Annex 1: Inventory of indicators from surveys and registries

TACKLING SOCIAL INEQUALITIES IN HEALTH 

THE ROLE OF HEALTH PROMOTION 

RESEARCH REPORT 

PREPARED BY 

THE FLEMISH INSTITUTE FOR HEALTH PROMOTION (VIG) IN COLLABORATION 

WITH THE EUROPEAN NETWORK OF HEALTH PROMOTION AGENCIES (ENHPA)

P ROJECT TEAM 

TIM JENNINGS , AUTHOR 

GERT SCHEERDER , CO-AUTHOR 

RIKKIE HEEMAN 

LINDA DE BOECK 

STEPHAN VAN DEN BROUCKE 

CATHERINE ANCION 

ELLY KERKHOFS 

PETER SIOEN 

LEEN VAN STRAETEN SEPTEMBER 2001 

Report on the role of Health Promotion in Tackling Inequalities in Health 

1

Contents 

Project aims, objectives and methods ............................................................................... 3 

� Background and Introduction .......................................................................................... 3 

� Aims and Objectives ....................................................................................................... 4 

� Methodological approach ................................................................................................. 5 

Analysis................................................................................................................................6 

� Part 1: monitoring social inequalities in health.................................................................. 6 

� Part 2: health promotion actions and policies ................................................................. 20 

Findings.............................................................................................................................. 25 

� The National Political Environment................................................................................. 27 

� National Inequality Targets............................................................................................. 28 

� Integration...................................................................................................................... 32 

� Legislative support for action at regional and local levels ............................................... 33 

� Cross-sectoral partnerships and integrated planning locally........................................... 34 

� Improving access to healthcare services........................................................................ 42 

� Community Development ............................................................................................... 48 

� Migration ........................................................................................................................ 55 

� Evidence and the evaluation .......................................................................................... 60 

References ......................................................................................................................... 67 

Appendix 1: Organisations involved in this project ........................................................ 70 

� The Flemish Institute for Health Promotion (VIG) .......................................................... 70 

� The European Network of Health Promotion Agencies (ENHPA) .................................. 71 

Appendix 2: Descriptives – The National Reports........................................................... 73 

Appendix 3: Members of the European Network of Health promotion Agencies.......... 97 

Appendix 4: National co-ordinators................................................................................ 104 

Appendix 5: National reports: contact persons and organisations ............................. 108 

Annex 1: Inventory of indicators from surveys and registries ..................................... 126 


2

Background and introduction 

PROJECT AIMS, OBJECTIVES AND METHODS 

In the past decade, health promotion has become a key issue of the health policy in most 

western countries. Building upon the principles and strategies espoused by the WHO in its 

Health for All programme (WHO, 1985) and the subsequent Health 21 strategy (WHO 1999), 

policy-makers at the regional, national and international levels have introduced a range of 

measures to improve the health expectancy of the population by addressing unhealthy 

lifestyles and health-damaging aspects in the environment. In addition to education and mass 

media communication (i.e., the health education strategy) these measures also include 

structural changes such as legislation, fiscal measures including taxation and subsidies, 

organisational change, and community development. 

Although one of the key principles of health promotion is to involve the population as a whole 

rather than aiming at people at risk for specific diseases, it also focuses explicitly on 

inequalities in health. This focus reflects the concern of policy-makers and health professionals 

with the increasing health gap between socio-economically deprived and more advantaged 

groups. In all western countries, health status as measured by morbidity for major diseases, 

varies significantly with socio-economic status (Black et al., 1988; Marmot et al., 1991; 

Wilkinson, 1992). 

Accordingly, tackling health inequalities has become an increasing priority for health policymakers 

both nationally and internationally. This is exemplified by the Declaration of the 1998 

World Health Assembly, which confirmed that a reduction in socio-economic inequalities in 

health was a priority for all countries. 

‘We assert that all people should be offered equal opportunities to 

achieve their full health potential, regardless of their position in society. 

Any fair and just society should consent to be evaluated on how well 

they fulfil this aim. 

Authorities in all sectors should promote equity in the opportunities for 

people to maintain and improve their health and thereby reduce social 

inequalities in health. This requires focusing on the prerequisites for 

health in its broadest sense, encompassing training, research and 

practice’. 

Declaration, International Conference on Reducing 

Social Inequalities in Health, September 2000 

In the health strategy for Europe, Health 21, which was launched by the World Health 

Organisation in 1999, improving health and promoting equity were central principles (WHO 

1999). The European Union Action Programme on Public Health gave priority to the health of 

disadvantaged groups. 

‘By the year 2020, the health gap between socio-economic groups 

within countries should be reduced by at least one fourth in all Member 

States, by substantially improving the level of health of disadvantaged 

groups.’ 

WHO Health 21 Target 2: equity in health 


3

There has been a growing recognition that inequalities are avoidable and their reduction cost 

effective. These views have been summarised by authors such as Woodward and Kawachi 

(2000), who wrote that ‘disparities in health are avoidable to the extent that they stem from 

identifiable policy options exercised by governments, such as tax policy, regulation of business 

and labour, welfare benefits and healthcare funding’. They went on to say that ‘health 

inequalities were, in principle, amenable to policy interventions and that public health 

programmes that reduce health inequalities could also be cost effective. The case could be 

made to give priority to such programmes (for example, improving access to cervical cancer 

screening in low-income women) on efficiency grounds’. 

The association between low SES and poor health is not only due to the differential access to 

healthcare provision but must also be explained in terms of behavioural and environmental 

factors. People in lower SE positions engage in more health-damaging behaviours than the 

economically more advantaged (Bennett & Murphy, 1997; Thomas et al., 1992) and are more 

exposed to environmental hazards such as industrial toxins, air pollution and low quality 

housing (Martin, Platt & Hunt, 1987; Watt & Ecob, 1992). Although these factors cannot fully 

explain the higher morbidity and mortality rates among low SES people (Marmot, Shipley & 

Rose, 1984), their relationship with a poor life situation is not coincidental. It has been 

suggested that apart from its direct impact on health through physical causes, a low standard 

of living also influences health indirectly, by mediation of social and psychological processes 

such as stress, perceived control, communication skills, social norms, or social support 

(Bennett & Murphy, 1997). 

In accordance with these views, it is suggested that health promotion can play a major role in 

tackling health inequalities. At the same time, however, it is also recognised that traditional 

methods of health education, such as mass media campaigns or information sessions aimed 

at influencing health-related cognition’s or attitudes, are ineffective to reach disadvantaged 

groups (Labonte, 1994; Travers, 1997). Instead of relying primarily on health education to 

change health-related lifestyles, a more effective strategy to improve the health of socioeconomically 

disadvantaged people is probably to bring about structural or organisational 

changes, creating a physical, economic and social environment that facilitates health. 

Despite the overall agreement that the reduction of social inequalities in health is a major 

priority, and that health promotion may significantly contribute to this goal, there is a lack of 

clear guidelines as to which policies and health promotion interventions are effective in 

reducing social inequalities in health. As such, there is a need to draw from the experience 

that is building up in several European countries. 

The project presented in this document set out to identify policies and health promotion 

interventions across Europe, which sought to tackle health inequalities, and to identify 

monitoring systems that can support these policies and interventions. 

Aims and objectives 

The project’s overall aims were to: 

• Examine the availability and extent of information with regard to social inequalities related 

to health promotion in the different European countries. 

• Develop policies and strategies in relation to the reduction of inequalities in health through 

health promotion. 

• Move towards a consensus on actions at a European level. 

Its objectives were to: 

• Develop a ‘state of the art’ of health monitoring systems and indicators related to social 

inequalities by carrying out a systematic literature survey. 


4

• Develop a ’state of the art’ concerning the practice of tackling health inequalities within 

the context of health promotion by comparing and contrasting evidence drawn from 

reports developed by member countries. 

• Provide strategic recommendations on future work on health inequalities in the 

European Union. 

• Improve the exchange of information between Member States. 

Methodological Approach 

To reach these objectives, a twofold approach was used. To assess the availability and extent 

of information related to social inequalities in health within Europe, a systematic literature 

survey of health monitoring systems and indicators in EU member countries was performed, 

using Nutbeam’s (1998) health promotion outcome model as a theoretical framework. 

For the second strand of the project, focusing on the practice of tackling health inequalities 

through health promotion and on the policy environment, key informants were selected in each 

member country to collect data and supply information, in the form of a national report, on the 

policies, strategies and the practice of tackling health inequalities within the context of health 

promotion. 

Both approaches will now be presented in more detail, together with their results. 


5

ANALYSIS 

PART 1: MONITORING SOCIAL INQUALITIES IN HEALTH 

To study the availability and extent of information related to social inequalities in health, for the 

purpose of this study, a literature search was carried out of information sources providing 

health indicators linked to socio-economic variables, using a series of pre-defined criteria for 

the inclusion of information sources. Because there are various kinds of indicators that can be 

collected by way of different kinds of information systems, a theoretical framework was chosen 

to allow for a systematic review and analysis of the various indicators that were identified. 

Theoretical framework 

hen monitoring socio-economic inequalities in health, numerous indicators at different levels 

can be informative and need to be looked at. To consider these indicators for the purpose of 

this study, we opted for the model for health promotion outcomes developed by Nutbeam 

(1998). In this model, which is represented in Figure 1, four levels of indicators are identified 

for each of three different types of health promotion interventions (i.e., health education, 

facilitation and advocacy). The indicators range from distal too proximal. The most distal 

indicators provide information on the final outcomes of health interventions, i.e. mortality and 

morbidity. Morbidity indicators include chronic disease or disability, as well as perceived 

general health and mental health. On a second level, intermediate health outcomes are 

identified, which refer to determinants of health. These include lifestyle and environmental 

variables, as well as the quality of health services. On the third level, more proximal indicators 

are given, i.e. indicators that are more closely linked to the immediate output of health 

promotion interventions, such as health literacy, social mobilisation 1 and organisational 

change, and public health policies. Finally, on the lowest level, indicators are provided which 

describe the health promotion actions themselves. 

These health indicators can be linked to measures of socio-economic status, such as 

occupation, education and income level, or with variables referring to ethnicity, gender and 

age. This way, the distal indicators on the top level of the model enable us to identify 

vulnerable groups in society, which have a higher mortality or suffer disproportionally from ill 

health, whereas the proximal indicators on the intermediate levels provide information on the 

main determinants of the health problems encountered by these groups, such as unhealthy 

lifestyles, poor health literacy, or improper use of healthcare. 

Health and 

Social Mortality and morbidity (e.g., chronic disease, perceived health) 

outcomes 

Intermediate Healthy Lifestyles Effective Health Healthy environ- 

Health (e.g., smoking and services (e.g., access ments (e.g., housing, 

Outcomes dietary habits) to and use of services) working conditions) 

Health Health Literacy Social mobilisation Healthy public policy 

Promotion (e.g., knowledge, (e.g., community and organisational 

Outcomes attitudes, skills) development) practice 

Health 

Promotion Health Education Facilitation Advocacy 

actions 

Figure 1: Outcome model for health promotion (Nutbeam, 1998) 

1 Social mobilisation includes organised efforts to promote or enhance the actions and control of social groups over 

the determinants of health. This may be conceptualised as social capital or social connectedness (Nutbeam, 1998). 


Proximal distal 

6

This theoretical model provides a comprehensive way to consider current health promotion 

practice. We therefore consider it as a useful framework for our analysis of indicators 

regarding social inequalities and health. In order not to be too reductionism or restrictive, 

however, we will use it in a flexible manner. The way this model is used in this study and how 

the indicators are operationalised, is described in the next paragraph. 

Literature Search 

The aim of the literature search was to find out to what extent the various health indicators that 

are described in the Nutbeam model, as linked to socio-economic variables, are currently 

being collected by information systems in the member states of the EU 2 , in the accession 

countries 3 and on a pan-European level. To that effect, various information sources were 

consulted, including information from Ministries of Health and Social Affairs and from National 

Institutes for Statistics, reports and other information from National Institutes for Public Health 

or Health Promotion, review studies from the European Working Group on Socio-economic 

Inequalities in Health, and references from studies in international literature. The latter were 

identified by means of the Health-Promis database of the Health Promotion Information Centre 

at the Health Development Agency (HDA), using the following key words: “socio-economic 

status OR inequality”, “health OR mortality OR morbidity”, “cohort studies”, “NOT United 

States”, “NOT Canada”. Furthermore, use was made of the Sources and Methods part of the 

OECD 4 Health Data, and of the European Health and Safety Database (HASTE) of the 

European Foundation for the Improvement of Living and Working Conditions. 

The following criteria were used for inclusion of data in the study. 

a) The monitoring systems considered for the study include health surveys, surveys of living 

conditions, population censuses, labour force surveys, household surveys, youth surveys, 

mortality and birth statistics and cancer registries. These information systems were included 

when they were representative for the population under consideration, and intended to monitor 

trends either on a national level or on a regional level, if this region is responsible for health 

promotion and/or for the collection of data regarding the health status of its population and if it 

is an administrative areas of at least 1 million people. The latter criterion is also used in the 

Health Behaviour of School-aged Children study. Local or small-scaled studies were therefore 

excluded from this review. For example, the study on ‘Bridging the East-West Health Gap’ was 

not taken into account because its data are based on smaller areas, and the Barcelona Health 

Interview Survey is excluded because it only covers this city. Furthermore, to be considered 

for the study the monitoring systems had to be in use and/or intended to be continued in the 

future, have started in 1994 or later, and be available to the scientific community. Commercial 

marketing surveys are not taken into account. 

b) The health indicators considered for the study were defined according to the Nutbeam 

model described above. However, not all the indicators of this model were considered: 

indicators on the most proximal level of the model, describing health promotion actions, were 

not included. Although such indicators would provide valuable information, the population 

exposure to health promotion interventions is not systematically monitored in any of the 

European countries. With regard to morbidity, indicators were included which measure 

perceived general health, mental health and dental health, as well as information deriving from 

cancer registries. In contrast, registries of specific or rare diseases were excluded from the 

study, as were studies on specific patient groups, since these by definition represent a smallscaled 

population that is not representative for the (sub) national population. For example, the 

2 

Austria, Belgium (Flanders and Wallonia), Denmark (+Greenland), Finland, France, Germany, Greece, Ireland, 

Italy, Luxembourg, the Netherlands, Portugal, Spain (also Catalonia and the Basque country), Sweden and the 

United Kingdom (England, Scotland, Wales and Northern Ireland) 

3 

Czech Republic, Estonia, Hungary and Slovenia 

4 

Organisation for Economic Cooperation and Development 


7

Scandinavian Simvastatin Survival Study, which studies people who suffered myocardial 

infarction, was not taken into account. Indicators of ‘healthy lifestyle’ were separated into 

health promoting behaviours (e.g., diet, physical activity, use of alcohol and tobacco, use of 

contraceptives, etc.), medical prevention (e.g., cancer screening or vaccination), and social 

and family relations. ‘Healthy environment’ was operationalised as housing and working 

conditions. For ‘health literacy’, a distinction was made between knowledge of and attitudes 

towards healthy behaviour and prevention. Finally, ‘healthy policy’ was defined as the extent to 

which people are subjected to healthy public or organisational policy, and was considered 

separately for the school and work setting. 

c) With regard to indicators of socio-economic status (SES) we mainly looked into the three 

measures that are generally agreed upon in the literature as operationalisations of SES, i.e., 

income (household or individual), educational level and occupational class. Additionally, any 

available information was also considered on material belongings, on specific population 

groups such as immigrants (ethnicity), refugees and homeless people, and on regional origin 

as a measure of socio-economic status. In order to be considered for the study, the socioeconomic 

measures had to be available at the individual level. Aggregate measures for cities, 

regions, provinces, etc. were not taken into account. 

As a result of this literature search, an extended list was obtained of monitoring systems that 

link health indicators to measures of socio-economic status. This list was organised by country 

and submitted to the national co-ordinators in the project for review and comments. If 

necessary, they could consult with the experts in the area of health monitoring in their country. 

Results 

Conclusions Recommendations to policy-makers 

Health interview surveys, which are currently used 

in most EU countries provide adequate 

information on morbidity, perceived health status 

and lifestyle variables, linked to socio-economic 

status. 

Very few countries have mortality statistics related 

to socio-economic status. 

Indicators yielding information on determinants of 

health other than lifestyle, such as health 

services, environmental factors, or proximal 

indicators of health are seldom provided. 

The collection of data on social inequalities 

related to health is complicated by a number of 

methodological problems, such as the 

representativeness of samples and the use of 

different indicators for SES. 

Several examples of good practice, such as the 

POLS survey in The Netherlands and the HEMS 

survey in the United Kingdom, indicate that it is 

possible to obtain information on these indicators 

in a valid and reliable way. 

Summary indicators, such as the Health Practices 

Index (HPI) have been proposed as an elegant 

way to describe results concisely. 


� Support the development of indicators 

and monitoring systems to measure 

social inequalities regarding the 

determinants of mortality and 

morbidity, such as health services, 

health literacy and structural 

determinants of health 

� Develop guidelines for the routine 

collection of data regarding socioeconomic 

inequalities in health on a 

national level 

8

The comparison of data on social inequalities 

related to health across countries is often 

problematic. 

Examples of health monitoring systems involving 

more countries, such as the Finbalt Health 

Monitor, the Health Behaviour of School Children 

study (HBSC), and the Monitoring of Trends and 

Determinants in Cardiovascular Disease (Monica), 

are very promising. 

Collecting data on social inequalities in health is a 

means to set targets and to evaluate the progress 

towards their achievement. In turn, target setting 

increases the need for further health information. 

� Establish a better co-ordination of 

health monitoring efforts on a 

supranational level 


� Consider the creation of a European 

Health Observatory or Health 

Monitoring System, as a new and 

separate EU body for the organisation 

of health monitoring 

� Use the available information on social 

inequalities in health to refine the 

existing targets, focusing on specific 

health aspects in specific target 

groups or settings of low socioeconomic 

status. 

The resulting inventory of available indicators regarding social inequalities and health identified 

for each of the 16 countries in the study (EU countries plus Norway) is presented in Annex 1. 

For each country, it lists the data source, the years for which the information is available, the 

number of respondents and age limits, and the variables of health and socio-economic status 

measured. Due to poor accessibility of some information and the differences with which the 

national co-ordinators provided remarks and additions to the preliminary inventory, not every 

monitoring system could be described in the same detail. Annex 2 presents a summary 

overview. 

Figure 2 summarises the results in terms of the theoretical framework provided by the 

Nutbeam model. For each cell within each level, the number and percentage of EU countries 

plus Norway are given for which one or more indicator(s) are available. 

Mortality 

9 (56,3%) 

cancer perceived general health 

Morbidity 

mental health dental health 

6 (37,5%) 14 (87,5%) 7 (43,8%) 6 (37,5%) 

Lifestyle Health services Healthy environment 

Health promotion screening social relations access and use housing working conditions 

15 (93,8%) 3 (18,8%) 9 (56,3%) 10 (62,5%) 7 (43,8%) 9 (56,3%) 

Health literacy social organisation healthy policy and organisation 

knowledge attitudes school work 

3 (18,8%) 3 (18,8%) 2 (12,5%) 1 ( 6,3%) - 

Figure 2: Availability of health indicators linked to measures of socio-economic status in EU countries plus 

Norway, using the Nutbeam model for health promotion outcomes. 

9

The results indicate that for the EU countries and Norway there is a good availability of 

monitoring systems linking indicators of socio-economic status to perceived general health 

(87,5%) and health promoting behaviour (93,8%). This is mainly due to the fact that most 

countries (14 out of 16, or 87,5%) conduct a Health Interview Survey, which generally 

measures perceived health status and health behaviour. However, there is a difference in the 

extent to which these surveys provide information on other measures of morbidity such as 

mental health (43,8%), on behavioural measures such as screening behaviour (18,8%) and on 

social relations (56,3%). Indicators on determinants of health behaviour such as health literacy 

(18,8%) are also less available. Information linked to socio-economic measures on the use of 

health services (62,5%) and on housing (43,8%) and working conditions (56,3%) is available 

to a moderate level of EU countries, either through Health Interview Surveys, Labour Force 

Surveys or Surveys of Living Conditions. 

Information on mortality that is reliably related to socio-economic measures at the individual 

level is only available in 56,3% of the surveyed countries. This is due to the fact that only some 

countries, mainly Nordic ones, link causes of death registries to population censuses or other 

databases through the use of unique identification numbers for all inhabitants. In other 

countries this linking of data is either illegal (for example in Germany), or simply not carried 

out. 

Indicators regarding the degree of social organisation (12,5%) and regarding the extent to 

which people are subjected to healthy public or organisational policy (6,3%) in relation to their 

socio-economic status are seldom available. A possible explanation for this finding could be 

that these aspects do not involve personal issues, and therefore are not easily surveyed at the 

individual level, which is necessary to generate individual socio-economic measures. 

In addition to national data, there are also a few monitoring systems, which link health 

indicators to measures of socio-economic status on a pan-European level. Some of these 

monitoring systems, like the Finbalt Health Monitor, are based on the co-operation between 

selected countries. Others cover (almost) all EU-countries, and are either carried out by one 

European institution in all countries (e.g., the Eurobarometer studies), or by different agencies 

for each country (e.g., the Health Behaviour in School-aged Children study). The former type 

is generally more uniform and comparable than the latter. With the exception of the HBSC 

study and the Finbalt Health Monitor, these monitoring systems are generally not developed in 

order to monitor national trends, but to provide a comparison between European countries. 

The samples surveyed are most often smaller than the ones for national surveys, and the 

degree to which they are their representative is not always guaranteed. 

Nevertheless, these European-wide surveys provide a useful addition to the national surveys, 

and shed light on several health indicators linked to measures of socio-economic status that 

are not available at the level of some individual countries. The European Community 

Household Panel Study (ECHP), for example, provides information about the use of health 

services, housing conditions, mental health and social relations related to socio-economic 

status for all EU-countries except Sweden. In a similar vein, the Eurobarometer studies offer 

information about screening behaviour and working conditions. The HBSC study also fills a 

gap in the available information, by providing health indicators related to socio-economic 

status for children aged 11, 13 and 15 years old. Most of the surveys in the individual countries 

only take into account people of 16 years and older. 

The available information in the accession countries is not analysed in the same detail as for 

the EU member countries due to a lack of resources. However, the results of the literature 

search for these countries are given in the inventory in Annex 1. From these results it can be 

inferred that there is a reasonable amount of health information available in the Czech 

Republic and Hungary. Both countries carry out a Health Interview Survey. This is also the 

case in Estonia, through its co-operation with Finland. 


10

Examples of good practice 

Of the many data sources retrieved, some stand out as examples of good monitoring practice, 

either because of their innovative approach or their broad scope of indicators. Because these 

examples can be a source of inspiration for other countries, we will discuss them in more 

detail. 

Finland and Baltic Countries: Finbalt Health Monitor 

The Finbalt Health Monitor is a collaborative system for monitoring health behaviour and 

related factors in Estonia, Finland, Latvia and Lithuania. It is a very comprehensive health 

survey, providing information on a broad range of indicators at different levels of the Nutbeam 

model. It is also a good example of co-operation between various countries with a different 

public health status and a different level of experience in health monitoring. 

This monitoring system originated from a survey in Finland, the ‘Health Behaviour among 

Finnish Adult Population’ (AVTK), which was set up in 1978 and conducted annually. In 1990, 

a similar monitoring system was launched in Estonia, in collaboration with the National Public 

Health Institute of Finland (KTL). Lithuania joined the system in 1994, and Latvia in 1998. 

Each participating country is responsible for the national data collection and analysis, whereas 

the Finnish centre co-ordinates the collaboration between the national research teams and is 

responsible for comparative analysis. 

Despite the cultural and socio-economic differences between the countries, the system of a biannual 

self-assessment mail survey has been relatively easy to transfer from one country to 

another. The survey contains core questions that are obligatory, recommended or optional for 

each country, and supplementary questions which individual countries can add depending of 

local interests. The core questions in the survey have remained unchanged in order to ensure 

comparability over time. Aside form socio-economic information (years of schooling and type 

of work), height and weight, these questions deal with health status (including mental and oral 

health) and several behavioural measures, such as the use of health services (e.g. visits to the 

GP), smoking, food habits, alcohol consumption, physical activity and traffic safety. Questions 

about the opinion on health and health policy are optional, as are questions on behaviour 

change intentions and attempts and exposure to health promotion interventions. The latter are 

mainly used in the smoking section. 

A feasibility study revealed that the response rates for this survey are relatively high (ranging 

from 64% in Lithuania to 77% in Latvia, as a mean for the period 1994-1998). Late responders 

do not differ significantly from early responders, and the proportion of missing data is low, with 

the exception of some food-related questions. The final data can be used to compare time 

trends and patterns of health behaviour in the participating countries. In addition to providing 

public information and serving the program planning and evaluation needs of the individual 

countries, the system also produces data that can be used for comparative research on health 

behaviour across countries (Prattle et al., 1999). 

The Netherlands: Permanent Survey of Living Conditions 

The Permanent Survey of Living Conditions (Permanent Onderzoek naar de Leefsituatie, 

POLS) is a large, continuous survey of different aspects of living conditions in The 

Netherlands. Since 1997, it integrates a number of surveys which previously existed 

separately, thus enabling data provision on almost all types of indicators on health and wellbeing 

identified in the model of Nutbeam, including health, working conditions, living 


11

conditions, safety, protection of rights and leisure time spending. The survey comprises a 

basic questionnaire and several modules on specific topics. All participants received the basic 

questionnaire, which includes background information and general characteristics of living 

conditions. Indicators of socio-economic status in this questionnaire are the level of education, 

occupation, health insurance, household income, material belongings, ethnicity, geographic 

area, degree of urbanisation and neighbourhood characteristics. Questionnaires on the 

different modules are only given to a subsection. 

The most relevant module with regard to the present review concerns ‘health and work’. This 

module aims to provide detailed information on health status and disabilities; the use of 

healthcare and medication; lifestyle, including preventive behaviour; social support; and 

working conditions (including shift work, noise, smell, danger, physical strains, monotony, and 

overall job satisfaction). A second module deals with youth, and is targeted at 12 to 30 years 

olds. It aims to measure aspects of living conditions that are especially relevant to this age 

group, such as sexuality, risky behaviour, attitude towards school, educational climate at 

home, problems with parents, and age of leaving home. The module on participation includes 

data on feelings of (un) safety, police services and participation in civilian life. There are also 

modules on leisure time spending, law and criminality and natural environment. A separate 

module on living conditions calculates an index of living conditions based on housing 

conditions, living environment, working environment and social relations. 

