development of F & HRAC. Taking the political interest for research-based interventions into account, it is important that future strategies include teachers’ capacity building. Research is also needed regarding further development and test of the IVACE matrix as a method in participatory, health education approaches. This should be seen in combination with a renewed focus on integrated curricula models related to the on-going discussion on redesign of western school curricula.