United Kingdom: Health Education Monitoring System (HEMS) 

The Health Education Monitoring Survey (HEMS) is an innovative and very informative 

national survey which measures a range of health promotion indicators amongst adults aged 

16-74, focusing also on proximal indicators like health literacy (knowledge, attitudes and 

behaviours), social capital and community involvement. The Social Survey Division (SSD) 

carried it out in 1995, 1996 and 1998 of the Office for National Statistics (ONS) on behalf of 

the Health Education Authority (HEA). The HEMS was initially developed within public health 

strategy of the UK Government, to assess the contribution of health promotion to the 

achievement of the health targets defined in the ‘Health of the Nation’ program. The 1995 and 

1996 versions of the HEMS were inspired by two complementary psychological models of 

behaviour change: the Theory of Planned Behaviour, which describes the factors that 

influence individual health behaviour, and the Stages of Change Model, which provides an 

overview of the process of behaviour change. Accordingly, the focus of the 1995 and 1996 

surveys were on the monitoring of knowledge, attitudes and behaviours towards health. In 

addition, a range of demographic (age, gender and marital status) and socio-economic 

variables was collected as well, including social class (based on current or last job), 

employment status, educational level (highest qualification), gross household income and 

housing tenure. 

In 1998 the questionnaire was altered to accommodate for the recommendations of the 

governmental White Paper on ‘Saving Lives: Our Healthier Nation’, which gives greater 

recognition to the structural determinants of health, such as the social environment and the 

wider community. Aside from the continued monitoring of health-related behaviours and health 

literacy, the 1998 HEMS survey therefore also investigated the links between these measures 

and a number of indicators describing the respondents’ social environment. These include 

social support (number of people to rely on in crisis), deprivation, social capital (as measured 

by the amount of community involvement), neighbourhood decision latitude, and 

neighbourhood characteristics. 

Social capital is a concept, which originated from political science, and has only recently been 

suggested as a resource for health promotion. It is argued that this resource is produced by 

social support and public involvement, and that it builds trust in neighbourhoods and in society 


12

at large. The introduction of social capital can support the development of new theoretical 

frameworks for understanding health and health-related behaviours within a broader social 

environment. By including this concept, the new version of the HEMS questionnaire can 

therefore contribute to a better understanding of the relationship between health behaviour 

and social environment (Rainford et al., 2000). 

Sweden: Swedish National Survey of Living Conditions 

The Swedish Survey of Living Conditions (Undersökningen av Levnadsförhällanden, ULF) has 

been carried out annually since 1975 by the Department of Welfare and Social Statistics of 

Statistics Sweden. This nation-wide survey, which involves a sample of 16-84 year olds, 

provides information on a broad range of indicators, and is linked to several other databases, 

including the causes of death registry. It provides public debate and social planning with 

information about the current situation and trends in living conditions in Sweden. 

The components of the survey are grouped into four main themes. The data collection period 

for each of these themes comprises a period of two years, thus forming a series of integrated 

surveys. Each component is given a broader and deeper illumination every 7 to 8 years. 

These components are first of all health and public care, with measures of long-term illness, 

functional disorder, outpatient care, health status, use of medicines, smoking and dietary 

behaviour and dental care. The second component is working life, and inquires into the type of 

occupation, experience of unemployment, working hours, working environment (dirty work, 

noise, heavy lifting, mentally strenuous) and industrial safety. The third component focuses on 

physical environment, providing information on housing (type of dwelling and tenure space, 

equipment and facilities) and experience with physical violence, theft or damage of personal 

property and traffic accidents. The fourth component concerns social relations, and contains 

items on contacts with family, friends, neighbours and colleagues, social support, leisure 

activities spent together with others, and participation in various associations. In addition, 

background information is assessed about the socio-economic situation, including educational 

level, participation in courses, individual and household income and material standard of living. 

The combined information about these topics provides a comprehensive picture of the health 

of people in Sweden. 

The ULF interviews are supplemented by data from various records and registries, which can 

be linked on a one-to-one basis to the respondents of the survey due to the unique 

identification number attributed to the inhabitants of Sweden (and the other Scandinavian 

countries). This option significantly increases the usefulness of the data source. Registries that 

can be linked to the ULF include the Swedish Causes of Death Register, fertility, marriage and 

criminality records and data on income, pension, taxation, housing allowance, social 

assistance and scholarship. Several of these records are based on the entire population. As 

such, the ULF and registries with which it is connected constitute a large database providing 

the opportunity to describe the Swedish population in greater depth and from various 

perspectives. 

In 1996, the survey interview and sampling technique of the ULF was used to investigate 

perceived health and the use of health services in a sample of ethnic minorities living in 

Sweden. This survey was called the Immigrant Survey of Living Conditions. The study groups 

were Swedish residents born in Chile, Turkey, Poland (n=840 each) and Iran (n=420) who had 

settled in Sweden at age of 20 to 44 years between 1980 and 1989 and who according to the 

Swedish Register of the Total Population (RTP) were still residing in Sweden in 1996. These 

subjects were compared against a sample of Swedish-born adults surveyed by the ULF in 

1996. For the purpose of the study, use of health services was operationalised by 

consultations with a physician, unmet needs for consultation, and confidence in Swedish 

health services (Hjern, Haglund, Persson & Rosén, 2001). This application of the ULF 


13

provided information on an important determinant of health in a subgroup that reports more ill 

health, while being comparable to the well-known situation of the general Swedish population. 

Discussion 

The discussion that follows contains three parts. The first section discusses the results of our 

survey of available health monitoring instruments linked with socio-economic data. The second 

part discusses methodological problems associated with the measurement of socio-economic 

status as emerging from this study. The final part focuses on the use of summary measures 

for cross-national comparisons. 

Availability of health indicators linked to socio-economic factors 

The results of this literature search reveals that existing health monitoring systems in the 

European countries considered in this study provide a great deal of information on health and 

its determinants linked to measures of socio-economic status. Most European countries (14 

out of the 16 countries, or 87,5%) conduct a form of the Health Interview Survey, yielding 

information on the perceived health status and lifestyle variables, and at least measure one 

indicator of socio-economic status related to health data. This finding suggests that a part of 

the information which is required to plan and monitor health promotion interventions aimed at 

socio-economically disadvantaged groups is already available, and that the importance of 

measuring socio-economic status in health-related surveys is gaining wide recognition. 

However, with regard to health indicators other than health status and lifestyle much less 

information is available that can be linked to socio-economic status. 

The most surprising finding is perhaps the lack of mortality statistics linked to socio-economic 

status. In only 9 out of the 16 countries under investigation did the causes of death registries 

contain information on socio-economic status, or can they be linked to census data. Progress 

can and needs to be made in this area, since mortality (by age and cause) is the most basic 

information regarding socio-economic inequalities in health, and a starting point for further 

action. The ULF survey in Sweden provides a good example of how mortality data can be 

linked to information about health and socio-economic status. The problem with mortality 

registries is, however, that they measure mortality as an incidence rate (over a designated 

period of time, e.g. 1 year) and not as a prevalence rate, which is the case for other health 

measures. Consequently, registries do not reveal how many people belong to the different 

socio-economic categories. To overcome this problem, the Scandinavian countries use a 

longitudinal approach, in which they assign unique identification numbers to their inhabitants in 

order to link mortality data to population census data. France, England and Wales, on the 

other hand, use a cross-sectional approach, whereby a representative sample of the 

population is followed up for mortality after a census. In Germany the social insurance registry 

contains information on both socio-economic characteristics and mortality for the whole 

(working) population, so links with other data are not necessary. Other countries do not 

measure socio-economic status in their mortality registries in a valid way, or cannot link it at 

the individual level to census data, and are therefore obliged to analyse data on an aggregate 

level (e.g. regional measures of unemployment, illiteracy, gross income,…). 

A second important finding from this study is that there is very little information available on 

socio-economic status related to determinants of health other than lifestyle, for example 

access to, and use of healthcare, housing and working conditions and especially proximal 

indicators like health literacy, the degree of social organisation and the extent to which people 

are subjected to healthy public or organisational policy. Data collection for these types of 

indicators should be encouraged, since they are very important to identify the specific 

determinants that can be tackled by health promotion efforts. Also, structural determinants of 


14

health, like housing and working conditions, neighbourhood characteristics, public and 

organisational policy and public organisation must be acknowledged, for they have a major 

role to play in tackling health problems in lower socio-economic groups. Other researchers 

have also highlighted the need for more information on the specific factors that contribute to 

socio-economic inequalities in health (Kunst, Bos & Mackenbach, in press). The examples of 

good practice, especially the POLS survey in The Netherlands and the HEMS survey in the 

United Kingdom, indicate that it is possible to obtain such information on proximal indicators. 

As mentioned earlier, a fair amount of information is already available in European countries 

on health and its determinants linked to measures of socio-economic status. However, in the 

present review we have only looked at the availability of health monitoring systems and the 

indicators they use, and not at the quality of the information they provide. Although a detailed 

account of this aspect is beyond the scope of this study, it seems appropriate to question the 

quality of some indicators in terms of their reliability, validity and comparability across 

countries. Above all, representativeness of the survey samples and sample size are important 

elements which determine the quality of the surveys, and more particularly their external 

validity and reliability. To the extent that these qualities could be found, we have mentioned 

them in the inventory of indicators given in the annex. Information on the non-response and 

the internal validity (e.g., wording of the questions) of the surveys is not readily available, and 

therefore could not be mentioned. 

A final comment is that in order to make this inventory of available data sources for monitoring 

socio-economic health inequalities, we have followed a priori criteria for the inclusion of 

indicators and used a theoretical framework for their classification. However, the surveys and 

registries have all been designed for their own purposes, make use of different methodologies 

and are suited to the specific national situation (e.g. the organisation of healthcare, health 

insurance, the educational system, …). As such, the fact whether or not they meet the criteria 

or fit within the framework does not imply a quality judgement, for the latter should only be 

regarded as heuristic tools. 

Methodological issues in the measurement of socio-economic status 

Our study also highlights a number of methodological concerns. An important problem, for 

example, is the representativeness of the samples surveyed. Age groups of respondents 

included in surveys are not all the same in the different countries. Also, people younger than 

16 years or older than 65 years are often excluded from the sample population, as is the 

institutionalised population 5 . Some surveys and registries are restricted to men or women or 

are specifically targeted at the working population (e.g. registries of occupational hazards). 

There are also differences in the degree of non-response to the surveys. This is problematic 

since non-response tends to be higher in the lower social classes. 

Secondly, the comparison of different kinds of indicators of socio-economic status (SES) is 

rather problematic. With regard to occupational class, for example, it is very difficult to rank 

different occupations along a single dimension using an interval scale. Occupational class is 

usually measured using two classes (manual and non-manual), three classes (manual, farmer 

and non-manual) or five classes, in accordance with the Registrar General’s classification 6 that 

has been used for almost a century in England and Wales. The Erikson-Goldthorpe 

classification, which is applied in various countries, even distinguishes seven different classes. 

These classifications are somewhat artificial, however, because there is no clear hierarchical 

relationship between the different occupational classes. It can for instance be questioned 

5 

E.g. people living in homes for elderly care, the military, prisoners, … 

6 

The Registrar General’s classification distinguishes between professional (I), intermediate (II), skilled non-manual 

(III NM) and skilled manual (III M), semiskilled manual (IV) and unskilled manual (V) (Kunst & Mackenbach, 1995). 


15

whether skilled manual workers always occupy a lower position in the social hierarchy 

compared to lower-level employees. Moreover, the use of occupational class is often 

problematic when surveying children and people who are economically inactive. It is not 

possible to know if these subjects are unemployed or retired persons, women staying at home 

to do the household, or people who are inactive due to a long-standing disease or disability. 

Most surveys do not ask for information on the former occupation of economically inactive 

people. This may bias estimates of inequalities, because inactive men tend to have higher 

mortality and come from lower occupational classes (Mackenbach et al., 1997). 

Data on income, which is another common indicator of socio-economic status, are available 

only in a moderate degree. This data can be measured both as individual and as household 

income. The latter is more appropriate because it adds all income components of all 

household members. However, this also requires information on household composition to 

make a correct division. Another obstacle with this measure is that most people, especially if 

they belong to lower social classes, are not so eager to mention their salary. If they do, they 

may not report their income accurately or validly (Kunst & Mackenbach, 1995). 

The best way to measure socio-economic status therefore seems to be educational level. This 

indicator is available for most surveys. It is usually measured as the highest educational level 

successfully completed, or as the total number of years of schooling. This indicator can be 

converted according to the OECD 7 standard classification, which has four levels ranging from 

no education or primary education only, lower secondary education, upper secondary 

education and higher or postsecondary education. Educational level can be a problematic 

measure for countries for which the classification of people by educational level produces a 

very skewed distribution, i.e. where a large part of the population is assigned to one single 

educational category (Kunst, Geurts & van den Berg, 1995). However, since this is not very 

common in European countries, educational level remains the best socio-economic measure 

available to date. 

Nevertheless, educational level must not be regarded as the only reliable measure of SES. All 

three measures (income, education and occupational status) cover different aspects of social 

stratification. Whereas educational level is related to access to and being able to cope with 

information, income is an important factor in the ability to procure material goods. Both aspects 

are included in occupational status, which additionally enables people to acquire professional 

and social skills, power and prestige. Ideally, SES should therefore be including all three of 

these aspects. Whatever measure is chosen, one should strive towards a standard 

classification that remains unchanged in subsequent surveys in order to ensure comparability 

over time. 

In some cases no information on education, occupation or income is available at all. In such 

cases a good solution consists of using proxy measures of socio-economic status, such as 

indicators of living standards (indicators of material belongings, like house tenure and car 

ownership) or indicators related to socio-economically disadvantaged subgroups of the 

population (e.g., immigrants, ethnically different groups, refugees and homeless people). 

However, when using these proxy measures there is a danger of confounding the effects of 

socio-economic status with those of the specific characteristics of the proxies (Kunst & 

Mackenbach, 1995). Geographical area is also sometimes used as an aggregate measure of 

individual socio-economic status. This information is easy to obtain, but may not be the best 

option, since it only moderately correlates to individual SES (Soobader, LeClere, Hadden & 

Maury, 2001). 

7 Organisation for Economic Cooperation and Development (OECD) 


16

Cross-national comparisons 

Comparing health indicators across countries has restrictions as well. For example, disabilities 

and chronic conditions may be differently defined. Similarly, questions on health complaints 

often differ in the way they are assessed (e.g., short versus long lists of possible complaints) 

and the period that is considered for the complaints to be experienced. In a similar vein, there 

are numerous indicators and questionnaires available to measure food intake, physical activity 

and smoking behaviour, which can differ substantively, both in content and extent. There exist 

numerous health indicators and they are comparable only in as much as the survey questions 

have approximately the same structure and content in the different countries involved in the 

comparison. 

Measuring many health indicators has other disadvantages too. For the sake of clarity and 

parsimony, researchers have to restrict themselves to a limited number of important health 

measures in the analysis and presentation of results. For that purpose, summary indicators 

have been proposed as an elegant way to describe results concisely. An example of a single 

measure for health behaviour as the Health Practices Index (HPI) (Alvarez-Dardet, Montahud 

& Ruiz, 2001), which is a composite index that combines several lifestyle variables which 

affect health, notably smoking, alcohol consumption, physical exercise and obesity. Such an 

index facilitates the calculation of (time trends in) the association between health behaviour 

and socio-economic status, and provides a more straightforward description of the situation. 

However, it is less useful to serve as a basis for the planning of interventions, since it does not 

indicate which specific health factors account for the association with socio-economic status. 

The aforementioned recommendation for measures of socio-economic status applies to health 

indicators as well: to ensure comparability over time and, ideally, across countries, one should 

strive for a standard classification of indicators which remains unchanged in subsequent 

surveys in order. To facilitate such a process, the WHO Regional Office for Europe has 

conducted a series of consultations resulting in internationally agreed methods and 

instruments for health interview surveys (de Bruin, Picavet & Nossikov, 1996). 

A very important element in the comparison of socio-economic inequalities across different 

European countries, which we have not discussed so far, are measures of the association 

between socio-economic status and health. These measures are important, because they 

describe the magnitude of the socio-economic inequalities in health. The most straightforward 

measure is the variation of age-standardised morbidity and mortality rates between groups of 

different socio-economic status. If this shows a regular pattern, summary measures may be 

calculated for the magnitude of the socio-economic inequality in health, allowing for a 

monitoring of change over time. Target 2 of the WHO health strategy for Europe, Health 21, 

formulates socio-economic inequality in health in a general term 8 . A summary measure is 

therefore well suited to monitor progress towards the achievement of this target. 

As deriving from the literature, a variety of such measures are available. The most simple and 

straightforward ones make use of rate ratios and rate differences, which enable a relative or 

absolute comparison of rates of morbidity or mortality in different socio-economic groups. The 

index of dissimilarity is the percentage of all cases that have to be redistributed to obtain the 

same morbidity or mortality rate for all socio-economic classes. This index also takes into 

account the size of the different socio-economic groups, and is thus a measure of the total 

impact of health inequalities on the health status of the general population. The dissimilarity 

index will be larger if the higher or lower socio-economic groups are more numerous. Another 

frequently used measure of the association between socio-economic status and health is the 

relative index of inequality. This is a more sophisticated measure since it uses regression 

8 “By the year 2020, the differences in health status between countries and between groups within countries should 

be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups.” 


17

analysis. The advantage of this complexity is that, unlike the other measures already 

mentioned, it takes into account the morbidity or mortality rates of the socio-economic groups 

between the highest and the lowest groups, as well as the relative position of these groups. 

Since all these measures use different perspectives, it is recommended to assess the 

association through a set of diverse measures that together cover all the relevant perspectives 

(Kunst & Mackenbach, 1995). 

It is clear that every country needs its own database to collect information about (socioeconomic 

inequalities in) different aspects of health (determinants) and mortality and to 

develop and monitor health targets. Nevertheless, a strong case can be made also for 

supranational co-operation in conducting surveys and for developing a health information 

system on a European level. For one, the comparison with other countries often triggers 

policy-makers to take action. For another, cross-country comparison of socio-economic 

inequalities in health illustrates whether there is potential for reducing these inequalities, to 

what extent, and in which manner. Furthermore, it is to be expected that health policy activities 

at the European Union level will expand in the future (Van de Water &. Van Herten, 1998). 

Therefore, a reliable and practical European health database would be a major step forward. 

Such a monitoring system does not yet exist, but initiatives to establish it are being undertaken 

by the European Union within the framework of the Health Monitoring Programme, as well as 

by the European regional office of WHO and by the OECD. Effective communication and coordination 

among these groups is needed. Accordingly, Van de Water and Van Herten (1998) 

suggest that it would be much better if these three organisations sponsored a joint initiative to 

set up a European health information and monitoring system. In a similar vein, Aromaa (1999) 

reports that an expert group has evaluated four main alternatives for the organisation of 

European Community Health Monitoring and recommended the creation of a new European 

body for health monitoring (a ‘Health Observatory’) as a long-term goal. 

It should be noted that supranational co-operation in monitoring health already exists. The 

Finbalt Health Monitor, the Health Behaviour of School Children (HBSC-study) survey, and the 

European Community Household Panel Study (ECHP) described earlier are good examples. 

They are all surveys which are conducted in the same way in different countries across 

Europe and which at least have a series of core questions in common. The Eurobarometer 

conducts comparable surveys on several topics in all European Union countries. 

Conclusion and recommendations 

Monitoring health data is a demanding task. It is therefore reasonable to carefully consider the 

actual use of the indicators that are measured. Apparently, their main use is in setting health 

targets and strategies. Health monitoring data provide an assessment of the present health 

situation and its determinants, and to some degree indicate future trends. Current health 

behaviour, for instance, can partially predict future mortality, and is therefore appropriate to 

determine health policy priorities and to set health targets. Smith, Morris & Shaw (1998) in an 

editorial of the British Medical Journal argue for recommendations and targets that address the 

fundamental causes of inequalities in health, and point out that they should be formulated in 

considerable detail to avoid them from being too vague. So in effect, target setting and 

monitoring health data is a dual process, whereby one is necessary to do the other. Monitoring 

data are necessary to set up and evaluate the (progress to the) achievement of targets, and 

target setting increases the need for (further) health information. 

Several elements in the discussion have highlighted existing challenges in monitoring socioeconomic 

inequalities in health, and suggested possible ways of tackling these challenges. We 

have tried to summarise these suggestions and to make them more concrete. It is hoped that 

the following set of recommendations will inform policy-makers in the development of health 

monitoring surveys linked to socio-economic status. 


18

1. Guidelines must be developed for the routine collection of data regarding socioeconomic 

inequalities in health on a national level. 

2. A better co-ordination of health monitoring efforts must be established on a 

supranational level. Promising tools so far in this regard are e.g. the Finbalt Health 

Monitor, the Survey of Health Behaviour of School Children (HBSC-study) and the 

Monitoring of Trends and Determinants in Cardiovascular Disease (Monica-Project). 

3. Data on socio-economic inequalities with regard to the determinants of mortality and 

morbidity, such as health literacy and structural determinants of health, must be made 

available, to serve as a basis for effective health promotion policies and interventions 

tackling social inequalities in health. 

4. The creation of a European Health Observatory or Health Monitoring System, as a new 

and separate EU body for the organisation of health monitoring, must be considered. 

5. The general targets regarding socio-economic inequalities in health which currently 

exist in most countries need to be refined into targets which focus on specific health 

aspects in specific target groups or settings of low socio-economic status, 

accompanied by measures to achieve them. 


19

PART 2: HEALTH PROMOTION ACTIONS AND POLICIES 

To collect information about strategies, interventions and policies to tackle health inequalities 

through health promotion, preference was given to the identification and subsequent analysis 

of good practices and policies through involving key informants in each member country. The 

concept of this approach was discussed and developed via a series of meetings of the ENHPA 

in Brussels (1998), Berlin (1999), and Utrecht (1999) and formally initiated on the 1 st July 

1999. 

Key informant approach 

For this part of the project, a two-phased approach was followed, as shown in the Figure 3. 

Figure 3: Summary diagram of the methodological approach to collect data on health promotion actions 

and policies 

Phase 1 (July 1999-December 1999) 

Selection and 

appointment of key 

informants (national 

coordinators) 

Phase 2 

Agreement of 

theoretical basis and 

definitions 

Report assessment 

and follow up further 

information 

These phases were carried out as follows. 

Design and agreement of 

proforma/questionnaire 

and analytical framework 

Analysis 

Phase 1: Selection of key informants, definitions and data collection 

A literature review was conducted, informing the development of the theoretical background to 

the project. Key informants (national co-ordinators) were then identified and nominated by the 

17 members of the ENHPA. 

A questionnaire was constructed by the advisory group, which aimed to collect information on 

the following issues mentioned in Table 1. 

The national co-ordinators spent time consulting appropriate experts and collating information 

on a number of interventions and policies. This number of experts, and the number of 

interventions and policies, varied. Some co-ordinators did not report that they had consulted 

any experts. The largest number of experts consulted (16) was reported by the co-ordinator 

from the United Kingdom. As far as content is concerned, the range was from a single 

intervention and a single policy (Ireland) through to fifteen interventions (United Kingdom) and 

ten policies (Austria) (see below). The completed questionnaires or proformas were 

collectively referred to as the national reports. 

Responses were received from Austria, Belgium, Denmark, Finland, Germany, Greece, 

Ireland, Italy, the Netherlands, Norway, Portugal, Spain, Sweden and the United Kingdom. 

France, Iceland and Luxembourg did not submit reports. These countries were not able to 


Data collection – 

construction of national 

reports (inc. 

consultation of experts) 

Report – Findings, 

conclusions and 

recommendations 

20

allocate sufficient resources to enable them to construct a report within the timeframe of the 

project. 

Table 1: Summary of questionnaire 

General Interventions Policies 

� Country 

� National Co-ordinator 

� National Experts 

consulted 

� General Description of 

Intervention 

(Date/length/frequency) 


� Provide general 

information on social 

policy 

� Who took the initiative � Provide contextual 

information on policy 

� Who were the 

providers? (health 

professionals/others) 

� Who was the target 

group? 

� What were the 

characteristics of the 

target group 

� How many participants 

were there? 

� What was the setting for 

the intervention? 


objectives of the 

intervention? 

� What were the methods 

used? 


strategies employed? 

� How were the objectives 

evaluated? 

� What was the design of 

the evaluation? 

� Comment on the 

transferability 

� Comment on how the 

intervention contributes 

to policy 

� Provide details of the 

evaluation of the 

intervention 

formulation 

� Provide a description of 

trends in social policy 

(last 10 years) 

� Provide information on 

the population the policy 

is directed at 

� Provide policy details 

� Provide details of any 

health benefits 

� Provide details about the 

implementation of the 

policy 

� Were there any positive 

or negative side effects 

of the policy? 

21

Table 2 shows the number of interventions and policies identified by each of the countries 

participating in the project. 

Table 2: Summary statistics for the national reports (interventions and policies) 

Country Interventions Policies 

Austria 5 10 

Belgium 5 6 

Denmark 3 6 

Finland 4 5 

Germany 5 3 

Greece 3 6 

Ireland 1 1 

Italy 4 1 

Netherlands 4 6 

Norway 4 7 

Portugal 4 6 

Spain 2 2 

Sweden 5 5 

United Kingdom 15 5 

Phase 2:Assessment of the national reports and data analysis 

The data collected from the national reports were analysed using ‘Framework analysis’, a 

qualitative analytical approach described by Ritchie and Spencer (in Bryman and Burgess eds. 

1994). ‘Framework’ was initiated, developed and refined in a specialist qualitative research 

unit based within the National Centre for Social Research in the United Kingdom [formerly 

Social and Community Planning Research (SCPR)]. The method was specifically developed 

for applied policy research. The approach has been found to have particular strengths where: 

new data have been collected; where it has been important that an explicit research 

methodology can be viewed; and where timescales have been short. 

The aims of the data analysis were to tackle the national reports and provide some coherence 

and structure while retaining a hold of the original accounts from which they were derived. 

‘Framework’ was used to facilitate detection, defining, categorising, theorising, explaining and 

exploring. 

Key features of framework, which justified its use in this context, are: 

• Grounded or generative: It is heavily based in, and driven by, the original accounts 

and observations of the people it is about. 

• Dynamic: It is open to change, addition and amendment throughout the analytic 

process. 

• Systematic: It allows methodological treatment of all similar units of analysis. 


22

• Comprehensive: It allows a full, and not partial or selective, review of the material 

collected. 

• Enables easy retrieval: It allows access to, and retrieval of, the original textual 

material. 

• Allows between-case and within-case analysis: It enables comparisons between, and 

associations within, cases to be made. 

• Accessible to others: The analytic process, and the interpretations derived from it, can 

be viewed and judged by people other than the primary analyst. 

The analytical process involved a number of distinct and interconnected stages, including 

sifting, charting and sorting materials according to the key issues and themes. The five key 

stages were familiarisation; identifying a thematic framework; indexing; charting; mapping and 

interpretation. Although the presentation of the different stages might imply rigidity, in 

practice, areas were often re-visited, re-examined or simply rejected and re-done. In more 

detail: 

Familiarisation 

An attempt was made to become familiar with the range and diversity of the data within the 

national reports and to gain an overview. Familiarisation involved immersion in the data: a 

great deal of time was spent reading the reports. Key ideas and recurrent themes were listed 

whilst reading material. 

Identifying a thematic framework 

Data were examined and referenced in order to identify key issues, concepts and themes. A 

thematic framework within which the material could be sifted and sorted was established. 

Special attention was paid to comments made by co-ordinators themselves, and analytical 

themes arising from the recurrence of particular views or experiences. This was then applied 

to transcripts and refined to become more responsive to emergent themes. Time was spent 

making judgements about meaning, relevance and connections between ideas. The index 

developed provided a means of labelling data in manageable ‘bites’ for subsequent retrieval 

and exploration. 

Indexing 

The thematic framework (index) was systematically applied to the national reports. All data 

were annotated according to the thematic framework. 

Charting 

Data were ‘lifted’ from their original context and rearranged according to the appropriate 

thematic reference. Charts were devised with headings drawn from the thematic framework. 

Mapping and Interpretation 

Once all the data had been sifted and charted according to the themes, charts were reviewed; 

patterns and connections were sought; emphasis was placed upon structure rather than a 

multiplicity of evidence, the salience and dynamics of issues was considered rather than 

simply aggregating patterns. 

Remarks on the methodology 

McKee and Jacobson (2000) warned that ‘an exploration of public health issues in Europe is 

difficult’. They noted that compared with, for example, North America, the diversity of issues is 


23

far greater in Europe. Countries and regions within countries have many languages, prevailing 

values, and political systems. They found that the term ‘public health’ has many different 

interpretations, with some languages using several words, each with subtly different meanings. 

On the other hand, it also appears difficult to define terms because ‘many of the other words 

required, such as environment or inequalities, are also understood in other ways in different 

countries’. 

Aiach and Carr-Hill (1989) observed that ‘..such analyses do not take place in a vacuum. To 

assess them in comparative context, it is therefore essential to locate the analyses in their 

cultural, economic, political and social contexts’. In their review they drew learning points from 

a comparison of British and French cases. These authors emphasised that there were 

‘structural (economic, ideological and political) and conjectural factors which interacted to 

influence the nature of the debate’. They illustrated this by highlighting the fact that the British 

NHS had no equivalent in France: instead the French instituted a Social Security system 

founded on the insurance principle. 

A number of the difficulties considered by the authors above were also encountered during this 

project. This was probably best illustrated by the discussion over various working definitions 

for the project. For example, a definition of social inequalities was never finally agreed upon 

by the advisory group. The discussion documented within the phase 1 maps the course as 

follows: (1) Consideration and rejection of the WHO definition (on the basis that it could not be 

put into operation); (2) Construction of a project working definition and its subsequent 

rejection, on the basis that it did not successfully cover the consensus view of health inequality 

held by the advisory group); and (3) Commitment to further develop and agree upon a working 

definition. 

In a similar vein, a central focus upon disadvantaged groups arose. The project restricted its 

standpoint to that of health promotion interventions and policies, but again a working definition 

was not formally identified. 

Many of the problems faced by the key informants (co-ordinators) and subsequent effort 

expended trying to solve them were inevitably related by the failure of the project to define and 

delimit its scope. For practical purposes, the following working definitions were adopted for 

the latter part (phase 2) of the project. 

WHO definition of health: 

Health is a dynamic state of complete physical, mental, spiritual and social well-being 

and not merely the absence of disease and infirmity 

Ottawa charter definition of health promotion: 

Health promotion is the process of enabling people to increase control over, and 

improve, their health. To reach a state of complete physical mental and social wellbeing, 

an individual or group must be able to identify and to realise aspirations, to 

satisfy needs and to change or cope with the environment. Health is seen therefore as 

a resource for everyday life, not the objective of living. Health is a positive concept 

emphasising social and personal resources, as well as physical capacities. Therefore 

health promotion is not just a responsibility of the health sector, but goes beyond 

healthy lifestyles to well-being. 

Pragmatism was the approach, which characterised the progress of this project with the 

adoption of an inclusive stance rather than an exclusive one with respect to the inputs of key 

informants (national co-ordinators). 


24

FINDINGS 

It was found that there were clear areas of consensus across Europe, where common 

approaches were being used in an effort to combat health inequality. It was also found that 

there were innovative methods applied in certain settings and environments that were unique. 

A total of 67 policies and 60 interventions were reported within national reports. Table 3 below 

presents the common themes that emerged from the analysis and also indicates from which 

countries examples have been drawn to support and illustrate such themes. 

Table 3: common themes emerging from the analysis 

Policies and Interventions Specific examples from 

The national political environment 

� National public health targets 

� The broad determinants of health 

� The role of legislation in supporting work 

locally 

Cross-sectoral partnerships and integrated 

planning locally 

� Cross sectoral approaches (nationally and 

locally) 

� Partnership working 

Improving access to healthcare services 

� Outreach work and hard-to-reach groups 

� Health insurance – reforms and improving 

access 

Community development 

� Community-based approaches 

� Advocacy work and peer educators (culturally 

grounded and sensitive to tradition) 

Migration 

� Impacts nationally (rural and urban) and 

internationally (European expansion and 

integration) 

Evidence and the evaluation of interventions 

� Health impact assessment 

� Intervention effectiveness 

� Austria 

� Belgium 

� Denmark 

� Germany 

� Netherlands 

� Norway 

� Sweden 

� United Kingdom 

� Belgium 

� Denmark 

� Germany 

� Greece 


� Norway 

� Portugal 


� Austria 

� Belgium 

� Germany 

� Greece 


� Norway 

� Portugal 

� Spain 

� Sweden 


� Germany 

� Greece 

� Portugal 


� Norway 

� Belgium 


� Austria 

� Belgium 

� Germany 

� Norway 

� Sweden 

� Spain 

� Germany 

� Greece 


� Norway 


Figure 4 on the next page provides a graphical depiction of the scope of the project findings. 


25

Categories or themes were not mutually exclusive, but overlapping and complimentary. As will 

be seen in the chapters that follow, certain examples of interventions or policies were used to 

illustrate and support different themes. 

Many of the areas were closely related. For example, partnership working was a component of 

successful community based approaches but they were dealt with separately. Using 

community consultation as a tool was considered within the chapter on improving access to 

healthcare, but community development as an overall approach was such a strong theme that 

emerged that it was given its own dedicated section. The different areas therefore were an 

attempt to untangle the various elements considered within national reports. 

Figure 4: Project map summarising the scope of the European inequalities project 


� Broader determinants of 

health 

� Social capital generation 

� Tackling exclusion 

The chapters that follow provide detailed explanations and illustrate, using examples, the 

different elements that emerged from the analysis. The chapters follow the same format with a 

summary table with conclusions and recommendations coming first, discussions and 

illustrations follow. 


Political environment 

� Global Targets (Inequality) 

� Broader determinants/socioeconomic 

links with health 

� Approaches to social policy 

formulation (legislation) 

� Special agencies/initiatives 

� Budget priorities 

Action and planning regionally and locally 

� Integration 

� Intersectoral cooperation 

� Partnerships and alliances 

Provision of healthcare services – Improving access 

� Innovative 

educators) 

approaches (advocacy, peer 

� Community involvement 

� Outreach (inclusion) 

Impact of migration 

� Financial access 

� Across national boundaries 

� Rural/urban 

� Economic recession Research, evaluation and the evidence base 

� Relationship with funding 

� Outcome and process 

� Action research 

26

The national political environment and tackling health inequalities 


National health inequality targets are considered 

as an effective way for governments to send out a 

clear signal about their commitment to tackling 

health inequalities and to focus attention on the 

issues 

Inequality targets are seen as a useful starting 

point for integrating policy across different sectors 

Potential health improvements resulting from 

policy reforms in areas such as housing, 

education and employment remain unclear 

Integration across policy areas are being driven 

nationally but implemented locally 

Legislation is an effective tool for supporting the 

implementation of initiatives at regional and local 

level, providing a focus for cross-sectoral cooperation 

Overt political support from government ministers 

is significant and useful to those with a direct 

interest in health promotion initiatives 

Adequate financial resources are essential for 

effective work in this area, whereas spending 

cutbacks represent a threat 


� Encourage the adoption of national 

health inequality targets where 

possible 

� Support and encourage the further 

development of health impact 

assessment approaches (in which 

inequality impact assessments are an 

integral part) 

� Support (and monitor progress of) area 

based policies which are aimed at 

engaging broad determinants of health 

and advocating cross sectoral cooperation 

� Where appropriate create supportive 

legislation 

� Where possible engage high level 

politicians as champions for tackling 

inequality 

� Require that adequate financial 

resources are made available 

The national political environment was the starting point for many accounts given by the coordinators, 

more specifically, the way in which this influenced health promotion in their 

respective countries. Some of the comments were quite general and revealed frustrations with 

opposition (or lack of support) for tackling health inequality. Others were more specific and 

focused on the details of policy reform and moves towards integrating different policy areas. A 

number of co-ordinators emphasised examples of legislation being designed to support action 

in a range of settings at local level. 

Some co-ordinators found it difficult to provide a meaningful commentary on the political 

environment and policy reforms. This was a reflection of their lack of expertise in this area (by 

their own declaration) and their failure to engage relevant experts. Many provided long lists of 

social policy but were not able to explore them further and consider them from a public health 

perspective. This was also understandable considering the lack of health impact assessment 

on social policy development and reforms in all of the countries in this study (this in itself was 

the subject of some accounts). [A conceptual model for the study of the policy impact on the 

pathways to social inequalities in health (Diderichsen et al 2000) was included within the 

Swedish report. This model was used in the Swedish government’s official report, “Health on 

Equal Terms” 1999, 137.] 

27

Positive accounts came from Sweden, Denmark, the Netherlands, and the United Kingdom. In 

these countries there were reports of: declared political support for tackling health inequality; 

moves towards integration across policy areas; funding streams to support the reduction of 

health inequalities; and legislative support for action at regional and local levels. Additionally, 

in some instances reports included significant verbatim comments from government ministers 

registering publicly their support for tackling inequality. 

In the Netherlands for example the Minister of Health was attributed with demanding a more 

systematic policy development to reduce avoidable and unfair health inequalities. She (Mrs. 

Borst) acknowledged that too little attention was given to the issue in the past and that the gap 

was widening, she had formerly called for the situation to be addressed and greater attention 

given in the future. The Ministry for Health, Welfare and Sport was funding a programme 

whose central aim was to provide insight into policies and interventions, which reduced 

inequality. 

National Health Inequality Targets 

Health inequality targets were increasingly seen as important in a number of countries: 

examples were given within reports from the United Kingdom, the Netherlands, Finland and 

Denmark. They were viewed as important because they provided a clear framework for 

relating health inequalities to the overall aims of health services. They also reflected 

aspirations and represented a high level of commitment, and they sent out a clear signal of 

what governments were trying to achieve. 

The National Health Inequalities Targets from the United Kingdom were announced in 

February 2001. They encompassed two key areas - infant mortality and life expectancy. The 

infant mortality (deaths in the first year of life) target aimed to, ‘by 2010, reduce by at least 10 

per cent the gap in mortality between manual groups and the population as a whole’. In more 

detail, associated with this overall target was a range of measures including: the effect of 

prevention; parent support; health promotion and access to services including antenatal care 

and neonatal intensive care. Interventions identified in relation to this target were: smoking 

control; breast feeding; parent support from health visitors and the community; reduced 

poverty and improved maternal mental health; and better access to healthcare – NHS Direct, 

primary care, accident and emergency, and paediatric and neonatal intensive care. The target 

was formulated in terms of socio-economic groups and therefore was intended to compliment 

the area-based life expectancy target. The significance of this target was that infant mortality 

was judged to reflect a range of influences within and outside the health services. Success in 

achieving the target was to be a measure of progress across a much broader front than the 

immediate measure of mortality within a small age group. 

The second target from the United Kingdom was aimed at expectation of life – ‘starting with 

Health Authorities, by 2010 to reduce by at least 10% the gap between the quintile of areas 

with the lowest life expectancy at birth and the population as a whole’. The rationale for 

selection as an inequality target was that life expectancy provided a measure of wider 

determinants, health prevention programmes, improved access to care, resource allocation 

and treatment. There was to be a focus on interventions including the cancer plan, coronary 

heart disease and smoking prevention, wider determinants including the Sure Start 

programme, opportunities for all, and neighbourhood renewal. 

In Sweden, the government in April 1997 set up a National Public Health Commission. The 

aim was to define national objectives for health development and strategies to achieve them. 

According to the government these objectives were to guide society in promoting health and 

preventing diseases and injuries and their consequences in terms of disability and mortality. 

These targets and strategies were to contribute to the reduction of inequalities in health 

among: 


28

� socio-economic groups; 

� women and men; 

� ethnic groups and; 

� geographical regions of the country 

In Sweden, equality in health formed a national vision for health policy and ‘efficiency in 

measures and equity in outcome’ was expressed in general Swedish welfare policies. 

Furthermore, Sweden decided to draw up a comprehensive equity-oriented national public 

health strategy for the country. This was done by appointing a political/parliamentary 

commission consisting of both politicians and experts and ensuring that the national public 

health strategy was coupled to clear priority setting and resource allocation. (Ostin and 

Diderichsen (2000) quoted in Swedish national report). Of interest within this context were 

particular aspects of the national public health strategy. These included visions, strategic 

intents and the first two objectives for a health-friendly society: 

Vision 

� A health-friendly society gives everyone equal opportunity to influence individual and 

shared causes and consequences of sickness and disease. 

� In such a society, everyone has the opportunity to manage the challenges of life and to 

take personal responsibility for those aspects of health that can be influenced by the 

individual. 

� Factors in the surrounding environment that cause physical and mental illness, such as 

inequitable living conditions and unsanitary environments, have been eliminated to a 

significant extent. 

Strategic intents 

� Strengthen social cohesion and solidarity in society 

� Increase opportunities for integration into the labour market and reduce social 

exclusion 

� Increase the influence and security of people in the workplace 

� Give priority to families with children, in economic terms, and in respect of the time 

available for being together 

� Give children and young people equal chances in life by reducing segregation and 

implementing compensatory measures 

� Give senior citizens and people with long-term illnesses or disabilities opportunities to 

shape their lives according to their needs 

� Create opportunities for sustainable enhancement of health 

� Increase solidarity with those who are vulnerable to lifestyle risks 

(First two) objectives 

� Counteraction of the wider disparities in income (Indicator: Gini coefficient under 0.25 

(in 1988, 0.25) 


29

� Reduction of relative poverty (Indicators: Proportion of people living in poverty 

according to EU norms under 4% (was 4.8%); Proportion of people with income below 

the social welfare poverty line under 7% (was 8.9%); Proportion of households with 

children with long-term dependency on social assistance reduced to a half.) [The 

complete set of 19 objectives is given within appendix **]. 

Finland has a tradition of egalitarian social and health policies dating back to the 1950s. 

Health-related equity policy has also been an objective of all Finnish Health for All (HFA) 

programmes. In the first HFA programme (1986) two general bases were formulated: the level 

target, i.e. the best possible level of health, and the distribution target, i.e. the most even 

distribution of health. The equity goals of the 1986 HFA strategy concentrated on health 

services and health education. The principle of equal access to care and meeting of the needs 

of the most disadvantaged were emphasised. Regarding the goal of promotion of healthy 

lifestyles it was stated that special measures were required to reduce health problems arising 

from lifestyles in the population groups most at risk. 

In the revised HFA programme for 1993 action-oriented measures concentrated on primary 

health care and social services to secure that both preventive and care activities were directed 

to the part of the population which had the greatest health problems. Also health education 

measures were cited as a means to improve the health of these groups. The lifestyle approach 

was complemented by other, more community-oriented and cross-sectoral measures. They 

concerned the quality of residential areas (noise, air pollution, and opportunities for physical 

exercise) with respect to health and certain population groups (children and elderly and 

disabled people), and created programmes to develop the worst-off regions. Measures were 

also related to occupational health and to the living conditions of the elderly and their 

opportunities for independence. Although the lifestyle approach is continuously utilised in 

these programmes, it is also emphasised that the availability of healthy and safe choices 

should make possible and modify the determinants of health which are beyond the choice of 

an individual. One example of this is to increase the availability of healthy (low-salt, low-fat) 

food and of healthy catering in work places and schools, which can diminish socio-economic 

inequalities in nutrition. 

In both of these programmes the targets have been expressed in the form of policy statements 

but generally do not include measurable target values of health outcomes. This is explained 

with the argument that the main emphasis is on the processes and means through which 

commonly accepted targets can be reached. 

In the most recent Government Resolution on the Health 2015 public health programme 

(2001) the target is to reduce inequalities in health. The objective will be to reduce by a fifth 

the mortality differences between genders, between groups with different educational 

backgrounds and between different vocational groupings. The aim is to primarily affect the 

entire population, while also paying attention to risk groups. 

The Danish report drew attention to the Government Programme on Public Health and Health 

Promotion 1999-2000 in which high priority was given to initiatives for vulnerable and 

disadvantaged groups. This was the stated case within education and employment as well as 

the social and health sectors. There was a clear acknowledgement that there were 

considerable differences in health between social groups depending on education, income, 

occupation and involvement in the labour force [and groups with different ethnic backgrounds]. 

There were some clear areas of emphasis including inequalities in: birth weight; mortality of 

the adult population; working environment; and life-style. An overall equity target (one of two 

overall targets) was identified in which ‘social inequality in health should be reduced to the 

extent possible – above all by strengthening efforts to improve health for the most 

disadvantaged groups’. It was the stated intention that this overall target should be ‘a 


30

ecurrent element underlying all the programme’s targets and initiatives’. It was to be applied 

to all other target areas including those identified for risk factors (tobacco, alcohol, nutrition 

and exercise, obesity, traffic accidents), age groups (children, young people, senior citizens), 

health promoting environments (primary schools, the workplace, local communities, health 

services) and structural targets (co-operation between the state, counties and municipalities, 

research, education). 

Within Flanders (the Flemish speaking community) in Belgium, five priority health objectives 

were identified to which all health initiatives were orientated from 1998 onwards (until 2002). 

These priority objectives were also aligned with federal government and European Union 

policy objectives and focused on cancer, smoking, nutrition, accidents and infectious diseases. 

Tackling health inequality in this approach was through supporting community needs via a 

network of regional consultative bodies entitled Logos. The priority objectives were translated 

through a process of consultation by Logos in terms of the health needs of their particular 

community. Special emphasis was placed upon the ‘disadvantaged’ and ‘underprivileged’. 

In other countries, too, there were examples of setting targets and co-ordinating action 

nationally but delivering at the community level. For example, in the United Kingdom a broad 

range of area-based initiatives was influential in shaping intervention approaches. The 

problem of social exclusion was a declared priory of the government along with economic and 

social regeneration. The following were mentioned in the report: Local Agenda 21; Health 

Action zones (see case studies); Sure Start; and Early Years Development and Childcare 

Partnerships. These initiatives operated in different ways. Some covered large geographical 

areas and others small neighbourhoods. Some were aimed at facilitating local partnerships 

whilst others were piloting new service delivery mechanisms. The Neighbourhood Renewal 

Unit was leading a national strategy for neighbourhood renewal within and outside central 

government. Amongst its aims were the improvement of life in deprived areas and the support 

of development strategies at local level through funding a Neighbourhood Renewal Fund and 

a Community Empowerment Fund. Local Strategic Partnerships (LSPs) were also highlighted. 

They aimed to bring together the private and public sectors along with community 

representatives and voluntary organisations to ensure mutual support and co-operation. One 

important goal of this approach was to allow strategic decisions to be made at the community 

level. A Regional Co-ordination Unit was initiated to support the development of LSPs. 


31

Figure 4: Relationship between government policies 

Increasing 

opportunity for all 

More funding for 

education: 

• School standards 

• Lifelong learning 

Employment: 

• Employment 

Opportunities Fund 

to make New Deal 

permanent 

• Extend the ONE 

service (integrated 

benefits and 

employment advise) 

• Enhance New Deal 

25 plus 

• Extend New Deal for 

Disabled People 

• Expanding childcare 

provision 

Children - interventions in 

areas of greatest need 

and targeted at those 'at 

risk': 

• Neighbourhood 

Renewal Fund 

• Expansion of Sure 

Start 

• Connexions 

personal adviser 

service 

• Children's Fund for 

preventive services 

for vulnerable 

HM Treasury 2000, Spending Review 2000. London: The Stationery Office 

Integration 

Long term goals 

Abolishing child poverty 

Providing educational opportunity for all 

Increasing employment opportunity for all 

Raising prosperity 

Building responsible 

and secure communities 

Crime - increase 

spending on the police 

Tackle drug abuse 

through more treatment 

and prevention 

Sustained funding growth 

for the NHS 

Better social services: 

• Promote 

independence, 

rehabilitation and 

care close the home 

for the elderly 

• Improve life chances 

for children in care 

• Implement the NSF 

on mental health 

Promote volunteering in 

the community 

Extend cultural, sporting 

and creative opportunities 

for children 

Improve the environment: 

• Cleaner air ( Ten 

Year Plan for 

Transport) 

• Fewer greenhouse 

gas emissions 

• Increased recycling 

of household waste 

Public investment in 

infrastructure: 

• Integrated transport 

(Ten Year Plan of 

Transport) 

• Modern schools 

• Modern hospitals 

A number of national reports provided examples of attempts to integrate policy across different 

sectors, or at least to link health objectives with other areas, such as housing. On the whole 

however there was a paucity of information this subject. 

The significance of the UK government Spending Review 2000 was highlighted and its 

importance in promoting an integrated approach across a diversity of policy areas. The 

diagram presented in Figure 4 attempts to summarise the relationship between government 

policies. 

Within Sweden, legislation, funding and policy reform was helping to integrate across policy 

areas, and support local action. The role of County Councils (21 regional units) and 

municipalities (289 in number) were increasingly important at the national level. 


Raising productivity and 

sustainable growth 

Increase spending on 

science - Science Research 

Investment Fund 

Regeneration: 

• Increased funding and 

enhanced role for 

Regional Development 

Agencies 

• New Deal for 

Communities 

• Neighbourhood 

Renewal Fund 

More skilled, healthy and 

motivated workforce 

Measures to improve 

competition, enhance 

enterprise and make it 

accessible to all - role of 

RDA's 

Advance Modernising 

Government principles on 

policy making, responsive 

and quality public services, 

information age government 

and valuing public services 

Improved 

health 

Narrower 

health gap 

32

The European Health For All strategy was reported to be having an impact on the programmes 

of the County Councils. The national government was supporting County Councils' disease 

prevention and health promotion work through an annual transfer of 48 SEK (about 6 USD) 

per capita. Intersectoral local public health committees were to be found within more than twothirds 

of all Swedish municipalities and a national network (which followed a modified version 

of the WHO Healthy Cities model) had more than 60 local government members. 

Separate networks were set up within Sweden’s three largest cities (Stockholm, Gothenburg 

and Malmö). Other networks worth mentioning were created for middle-sized cities (22 

cities/municipalities with 50,000 to 100,000 inhabitants) and larger cities (7 cities with 100,000 

to 250,000 inhabitants). In addition, there is a national Swedish network for local public health 

work with more than 100 out of 289 municipalities, which have actively applied for 

membership. The focus of public health on the municipal level was reportedly shifting to 

structural determinants of health like economics, (un) employment, education, demographics 

(home care, including out-patient care, concerns for the elderly), the environment, and 

sustainable development. The process of developing local Agenda 21 plans was increasingly 

integrated into public health and environmental issues. 

The report from the Netherlands included a long list of social policies. The co-ordinator felt 

that these were not integrated. Integration was not being achieved at the national level at all; 

instead there was a shift in focus, which was viewed as part of a wider move towards the 

democratisation of society. Involving citizens in policy to a greater degree via initiatives such 

as ‘Social Participation’ and ‘Social Renewal’ were examples of this. Where integration was 

being achieved was through the urban or ‘Big City Policy’. This brought together Welfare 

Policy, Local Health Policy, Employment Policy, Social Participation, Social Renewal and 

Minority Policy. 

Within Germany, progress was made in the same way with the introduction of two new 

policies. There were strong elements within both which attempted to ensure effective 

implementation at the local and community level. The first (Germany policy 1) was part of the 

national provincial programme and concentrated on the ‘special development needs’ of towns 

and other small geographical areas. The policy’s aim was to draw together and integrate the 

planning of health, housing, transport, job market and other economic factors. At the time of 

writing few details were available about the implementation (which was still in the early stages) 

and concerning any evaluation of effectiveness. 

Public health planners were given the power to operate within areas beyond traditional health 

services in the second German policy initiative, The Co-ordination of Health and Social 

Services (Germany policy 2). This was initiated by the Ministerium für Frauen, Jugend, 

Familie und Gesundheit (Ministry for Women, Young People, the Family and Health) in 1995. 

A ‘round table’ committee for ‘harmonising and steering’ was set up to formulates ‘joint 

recommendations for action’. On the surface this initiative, based upon Health for All 2000 

principles, appeared to be important and exciting, but again at the time of writing few details 

were available. 

Legislative support for action at regional and local levels 

In Austria, one approach was to legislate. In 1998 the Health promotion Act was passed, 

which considered life stages and was built on WHO definitions of health. It was designed to 

standardise national, provincial and municipal policy, and to ensure funding for health 

promotion across a range of settings including schools, workplaces and within communities. 

There were a number of goals relating to an increased emphasis on health promotion and 

improving the scientific basis of health promotion. It was influential in other sectors, a link was 

made with the determinants of health and policy-makers at all levels were charged with 

improving ‘the environment of people’. 


33

Framed within the context of occupational health inequality, the Swedish Work Environment 

Act (1999) was used to improve working environments and work related health. A series of 

problems were identified via surveys in the 1990s including increasing mental ill health 

amongst staff (low-paid, female, pre-school teachers) and increasing allergy levels amongst 

children and young people. The ill health was associated with the general decline in physical 

conditions within nurseries and schools. The Labour Inspectorate, who was empowered to 

impose financial sanctions on non-compliant employers, worked closely with unions and health 

professionals. The evaluation of this initiative noted significant improvements in a number of 

measures of the physical environment (including ventilation and air-quality). At the time of 

writing no information was available on whether any health improvement had been detected. 

Conclusions 

The reduction of health inequalities through national target setting was seen as increasingly 

important by a number of the national co-ordinators in this study. They were symbolic of 

support by policy-makers for tackling health inequalities. 

For many others they were unattainable or inappropriate. In the case of the latter this was 

because there were no suitable data on which to construct them or simply because health 

inequality didn’t feature on the political agenda. 

There were distinctly different approaches to target setting. The Danish approach was to 

devise a single overriding target which was applied as a principle to all their health target 

areas (risk factors, age groups, health promotion environments and structural targets). 

Detailed targets were favoured within Sweden and the United Kingdom. In the case of the 

United Kingdom, it was decided to use the summary measures of infant mortality and life 

expectancy. It was argued that they were both health outcomes reflecting a broad range of 

activities within and outside the NHS. There was an acknowledgement that there was a lack 

of strong evidence across a broad range of interventions, and that this would limit the 

opportunity to quantify in a meaningful way the overall impact on the life expectancy target. 

However, it was felt that indirect evidence supported the case for such targets being realistic 

and challenging measures of success. Within the guidance provided to accompany these 

targets there was clear engagement with the broader determinants of health, cross-policy 

initiatives were identified and their relationship with the two targets described. 

There was little evidence in the accounts provided for the integration of policy across different 

sectors at the national level. An area of considerable progress was area-based initiatives, 

which used determinants of health in a holistic way amongst communities. 

Legislative support for actions locally was a useful tool – it offered a potential focus for crosssectoral 

working and greatly assisted the effective implementation of health initiatives. 

Co-ordinators indicated that overt political support in the form of public statements was very 

significant – it focused attention on the issues and in turn, by identifying health inequalities as 

a priority, made the efforts of heath promoters easier. Perhaps not surprisingly co-ordinators 

felt that dedicated funding streams were essential and that spending cutbacks represented a 

real threat to effective work in this area. 

Cross-sectoral partnerships and integrated planning locally 


Cross-sectoral partnerships and integrated 

planning of services at all levels 

(government, local authorities, agencies and 

communities, families and individuals) offer 


� Encourage and support efforts 

which are specifically designed to 

34

communities, families and individuals) offer 

the potential to tackle health inequality by 

addressing the broad determinants of health. 

Action with a local, community focus is 

making significant progress in this context. 

Round table and planning committees offer 

an effective means for planning resources 

and for implementing change at the local 

level 

Factors that are important in achieving their 

goals are: 

� The support of central government, in 

terms of funding and legislative support 

� Shared strategic vision and common 

goals agreed at the outset 

� Strong Community representation 

� Flexible funding arrangements to allow 

change including pooled budgets 

� The support of local champions 

Round table forums are important to fulfil the 

following potential roles: 

� Offer cross-training courses 

� Offer consultative assistance 

� Act as a centre for the evaluation of 

progress 

� Offer networking capacity and advice 

� Engage and enlist the support of local 

champions 

Significant threats to successful partnership 

include: 

• Changing political environment/loss of 

political support 

• Failure of planning groups to engage the 

interest and support of local 

communities 

• Funding problems, including deficient 

funds (for increasing demands) or 

numerous funding sources 


tackle health inequality through 

integrating local services and 

creating new working patterns at 

local and community level 

� Support and develop local 

multidisciplinary planning 

committees as an effective means 

of implementing change at local 

level 

� Encourage the dissemination of 

examples of good practice. 

� Explore and collect evidence on 

the effectiveness of new 

approaches within this context 

� Where possible, recognise 

potential threats to progress and 

minimise their impact 

Cross-sectoral partnerships were being formulated to deal with problems and provide 

integrated solutions locally. There was recognition that this was imperative if inequalities were 

going to be tackled by addressing the broader determinants of health. Within this context the 

links between social exclusion, lifestyle and health were explicitly considered. Although there 

was an emphasis placed upon partnership at all levels (government departments, local 

35

authorities, agencies and communities, families and individuals) there was a focus on localities 

and communities which acknowledged that action at this level was an effective starting point. 

Co-ordinators identified the way in which these new ways of working were being developed, 

some of the obstacles that were encountered, and various solutions that were adopted to 

counter such obstacles. In some cases these new formulations appeared to be evolving in a 

haphazard way, responding and reacting to problems as they were encountered. In others, 

partnership working was planned and executed systematically: key components of success 

were nominated during the planning stages; elements of management and leadership 

responsibility were clarified; aims, objectives and targets of success were agreed upon; 

consultation mechanisms were devised and engaged; and subsequent progress was 

monitored and evaluated. 

These developments, in some cases, were driven and supported by central government, for 

example, the Government in the United Kingdom proposed new duties and roles for 

authorities. These were outlined in a public health White Paper (1999) 

‘The roles of the NHS and of local authorities are crucial. They 

must become organisations for health improvement, as well as for 

healthcare and service provision. We are underlining this joint 

responsibility by the new duty of partnership on NHS bodies and 

local government in the Health Act…’ 

‘Through the Health Act 1999 we have extended the existing duty 

of partnership between health authorities and local authorities to 

NHS trusts and primary care trusts, reflecting the need for 

partnership in service commissioning and delivery as well as 

strategic planning. All this is underpinned by new financial 

flexibilities, including powers to operate pooled budgets. This will 

create the opportunity for the new style of partnership we want to 

promote.’ 

‘Tackling poor health and health inequality needs the NHS and 

local government to take joint responsibility…Successful 

partnership working is built on organisations moving together to 

address common goals on developing in their staff with the skills 

necessary to work in an entirely new way – across boundaries, in 

multidisciplinary teams, and in a culture in which learning and good 

practice are shared’. 

Taken from ‘Making T.H.E. links – 

Integrating sustainable transport, health 

and environmental policies: A guide for 

local authorities and health authorities’ 

HEA 1999 

Within the same White Paper broad guidelines were issued on ‘Making partnerships work’: 

� Clarify the common purpose of the partnership 

� Recognise and resolve potential areas of conflict 

� Agree a shared approach to partnership 

� Establish a strong leadership based on a clear vision and drive, with well-developed 

influencing and networking skills 

� Continuously adapt to reflect the lessons learnt from experience 

� Promote awareness and understanding of partner organisations through joint training 

programmes and incentives to reward effective working across organisational 

boundaries 


36

United Kingdom Department of Health 1999 

Evans and Killoran (2000) observed that whilst policy within the United Kingdom strongly 

supported partnership working for tackling health inequalities, there was a lack of evidencebased 

operational guidance for the development of local partnerships in health. These 

authors investigated different models in partnership-working in tackling health inequality and 

identified six key themes: 

� Shared strategic 

vision 

� Leadership and 

management 

� Relations and local 

ownership 

The early creation of a shared strategic vision about the focus of the 

project and how it would impact on inequalities was a critical 

enabling factor. The absence or partial agreement of the strategic 

vision, both within and between partner organisations undermined 

progress. 

Leadership provided by local ‘champions’ for integrated working 

was crucial. This was important at the strategic level, with project 

‘sponsors’ seeking to position the project on the strategic agenda as 

well as ensuring that the project has the space and resources to 

work. Leadership was also crucial at the project management level. 

Management of conflict proved problematic in some cases, and 

skills that enabled conflicts arising from diversity of perspectives to 

be addressed and resolved were valuable in making progress. 

Shared ownership for the project was related to the degree of 

participation in, and accountability for, the project among 

stakeholders, as well as the quality of relations between parties. 

Developing and maintaining good relations required mutual 

understanding and respect of other stakeholders’ professional 

backgrounds and contributions, and this could be facilitated through 

the project. An audit of the quality of relationships between parties 

would seem to be a pre-requisite of developing integrated working. 

Furthermore partnership structures and processes must seek equity 

in participation and accountability. An early focus on joint 

assessment of community needs proved important for deepening a 

shared vision, identification of contributions and engendering 

ownership of practical steps 

� Accountability There was a need for partners to acknowledge and address the 

complexities of fluid and multiple accountability’s in partnership 

working. Establishing formal accountability arrangements (e.g. 

steering groups) was not sufficient to ensure genuine accountability. 

[Given that democratisation of processes and structures were an 

important aspect of building social cohesion in deprived 

communities with potential health benefits] greater attention was 

needed to find effective ways of genuinely engaging communities 

� Organisational 

readiness and 

responsiveness to a 

changing environment 

and shifting power balances. 

The organisational readiness of partners to engage in inter-agency 

working to tackle inequalities varied markedly between (and also 

within) projects and was influential in determining the extent and 

pace of progress. Some projects were based on histories of joint 

organisational and personal relationships and were integrated 

within existing joint planning mechanisms. Other projects needed 

to establish new forums and structures and forge new relationships. 

Many of these new patterns of working were reflected within the co-ordinators accounts. 

An attempt was made to consider the combined needs of deprived urban areas in a policy 

initiative reported within the German national report (Policy 1). Towns with special 

development needs – ‘the social town’ focused on the integration of health, housing, transport 

and economic aspects of the area under scrutiny. The programme was instigated in response 


37

to a growing awareness of problems, which compounded and exacerbated one another, 

especially with respect to younger people. These problems were to be found in 

unemployment and lack of prospects; disharmony between groups and individuals; and poor 

quality physical environments. Careful town planning and redevelopment were the starting 

points for this ambitious programme, which sought to: 

� Strengthen the local economy by safeguarding jobs; 

� Provide assistance to those seeking work; 

� Support and facilitate social structures with and between population groups; 

� Create greater security in public areas; 

� Provide integrated ecological (sustainable) planning; 

An underpinning value behind this programme of activity was a greater level of community 

participation in the planning process combined with greater levels of ownership and 

responsibility. The provision of considerable financial (10million DM 1999-2003) and 

legislative (article 104a para 4 of the basic law for the promotion of town building measures 

1999) support was important in the continued success of the programme which had the direct 

involvement of the following stakeholders: 

� The Federal Government via the national-provincial programme 

� The National Ministry for the Family, the Aged and Young People 

� The programme ‘Development and Chances for Young People in Social Problem 

Areas’ 

� The National Ministry of Labour and Social Order 

� The National Ministry of the Interior 

� The National Ministry for Business and Technology 

� The National Ministry for Traffic, Building and Housing 

Cross-sectoral partnerships across Europe did not necessarily receive the same level of 

interest, emphasis and support from central government as they did within the United Kingdom 

and Germany. There were, however, many examples identified within the national reports, 

which provided valuable learning points, which could potentially be transferred to other 

national settings. 

Within Belgium (Intervention 4) for instance, a concerted effort was made to reorganise health, 

mental health, judicial and legal support, adult education and literacy services. The need for 

‘social co-ordination’ was identified and driven by professionals working within existing 

community healthcare services in Forest Quartier Santé (Brussels). A commission was set up 

with the goal of tackling health inequality through reorganising the resources and efforts of 

different sectors. A local planning committee (‘Forum Santé’) with strong community 

representation was initiated to identify needs and agree priorities. The ‘Forum Santé’ then 

delegated responsibility for specific tasks to working groups whose membership comprised 

both community members and officials from appropriate authorities. The ‘Forum Santé’ played 

an important facilitatory role, offering training, networking advice, and supervising goaloriented 

(nominal) group discussions. Information from the discussions was returned to the 

forum and analysed as part of the evaluation of the initiative. The evaluation concluded that 

the framework that was set up was successful in offering a new approach to resource planning 

within the district. It also endorsed the way in which community members were involved in all 

aspects of the process – from the identification of problems through to prioritisation of 

resources. Importantly it was able to identify that community leaders, who had become 

interested in the Forum, considered it worthwhile in that their opinions were valued and their 

efforts realised. 

A similar model was adopted in a deprived neighbourhood of Anderlecht (Brussels, Belgium) – 

‘Les Relais-Sante’, Cureghem. Within this account, the support of the political leader was 


38

crucial in the initiation of the ‘District’s Social Development Plan’. The overall goal of this 

project was to improve the quality of life within the district by integrating the efforts of a range 

of services to tackle problems related to the: prevailing economic conditions; health status of 

the local population; educational services; the urban environment; and social infrastructure. 

The success of this project was limited by a failure to engage the local population to a 

sufficient level and through the loss of the political champion mentioned, who was instrumental 

in achievements early on. 

Within Belgium again, progress was made in forging links between different sectors through 

the use of social interpreters and mediation services (Interpretariat et Service de Mediation, 

Belgium Intervention 3). The programme, whilst initiated by primary healthcare professionals, 

did not restrict operation within the boundaries of health service infrastructure. Social 

services, schools, adult education establishments, judicial services, socio-cultural 

development organisations, support centres for prostitutes and asylum seeker reception 

centres were the target settings for this service. The progress and development of the 

organisation behind this programme was not without problems. The changing political 

environment, deficient funds to meet increasing demand for services, numerous and diverse 

funding sources were all cited as threats to success. The account reported considerable 

recent increases in demand notably from eastern European immigrants. 

Social workers, insurance company representatives, union representatives, workplace health 

promotion services and company representatives composed the membership of intersectoral 

planning forums in a project in Denmark. The scheme was designed to lessen the impact of 

sickness absence in the workplace in 5 municipalities (Denmark Intervention 1). Round table 

discussions focusing on selected case studies allowed integrated solutions to be created for 

individuals suffering sickness and consequently absence from work. The response was 

initiated due to growing pressure on private institutions and support services and driven by the 

Ministry of Social Affairs. Improved and more systematic case handling along with a greater 

degree of co-operation between partners was reported by the evaluation. Figures on whether 

the initiative had made an impact in terms of decreasing sickness benefit payments were not 

available but the indications were that this was expected. 

Strong intersectoral co-operation characterised an intervention conducted in Djursland 

(Denmark intervention 2) which aimed to provide rapid assistance to families where alcohol 

use was identified as being problematic. Social workers, teachers and day-care assistants 

formed teams to ensure that signs of problems were detected early and the appropriate 

support offered quickly. More radical measures were instigated where the abuse of children 

came to light. Emphasis was placed on treating the whole family and for this to be achieved a 

range of appropriate services were delivered by the teams. Important in the success of this 

initiative were cross-training courses and consultative assistance for the professional involved. 

Co-operation between and co-ordination amongst: primary healthcare professionals; health 

insurance representatives; adult educators; self-help group and other community 

representatives, was an objective of a nutritional programme in Kaltenmoor Germany 

(Intervention 4). A holistic response to poor nutritional intake was instigated among this 

socially disadvantaged population in the Lower Saxony region. High levels of community 

participation were reported with activities being conducted in a number of settings including: 

schools and day care centres; community health centres; adult education centres; and day 

facilities for the elderly. Amongst the positive aspects of the programme, participants stated 

that they felt that there was an ‘increased availability of alternative ways to act’. 

The co-ordination of health and social care was one of the aims of the Provincial Health 

Conference of North-Rhine Westphalia, which based its approach on Health for All 2000, but 

which reduced the 38 targets down to ten more manageable ones (German policy 2). The 


39

initiative was driven by the Ministry for Women, Young people, Family and Health and 

commenced in 1995. Specific objectives relating to the co-ordination of services were: 

� Optimising the overall provision for the sick and those needing care, by directing and 

developing the provision of services according to need 

� Providing those services which are lacking and avoiding those which are superfluous, 

by taking action against the causes of lack of agreement and gaps in services by cooperating 

with those responsible for planning and providing services 

Whilst the evaluation was not able to demonstrate improvements in health which could be 

attributed to the initiative within the time period, it was however, able to report a number of 

positive effects in terms of process. Amongst these were the: rationalisation of information 

and advice services; regular positive media reporting of the initiative; improved responses from 

doctors and pharmacists. 

Specific improvements for disadvantaged people, which arose from the initiative, included: 

� A more responsive addiction care system 

� Increased levels of access to care for people with mental health problems including, 

faster response times for diagnosing and treating (especially in more extreme cases 

where there was a need for supervised accommodation) 

� Better access in the workplace for people with mental health problems 

‘Round table committees’ (‘communal health conferences, and ‘subject-related working 

parties’) were created specifically to manage the harmonisation process. Their remit was to: 

� Identify problem areas and gaps in the provision of services at the community level 

� Formulate priorities for specific working groups 

� Issue ‘joint recommendations for action’ 

Overall the effect of these reforms was to provide public health services with greater powers to 

act at the community level, extending beyond traditional healthcare infrastructure. These were 

being used particularly to target the socially disadvantaged. 

Strengthening coherence in prevention in Amsterdam (Netherlands Intervention 1) was a joint 

initiative instigated by the municipality and a health insurance company. It aimed to 

strengthen collaboration between prevention, cure and care. There were four main pilot 

project areas (including strengthening coherence and reduction of inequalities) and these were 

operationalised in three distinct phases via the following strategies: 

� Setting up a multidisciplinary steering groups (which included community members) 

for each pilot area 

� Working in ways prescribed by the community 

� Developing intersectoral collaboration between institutions, organisations and 

disciplines 

� Supporting progress by research 

There were three themes that were identified by the steering groups, which were: families 

under pressure; health problems of the elderly; and cultural differences in care facilities for 

ethnic minorities and migrants. 

Despite a number of operational problems the project was able to report considerable 

progress and to make recommendations on the factors that were important in this context. 

Amongst these were: 


40

On progress: 

� Access to municipal and health insurance’s was easier 

� The community approach to tackling problems was high on the political agenda and 

there was a willingness created for organisations to work together 

� There were improved connections between policy and practice 

� Involvement of community representatives was positive and enhanced the process 

On important facilitator factors: 

� Community involvement despite being challenging was appropriate 

� Steering groups required a degree of financial autonomy and control 

� Research findings needed to be action-oriented 

� Shared funding and collaborative goal setting was important 

� Clarifying management responsibility at the outset was critical 

� Utilising existing network structures was a valuable resource 

� Time was needed if trust and respect was to be built between different players 

Conclusions 

Across Europe there were many examples where new ways of cross-sectoral working were 

being embarked upon. This was not simply a reflection of moves towards rationalising existing 

services to make them more efficient. Underpinning these efforts was a desire to provide 

integrated solutions to complex problems. These new partnerships were a means by which 

health inequalities could be engaged through addressing the broader determinants of health. 

Creating new ways of working meant quite radical shifts, challenging the existing service 

infrastructures, resource allocation and policy. This context proved extremely difficult for those 

trying to oversee reforms and for those implementing new initiatives at the community level. 

Despite this adversity considerable progress was being made and the process of change was 

being made easier by a range of measures which were ensuring success. 

Supporting staff skills development through cross-training courses was one of the approaches 

within this range of measures. These not only enhanced the existing skills base but also 

facilitated learning by allowing professionals to see some of the problems they were facing 

from other perspectives. This was important in encouraging co-operation amongst newly 

formulated multi-disciplinary teams. External consultative assistance was also useful in this 

context. 

The creation of new ‘round table forums’ or ‘local planning groups’ who controlled ‘project 

working groups’ was a particularly effective means of moving forward. It was important that 

these forums were given a real chance to make changes, and financial flexibility, allowing 

pooling of budgets was an important contributory factor. Ensuring that there was a shared 

strategic vision and that there were common goals was imperative at the outset. Where 

adequate support was afforded, the forums were well placed to: engage the support of local 

champions; ensure the local community was being fully consulted; provide a central point for 

evaluation; offer a facilitating and networking role along with potential training capacity. 


41

Improving Access to Healthcare Services 


The modification of existing services to improve 

access to excluded groups is a way of tackling 

health inequalities directly: 

� Partnership protocols and harmonising 

committees are a means to integrate 

services to offer greater levels of 

accessibility within communities 

� Training and development is important to 

ensure that professionals are aware of 

cultural and language barriers, and to 

assist them in providing appropriate and 

sensitive responses to patient needs 

� Community representation and 

involvement can successfully be used as 

a tool for service reforms 

� Access charters can be initiated to 

ensure acceptable access levels for all, 

including the socially excluded 

� Improving information systems is a basic 

practical measure to raise awareness of 

available services (information 

technology, databases, telephone help 

lines and drop-in counselling services) 

Outreach work is a successful means to target 

socially excluded groups 

� Multidisciplinary mobile teams can target 

socially excluded groups with special 

health needs (e.g., sex workers) 

� Investigatory home visits and home care 

networks can provide basic in situ care 

and refer patients for additional treatment 

where appropriate (Elderly, Mothers and 

young children) 

Interpretation and advocacy can increase 

awareness of available healthcare services and 

resources, improve interaction between medical 

personnel and patients, and provide support 

where language and cultural differences are a 

barrier to patients receiving appropriate levels of 

service and treatment. 

� Language translators can improve 

communication between immigrants and 

medical personnel 


� Support and encourage the reform 

and modification of existing 

healthcare services by the methods 

identified to ensure that socially 

excluded groups are aware of and can 

access services available to them 

� Encourage the development of 

outreach services where barriers 

mitigate against certain groups of 

people accessing appropriate services 

� Create and support opportunities for 

interpretation and advocacy services 

in situations where specific cultural 

42

medical personnel 

� Cultural interpreters offer language 

services and can tackle other potential 

barriers to patient satisfaction 

� Advocacy services are a means of 

support and advice to those who are 

excluded from service provision due to 

range of obstructions (language, cultural, 

financial) 

� Increased coverage can be achieved 

through the initiation of telephone help 

lines offering interpretation services 

Improving financial access to services affords 

greater levels of protection to disadvantaged 

groups and reduces the financial burden on 

service providers. 

By reducing financial pressures on those needing 

treatment, they are more likely to present to 

appropriate primary services rather than wait 

and/or needlessly burden secondary services. 

� Greater levels of access achieved through 

legislation provide ‘safety nets’ to those 

who would otherwise have been excluded 

from participating in health insurance 

schemes. 

� Local agreements between primary care 

services and insurance companies initiate 

fixed payment schemes which offer 

greater levels of access to low-income 

people 


and language barriers have been 

identified 

� Encourage the development of 

curricula, codes of ethical practice and 

qualifications within this field to 

ensure appropriate quality standards 

� Support and encourage the 

development of legislation and 

schemes which provide greater access 

or afford greater levels of protection to 

those who are prevented from 

accessing services due to their lack of 

financial means 

Improving access to healthcare services was a subject that received a great deal of attention 

within national reports. Co-ordinators provided examples of innovative approaches that were 

designed to extend the boundaries of existing service provision. Generally this activity was 

related to groups of people with special needs with respect to services, or to those who were 

prevented from accessing services because of barriers (legal, cultural, financial) that had been 

identified. The consideration of this subject covered a number of approaches including: 

outreach work amongst difficult-to-target populations (migrant workers, rural-to-urban 

migrants, ethnic minorities, sex workers); providing services within specific geographical 

areas characterised by multiple deprivation; modifying the access points of traditional services 

to make them more responsive to the needs of certain groups; and providing improved 

financial access to care to those lacking sufficient funds or insurance 9 . 

The links between health inequality and health services has long been an issue considered by 

many writers. It was not considered necessary to reproduce here the entire debate. A brief 

look at some of the issues is included for completeness. 

9 Some of the examples that illustrated the extension of existing healthcare boundaries were part of 

wider moves towards the integration of services and the creation of new working partnerships. This 

closely related issue receives fuller attention within the section on cross-sectoral partnerships 

43

Macintyre (1989) noted that reviews of patterns of ill-health often started by arguing that their 

causes lay outside the healthcare sector, but then proceeded to recommend changes in 

healthcare provision without explaining why this should be an appropriate type of remedy. 

She cited the famous thesis of McKeown (1965) who argued that the decline in mortality that 

occurred in Western Europe from the early nineteenth century was due to a rising standard of 

living and the control of the physical environment. This position, Macintyre observed, was 

frequently extended by others to suggest that health services had little influence on aggregate 

levels of morbidity and mortality. She considered this to be erroneous since McKeown’s point 

was that specific therapies were not important in reducing aggregate mortality until the 

beginning of the twentieth century and not that they were never important. She pointed to the 

lack of evidence supporting both viewpoints, either that health services were relatively 

unimportant in determining health or that the use of health services was automatically effective 

and beneficial. It was the latter view she reported as apparently being manifest in the way 

consumption of health services was equated with health, or the equalisation of health service 

use was seen as a remedy for inequalities in health. Macintyre took a pragmatic stance and 

considered that arguments about whether health services matter were not useful at a 

generalised level and that since health services of some kind or another were not likely to 

disappear, scrutiny of how they could do most good was more productive than worrying about 

whether they did any good at all. Co-ordinators took a similarly pragmatic stance and 

identified a large number of examples attempting to tackle some of the problems mentioned at 

the outset of this chapter. 

All of the interventions from the Portuguese national report were aimed at improving access to 

healthcare services through outreach work amongst hard to reach populations. Two 

interventions were targeted at sex workers in the most northern region of Portugal. These 

groups of people were identified as having particular health needs, especially with respect to 

drug use and sexual health, but because of their relative social isolation were often not 

receiving or accessing them. 

Espaco Pessoa in Oporto city was an outreach support programme for male and female 

prostitutes. Multi-disciplinary teams were convened to try to provide better access to a range 

of social and health services. In the early stages of the project research revealed that the 

prostitution phenomenon in this region generated highly closed social systems which 

contributed to individuals becoming alienated. Efforts were focused on the provision of 

services from doctors, nurses and psychologists but in addition were extended to provide 

improved legal and housing conditions. A number of protocols were devised between the 

partners involved (Association for the Equality of Women’s Rights, Sub-Region on Health in 

Oporto, Foreigner and Borders Service, the Association for Family Planning and all of the local 

hospitals) to try to facilitate more co-operative methods of working. 

The AUTOESTIMA programme (Portugal intervention 4), again based in Northern Portugal, 

focused on the sexual health of prostitutes. It was particularly targeted at street prostitutes 

who unlike their counterparts working within clubs or from apartments were much less likely to 

visit clinics and counselling services. This group was reported to have: high levels of 

intravenous drug-use; poor housing conditions; a high proportion of cohabitants who were 

unemployed; low educational achievement levels; a high proportion of offspring no longer 

living with them; high numbers not using any form of contraception; and low attendance levels 

at family planning and sexually transmitted disease clinics. Making contact with these isolated 

individuals was the first step in a process of socialisation and the project did this by going 

mobile and operating during the night. A vehicle with teams of professionals offered 

immediate medical services, support and information. 

A range of problems related to the ‘functional access’ to social services and healthcare were 

detected, which was the starting point for the Quinta do Mocho and Marvilla projects for 

immigrants and illegal immigrants (Portugal intervention 2). The target group were young 


44

migrants from Africa (Angola, S.Tome and Guinea) who were living in a district of Lisbon 

characterised by high levels of unemployment, poor housing, and security problems. 

Additional problems included children with low levels of immunisation uptake, poor nutritional 

intake who remained at home alone during the day and who were subject to physical and 

sexual abuse. Protocols were drafted outlining agreements for partnership working and 

mobile teams of professionals were initiated to take services out of the immediate location of 

the health centres into the communities. Planning committees with representatives from 

communities were established to identify local needs and prioritise available resources. A 

range of media in African languages was produced to raise awareness on health issues. An 

array of formal targets was devised as part of the evaluation (tuberculosis levels, pregnancy 

and post-natal care, vaccination uptake, STD’s, HIV and AIDS transmission rates) and levels 

of community participation were monitored. 

‘Soares dos Reis’ (Portugal intervention 3) was a project initiated by a group of volunteers who 

worked in co-operation with health professionals amongst urban dwelling (Oporto) older 

people living in isolation. Data from a study entitled ‘Eldest Generations’ (1999) conducted by 

the Institute for Statistics (INE) was included within this national report: 

� The number of older people living in Portugal doubled in the last 40 years 

� In 1998 the number of older people (65+ ) exceeded 1 million 

� Older people were not in regular contact with friends and family and very few belonged 

to social or cultural organisations 

� There was a low participation of older people in active living 

� The living conditions of single older people was worse than for older people as a whole 

� Older people characteristically were on low incomes and had greater levels of poverty 

than the population as a whole 

The overall objective was to improve the quality of life and well-being of low-income older 

people who were living in poor housing conditions and who were not receiving any family 

support. Work concentrated on solving daily practical problems through home visits (cleaning 

and basic maintenance) and ensuring that more formal services were accessed if they were 

required. 

An attempt to improve access to services for pregnant women, young mothers and children 

through outreach work was undertaken in Ciutat Vella, a deprived inner city district of 

Barcelona (Spanish intervention 2). Infant mortality within this area compared badly with 

aggregated figures for the whole of Barcelona. For the period from 1995-1999 for instance, 

the infant mortality rate for Ciutat Vella was 7.1 per 1000 births compared with 4.1 per 1000 

births for the city as a whole. The starting point for the intervention was the detection of 

unregistered pregnancies and births in the first place amongst a population who were not 

presenting to the care services available. This task was undertaken by nurses and social 

workers that conducted investigatory home visits. Their role was then to provide any 

immediate care that was necessary and to refer those in need to appropriate services 

(obstetric, paediatric and family planning services). 

In East London (United Kingdom Intervention 8) a charter of access was developed to tackle 

some of the problems experienced by a culturally and racially diverse population in a deprived 

inner-city area. The minority ethnic population of the boroughs of East London were: Newham 

51%, Hackney 39% and Tower Hamlets 27%. The composition of these varied considerably, 

with some boroughs for example having a concentration of Turkish/Kurdish people (Hackney) 

or Bangladeshi people (Tower Hamlets). Disease amongst the ethnic minority population was 

disproportionately prevalent (heart disease, diabetes, asthma, HIV/AIDS) with one of the 

highest incidences of tuberculosis in the UK. Health advocacy and interpretation services 

were developed in response to the factors mentioned above. The National Health Action Zone 


45

programme (see case studies) was providing an opportunity to develop cohesive, responsive 

and equitable advocacy services. This was done through the introduction of: 

� a training and development programme; 

� increased levels of community involvement in the planning of local services; 

� local planning forums; 

� a local database of services and resources; 

� telephone interpreting services 

� an access charter 

The charter of access, which all-relevant organisations were encouraged to adopt, was 

grounded within the principles of equal opportunity and consistent with regional and national 

initiatives. An incremental programme covering areas such as recruitment and physical 

access was being phased in. 

A further example of improving access to those who were experiencing language and cultural 

barriers was provided within the Belgian national report (Belgium intervention 3), in which 

intercultural interpreters were made available to non-French and Flemish speaking people 

within the Brussels region. The project was initiated jointly in 1999 by two non-governmental 

organisations - ‘Interpretariat et Service de Mediation’ and ‘Co-ordination et Initiatives pour 

Refugees et Etrangers’. It operated within a number of sectors, including medical (preventative 

and curative); social, educational; judicial; and socio-cultural). In addition to offering basic 

interpretation services (52 European, Asian and African languages) the objective was to work 

at tackling problems that had arisen as a result of cultural differences. Support was provided 

in a diversity of settings, including such examples as: homes for women in difficulty, asylum 

seekers and organisations campaigning against the trade of human beings and its links with 

prostitution. More than half of the services offered by this project were taken up by Eastern 

Europeans (55%) (mostly Russians and Albanians) and the demand was reported as 

‘increasing dramatically’. The interpreters took a neutral stance themselves who had 

developed their own code of ethical standards. 

In mid-1995 the Provincial Health Conference of North-Rhine-Westphalia passed a series of 

health reforms designed to improve co-ordination between health and social care and improve 

access. (Germany policy 3). The plan developed was based on the WHO’s ‘Health for all’. 

Improving opportunities for disadvantaged groups was a theme given priority within the plan 

which explicitly mentioned ‘directing and developing the provision of care services according to 

need’. There was a strong emphasis on efficiency and calls for the ‘avoidance of superfluous 

services’. Among the significant impacts resulting from this initiative were: community 

programmes to improve addiction care and reduced timescales within which the mentally ill 

accessed supervised residential services. Examples of improved public information about 

healthcare services were reported including drop-in counselling offices, telephone help lines 

and printed material. Work was also conducted amongst general practitioners and 

pharmacists to raise the potential for the sensitive handling of disadvantaged clients. The 

Public Health Service Act (introduced subsequently within the same region of Germany) 

stipulated that new harmonising committees should be set up; these were responsible for the 

identification of gaps in services. They had powers to make ‘recommendations for action’ 

which extended beyond traditional healthcare services. 

Some national reports revealed that financial access to healthcare services had been 

improved by initiating reduced and/or fixed price payment schemes or the creation of financial 

‘safety nets’ for disadvantaged groups through legislation. 

These initiatives were set up to provide greater protection to immigrants (illegal immigrants), 

the unemployed, older low-income citizens, and those living in poverty who otherwise would 

not have been able to access essential services. In the case of unemployed people, their 


46

position meant they were no longer able to keep up national/health insurance payments and 

would therefore have been ineligible to receive or access care. Similarly, recent immigrants 

found themselves ineligible and excluded due to the fact that they were not officially registered 

and had no history of payments. 

In Sweden, factors in the rise in health insurance costs were absenteeism and early 

retirement. This, against a background of the collapse in the demand for unskilled labour, 

combined with a rise in work demands generally, were identified as factors contributing to the 

rise of social inequalities in health (where an increasingly sharp SES gradient was observed). 

A particularly disadvantaged group within this context were those who were unemployed due 

to long-term illness (They were also a significant financial burden). Financial Co-ordination 

between Healthcare and Health Insurance for Rehabilitation (FINSAM, Swedish intervention 5) 

was an attempt to alleviate the problems faced by this group by integrating the two systems 

(healthcare and insurance for rehabilitation). This initiative led to a significant lowering of 

costs for health insurance and increased resources for the providers of rehabilitation services. 

The drop in absenteeism was greater in areas where this financial co-ordination was 

implemented, than in areas where the initiative was not introduced. There were also positive 

cross-sectoral co-operations among professionals from different sectors learning from each 

other’s skills. 

In Germany, an administrative agreement on the provision of financial assistance from the 

National Government of the Provinces provided underpinning support for towns identified as 

having ‘special development needs‘ (Germany policy 2). The overall aim was to integrate 

social and healthcare infrastructure and provide better access for young people especially. 

There was a strong emphasis on community involvement and responsibility within this 

approach. 

In Belgium, a Royal decree was issued on 16 April 1997 (Belgium policy 3) which extended 

the medical coverage by the mutual health insurance funds (mutualité) of widowers, disabled 

people, children in care and those falling below a certain income, including the following 

groups: 

� older people (65+) 

� the long-term unemployed (1 year +) 

� informal family carers looking after disabled family members 

The reform took a considerable burden away from general practitioners who were reported to 

be tackling problems identified with individual patients through informal arrangements with the 

“mutualités” and personal generosity. The measure impacted in a number of ways. It was 

thought to have reduced unnecessary hospital visits because patients were more likely to 

attend general practitioner clinics earlier without fear of heavy payouts. 

Also in Belgium, in 1994, fixed prices were introduced for services (doctors, nurses and 

physiotherapists) offered within community health centres (Belgium policy 4). The fixed price 

scheme consisted of an annual subscription fee paid by the patient (maximum EUR 2.5 per 

individual, EUR 10 per family) to the “mutualités”, which established a contract between 

patient, insurance company and health centre. The health centre was then paid a monthly 

fixed sum by the “mutualité” to cover costs incurred by visits made by the patients. Positive 

effects, in addition to the overall provision of greater access, were that health professionals felt 

that the exchange with patients was more productive and there were less complications 

related to financial matters. 

In Austria the General Insurance Act (ASVG) (Austria policy 10) was passed and covered 

general health insurance and occupational accident insurance. This ‘people’s insurance’ was 

specifically designed to reduce inequalities caused by the introduction of private health 


47

insurance schemes. The starting point for the act was the regulation of nursing care, medical 

rehabilitation, certain therapies and health promotion that were consequently guaranteed to 

the whole population. 

Conclusions 

Improving access to healthcare was seen as an important priority by national co-ordinators, 

and the subject received a great deal of attention within national reports. Some of these were 

simply measures modifying and updating existing services to ensure greater access. Others 

were part of wider reforms aimed at the integration of the social and healthcare sectors. 

Efforts were made to specifically target those who were identified as having certain needs, or 

where there were barriers to access, and there were a number of examples of innovative 

outreach programmes. 

A range of practical measures was identified with the objective of improving access and raising 

awareness about the rights of individuals and the availability of basic service provision. 

Interpreters were identified in different forms. Some were language translators, while others, 

while offering this basic service, also served as mediators between medical professionals and 

patients, where there were additional cultural barriers to understanding. Interpreting services 

often overlapped with advocacy services and there were alternative stances adopted in 

different settings, such as ‘neutral’ or ‘pro-patient’. Formalised curricula, in some cases 

leading towards formal qualifications, were devised to control the development and quality of 

the work. 

Financial reforms were an important way in which greater access could be afforded to those 

who otherwise would have been excluded. These reforms prescribed new patterns of working 

between primary healthcare providers, insurance companies and community members. 



Across Europe, community development 

approaches are used effectively to offer 

integrated assistance in tackling health 

inequality problems 

These approaches allow the broad 

determinants of health to be addressed: 

� The relationship between unemployment 

and health and associated problems 

� Improvements in education and training 

� Crime and security problems 

Community development approaches can be 

used to tackle specific problems related to : 

� Geographical areas in economic crisis 

characterised by multiple deprivation 

� Special health needs of certain socially 

excluded target groups, such as children 

and families minority ethnic groups and 


� Recognise and acknowledge the 

considerable achievements that 

have already been made by 

community development 

approaches in tackling health 

inequalities 

� Learn from and disseminate 

models of good practice within this 

field 

� Support and develop these 

approaches in the future 

48

and families, minority ethnic groups and 

immigrants, and sex workers 

Community development approaches are an 

effective means to implement national health 

targets locally 

By implementing interventions that address 

the problems within communities holistically, 

the efforts of local support organisations are 

unified. 

Key elements of community development 

approaches identified as being important to 

success are: 

� Conducting well-planned needs 

assessments 

� Working within a range of settings 

� Placing ownership of projects within the 

hands of the target population 

� Ensuring adequate community 

representation on local planning 

committees and collaborative goal setting 


� Use community development 

approaches as an effective means 

to implement national health 

(inequality) targets at a local level 

� Use community development 

approaches as an effective means 

of unifying the efforts of local 

support services 

� Support and develop specific 

approaches that have been proven 

successful within the context of 

community development 

Health promotion works through concrete and effective community action in 

setting priorities, making decisions, planning strategies and implementing them 

to achieve better health. At the heart of this process is the empowerment of 

communities, their ownership and control of their own endeavours and 

destinies. 

Community development draws on existing human and material resources in 

the community to enhance self-help and social support, and to develop flexible 

systems for strengthening public participation and direction of health matters. 

This requires full and continuous access to information, learning opportunities 

for health, as well as funding support. 

The Ottawa Charter for Health Promotion 17-21 November 1986 

Participatory approaches were a feature of both health promotion interventions and policies 

cited by almost all of the national co-ordinators. The history and tradition of participatory 

approaches identified within reports was diverse, and the way in which they were defined was 

diverse. The approaches identified within this study and the context within which they were 

implemented posed difficulties both in terms of their definition and delimitation. 

The difficulties of defining any of the terms related to this area (which were exacerbated by the 

translation into English) were not confined to this work. They were reflected within the 

published literature, which was consulted. 

Rifkin., et al (2000), in a review of community participatory approaches in health and health 

planning, highlighted the tension between whether community participation should be seen as 

‘a specific intervention for health improvement or a process of change’. They placed emphasis 

on the historical development of participatory approaches, which was ‘flexible, 

accommodating, creative and exploratory’. As a result of this flexible evolution they remarked 

that “to date, it is not possible to give a universal definition to either ‘community’ or 

‘participation’.’’ They went on to say that “these terms in theory and practice, depend upon the 

49

environment in which they exist” and that “the model for participatory approaches is still 

ephemeral and often rhetorical”. An article by Hillery (1955) was cited in which he provided 55 

definitions of community. 

Since the national reports did not define clearly the communities to which they were referring 

in most cases it would have been inappropriate to attempt to impose a single working 

definition post hoc. It was deemed useful however to explore some definitions to provide 

clarity and to map out the scope of this section more thoroughly. 

Rifkin et al., (2000), when considering definitions of ‘community’, cited Jewkes and Murcott 

(1996), who argued that “the definition of community is a geographically located group of 

people with shared economic, social-cultural and political interests and shared problems and 

needs”. Geographical characteristics were not necessarily attached to definitions of 

community, however, Suliman (1983) saw communities as “groups of people with common 

perceptions of needs and priorities and the capacity to take responsibility to act upon these 

needs”. The Ottawa Charter for Health Promotion (1987) took this notion forward and based 

its definition on social units as formal administrative units. 

On ‘community participation’ the same authors (Rifkin et al 2000) noted that the range of 

definitions was equally as vast. On both sets of concepts they concluded by making the 

observation that context (historical and views of social theory) and experience had militated 

against standard definitions. 

Characteristics of successful approaches, which address inequalities based on work by Gillies 

(1997) and the Centre for Reviews and Dissemination (1997), were presented within this 

useful review. 

� Local assessment of needs, especially involving local people in the research process itself. 

� Mechanisms that enable organisations to work together – ensuring dialogue, contact and 

commitment. 

� Representation of local people within planning and management arrangements (the greater 

level of involvement the larger the impact). For example, local committees are vital to support 

� the sharing of power and responsibility for change, and allow local people to voice approval 

or dissent. 

� Design of specific initiatives (‘interventions’) with target groups to ensure that they are 

acceptable, culturally and educationally appropriate; and working through settings that are 

accessible and appropriate to them. 

� Training and support for volunteers, peer educators and local networks (ensures maximum 

benefit from community-based activities). 

� Political visibility of support and commitment. 

� Reorientation of resource allocation to enable systematic investment for community-based 

programmes. 

� Policy development and implementation that brings about wider changes in organisational 

priorities and policies, driven by community-based approaches. 

� Increased flexibility of organisations that supports increased delegation and a more 

responsive approach 

Rifkin et al (2000) 

Whilst this review was based on material drawn solely from the United Kingdom it was found 

that the elements identified here were also present in the approaches that were identified from 

across Europe. 

The factors identified above were used to guide the discussion of work identified within this 

project. 

The second German intervention (the project appears not to have been given a name) was 

designed to tackle problems associated with high unemployment levels in the east German 

rural province of Brandenburg (Prignitz district). The objectives were focused both on longterm 

unemployment and health, and the project aimed to provide ‘integrated assistance’. A 


50

specific need was identified and was related to people being unemployed for a long period 

(half of the people n=90 on the project were unemployed for more than 24 months). This in 

turn had detrimental effects on their health which consequently further impaired their chances 

of re-employment. Support was provided to break this cycle and to help people cope with 

being unemployed, remain healthy, and where possible help them back to work. The project 

operated at two levels: through the provision of support and information to individuals affected; 

and the provision of support, training and resources to community counsellors. Counsellors 

focused their efforts on working closely with clients to devise individual ‘back to work/back to 

health’ strategies and then operated as advocates to ensure that goals were met and 

additional services accessed. Particularly strong characteristics of this intervention were the: 

assessment of needs, locally and individual specific; representation of local people; training 

and support for networks and counsellors; and responsive, co-operative approaches between 

local support organisations. 

A project initiated by the Ministry of Food, Agriculture and Forests of the Province of Lower 

Saxony in Germany (German intervention 4) employed similar approaches. Work was 

conducted amongst ‘disadvantaged inhabitants’ of a town district ‘characterised by poor living 

standards and defective infrastructure’. Work with this group of people (around 3000 people, 

approximately one third of the total population of the town) was centred upon a nutritional 

programme specifically designed to address the difficulties faced by people on low incomes. 

The key to the work was that ownership was placed in the hands of the target population 

themselves. Clubs and ‘join-in’ events took place at local venues such as schools and were 

organised by community members. Whilst the primary objectives were preoccupied with 

elevating the nutritional intake of the population, there were significant elements which were 

involving and empowering. Because of the relatively short lifespan of this project the 

evaluation was unable to report on improvements in terms of nutritional knowledge or 

behaviour. It was able to report on positive side effects - for example, the population taking 

control and organising themselves to deal with general problems facing them. 

A nutritional focus was also adopted by an initiative taken by the Greek Gerontological and 

Geriatric Society amongst the ageing population of the Attica region (Greek intervention 2). 

The total project length was two years and took place between 1997 and 1999. Cross-sectoral 

co-operation was important - health and community workers joined forces to support the work 

of a number of peer educators (‘healthy nutrition consultants’) who operated from community 

locations such as workplaces and community centres. Particular importance was attached to 

the fact that peer educators were drawn from the local population. They were found to be 

cognisant of the needs of the population and messages were conveyed in a sensitive way, 

consistent with local traditions and customs. A well-designed process and outcome evaluation 

ran concurrently with the project (knowledge and self-reported behaviour amongst peer 

educators and participants). 

A workshop for primary medical care was initiated in 1994 in Oslo, Norway (Norwegian 

intervention 2). It trained women drawn from a minority ethnic community (Pakistani in origin) 

as peer educators. The focus was on improving nutritional intake (reducing saturated fats and 

increasing mineral and vitamin intake) of this group, who were identified as being particularly 

socially isolated amongst the Norwegian population. Peer educators also provided a link with 

local services - feedback was used to refine and modify services (increased cultural sensitivity 

and ability to cope with non-Norwegian speakers). The evaluation identified a number of 

important outcomes in addition to raised levels of awareness on nutritional issues – these 

included self-reported improvements in parenting skills, reduced social isolation and improved 

ability to compete for jobs. 

A distinction that was made by many of the interventions, which incorporated community 

participation, was that between the ‘formal’ and ‘informal’ objectives. This was illustrated in an 

example reported from Hasvik in Norway. This intervention commenced in 1989 and was 


51

initiated in response to a ‘collective depression’, which was identified in a far northern fishing 

community. This town was suffering economic deprivation as a result of the collapse of the 

fishing industry, due to over-fishing, throughout the whole of north Atlantic coastline of Norway. 

It was part of a national policy initiative, entitled ‘Health and inequality in Finnmark’ which was 

designed to benefit several similar communities in this region. A project house was funded 

from which a number of initiatives evolved to serve the population of 1300 people. Formal 

objectives included assisting local people to identify and apply for appropriate benefit grants 

that were available to them. Additionally, a ‘network credit system for women’ was set up 

following a model that was developed in the third world. Amongst the informal objectives were 

those related to the physical aspect of the project – the ‘house’. The ‘house’ provided a focal 

point for local people to meet and discuss common problems and potential solutions. The 

house was used in the summer months as the local tourist information service, staffed by local 

people. The model has been transferred to many other communities in the region who were 

also suffering similar economic crises. 

Incorporating a community approach was one feature of strengthening the coherence of 

prevention in Amsterdam (Netherlands intervention1). It was evaluated and found to be 

appropriate. Key community representatives and members were involved in collaborative goal 

setting in partnership with health and community workers, volunteers and health insurance 

professionals. The account of this intervention provided by the co-ordinator from the 

Netherlands was self-critical and highlighted some of the implementation problems associated 

with community involvement. Amongst the problems identified by the process evaluation were 

that ‘the inventory of problems identified by community members was too general’ and 

‘involvement of local inhabitants in steering groups was difficult’. Despite the problems, the 

project had been extended and a new objective strengthening the role of the community 

approach to improve accessibility of care formulated. Noted as particularly important in this 

project was the overt political support, which came from the Alderman for Care of the 

Municipality of Amsterdam. [This intervention and the Large City Policy (Grotestedenbeleid) 

are discussed further in the case study section]. 

Intervention mapping was used to help clarify with community members what health 

determinants were important and to formulate and prioritise objectives within ‘Het Arnhemse 

Broek, Gezond en Wel’ (Netherlands Intervention 3). It was felt that by implementing this 

approach at the outset it would make it easier (more understandable and significant to 

participants) to evaluate process and outcomes meaningfully. This geographical area was 

characterised by high numbers of minority ethnic groups and migrants (27%); low levels of 

average income (

� Empowerment of the organisations involved 

� Health promotion activity within the community 

Whilst the account was again self-critical, highlighting difficulties related to the unclearness of 

some objectives and to the fact that they have changed over time, new guidelines and 

recommendations have evolved for community projects as a result. Significant successes 

reported were in the areas of achieving consensus and co-operation between participating 

organisations and the community, and in translating the needs of the community into 

measurable activities for tackling problems. 

An attempt was made in Oporto City in Portugal to address the needs of male and female sex 

workers (Portuguese intervention 1) using principles derived from community development. 

The account described a methodology entitled the ‘investigation-action method’, which aimed 

to promote social development through participation and empowerment. Individuals were 

given support and encouraged to resolve their own problems. The project, which commenced 

in 1997, was ongoing; it was initiated by the Welfare Council of Oporto in partnership with the 

Family Planning Association. A cross-sectoral team was convened, composed of 

representatives of the target group, sociologists, psychologists and supported by health and 

community workers. Amongst the primary (formal) objectives were the provision of medical 

(emergency) care and education about the prevention of HIV and AIDS. Amongst the 

secondary (informal) objectives were the provision of psychosocial support; acquainting sex 

workers with their rights and duties as citizens; liasing between sex workers and supportive 

institutions. There was also a monitoring programme integrated with this intervention. This 

was designed to map out the scope of the problem and to study the relationship between 

prostitution and broader deprivation characteristics of this area. The alienation and isolation 

associated with prostitution was of particular interest. The project adopted an action research 

approach and re-appraised its objectives according to the findings. 

Migrants and illegal immigrants (Africans from Angola, S. Tome, Cabo Verde, Guinea) were 

the target population for a community intervention in Qunita do Mocho and Marvilla in Portugal 

(Portuguese intervention 2). The project commenced in 1996 and was ongoing. Very poor 

living conditions were described as the setting for this project in Lisbon. Formal objectives 

were related to child health and family planning. These were extended to encompass a range 

of other areas including education and training; employment; family well-being and harmony 

(including domestic violence, child neglect and sexual abuse). Of particular interest within this 

context were two (of five) of the main aims: 

� to promote the capacity of the population to solve their own problems 

� to empower community resources in order to create new ways of community 

participation 

Community representatives and peer educators were important in forging links between the 

local community and services. Resources were produced including a local journal and a roleplaying 

video in Creoles. Fundamental principles underpinning the work were tolerance; 

respect; unconditional acceptance and empathy. The evaluation of this work was designed 

not only to look at various health outcome measures like childhood vaccination; tuberculosis 

therapeutic programme compliance; and STD and HIV transmission rates. It also considered a 

number of measures relating to community participation. 

Community Action on Health was identified as an approach to developing a community-led 

health agenda in partnership with a Primary Care Group in the west end of Newcastle in 

England, United Kingdom (United Kingdom intervention 7). It incorporated many of the 

characteristics of successful approaches, which address inequalities cited by (Rifkin et al 

2000). The area under consideration included some of the most deprived wards in the 

northern region of England, which experienced some of the worst levels of health, and the 


53

lowest incomes in the United Kingdom as a whole. General Practitioners met in 1994 to 

consider future service provision for the area. Early in this process the support of a community 

development worker was enlisted to create a structure for participation in commissioning 

processes by local people. Within the Primary Care Group, a culture of community 

participation with a local focus and inter-agency partnership was created. Work in this area 

was attributed with ‘challenging the traditional resource allocation, and making it fairer by 

diverting resources to the most deprived populations’. The work was evaluated by the Health 

and Social Policy Department at the University of Northumbria in conjunction with the Health 

Services Management Centre at the University of Birmingham. They found that: 

� the approach resulted in a greater focus on health inequalities, determinants of health 

and the re-design of services when compared with other groups within adjacent areas 

� issues raised by local people were more likely to be incorporated into priorities for 

change through resource allocation or service development when compared with other 

groups within adjacent areas 

� many service developments responded directly to the expressed needs of ethnic 

minority groups, families living in stressful conditions and young people 

This intervention had already been cited as a model of good practice within the National 

Health Service guidance document ‘In the Public Interest’ and within the Department of 

Health’s ‘Patient and Public Involvement in the New NHS’. 

Another example focused its efforts at a different level and established an independent 

regional network of people working to support community action. The Community 

Development and Health Network in Northern Ireland (United Kingdom Intervention 3) 

combined the efforts of more than 400 organisations and groups. It aimed to provide an 

intersectoral, inclusive and democratic network. Additionally, it aimed to raise awareness of 

the links between poverty, health, inequality and potential solutions provided by community 

development. 

Health Action Zones (HAZ - www.haznet.org.uk) (United Kingdom Intervention 9) were 

introduced as part of national Government policy to target funding at areas in the United 

Kingdom with the highest levels of deprivation and the poorest levels of health. Their aim is to 

develop and implement health strategy that reduces inequalities and delivers measurable 

improvements in public health and health outcomes. HAZs were set within inner city areas, 

rural areas and ex-coalfield communities across 26 locations in the United Kingdom covering 

approximately 13 million people or 40% of the country’s total deprived population. Amongst 

the key areas that they focused on were the broader determinants of health and community 

empowerment. They were multi-agency programmes between the National Health Service, 

local government, voluntary and private sectors and community groups. Their principal aim 

was ‘to tackle inequalities in health in the most deprived areas of England through health and 

social care service modernisation programmes with opportunities to address other wider 

determinants of health such as housing, education and employment’. They were selected 

between 1998-9 on the basis of a need threshold based on health, healthcare and deprivation 

indicators. HAZs were asked to sign up to seven key principles or values. These were: 

� staff involvement 

� person-centred services 

� engaging communities 

� an evidence-based approach to service planning and delivery 

� equity: in resource allocation, in reducing health inequalities/promoting equality of 

access to services 

� partnerships/multi-agency working 


54

� a whole systems approach to taking forward change, engaging stakeholders across 

the local health and social care systems 

Each HAZ developed its own priorities and targets guided by national targets but adapted to 

local needs. Approaches were deliberately flexible as parts of changing the way services were 

delivered, and budgets were pooled between health authorities and local authorities. 

Although there were many more examples of interventions within the national reports that 

incorporated community involvement and development strategies, the examples referred to 

above were considered to be illustrative of the body of information on this area. Practice 

under this very general heading was diverse and reflected specific responses to complex 

problems often characterised by multiple deprivation. It was apparent that community 

development was viewed and utilised quite differently reflecting the tension that Rifkin., et al 

identified as to whether community participation should be seen as ‘a specific intervention for 

health improvement or a process of change’. 

The process of ‘engaging communities in issues which they believed important’ and ‘providing 

them with support and resources to enable them to take action and provide their own 

solutions’ gave health promoters considerable scope for tackling inequalities. It offered the 

means by which broader determinants of health could be addressed explicitly and the 

combined resources of different sectors brought together with common aims. 

Migration 


Problems associated with migration across and 

within national boundaries include: 

� Migration across national boundaries from 

Asia, South America and Africa into the 

Member States and from Eastern Europe 

into Member States 

� Migration within national boundaries 

Interventions and policies deal with: 

� The impact of emigration from rural areas 

(leaving ageing populations behind) 

� The impact of emigration from areas 

suffering economic recession 

� The impact of immigration on urban areas 

Approaches within this context are typically: 

� Developing the capacity of communities 

to cope with problems 

� Empowering and enabling 

� Culturally sensitive and conducted in the 

language of the target group 

Practical measures include: 


� Recognise and consolidate the 

significant efforts already being 

55

� Changing the status of migrants through 

legislation, recognising their basic human 

rights, giving them labour status and 

access to healthcare services (temporary 

migration licences were issued in some 

cases) 

� Involving peer educators, cultural 

mediators, community interpreters 

� Developing formalised curricula and 

certification of the above to ensure quality 

� Developing practice protocols to underpin 

operational guidelines and to form a basis 

for evaluation 

� Lifestyle programmes underpinned by 

values such as empowerment and selfdetermination 

� Culturally sensitive counselling, 

information and advice 

The special health needs of certain 

disadvantaged target groups being addressed 

include: 

� Children who have experienced war 

� Elderly people returning to their place of 

origin 

� Migrants working within the sex industry 


undertaken to address the various 

impacts of migration on health 

� Learn from models of good practice 

and develop the knowledge base 

concerning interventions and policies 

which address the impact of migration 

� Support the development of health 

promotion measures which counter the 

impact of migration on health 

inequalities 

� Recognise and support the special 

health needs of certain disadvantaged 

migrant groups through interventions 

and policies which directly address the 

problems they face 

Many of the interventions and policies that were identified within this study were designed to 

address the special health needs of migrants and their second and third generation 

descendants. Included within the broad category were migrants, illegal (im)migrants, refugees 

and war refugees (in one case, specifically war children). Problems associated with the 

immediate impact of migration on health; integration, exclusion and isolation; access to 

support service provision; and broader problems associated with geographical areas 

characterised by multiple deprivation (in which migrants were located) were all considered. 

The impact of migration across national boundaries and within countries was the 

preoccupation of a diverse range of health promotion interventions and policies. In the case of 

the latter, interventions and policies were identified, which addressed the impact of movement 

from rural areas (including those in economic and social decline which had suffered industrial 

collapse) and the related effects of movement into adjacent urban locations. 

Approaches addressing the broad range of problems and impacts were characteristically: 

innovative and flexible, responding to immediate needs; aimed at developing the capacity of 

communities and individuals to deal/cope with problems; empowering and enabling; culturally 

sensitive and conducted in the language of the migrant group. 

Davey Smith et al., (2000) in a review of epidemiological evidence of ethnic inequalities in 

health noted that a history of migration was often the root factor in the formation of selfconscious 

ethnic minorities and majorities, and was often a key issue in explaining patterns of 

health. They identified as important, the biographical experience of at least two economic 

systems, one current and one in the past, and of at least two cultures. They noted that among 

56

their [migrants’] descendants, likewise, there was a continuing consciousness of this dual 

experience. Many factors that this group of researchers explored were complicated by this 

duality and they considered that material factors in both economic systems may have shaped 

migrants’ health, and that the culture of migrants was not straightforwardly that of the country 

of origin but that it was affected by experiences in the receiving country. 

In the same paper these authors noted that factors associated with the period immediately 

surrounding the migration also frequently presented specific explanations for the health of 

ethnic minorities. Migrants tended to be selected by health characteristics from the population 

of origin – usually having better health if they were long-distance migrants (they cited the work 

of Marmot et al., 1984 who looked at immigrant mortality in England and Wales between 1970- 

78). These health characteristics were present at the time of the decision to migrate and were 

reflected in the health of migrants in their place of destination. They described how, over time, 

such differentials ‘wore off’ and the health of migrants tended to revert to the mean standard of 

the population of origin. This was particularly the case when the next generation was 

considered. Also outlined were other health selection aspects of migration including a 

phenomenon called ‘salmon bias’ in which there was a selective return of those with a high 

mortality risk to their original home (following a desire to return to one’s birthplace when sick or 

dying). 

The first three interventions identified within the Austrian national report were all aimed at 

addressing problems associated with these phenomena. The target group for the first 

intervention was non-German speakers mainly of Turkish or Kurdish origin who comprised 

18% of the local population. The need was originally identified by medical professionals 

working within hospitals in Vienna who had to enlist the support of auxiliary workers and 

patients’ children to aid communication. A pilot project was instigated by a local government 

officer in charge of migrant integration. A range of complimentary services was developed that 

was not restricted to healthcare. These included: a telephone help line (expanding the 

outreach beyond Vienna); and training in community interpretation (leading to the certification 

of successful candidates in a ‘diploma of community interpretation’). 

‘Ausländer und Ausländerinnen als Gesundheitsmultiplikatorinnen’, the second Austrian 

intervention, was focused primarily on language barriers but also sought to address culturally 

determined differences in the perception of health and disease. The target groups, in this 

case were Turkish, Kurdish and people from the former Yugoslavia (comprising an estimated 

10% of the population of Graz). Specific needs that were addressed which were not already 

part of the remit of existing services were; adjustment to new surroundings and coping with the 

trauma of the past; sexual health; and nutritional adaptation. The centrepiece of the work was 

the training of key community members to become peer educators. A curriculum was 

developed jointly with the target group reflecting specific information needs and covering 

methodology. Protocols were also developed to guide exchanges between the target groups 

and peer educators. These protocols formed the basis of the evaluation of the project, which 

was conducted jointly between the organisation ‘Zebra’ running the project and members of 

the target group. 

Also within Vienna was a project that was initiated in response to the findings of a survey 

conducted in 1977 by the Ludwig Boltzman Institute for Women’s Health Research. Fem Sud, 

a health centre for women, parents and girls was set up in 1999. Activities were targeted at 

women from the south of Vienna (densely populated with a high proportion of people from 

lower socio-economic groups) with special emphasis on migrant women (15% of this 

population originated from Turkey and the former Yugoslavia). A multidisciplinary team 

composed of medical staff and guests from other professions delivered a tailored programme 

focusing on healthy lifestyles and underpinned by principles of empowerment and selfdetermination. 

The centre also lobbied on behalf of the target group mainly amongst existing 


57

health services, but also beyond (other NGOs, police, Mosques), for improved access and 

more appropriate services. 

Also dealing with migrant Turkish people, but also Moroccan, was an intervention in Belgium, 

which provided a network of 25 ‘community interpreters’ for 22 hospitals. The intervention was 

aimed at overcoming the problems associated with language and cultural barriers. Their 

primary role was interpretation but in addition they performed an advisory role for both medical 

professionals and patients. A link was provided which made communication between patient 

and professional more meaningful and informed consent possible. There was an emphasis on 

interpreters ‘defending the best interests of patients and ensuring legitimate consumer 

demands’. Although many other national reports identified similar schemes, which provided 

networks of advocates, what was of particular interest in this account was the political interplay 

that had taken place around this project. Considered key to its success was the support and 

sponsorship of the Centre for Equity and Anti-racism which in turn was linked directly to the 

cabinet office and the Prime Minister. A new organisation was formed – the Healthcare 

Interpreting Co-ordination Unit within the Ministry of Social Affairs in collaboration with the 

Ministry for Public Health. This was set up to support the work of similar networks and to set 

practice standards. It was also set up to deal with the problem of such projects being initiated 

and then being closed as a result of annual budget cycles. Experts considered this to be both 

positive and effective. Ironically this unit met a similar fate and was abolished due to the 

discontinuation of funding. 

Transnational AIDS/STD Prevention Among Migrant Prostitutes in Europe (TAMPEP) was an 

intervention that spanned four European countries (Netherlands, Italy, Austria and Germany) 

and was started in 1993 (reported here from the German report). It was aimed at prevention 

amongst migrant women and transgender people working within the sex industry. The project 

dealt with people from more than 20 different nationalities originating from Central and Eastern 

Europe, South East Asia, Africa and Latin America. ‘Cultural mediators’ in collaboration with 

‘peer educators’ (trained sex workers) offered culturally sensitive counselling, information and 

advice as well as monitoring the dynamics of migration and investigating the living and working 

conditions of the target group. A well-designed evaluation was integrated and looked at 

questions concerning both process and outcomes. A number of key findings emerged from 

this related to the role of cultural mediators. Notably, it was found that the balance between 

mediators ‘defending’ patients’ interests and offering a more neutral ‘aid to communication’ 

was one that was difficult to achieve. The language skills, and personal qualifications of the 

mediator were found to be critical in this context. 

The provision of ‘help to children who have experienced war’ (Norwegian intervention 1) was a 

small-scale pilot project aimed at helping children (9-12 year-olds) from Bosnia deal with the 

traumas of war. More recently, (since 1998) children originated from Kosovo and Albania. 

The intervention was located in the municipality of Bergen where there were many refugees 

and asylum seekers from the countries mentioned. Multi-disciplinary teams were assembled 

to manage care and support for the target group, central to which was the provision of 

appropriate opportunities to talk about and reflect upon difficult past experiences. 

In terms of policy reforms to address the inflow of migrants over national borders, Spain, 

(policy 2) provided an example with its social welfare policy. Spain was receiving a steady 

stream of migrants from the Magreb and sub-Saharan Africa in addition to Latin America, 

Eastern Europe and Asia (mainly the Philippines). Newly passed legislation changed the 

status of thousands of people classed as illegal immigrants, recognising their basic civil rights 

and allowing them access to health service provision and amending their labour status. This 

was also found to be the case within Greece where, a steady stream of migration from Eastern 

Europe was occurring – here ‘temporary migration licences’ were granted; housing facilities 

were provided; and a specialist medical centre was set up to deal with special health needs. 


58

Migration was again an important factor identified when considering changing land use 

patterns and movement, within national boundaries, from rural areas in economic decline to 

urban areas. A number of reports described difficult situations arising from selective migration 

in which younger members of rural communities moved away leaving behind older less able 

members. Pictures of depressed communities with high levels of unemployment, poor health 

and poor future prospects were not uncommon within national reports. Health promotion 

responses to this kind of situation were characteristically innovative and focused on 

empowering the residual population. 

Within the Greek report, the impact of elderly Greeks returning to retire was identified and was 

being dealt with through protective policy reforms. Additionally, Greek policy explicitly set out 

to address the health and social needs of the ageing population within rural areas. Social 

security was also provided for those working in agriculture, normal regulations relating to the 

lifetime payment of premiums were waived. A social insurance fund, - ’The Organisation of 

Agricultural Insurance’, was established, to cover free access to healthcare. This was paid for 

by the national budget. 

The collapse of the fishing industry, the primary source of income for communities in the far 

north of Norway, was the driving force behind many people leaving this area during the late 

1980s. A ‘collective depression’ was described as characterising the residual population in the 

town of Hasvik (pop.1300) in the Municipality of Finnmark. A series of community 

development projects were set and funded through a national programme. ‘Health and 

Inequality in Finnmark’ (1989-1997). These self-help projects centred upon a house – the 

‘Hasvik House’, which also served as a meeting place for the community and tourist 

information (staffed by locals) in the summer (Norwegian intervention 4). The central focus 

helped create a sense of community identity and work such as counselling, applications to 

funding organisations and a network credit scheme for women were conducted from here. 

A depressed rural population, was the target for an intervention in Norsjö in Sweden, which 

had experienced economic recession during the 1990s. A national screening programme 

identified that this population had relatively high levels or cardiovascular mortality and 

morbidity (especially amongst women) when compared to the general population of Sweden. 

The local population was characteristically non-skilled, poorly educated with a high level of 

unemployment. The project was designed as a community intervention trial and monitored as 

part of the wider MONICA study, which compared a series of similar communities in the 

region. The evaluation focused its attention on shifts in cardiovascular risk factors such as 

diet, smoking and physical activity. 

It was clear from accounts as a whole that health promotion was at the forefront of tackling 

some of the direct impacts of migration across national boundaries in Europe and within 

countries (rural>urban). This issue has received a large amount of attention in the published 

literature (although attention has tended to focus on ethnicity and composition of geographical 

areas). It was neither desirable nor useful in this instance to try and separate out these 

complex related issues. 

Not a single report was without mention of the impact of migration. Solutions were diverse and 

focused upon different levels. At a national level, policy reforms were important in increasing 

the civil rights of these people. Access to healthcare services has been improved and 

financial assistance provided to allow existing infrastructure a greater degree of flexibility, with 

the provision of a safety net for the most vulnerable groups. At the local level the focus for 

health promotion has been through working with communities to improve their own ability to 

tackle a range of problems related to exclusion. This work was mindful of the difficulties 

presented by language and took into account differences in tradition and culture (especially 

where these have influenced perceptions of health and well-being). Approaches were 

innovative and priorities were driven by the target communities themselves. There were many 


59

good examples of health workers working effectively with professionals from other sectors. 

Training community members as peer educators or community interpreters appeared to have 

a special relevance in this context. 

Evidence and the evaluation of interventions 


Potentially useful participatory action research 

approaches or other social science methods that 

might have been useful are insufficiently being 

engaged 

Regarding the evaluation of interventions, 

examples of good practice identified in this study 

are successful in: 

� Demonstrating the impact on morbidity 

and mortality 

� Involving participants and translating their 

needs into measurable objectives 

� Identifying implementation problems and 

recommending ways forward 

� Measuring interventions at a range of 

levels, including individual, organisational 

and community 

� Informing the development of policy and 

practice in other settings 

� Allowing traditional mainstream service 

provision to be challenged 

� Justifying further funding and modifying 

the status of interventions from temporary to 

permanent 

� Contributing to knowledge development In 

a number of areas including cross sectoral 

working and community development 

� Generating support amongst policymakers 


� Continue to emphasise that 

practitioners need to incorporate a 

systematic examination and 

assessment of the effects of their 

interventions 


appropriate methodological 

approaches to the evaluation of health 

promotion interventions 


examples where evaluation findings 

have had a positive impact on the 

progress of interventions 

60

The conclusions of the WHO European Working 

Group on Health Promotion Evaluation (1998) 

were relevant when considering evaluation within 

the context of this study. 

The recommendations from this working group 

are reproduced opposite and adopted as part of 

the overall recommendations of this study. 


� Encourage the adoption of 

participatory approaches to evaluation 

that provide meaningful opportunities 

for involvement by all of those with a 

direct interest in health promotion 

initiatives. 

� Require that a minimum of 10% of the 

total financial resources for a health 

promotion initiative be allocated to 

evaluation. 

� Ensure that a mixture of process and 

outcome information is used to 

evaluate all health promotion 

initiatives. 

� Support the use of multiple methods to 

evaluate health promotion initiatives. 

� Support further research into the 

development of appropriate 

approaches to evaluating health 

promotion initiatives. 

� Support the establishment of a training 

and education infrastructure to 

develop expertise in the evaluation of 

health promotion initiatives. 

� Create and support opportunities for 

sharing information on evaluation 

methods used in health promotion 

through conferences, networks and 

other means 

One of the original specifications (reproduced in full within the phase 1 report, available on 

request from VIG) given to national co-ordinators was that ‘Interventions should not be 

based on presumptions or ideas but should have empirical data as a base’. 

Whilst there were discussions held at project meetings and apparent agreement on the 

criteria, they left considerable room for individual interpretation (misinterpretation and 

confusion). Additionally, guidance notes and detailed descriptions of measurement scales 

were given to support a systematic approach. 

The response of co-ordinators within this context was varied. The majority attempted to 

comply with the criteria and remain within the boundaries of the pro-forma. Their success in 

this exercise was mixed. Some used the template to produce self-critical responses supported 

by data where this was available. A number of co-ordinators did not use this process and 

produced accounts independently of the guidelines. There were numerous examples where 

co-ordinators completed the forms incorrectly. For example, in some cases co-ordinators 

indicated that certain small-scale interventions had impacted on health outcomes. On further 

investigation, additional information to support such statements was not forthcoming. Verbal 

communications revealed that some co-ordinators felt justified in recording such statements 

because they ‘knew’ that there was a positive impact on health outcome and/or they could 

‘explain the theoretical causal links’ even if there was no data available to illustrate such links 

(or any collected in the first place). 

The situation that arose raised a number of important issues. Firstly, there were clear failings 

on behalf of the project staff to produce guidelines, which were of practical use to the coordinators. 

Many found themselves faced with an overly technical framework, which was 

confusing. [Subsequent discussions with the designer of the original classification scheme 

61

(Joop Ten Dam for the Healthy Cities Project) revealed that he felt that the use of the 

framework within this project was not appropriate (Brussels meeting December 2000)]. 

Secondly, and more importantly, the broader issue of the evaluation of health promotion 

initiatives, both in the assessment of process and the evaluation of outcomes, was raised. 

Within the national reports, there was a general lack of interventions that were systematically 

examined and assessed for their effects. 

One factor, which was influential in this context, was that co-ordinators understandably took 

the opportunity provided by their involvement in this work to highlight small scale, pilot 

projects. Many of these were in the early stages of their implementation, operating in difficult 

circumstances, struggling under time and resource pressure, and where as a result, evaluation 

may not have been given high priority. Many of these projects were complex (with 

multidimensional foci on the determinants of health) extending beyond the traditional domain 

of health services. Clearly, in this environment evaluation would have presented a challenge 

to any practitioner. Needless to say, the narrow parameters of randomised controlled trials 

would have been inappropriate. The fact remained, however, that potentially useful 

participatory action research approaches or other social science methods that might have 

been useful were not apparently being engaged. In a number of examples the endorsement 

given by the health professionals who were working on the particular intervention in question 

was presented as ‘evaluation’ or ‘action research’. Clearly, as a key stakeholder group, it 

would have been remiss not to have represented this important perspective within any 

evaluation. In the absence of any other information however, there was the potential that 

these verbatim statements might have been dismissed by some as little more than anecdote 

or the biased opinions of those with a vested interest. 

The overall picture regarding evaluation however was not entirely negative and there were 

some fine examples of good practice supplied within national reports… 

An example of an well-evaluated community project was given within the Greek report – the 

intervention in Attica aimed to promote healthy nutritional habits amongst the elderly 

population. The initiative was taken by the Greek Gerontological and Geriatric Society who 

oversaw the training of volunteers from the community as nutritional counsellors. The 

evaluation focused its attention on both process and outcomes. A formative needs 

assessment study was conducted. In the early stages, a number of barriers to the successful 

implementation were identified within the process evaluation, these were subsequently 

overcome. There was pre- and post- measurement of both the knowledge of the trained 

volunteers and the members of the community who attended the training. 

A workshop for primary medical care amongst immigrant communities in Norway (Norwegian 

intervention 2) featured an action research approach. The intervention aimed to develop a 

dialogue between health professionals and members of the community in order to offer a 

greater level of effectively targeted services. The overall objective of the evaluation, which 

featured high levels of community involvement, was to map out how the intervention was 

accessed and experienced by participants. As a result of the process evaluation there were 

reports of valuable insights into information exchange between culturally diverse populations 

and health professionals. There were also higher levels of awareness of the importance of 

nutrition, and changes in self-reported nutritional behaviour (notably a reduction in the intake 

of fats in the diet). Of great importance in this context was that the findings from the 

evaluation were reported to have contributed to the project receiving further funding and the 

conversion of the status of this one year project into a ‘permanent institution’. 

A strong evaluative approach was a feature of the Varden Childcare Centre, also from Norway 

(Norwegian Intervention 3). The Centre was part of a nationwide network of childcare clinics, 

and situated in an area with a high proportion of single parents, many of them living on social 


62

welfare. The approach of the centre was cross sectoral, integrating health (outreach and 

vaccination), social (financial support, protection of children at risk), educational (parenting 

skills), and voluntary non-governmental services (day care and kindergartens). The evaluation 

focused not only on the desired outcomes for the target group but also on the main elements 

of the cross-sectoral team working. A number of observational methods combined with 

interviews with a range of stakeholders were employed over a two-year period. The project’s 

success and continuation was related to conclusions and recommendations that were made 

by the evaluation. In addition to reports on process aspects and outcome effects, transferable 

knowledge was also developed on the use of multi-disciplinary teams within community 

settings. 

The interventions identified within the national reports from the Netherlands and the United 

Kingdom generally featured an approach in which evaluation was an integral part of the 

implementation of interventions. 

For example, whilst methodological difficulties were acknowledged, the evaluation of the first 

intervention within the report from the Netherlands (Strengthening coherence in prevention in 

Amsterdam) was able to report that: ‘the community approach (adopted as part of this 

initiative) was appropriate’; that there was a good connection between policy and practice; that 

pilot projects (discrete components of this initiative) needed assistance at the city level; and 

that access to municipality and health services was made easier (as a result of the 

intervention). An ambitious quasi-experimental design was proposed at the outset but this 

proved to be unfeasible because it was too difficult to accomplish two repeated measurements 

of the same group of respondents. As a result a framework of process and outcome indicators 

were identified and measured throughout the implementation. It was possible to reach 

conclusions about the interventions effects and recommendations for future working. 

Reviewing available data sources such as registration data (visits to establishments; 

appointments made etc), combined with interviews amongst target group members, coordinators, 

members of steering groups, policy-makers and other key players helped inform a 

strong process evaluation. Factors facilitating or constraining effective intersectoral cooperation 

were also assessed by examining network structures, steering group function and 

written agreements and decisions. Future continuation following adjustments was a result of 

the findings of the evaluation, along with recommendations that the approach be applied 

elsewhere. Especially significant was that the effects that were demonstrated were enough to 

motivate policy-makers, including the local alderman, to support further development of the 

approach. 

Het Arnhemse Broek, Gezond en Wel (The Arnhemse Broek Area, healthy and well – 

Netherlands intervention 3) was an example in which the evaluation explored effects at 

different levels, including: individual; community; and organisational. The evaluation followed 

a quasi-experimental pre- and post-test design with two control communities. The University 

of Maastricht conducted it independently of the intervention project group. It set out to 

measure changes in the following: 

At the individual level: 

� identified determinants of health; 

� and experience and health behaviour. 

At the community level: 

� involvement of community groups and organisations in health promotion; 

� level of participation of the local inhabitants; 

� and health promotion activities; 


63

At the organisational level: 

� degree to which implementation was in accordance with original objectives; 

� communication and collaboration between organisations. 

A positive aspect of the evaluative approach was that it incorporated the wishes and needs of 

the target population and allowed these to be translated into measurable objectives. A series 

of guidelines and recommendations for community projects and policy were a by-product of 

the evaluation. 

The evaluation of Health Action Zones (HAZs) (United Kingdom, Intervention 9) was 

acknowledged as challenging. This was the case because the numerous goals, which were 

evolving over time, were dependent upon ‘synergistic change’. Capacity-building, generating 

social capital, promoting leadership development (all nominated components) were difficult to 

measure. Despite the many challenges faced, the evaluation was able to report that the 

initiative was: 

� already starting to have an impact on health inequalities for people in deprived areas 

and were on course to meet most milestones in individual programmes 

� making considerable progress in developing partnership working and relationships 

have been transformed − particularly between the NHS and local government. There 

was local enthusiasm to develop partnership working further 

� involving communities in decision-making and developing new ways of involving local 

people in decision-making 

� starting to challenge the way mainstream services were being delivered 

In Northumberland in Northern England, a direct impact on the reducing mortality had been 

associated with the HAZ programme. There were reduced admissions to hospital for heart 

attacks and stroke (which together with heart failure represented 40% of emergency 

admissions over the winter period). The combined disease register for Northumberland 

included 15.000 people known to be suffering from ischaemic heart disease (either to have 

had a heart attack previously or to suffer from Angina). The target was to reduce cholesterol 

in these patients. The evidence was suggesting that based on progress so far, that between 

100 and 250 strokes or heart attacks would be prevented over the next five years. Similar 

results were reported in East London where the HAZ programme had already been piloted. 

Local evaluations such as those mentioned above complemented that of the national HAZ 

programme which was overseen by Professor Ken Judge of the Personal Social Services 

Research Unit at the University of Kent. A ‘theory of change’ approach was adopted and 

defined as ‘a systematic and cumulative study of the links between activities, outcomes and 

contexts of the initiative’. The approach aimed to clarify the overall vision or theory of the 

initiative, meaning the long-term outcomes and the strategies that were intended to produce 

change. Steps were taken to explicitly link the original problem or context in which the 

programme began with the activities planned to address the problem and the medium and 

longer-term outcomes intended. [Further attention is given to HAZs within the case study 

section]. 

It was clear from a consideration of the contextual information supplied within most national 

reports that such high levels of evaluation activity (as illustrated by the examples drawn from 

the United Kingdom and the Netherlands) were simply not possible within the resource 

limitations of many interventions. An important comment that accompanied the profile given to 

the Het Arnhemse Broek, Gezond en Wel initiative (see above) was that the evaluation 

conducted would be ‘too intense for practitioners’ and was only possible through the 

involvement of the University of Maastricht. 


64

This situation was consistent with that within the wider literature - Mackenbach et al 1997 

(cited in Graham 2000) who developed guidelines and design recommendations to help in the 

evaluation of interventions (specifically designed to reduce inequalities in health) concluded 

that there were circumstances in which community intervention trials were feasible. In such 

circumstances it was possible to employ the basic rules of the classic study designs. 

Mackenbach’s team warned however that such community intervention trials were likely to be 

complicated and costly. 

A WHO European Working Group (1998) concluded that ‘over the last two decades knowledge 

and understanding about how best to evaluate complex programmes and policies had 

significantly increased’. They went on to say that ‘decision-makers and practitioners were not 

fully aware of these developments or their implications for the evaluation of health promotion 

interventions’. The working group had three objectives: to examine the current range of 

evaluation methods, both quantitative and qualitative; to provide guidance to policy-makers 

and practitioners to foster the use of appropriate methods for health promotion evaluation; and 

to provide guidance to policy-makers and practitioners to increase the quality of health 

promotion evaluations. Based on the principles of health promotion, the working group 

concluded that participation; multiple methods; capacity building; and appropriateness were 

the core features of approaches appropriate for the evaluation of health promotion initiatives. 

They made a number of recommendations including: 

� Encourage the adoption of participatory approaches to evaluation that provide 

meaningful opportunities for involvement by all of those with a direct interest in health 


� Require that a minimum of 10% of the total financial resources for a health promotion 

initiative be allocated to evaluation. 

� Ensure that a mixture of process and outcome information is used to evaluate all health 


� Support the use of multiple methods to evaluate health promotion initiatives. 

� Support further research into the development of appropriate approaches to evaluating 

health promotion initiatives. 

� Support the establishment of a training and education infrastructure to develop 

expertise in the evaluation of health promotion initiatives. 

� Create and support opportunities for sharing information on evaluation methods used 

in health promotion through conferences, networks and other means 

WHO European Working Group 1998 

‘Health Promotion Evaluation: Recommendations to policy-makers’ 

These recommendations were written with health promotion interventions ‘in general’ in mind 

and not those with a particular focus on inequality – they were just as relevant here however. 

With the increasing emphasis on effectiveness and evidence it was apparent that practitioners 

needed to be reminded that such recommendations have great importance for them also. 

Hilary Graham (2000 in Leon D and Walt G) wrote that national governments were ‘seeking to 

reduce inequalities and turning to the scientific community on how to do it’. In the words of the 

WHO’S Strategy for Europe, governments were looking for ‘a scientific framework for decision- 

makers’ and ‘a science-based guide to better health development’ (WHO 1998). 

In her keynote speech, Margaret Whitehead, at the International Conference on Reducing 

Social Inequalities in Health in Copenhagen (27 th September 2000) drew attention to ‘what 

policy-makers and practitioners need’: 

� Evidence of the extent of the problem 

� Understanding of the causes of the problem 

� Evidence of effective action 


65

� Feasible options for action in specific contexts 

� Practical tools/guidance on how to do it 

� Justification/motivation/political will 

Within this study there were examples of interventions which were ‘providing evidence of 

effective action’ and ‘feasible options for action in specific contexts’. There were, however, 

many that were not and this was disappointing considering the original discussions and 

specifications of the project. 

From a practical standpoint there were evaluative methods that could have been adopted that 

were not. This conclusion was drawn in full recognition of the difficulties of trying to trace the 

causal path from community interventions to subsequent changes in health. The standpoint 

developed was consistent with that of Nutbeam (1998) who considered that it was 

inappropriate and unrealistic in most cases for interventions to be expected to do this. He 

emphasised that it was more relevant for health promotion interventions to be judged on their 

ability to achieve their health promotion outcomes using evaluation methods which best fitted 

the activity. His pragmatic approach to evaluation emphasised the addressing of two basic 

questions, namely: Can change be observed in the object of interest?; and Can this change be 

attributed to the intervention? 


66

REFERENCES 

Alvarez-Dardet, C., Montahud, C. & Ruiz, M. The widening social class gap of preventive 

health behaviours in Spain. European Journal of Public Health, 2001, 11: 225-226. 

Aiach P., Carr-Hill R., Inequalities in health: the country debate in Fox ed. Health Inequalities 

in European countries. Gower. London, 1989 

Aromaa, A. Health Surveillance, In Weil, O., Mc Kee, M., Brodin, M. and Oberlé, D. (Eds.): 

Priorities for public health action in the European Union (pp.56-76). Paris: Commission of the 

European Communities, DG of Employment and Social Affairs,1999. 

Arve-Pares, B., ed. Inequality in health – A Swedish perspective. Stockholm, Swedish 

Council of Social Research, 1988. 

Bennett, P., & Murphy, S. Psychology and Health Promotion. Buckingham: Open University 

Press, 1997. 

Black, D., Morris, J.N., Smith, C., Townsend, P., & Whitehead, M. Inequalities in Health: The 

Black Report. London: Penguin, 1988. 

Briziarelli L., Pedone M.D., A review of policies for socio-economically deprived groups. 

European Network of Health Promotion Agencies, 1989. 

De Bruin, A., Picavet, H. & Nossikov, A. Health Interview Surveys: Towards international 

harmonization of methods and instruments. Copenhagen: WHO Regional Office for Europe 

(WHO Regional Publications, European Series no., 1996. 

Drever, F., Whitehead M., ed. Health Inequalities. ONS, 1977.. 

Evans D., Killoran A., Tackling health inequalities through partnership working: learning from 

realistic evaluation. Critical public Health, Vol. 10, 2000. 

HEA Making THE links, Integrating sustainable Transport, Health and Environmental policies: 

A guide for local authorities and health authorities. London: HEA , 1999. 

Hillery, G. Definitions of community: areas of agreement. Rural Sociology, 1995, 20:111. cited 

in Rifkin S.B., et al., Participatory approaches in health promotion and health planning: A 

literary review. Health Development Agency, 2000. 

Hjern, A., Haglund, B., Persson, G. & Rosén, M. (2001). Is there equity in access to health 

services for ethnic minorities in Sweden, European Journal of Public Health, 2001, 11: 147- 

152. 

Jewkes and Murcott, A. Meanings of community. Social Science and Medicine, 1996, 20 

(4):555-63. 

Jones J, Hunter D. Qualitative Research: Consensus methods for medical and health services 

research. BMJ 

Kunst, A., Bos, V. & Mackenbach, J. Monitoring socio-economic inequalities in health in the 

European Union: guidelines and illustrations. A report for the Health Monitoring Program of the 

European Union, in press. 


67

Kunst, A., Geurts, J. & van den Berg, J. International variation in socio-economic inequalities 

in self-reported health, Journal of Epidemiology and Community Health, 1995, 49: 117-123. 

Kunst, A., Groenhof, F. & Mackenbach, J. Occupational class and cause specific mortality in 

middle aged men in 11 European countries: comparison of population based studies, British 

Medical Journal, 1998, 30: 1636-1642. 

Kunst, A. & Mackenbach, J. Measuring socio-economic inequalities in health. Copenhagen: 

WHO Regional Office for Europe, 1995. 

Labonte, R. Health promotion and empowerment: reflections on professional practice. Health 

Education Quarterly, 1994, 21: 253-268. 

Leon D., Walt G. Poverty, Inequality and Health. An international Perspective. Buckingham: 

Open University Press, 2001. 

Lindholm, A.L., Emmelin, M.A. & Rosen, M.E., Health maximisation rejected. The view of 

Swedish politicians. European Journal of Public Health, 1997, 7: 405-410. 

Mackenbach, J., Kunst, A., Cavelaars, A., Groenhof, F., Geurts, J. and the EU-working group 

on Socio-economic Inequalities in Health (1997). Socio-economic inequalities in morbidity and 

mortality in Western Europe, The Lancet, 1997, 349: 1655-1659. 

Marmot, M.G., Shipley, M.J., & Rose, G. Inequalities in health: specific explanations of a 

general pattern? The Lancet, 1984, I: 1003-1006. 

Martin , C.J., Platt, S.D. & Hunt, S. Housing conditions and health. British Medical Journal, 

1987, 294, 1125-1127. 

Mays N, Pope C. Assessing Quality in Qualitative Research. BMJ, 2000, 320:50-52 

McKee M, Jacobson B. Public Health in Europe. The Lancet, 2000, 356. 

Nutbeam. D. Evaluating health promotion – progress, problems and solutions, Health 

Promotion International, 1998, 13 (1): 27-44. 

Ostlin P., Diderichsen F., Equity-oriented national strategy for public health in Sweden. A case 

study. European Centre for Health Policy, Brussels. Policy Learning Curve Series, number 1, 

2000. 

Ottawa Charter for Health Promotion. Ottawa: WHO/Health and Welfare Canada/Canadian 

Public Health Association, 1986. 

Pill J. The Delphi method: substance, context, a critique and an annotated bibliography. 

Socio-Economic Planning Science 1971, 5: 57-71 

Prättälä, R. et al. Finbalt Health Monitor: feasibility of a collaborative system for monitoring 

health behaviour in Finland and the Baltic countries. Helsinki: National Public Health Institute, 

1999. 

Rainford, L., Mason, V., Hickman, M. & Morgan, A. Health in England 1998: investigating the 

links between social inequalities and health. London: The Stationary Office, 2000. 


68

Rowe G, Wright G, Bolger F. Delphi: a re-evaluation of research and theory. Technological 

Forecasting and Social Change, 1991, 39: 235-51. 

Smith, G., Morris, J. & Shaw, M. The independent inquiry into inequalities in health is 

welcome, but its recommendations are too cautious and vague, BMJ, 1998, 317: 1465-1466. 

Soobader, M., LeClere, F., Hadden, W. & Maury, B. Using aggregate geographic data to proxy 

individual socio-economic status: does size matter?, American Journal of Public Health, 2001, 

91 (4): 632-636. 

Thomas, M., Goddard, E., Hickman, M. & Hunter, P. General Household Survey. London: 

HMSO, 1992. 

Townsend, P. & Davidson, N Inequalities in health. The Black Report. Baltimore, MD: 

Penguin Books, 1982. 

Travers, T. Reducing inequalities trough participatory research and community empowerment. 

Health Education and Behaviour, 1997, 24: 344-356. 

Van de Water, H. &. Van Herten, L. Health policies on target? Review on health target setting 

and priority setting in 18 European countries. Leiden: TNO, 1998. 

Whelan A., Trikey H., Tudor-Smith C., Robertson J., Farley P., Health Promotion amongst low 

income groups: a review of forty interventions. Health Promotion Wales. European Network 

of Health Promotion Agencies, 1989. 

Whitehead M., Dahlgren G., Diderichsen F., Social Inequalities in Health: What are the issues 

for health promotion? A working document. Copenhagen: WHO Regional Office for Europe, 

1998. 

Wilkinson, M. Income distribution and life expectancy. British Medical Journal, 1992, 304: 165- 

168. 

Watt, G.C.M., & Ecob, R. Mortality in Glasgow and Edinburgh: a paradigm of inequality in 

health. Journal of Epidemiology and Community Health, 1992, 46, 498-505. 


69

APPENDIX 1: ORGANISATIONS INVOLVED IN THIS PROJECT 

The Flemish Institute for Health Promotion 

The Flemish Institute for Health Promotion (VIG) is an expert centre on the subject of 

health promotion. It is appointed by the Flemish authorities to provide the government, health 

promotion organisations and health consultation groups with methodological support, to coordinate 

policy implementation and internal quality assurance in the area of health promotion, 

and to develop new strategies, programmes and materials for health promotion. In addition to 

offering specialised documentation and information to health professionals, VIG produces its 

own brochures; educational packages and manuals aimed at specific target groups. By 

conveying health promotion messages through the media, VIG also aspires to positively 

influence lifestyles among the general public. For the Flemish authorities, VIG serves as a 

reliable executive body in the area of health promotion, as a part of preventive healthcare. For 

health promotion services and local health consultation groups, on the other hand, VIG is the 

embodiment of health promotion in Flanders, and a contact point for international exchanges. 

It serves as a liaison between science and practice, and attempts to make it easier for 

scientific findings to reach the reality of practice, so as to ensure that fieldwork is scientifically 

validated. In addition, VIG aims to contribute to the practical relevance of research related to 

health promotion, keeping in mind the health targets established by the Flemish authorities. 

Being healthy is more than being free of illness, but also involves the entire social, 

psychological and physical well-being of the individual, including his/her ability to identify 

his/her aspirations and make his/her own choices in life. VIG regards health as a fundamental 

social right, which depends on the responsibility of policy-makers as well as on the 

participation of the individual himself. Because concepts like “prevention” and “quality of life” 

might seem a luxury to underprivileged people, confronted with a harsh daily reality, VIG has 

opted to make the promotion of equity in health one of its main goals. Signals coming from the 

field have revealed that social workers are becoming increasingly aware of the importance of 

health promotion among the disadvantaged. It has been noted that elements, such as 

unemployment, dangerous work environments, poor housing and security, malnourishment, 

substance abuse and a lack of education tend to have a negative effect on an individual’s 

health and life expectancy. Unfortunately, due to a lack of adequate information and materials 

on this inequity in the area of health, there is often a hesitancy to tackle this issue. For this 

reason, VIG aims to ensure that health promotion is given a prominent place in social work, by 

offering training to field workers, by supporting local social programs, by propagating the 

“empowerment approach” as a way to promote health among the underprivileged and by 

managing a consultative platform on the issue of deprivation and prevention. 

Related VIG Activities 

In addition to its efforts to co-ordinate the two-year European project “Tackling Inequalities in 

Health”, VIG has made a number of significant contributions in the area of health inequality in 

Flanders. These include a think tank, established in collaboration with the Locos, which are 

regional health promotion structures and the “Vereniging van Wijkgezondheidscentra”, another 

Flemish health promotion network. The purpose of this think tank is to encourage an exchange 

of information on the issue of inequality in health between aid organisations, health 

professionals and external researchers. VIG’s expertise centre has also been exploring ways 

to encourage a greater participation of the underprivileged in health promotion initiatives. 

Within this framework, VIG has shown a particular interest in the “empowerment” method, 

which offers individuals and communities tools to obtain a greater control over the socioeconomic, 

political and private powers that influence their lives. 


70

Finally, VIG has also issued several publications on inequality in health, including a book, titled 

“Kansarmoede en Gezondheidsbevordering in Vlaanderen” (1998), which analyses the 

complexity of marginalisation in Flanders and its repercussions on the health of the 

underprivileged. Another VIG publication, titled “Toepassingsmogelijkheden van empowerment 

in functie van gezondheidsbevordering bij mensen in kansarme situaties” (1999), describes a 

study on empowerment as a health promotion method among underprivileged groups in 

Flanders. The study was made in collaboration with four underprivileged communities and 

their animators. 

The European Network of Health Promotion Agencies 

The European Network of Health Promotion Agencies (ENHPA) operates through 

information exchange and sharing best practices with the aim of contributing to the policy 

process on health-related issues in Europe. The membership of the network includes all 15 

Member States as well as Norway, Iceland, and three accession countries: Slovenia, Hungary 

and Estonia. The current members are mainly the national health agencies of each country, 

often related to the Health Ministry. The network was created in 1996 with the mission to 

improve and to increase the capacity and quality of health promotion in Europe. The ENHPA 

office is based in Brussels, Belgium. ENHPA is a non-profit network and is co-funded by the 

European Commission and national agencies. 

ENHPA aims to contribute to significant improvements in the health of the European public by 

helping to develop appropriate policies at all levels that lead to effective outcomes. Within the 

current work plan the Network seeks to set up an information hub on good practices in health 

promotion and public health in EU, Member States, EEA and accession countries with the 

support of ENHPA members. It also aims to formulate recommendations on how to 

incorporate health promotion indicators in the 1st strand of the proposed EU public health 

framework. Additionally, it seeks to disseminate information, expertise and examples of good 

practice to Commission officials, MEPs, other policy-makers and national health promotion 

professionals by implementing and updating an innovative internet facility 

www.EuroHealthNet.org. This facility will be set up as a portal for public health and health 

promotion in the EU including many relevant references to national and local websites. 

Valuable links will be explored with the e-health initiative of EC DG Information Society. 

In the future, the ENHPA hopes to increase relationships and share expertise between 

Member States, EEA and the accession countries. This will be achieved by organising country 

visits to accession countries and to countries where health promotion is regionally organised, 

to better understand how regional health promotion policies and practices can benefit from EU 

work, and by organising policy seminars linked with the ENHPA business meetings. A first 

seminar was held in Stockholm (May 2000) addressing main features in public health policy 

development across Europe and presenting the state of the art in England, Italy and Sweden. 

The next seminar will focus on ‘integrated approaches to health determinants’ (November 

2001). 

The ENHPA is currently developing a position statement on the use of health impact 

assessment within Government policies and strategies in Member States, EEA and accession 

countries; on the role of national agencies and institutes in contributing to and implementing 

HIA; and on the relation of national HIA to EU-policy making. 

The networks approach incorporates the identification of good practices in Member States, 

EEA and accession countries in the use of integrated approaches to tackle health 

determinants compared with a topic-centred approach. Recommendations will be formulated 

on EU level in preparation for the 3rd strand of the proposed EU health strategy. These will be 

discussed in the second policy seminar (November 2001). Other tasks of the ENHPA include: 


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to monitor and respond to, in consultation with ENHPA members, health-related policies from 

the European Commission, European Parliament, Health Council, Ministers and their officials; 

to provide ENHPA members with information on EU mechanisms, developments and 

initiatives related to public health and health promotion; development of an EU policymakers 

database; development and strengthening of working relations with relevant European health 

networks to make maximal use of resources, reach advocacy agreements, organise events in 

EU Institutions, and communicate and disseminate functions and linking websites; to facilitate 

cross-national partnerships for the implementation of the new proposed EU health strategy; 

and to provide an overview for the Commission on European health networks. 

Related work by ENHPA 

The European Network of Health Promotion Agencies has already made a number of 

significant contributions within the area of European health inequalities. 

In 1997, a report entitled ‘An overview of the causes of the socio-economic disparity in health’ 

was conducted at the Danish institute for Clinical Epidemiology (Helweg-Larsen, 1997). The 

review considered methodological issues in the measurement of socio-economic status and 

health outcomes, and reviewed evidence for various explanations of the link between the two. 

These included: social selection; lifestyle factors; psychological factors, use of health services 

and structural factors at home and work. 

A second report entitled ‘Health Promotion amongst low income groups: a review of forty 

interventions’ (Whelan et al.,. 1998) reviewed 40 evaluated health promotion interventions, 

which specifically targeted low-income groups. The largest number of interventions came from 

North America and in the majority of cases the main focus of the interventions was women and 

children. The interventions identified within the review used a range of intervention approaches 

at both the individual and community level and were assessed by a variety of evaluative 

techniques. The authors acknowledged the limitations of the review, but concluded that there 

was sufficient evidence to suggest that health promotion activity could make a contribution to 

developing the health potential of low-income groups. In conjunction with this conclusion, the 

authors also suggested that a broader evidence base on health promotion interventions 

among low-income groups be called for, along with the development of a consensus for 

assessing such interventions. 

A third paper entitled ‘A review of policies for socio-economically disadvantaged groups’ 

(Briziarelli & Pedone, 1998) employed a Delphi questionnaire amongst a range of experts 

across 25 European countries. It considered definitions, actual policies and personal opinions 

of the expert respondents. The authors found that there were considerable differences in 

understanding as well as a great diversity in the tradition of tackling problems through health 

promotion. They recommended the further identification and dissemination of good practice 

examples in this field. 


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APPENDIX 2: Descriptives – The National Reports 

Austria 

Austria submitted a brief account of the growth in recent years of interest in health reporting 

with a regional and local focus. To illustrate the way in which socio-economic factors were 

deemed important within this context, two interventions were introduced (oral health 

programmes in Vienna) which were initiated as a result of this monitoring. 

The Austrian Statistics Office was responsible for collecting data on income distribution and 

consumer information, which allowed the mapping of the socio-economic situation. The 

Austrian Health Institute collected data on the distribution of disease. 

A total of five interventions and ten policies were described in this report. The first three were 

preoccupied with the multiple problems faced by immigrants in Austria (mainly originating from 

the former Yugoslavia but also amongst large Turkish and Kurdish groups). 

The first was a scheme for non-German speaking people and involved the development of a 

diploma in public service interpreting. The account described a well-planned systematic 

approach with a strong evaluative element (looking at awareness of, satisfaction with and 

uptake of services). The scope of this intervention extended further than the significant 

language barrier. It incorporated peer education approaches designed to build on links and 

identity within this excluded community. 

The second, a project administered by a non-government organisation called Zebra, followed 

a similar formula with the development of a formalised curriculum and certification for peer 

educators amongst immigrants in Graz. The community was involved in the early stages of 

this intervention to define and prioritise problems of access to healthcare services. A small 

pilot project at the time of writing, this also incorporated a comprehensive qualitative 

evaluation. 

Outreach work in a number of community settings co-ordinated from a health centre in Vienna 

was the third example submitted. This was specifically targeted at addressing the health 

needs of parents, women and girls (Fem sud) derived from a geographical area characterised 

by multiple-deprivation (again a large immigrant population was a component). 

‘Liefering is getting healthier’ was the fourth intervention. Notably this took a holistic view of a 

problematic geographical area described as having: an ageing population; high proportions of 

people receiving social security benefits; high numbers of single parent families; substance 

abuse; and a problematic “sinking’ housing policy. As with all of the Austrian examples this 

intervention was very systematic in its approach, from the initial identification of a set of 

problems through to a multi-faceted response with a comprehensive evaluation built into the 

design. 

Finally a programme of dental health promotion in Vienna was profiled. A clear socioeconomic 

gradient was described in which upper groups were decay free and lower groups 

saw levels reaching 70-75%. A strong evaluative approach was again evident here. 

The Austrian co-ordinator submitted a long list of social policies (11, full list provided below) 

covering: housing conditions; working conditions and the right to work; the ageing population; 

and access the healthcare services. Apparent in the overall approach was a desire to support 

improvements at a community level through integrated policy development and legislation. 

Generally the careful monitoring of the impact of each policy backed this. 


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POLICY DESCRIPTION 

Housing 

Landlords must inform the communal administration before 

issuing a notice of intent to evict a tenant – follow up 

support package for tenant 

Mobility and transport An integrated plan, which has evolved since the 1960s, 

aimed at protecting specially targeted groups e.g. children 

and elderly people. 

Social welfare and social Financial assistance for those in long-term care 

security 

Pension system Legislation to protect the standard of living of people 

reaching retirement age 

Employment and A set of integrated measures setting targets for including 

handicapped persons act people with disability in the workforce. Backed by penalties 

for employers not reaching targets 

Health promotion act The objective of this act is: 

- to promote and improve the health of the Austrian 

population during all phases of life, taking all dimensions of 

health into account (holistic view of health, in accordance 

with WHO definition) 

- to provide information on avoidable diseases and the 

determinants of health and disease 

Unemployment Insurance Means-assessed system based on household income 

Working time legislation Legislation controlling the frequency and duration and 

breaks in time spent working 

Social assistance (regional – A contingency fund providing a ‘safety net for those who 

lower Austria) 

are missed by other social protection’ 

Act for the representation of Representation and participation in the formulation of public 

the elderly 

policy 

Health insurance and Increasing levels of access for all citizens 

occupational 

insurance 

accident 

Belgium 

The Belgian Co-ordinator drew particular attention to the relatively high levels of social security 

in Belgium. The commercialisation within sectors such as education, the arts, the legal system 

and health and social services was highlighted. The difficulties surrounding the 

implementation of interventions to tackle complex social problems were discussed. A warning 

was given about considering the impact(s) of such interventions simply in terms of the original 

objectives and failing to explore the potential unplanned side-effects (positive or negative). 

On the subject of transferability the co-ordinator took a particularly pragmatic and self-critical 

stance. She stated that this issue could not be properly examined without looking at 

operational problems (like funding and project time spans). This point was made strongly in 

respect to the identification of ‘models of good practice’. The view of the co-ordinator was that 

it was too simplistic to judge such complex entities as ‘good’ or ‘bad’. 

The report mentioned significant policy changes in the last 20 years [although the official 

period under review was the last 10 years, the author justified this extension by stating that, in 

her opinion, the two periods (1980s and 90s) were consistent in policy terms]. 

The tightening of criteria regulating eligibility for unemployment benefit was important and had 

impacted on a number of related areas such as personal health insurance. 


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The issues raised by a policy approach, which focuses solely upon ‘disadvantaged groups’, 

were discussed. Short-termism and stigmatisation, were considered alongside the dangers of 

failing to tackle problems within a broader holistic view of society and inequality. 

A profile of the Belgian social security system was submitted in order to provide context for a 

discussion of the policies selected. Within this, financial provision was described, in respect 

to: sickness; maternity; invalidity; unemployment; old age; premature death of the head of the 

family; and work accidents. 

The Belgian Co-ordinator concluded her background remarks with a reminder of the 

complexities that exist within Belgium in terms of its political organisation and government; 

communities and language; and geographical territories. 

A total of seven interventions were reported within the Belgian submission. The selection 

featured a strong focus on socially excluded immigrant populations and on improving service 

access to those living in deprived conditions. Innovative and culturally sensitive approaches, 

advocacy and peer education was given as examples. Integrated planning at local community 

level was highlighted. 

The first three interventions were designed to improve access to healthcare services or to 

increase uptake through outreach work amongst socially excluded groups. Community group 

facilitators operated as advocates in a scheme devised by Culture et Sante amongst socioeconomically-disadvantaged 

groups where language was a barrier and where there was low 

educational attainment. Advocacy amongst Moroccan and Turkish people was also a feature 

of an intervention in 22 Belgian hospitals where interpreters were employed to assist 

exchanges between healthcare professionals and patients. The skills of ‘social interpreters’ 

were developed in a scheme in Brussels, which although centred on healthcare was not 

exclusively so and extended to other public service provision. 

The fourth intervention reported was an attempt to integrate health promotion services within 

two districts (Forest, Cureghem). The accounts given however suffered in translation and any 

sort of assessment was problematic. 

Translation hampered the description and learning points being communicated in the fifth 

intervention reported within the Belgian report - ETAPE ‘working together around early 

childhood. A verbal communication with the co-ordinator revealed that this was a supportive 

scheme for vulnerable young mothers to facilitate mother-baby bonding through therapeutic 

massage. 

Logos, the sixth reported Belgian intervention, highlighted the implementation of a network of 

regional consultative structures aimed at facilitating health improvements through community 

development. Their principle role was to ensure that national health targets were translated to 

address the specific needs of different regions. The account made it clear that this initiative 

was in the early stages of its implementation and comments on its effectiveness were 

problematic. 

Finally two schemes, Experience Experts initiated in 1992 and a healthy food scheme were 

reported upon. The former enlisted peer educators to facilitate educational assistance for 

underprivileged families. The latter scheme focused on healthy eating but the underlying 

goals extended well beyond this basic remit and sought to develop community cohesion in the 

local population. 

An historical perspective on significant milestones in policy formulation was incorporated within 

the report on Belgian policies. This was useful in terms of understanding more recent reforms. 


75

This also provided valuable background and context and illustrated the complexities of the 

Belgian system in which this activity was taking place. Within this preamble the following were 

cited: The change in the age of majority in 1990; The access to healthcare act in 1997; Rules 

on debts in 1998; Judicial assistance in 1998; and the regularisation of those without legal 

papers in 1999. 

The first of the five Belgian policies illustrated in more detail in this report was initiated by the 

Federal Government and was issued as a royal decree in 1997. This decree controlled 

standards for conditions in rented housing. 

Easing the financial access to healthcare was the focus of the second Belgian policy reported 

upon, again this was established in 1997. Social welfare, social security – healthcare 

insurance for disadvantaged groups sought to extend the number of beneficiaries of assisted 

access to include the elderly and those with disabilities. 

Fixed price community healthcare centres were established in 1994, the third Belgian policy 

that received attention. 

The last two policies to be reported upon were preoccupied with education and employment 

respectively. The former provided a safety net for 15 to 25-year-olds with low educational 

qualifications through the provision of Centres for Alternative Education and Training (CEFA 

1991). 

The latter, voluntary career interruption (1985), attempted to provide some protection for those 

needing to suspend their careers. Two examples of instances where this might have occurred 

were ‘carers of a family member with a serious disease’ (2 months suspension) and ‘parental 

leave’ in similar circumstances (3 months suspension). The uptake of this protective 

employment legislation was reported to be higher amongst women but this legislation 

remained contentious with disagreement between experts (in terms of its success in 

decreasing inequality between different socio-economic groups). 

Denmark 

The Danish co-ordinator provided a description of population studies conducted every four 

years by the National Institute of Public Health. The introduction centred upon the 

Government’s Public Health Programme 1999-2008. 

The Programme was cross departmental, drawing on the support of 10 ministries, and there 

were 17 targets, including two overall targets - one of these relating to equity in health, which 

should influence all decisions on strategy and priorities and all interventions. These were 

based on the Health 21 framework and included two with inequality dimensions: 

• ‘Social inequity in health should be reduced to the extent possible – above all by 

strengthening efforts to improve health for the most disadvantaged groups’ (target 2) 

• ‘Children’s health and well-being should be given top priority – and assistance to children 

in vulnerable families should especially be strengthened’ (target 8) 

There were targets for life expectancy and quality of life, including: 

• Risk factor targets for tobacco, alcohol, nutrition and exercise, obesity and traffic accidents 

• Age group targets for children, young people, and senior citizens, 

• Health-promoting environments for primary schools, the workplace, local communities and 

health services 

• Structural targets for co-operation between the state, the counties and the municipalities, 

research and education. 


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The Danish report included three examples of interventions and six examples of policies. The 

approach of all three interventions was very strongly oriented towards cross-sectoral cooperation 

and attempted to break down traditional barriers between discrete and competing 

authorities and organisations. 

The Ministry of Social Affairs and spread initiated the first intervention across 5 municipalities. 

The second, based in Djursland, was designed to support families with young children where 

alcohol was used problematically. Finally, the third intervention, was an outreach programme 

amongst homeless people aimed at preventing mental health problems, and supporting those 

with mental health problems. 

Co-operation and Planning in the Health Arena (1994); The 1997 Reforms in Sick Allowances; 

The 1996 Preventive Health Scheme for Children and Youth; and the Clean Environment 2005 

were provided as policy examples in this report. Inequalities were referred to explicitly, 

intersectoral working and new partnerships between the public sector and private business 

were featured with an emphasis placed upon a shift in civil responsibility in which companies 

played a much more significant role. 

Finland 

The report submitted by the Finnish Co-ordinator identified that reducing health inequalities 

was a target and had been since the late 1980s with the initiation of the Health for All 

programme. Since 1996 the Government of Finland had submitted an official annual report to 

the Parliament concerning the state of the health of the nation. Mortality, morbidity, use of 

healthcare services, risk factors and health behaviours were all reported on. 

Policy in Finland was aimed at reducing premature deaths, extending people’s active lives, 

ensuring quality of life for all and reducing differences in health between different sets of 

people. A meeting of the Nordic Ministers of Social Affairs and Health in June 2000 specifically 

discussed equity in health. At this the Finnish Health Minister stressed that socio-economic 

factors should be prioritised. 

On monitoring, there was a tradition shared amongst universities and government research 

institutes such as the National Research and Development Centre for Welfare and Health 

(STAKES), the National Public Health Institute (KTL) and the Institute of Public Health (TTL). 

Interventions identified within this report were: the Suicide Reduction Programme 1986-1996; 

Fit for life 1995; the National Screening Programme for Women; and the European Network of 

Health Promoting Schools (ENHPS). 

The policies reported were: The Preventive and Social Health Policy; Protection at Work; 

Provision of Income; the new strategy to finance social security; and the Production of 

Services Tax. 

Germany 

The German report included a nation-wide study of health promotion among the socially 

disadvantaged. Roughly 200 institutions involved in health promotion were approached (i.e. 

the National Health Association, state associations for health promotion, state associations of 

the industrial welfare organisations, state charity associations, public health research 

associations, universities, several government health offices, several health insurance 

companies, the German Medical Association, various initiatives, working groups and self-help 

groups, etc.). They were all asked to report projects relating to this subject to the national 

coordinating office. Eighty-three completed questionnaires were returned by the submission 


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deadline. Among the 83 completed questionnaires, 42 projects involving concrete intervention 

measures in the field of health promotion among the social disadvantaged were reported. 

With regard to the target groups, the projects mainly deal with children and young people and 

women in difficult social situations. These are followed by projects for the long-term 

unemployed, the homeless, migrants and people suffering from chronic mental illness. It is 

evident that none of the intervention programmes specifically targeted senior citizens or male 

youths living under difficult psychosocial conditions. The majority of methods used can be 

classified as support or educational offers. Only a few projects explicitly targeted socially 

disadvantaged people, with the aim of strengthening their ability to mobilise their own 

resources in dealing with their health and the health care institutions, and to practise selfdetermination. 

A small percentage of the reported 42 projects have been evaluated 

scientifically with regard to their theoretical foundations and actual effectiveness (i.e. using 

scientific methods and techniques). 

The following selection criteria for the best practice models were defined: 

• It should be evident that basic data and information supporting situation or demand 

analysis and goal definition, were available prior to the project. 

• The subject and the target population should have been selected on the basis of the 

need for preventive action indicated by the data. 

• Changes/improvements due to the intervention should be measurable. 

• The implementation and effect of the intervention should be subject to scientific 

evaluation. 

• Publications/reports on the project should be available. 

This selection is not a rating of the individual projects. Rather, the goal was to illustrate 

different, successful and promising methods and strategies of health promotion for the socially 

disadvantaged in Germany. However, innovative methods were to be identified in these 

projects, such as the combination of health- and employment-promotion measures, the active 

use of interpreters and cultural mediators in work with socially disadvantaged foreigners, the 

active involvement of the affected parties themselves, etc. 

Despite the encouraging nature of individual projects, the limited range of model projects of 

this kind must be emphasised here in view of the magnitude of the problem of social inequality 

in health in all age groups of the German population. These projects are still primarily geared 

towards socially marginalized groups and pursue the goal of reducing deficits through 

compensatory measures. It must be stated that neither politics nor science has been able to 

raise public awareness of the need for a national initiative or a broad social movement. 

TAMPEP was identified as an international HIV and AIDS prevention programme amongst 

migrant prostitutes. The project developed an empowerment approach through the work of a 

network of cultural mediators and peer educators. The participative approach of the project 

and the proven multiplier effect make this project especially attractive, even though the legal 

framework conditions and the extensive, undocumented areas of the prostitution business limit 

the success of interventions of this kind. 

Long-term unemployment and related health problems within a rural district of East Germany 

was the subject of the second intervention reported on. The intervention was delivered through 

the work of a team of counsellors who focused their efforts on an occupational reintegration 

and individual counselling program. An evaluation of the implementation was integrated with 

the work of the counsellors. 

The “Healthy Cities Model” was cited as the template for the third intervention targeting 

children and young people in a deprived city district (high proportion of low income and 


78

immigrants households). This involved physical activity promotion and leisure-time behaviour. 

An interesting aspect of this compensatory project was its implementation by means of a 

"cooperative planning strategy", which was to ensure that the program targets were not diluted 

or redefined by key institutions in the social environment (school, social education institutions). 

Even in Germany's generally affluent society, a health promotion programme focused on 

"affordable food" could be useful in a strongly socially disadvantaged residential area where 

the parents of every third child are dependent on social welfare. This is confirmed by the 

results of a joint project conducted by the Ministry of the Federal State of Lower Saxony and 

the Industrial Welfare Organisation. However, eating habits are highly resistant to change due 

to their early sociocultural establishment during the process of primary socialisation, but also 

due to their strong contextual dependence (access to, and affordability of, healthy food). The 

question also arises as to whether social workers in health care should and can become active 

in a field reserved for trained nutritionists. 

The final intervention to be profiled within this report was a health promotion scheme for young 

adults participating in vocational training courses. A life skills approach was adopted and 

monitored through measuring self-reported knowledge and behaviour. 

Health policy activities geared to reducing social inequalities in health 

Federal level 

In the Federal Republic of Germany, interest in the subject of "social inequality and health" has 

increased in the health and social policy sector over the past ten years. As a result of this 

interest, the "National Poverty Conference" was established in Autumn 1991 to serve as the 

German section of the European Anti-Poverty Network. The Federal Government also no 

longer denies the existence of poverty and social exclusion in Germany. In accordance with 

the coalition agreement between the SPD (Social Democrats) and Bündnis 90/Die Grünen 

(Alliance 90/Greens) of 20 October 1998, which declares the fight against poverty to be a 

focus of the policy of the new Federal Government and provides for the regular submission of 

a poverty and wealth report, the motion of the coalition to "submit a poverty and wealth report 

by the Federal Government in 2001" was adopted by the German Bundestag on 27 January 

2000. 

The "Poverty and Health" Committee was established in the German Federal Ministry of 

Health on 28 January 2000. The members of this federal and state committee include 

representatives of the Federal Government and the Federal States, as well as representatives 

of the health insurance companies, the National Association of Panel Doctors, the German 

Medical Association, the Public Health Service and individual experts from the fields of science 

and practice. The ministry's goal in establishing this committee is to study the effects of 

poverty on health (in terms of financial poverty and by applying the life situation method), and 

to identify potential means of improvement. Recommendation papers are now available from 

two subcommittees on the subjects of "health care for the homeless" and "migration and 

health". These papers contain action recommendations directed at all those who bear 

responsibility for public health care. 

The new version of Art. 20 SGB V undoubtedly strengthens health promotion for the socially 

disadvantaged in health policy. It enables German health insurance companies to once again 

offer their insured programmes in primary prevention and company-based health promotion. 

The wording of this act reads as follows: "(1) ... primary prevention services are intended to 

improve the general state of health and, in particular, contribute to the reduction of social 

inequality in the opportunities for maintaining good health." Consequently, health insurance 

companies can be expected to increasingly finance health promotion programmes geared to 

risk groups whose health opportunities are more restricted due to social conditions. The 


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support of prevention measures is subject to certain prerequisites. For example, the law 

requires proof of efficacy, cost-efficiency and quality assurance for programmes to be included 

in a catalogue. 

Measures for reducing unemployment 

The German Federal Government has given the struggle against unemployment absolute 

priority. Roughly DM 44.5 billion were available in 1999, which were used to support 

employment programmes for about 1.5 million participants. The Immediate Action Programme 

for the Reduction of Youth Unemployment successfully reduced unemployment in 1999, 

especially long-term unemployment. This immediate action programme consists of various 

sub-programmes geared to the individual problems of unemployed young people. For 

example, elements such as social support are included, in order to address young people from 

difficult social backgrounds, who are usually not registered as unemployed. 

Measures for improving the housing situation 

A change in tenancy law in 2000 lengthened the period for paying rent arrears and due 

compensation from one month to a total of two months after the launch of eviction 

proceedings. The purpose is to prevent homelessness. A government-sponsored model 

project known as "Permanent Housing for the Homeless" was carried out between 1993 and 

1997. Within the framework of this project, new housing space was provided for particularly 

disadvantaged people, usually homeless people or people threatened by homelessness, using 

low-income housing funds, along with accompanying social support, primarily funded by the 

social welfare, child and youth welfare and labour promotion system. 

The German Federal Government is providing DM 100 million a year from 1999 to 2003 for the 

national and Federal States programme "Districts With Special Developmental Needs - The 

Social City". This initiative is geared towards city and town districts that are at risk of social 

marginalization as the result of social/physical segregation. One-hundred and sixty-one 

districts with special developmental needs in 123 cities and municipalities were involved in the 

programme in the first year. Although improving health in the respective cities and 

municipalities is not an explicit goal of the programme, it targets the improvement of the living 

situation by means of active and integrative urban development policy. Positive effects on 

health can therefore be expected. 

State level 

The number of poverty and social reports from the Federal States and municipalities is rising 

steadily. Particularly great emphasis on the issue of "social inequality and health" can be 

observed in the health reporting of the state of North Rhine-Westphalia (NRW). In 1995, NRW 

was the first federal state to present a goal-oriented approach to achieving health policy 

targets to experts in the field. The State Health Conference of North Rhine-Westphalia 

adopted the "Ten Priority Health Targets for NRW" in mid-1995, these forming the foundation 

of health policy in North Rhine-Westphalia (Ministry of Women, Youth, Family Affairs and 

Health of the state of NRW (MFJFG), 1995). Although the WHO objectives for disadvantaged 

groups did not get into the top rankings on the NRW target list, the "establishment of equal 

opportunities in the health system is considered to be a cross- fashion in the event of illness. 

In this context, the MFJFG initiated a model intervention programme in health policy on the 

municipal level for the co-ordination of health and social services and provided funding from 

Autumn 1995 to the end of 1998. Model community initiatives, such as improved drug 

assistance planning, a faster transfer of the mentally ill to assisted living programmes, and job 

market transparency for conditionally employable, mentally ill persons, are examples geared to 

the qualitative improvement of the treatment and living situation of the socially disadvantaged. 

Longer-term improvements in medical and social care and support can result from optimised 


80

planning data and a comprehensive inventory of the treatment needs of the citizens of a 

municipality. The Public Health Service Act (ÖGDG) of the Federal State of NRW of 25 

November 1997 mentions "new forms of responsibility fulfilment and organisation" (Arts. 2, 4) 

"Coordination" (Art. 23) and the "Municipal Health Conference" (Art. 24). The public health 

service is given municipal-level competencies in health policy that go way beyond medical 

services and can be used to reorient the public health service to also provide better care for 

socially disadvantaged groups. 

Within the framework of the Lower Saxony State Poverty Conference, the activities of the 

"Poverty and Health" committee are worthy of mention. This committee published a project 

brochure for Lower Saxony, which presents 74 practical projects and key activities that work 

with and for the socially disadvantaged. 

A nationwide inventory of initiatives, projects and ongoing programmes for health promotion 

among the socially disadvantaged was performed and published in spring/summer 1996 by 

the Ministry of Social Affairs of the Federal State of Baden-Württemberg in cooperation with 

the Baden-Württemberg State Health Office. 

Greece 

Three interventions were submitted in the Greek report: Health and nutrition in primary school 

children in Crete; Nutritional consultants amongst the elderly population of Attica; and the 

prevention of anti-social behaviour amongst adolescents in Piraeus. 

The first and third interventions were school-based programmes, aimed at helping children 

from underprivileged or migrant families. In Crete, activities and seminars for parents and their 

offspring were organised in primary schools to improve children’s diets, fitness levels and 

general health. In Piraeus, health and community workers reached out to pre-adolescents from 

disadvantaged backgrounds to prevent drug abuse and delinquency. The programme was 

aimed at children of this particular age group, because they are in a crucial stage of their 

socialisation, during which they will adopt attitudes and habits, which will affect their future 

lives. The purpose of this project was to raise children and parents’ awareness of the dangers 

of drug abuse as well as to encourage a healthier lifestyle and participation in creative 

activities. Cultural and social events, including theatrical performances and exhibitions were 

organised with the participation of children, teachers and parents. A great emphasis was also 

placed on the development of good personal and social skills, such as self-esteem, 

responsibility, communication, the expression of feelings, teamwork, solidarity, conflict 

resolution and assertivity. 

The second intervention, presented in the Greek report, referred to a nutrition programme for 

senior citizens in a socio-economically-disadvantaged area of Attica. Twenty-seven elderly 

volunteers received training as healthy nutrition councillors and were sent out to various 

recreation centres for the elderly to discuss the importance of healthy nutritional habits. The 

main goal of the programme was to prevent cardiovascular disease. However, it also 

encouraged senior citizens to revive traditional recipes and discover the joys of volunteering. 

In addition to the above-mentioned projects, the Greek report highlighted the main points of 

the country’s social policy, which includes: 

• vocational training, consultation centres and assisted access to public transportation 

for the disabled and people with special needs 

• the provision of low-cost housing for people on low incomes 

• home help services to low-income elderly or disabled people and therapeutic holidays 

for the elderly 


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• social security payments for agricultural workers, low-income pensioners, the disabled, 

Greek migrants who return to their country of origin, families with more than 4 children 

or single parent families 

• programs directed at the socialisation and protection of street children 

• vocational training for women, young people and the long-term unemployed, as well as 

vulnerable social groups including the disabled, gypsies, migrants, migrants of Greek 

origin returning to Greece, refugees and ex-prisoners 

• financial advantages for employers who hire people from vulnerable social groups 

• special healthcare provision for people working in the agricultural sector 

• sport for all 

Ireland 

The Irish Co-ordinator highlighted the new National Health Promotion Strategy for the years 

2000-2005, and the emphasis placed on the socio-economic and 

environmental determinants of health. 

One of the recommendations from the strategy, is the need for a more comprehensive form of 

health-proofing of all policies in order to address health 

inequalities. 

The first National Health and Lifestyle Survey (SLÁN 1999), commissioned by the Department 

of Health and Children’s Health Promotion Unit revealed an socio-economic gradient in 

relation to lifestyle practices. The results of SLÁN have informed recommendations in the 

Strategy, and a follow-on survey is planned for 2002 to measure progress and re-assess aims 

and objectives. 

A new National Health Strategy is at an advanced stage of preparation and is due to be 

published in October 2001. It will focus on population health and the elimination of inequalities 

in health via Health Promotion intervention. 

Two interventions and one policy were profiled within the report from the Irish Co-ordinator. 

The first was a community peer-led nutrition intervention entitled ‘Healthy Food Made Easy’. 

The goal of this project was to improve the nutrition of low-income communities. Local women 

were trained by nutritionists to deliver a course to their peers in the community. Dublin 

Healthy Cities collaborated with the south western Area Health Board to pilot new structures 

and resources. The second intervention was aimed at promoting cultural diversity and raising 

public awareness on racism in Dublin. Information booklets outlining service provision in 

housing, health and social welfare were developed in different languages. 

The National Anti-Poverty Strategy (NAPS), ‘Sharing in Progress’, was published in 1996 and 

identified five key areas: educational disadvantage; unemployment; income adequacy; 

disadvantaged urban areas; and rural poverty. Following on from a 2000 review of this 

strategy, health was identified as a key area in which inequalities prevailed. As a result the 

revised NAPS strategy 2001 also contains NAPS and Health targets. 

A recent and significant development was the establishing of an Institute of Public Health in 

1999. The aim of the Institute was to improve health in Ireland by working to combat health 

inequalities, and influence public policies in favour of public health. Fundamental to the 

philosophy of the Institute was the fact that the main determinants in health in society were 

people’s social and economic circumstances. The Institute worked to reduce inequalities in 

health and develop and strengthen partnerships for health. It was also involved with building 

the capacity of those who had key roles to play in improving the health of the people of Ireland. 

The main areas of work identified by the Institute were: 


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• Tackling health inequalities 

• Strengthening partnerships for health 

• Networking internationally and nationally 

• Contributing to public health information and surveillance 

• Strengthening public health capacity 

The Institute clearly set out the approach it would take towards achieving these goals: 

• Developing and promoting multidisciplinary and intersectoral ways of working 

• Working to strengthen the information and skills that people needed to achieve 

improvements in their health 

• Promoting co-operation between the Republic of Ireland and Northern Ireland 

• Raising awareness of public health matters 

Italy 

Attention was drawn within the Italian report to the fact that the Ministry of Health had recently 

(2000) commissioned the Experimental Centre of Health Education at the University of 

Perugia to conduct scooping research into ‘Health for all 2000’. Socio-economic indicators 

were examined and their suitability for the Italian situation assessed. 

Two longitudinal studies on inequalities in mortality were initiated. The first was being 

conducted by the social research department at the University of East Piemonte in Turin. 

Early results had highlighted the depth of inequality especially in relation to the social position 

of citizens. The second study at Florence was examining the relationship between educational 

indicators and cardiovascular disease. 

An exposition of the policy and legislative environment was provided in this report. Within the 

constitution there was an emphasis on solidarity with laws enforcing the equal treatment for all 

citizens. Health was viewed as a fundamental right of every individual with assurances given 

concerning the free treatment of the sick. The Italian National Health Service was initiated in 

1978 and based upon four key principles: a global service; guarantee of health for all persons; 

equal treatment for all; and the protection and respect for the dignity of all. 

Within the last National Health Plan (1998-2000) health promotion was the main objective. 

There were three main principles: universal access regardless of social level or financial 

situation; equal accessibility and distribution of health services; a guarantee that individual 

contribution is independent from the risk of disease. 

Four interventions were identified within this report. 

The first was entitled ‘Immigration and health’ and was initiated within the Umbrian region. It 

aimed to ensure that migrants, without a satisfactory permit for a stay in Italy, had access to 

adequate health services. Within this broad remit there were also moves to: promote cooperation 

between private and public sector service providers; monitor a range of infectious 

diseases; improve communication between the local population and immigrants; and devise 

health promotion programmes for the immigrant groups. 

Harm reduction from sexually transmitted diseases (STD’s) amongst prostitutes, ‘CABIRIA’, 

was aimed at contacting prostitutes and providing information about STD’s and appropriate 

services. 


83

‘Unita Mobile Donna’ was an intervention implemented by the non-government organisation 

PARSEC in Rome. It was initiated in 1997 and provided information about STD’s to the local 

female population. A particular feature of the intervention was the provision of safer sex 

information to ‘older’ widowed or divorced women (a particular group at risk identified by the 

local epidemiological observatory) who were not aware of risks and/or did not perceive 

themselves to be at risk from STD’s. 

‘Health culture and immigration’, based in the Lazio region of Rome, was again aimed at 

providing access to health services for immigrants without suitable permits for a stay within 

Italy (‘irregular, clandestine and illegal immigrants’). There was a strong surveillance element 

integrated into this intervention which was implemented by the Santa Maria and San Gallicano 

Dermatological Institute. 

Netherlands 

A comprehensive picture of inequalities within the Netherlands was presented within the report 

from this Co-ordinator. The National Institute of Public Health and Environment (RIVM) 

collected data on health, disease and the provision of healthcare. These data were presented 

within the report entitled ‘Public Health Status and Forecasts’ (1977). 

Inequalities in socio-economic status were measured using data on educational level, income 

and occupational status. A number of useful examples were provided to illustrate gradients 

that existed when comparing the morbidity and mortality of the top and bottom categories of 

these scales. 

In addition to socio-economic status, the aged, the unemployed, single people, ethnic 

minorities, and the homeless were also mentioned. There were no formal national inequality 

targets in the Netherlands, but these data were used to measure progress in reducing the 

health gap. 

A geographical focus was introduced which considered the concentration of these groups 

within certain suburbs of big cities. 

A picture of a very data rich and sophisticated monitoring programme was presented. Further 

examples of projected growth over the next 15 years for the groups mentioned above were 

submitted. 

The report highlighted the Globe Study conducted since 1991 by the Erasmus University of 

Rotterdam. This longitudinal study was carried out amongst 19,000 residents in the Southeast 

Netherlands and demonstrated that both behavioural factors and living conditions contributed 

to the poorer health and survival of the lower socio-economic groups during this period. 

The Dutch Ministry of Health, Welfare and Sports funded a research programme (Health 

Inequalities SEGV-II) which examined health promotion policies and interventions and their 

scope for reducing health inequalities. 

The report concluded its pre-amble by reporting that the Dutch Minister for Health (Ms. Borst) 

had requested that a systematic approach to policy–development be adopted with its aim 

being the reduction of ‘avoidable and unfair health inequalities’. 

Four interventions were identified within this report (including the Globe study mentioned 

above), a large number of policy initiatives were identified. 

Coherence in prevention in Amsterdam was involved with the development of a network 

combined with three pilot projects. By creating partnerships between the municipality and 


84

insurance company its goal was to offer continuity across a range of services for a number of 

groups within the population (the ageing population, migrants and minority ethnic groups). 

Priorities were identified and driven by the groups mentioned above. This project was 

presented as being part of a larger approach, ‘Grotestedenbeleid’ (large city policy). There 

was a very strong evaluative dimension integrated with the implementation and, although 

barriers prevented success, a longitudinal survey was attempted. 

The Arnhemse Broek healthy and well, the third intervention to be identified within this report, 

was a community-based intervention for the underprivileged in Arnhem. With high levels of 

community involvement this project was again reported as featuring strong evaluative 

components with process measurement combined with a quasi-experimental outcome study. 

The final intervention targeted children living in poverty in Breda. 

The table below shows the policies that were identified in the report from the Netherlands, the 

first five were mentioned within the opening introduction and the remaining group was formally 

submitted for consideration by the project. 


Social renewal 

policy 

Big city policy 

Welfare policy 

Urban renewal 

Local health 

Income support Including the provision of emergency assistance for the purchase of 

warm clothes and food 

Push-back on non- To ensure that those who have benefit entitlements are made aware 

use 

and can receive them 

Promote 

employment 

Financial benefits, social involvement and mental health are features 

Increasing social 

participation 

Minority policy 

City renewal 

Social renewal 

Medical help for 

illegal residents 

without medical 

insurance 

Social involvement and well-being. Empowerment. 

Increasing levels of access to health services 

(1997) Assessment of the impact of renewal programmes prior to this 

period. 

Identifies special action areas characterised by multiple deprivation 

(1988) 

Integration of Assisting low wage earners with medical bills 


85

people with labour 

disabilities 

Nutritional policy 

for people with low 

socio-economic 

status 

Physical activity 

and vulnerable 

youth 

Norway 

(1988/99) Health outcome targets relating to heart disease and cancer 

(1996) Lifestyle approach aimed at increasing social integration 

Whilst the Norwegian co-ordinator did not submit a formal introduction and complete the 

section on the identification of inequalities within her country. She did supply two papers: 

Tackling Inequalities in Health by Marit Rognerud and; Social Inequalities in Health – a review 

of the Norwegian evidence by Espen Dahl. It was beyond the scope of this project to report on 

all the information supplied within these extensive reviews. 

The information supplied presented a picture of a data-rich environment in which inequalities 

were clearly defined and integrated into the policy context. The Black Report, published in 

England in 1980 (Townsend and Davidson 1980), was classed as a significant milestone for 

both research and policy development across Europe. Dahl argued in his paper that the 

impact of the Black Report was not what it could have been in Norway. (More specifically 

related to the potential of the research to be used to illuminate avoidable inequality and 

recommend action for policy-makers). 

Dahl (who restricted his working definition to socio-economic inequalities but then engaged 

gender, ethnicity, marital status and age in his consideration of subgroups) wrote that Norway 

along with the other Nordic countries had a huge comparative advantage in the availability of 

‘high quality data with a unique richness’. He reported that there was a possibility to link data 

from a number of administrative and statistical registers. He highlighted some examples of 

administrative and statistical data that had the potential to shed light on life-course 

perspectives. These included: The Survey of Level of Living; The Health Study of North- 

Trondelag (HUNT); The Health Study in the Administrative Units and Regions in Oslo 

(HUBRO); and The Medical Birth Registry. 

The potential value of examining deprivation and social capital at the municipality level through 

the exploration of income and mortality data was put forward. 

Margit Rognerud selected a number of different groups including children in low-status 

families; single parents; unemployed people; immigrants, refugees and asylum seekers; and 

the homeless. She extracted data from Statistics Norway [The Health Survey 1995 (Pub.1999) 

and Levels of Living Survey 1995 (pub.1997)] and cited a number of academic studies. 

Statistics Norway conducted their ‘Health Survey’ in 1995 based on a representative sample of 

5100 households (12,832 respondents) with a response rate of approximately seventy per 

cent. 

The author illustrated how morbidity and mortality patterns vary in all the groups mentioned 

above. 


86

In Norway, both high and low income groups alike experienced increased prosperity within the 

last few decades. The percentage living in relative poverty, however was higher in 1996 than 

in 1986. 

Selected examples from this paper are given below: 

� Small children (0-6 years) from low-income families (income less than 160.000 NOK 

per year) had a higher prevalence of disease, injury or ‘handicap that affects everyday 

life’ than those from affluent families (all categories) 

� The long-term unemployed suffered more disease and mental distress more frequently 

than the average population across all age groups. 

� The Oslo Health Report (Rognerud M, Stensvold I 1997) showed that, when comparing 

babies of non-western women with Norwegian women (based on country of birth), they 

had higher rates of low birth rate, serious malformations, perinatal mortality and infant 

mortality. 

� A ‘healthy migrant effect’ was observed which was reversed for older migrants. 

Table: Self reported diseases (all diseases/long-lasting illnesses) 

Age group 16-24 year-olds 25-44 year-olds 45-66 year-olds 

Non- Norwegians Non-western Norwegians Non-western Norwegians 

Western 

immigrants 

immigrants 

immigrants 

Diseases 18.7% 39.5% 36.5% 47.6% 67.1% 59.9% 

Source: Statistics Norway 

The author described migrants characterised as healthy, young and resourceful people (the 

‘healthy migrant effect’). Over time this effect was weakened as a result of exposure to risk 

factors associated with low-socio-economic status and additional socio-cultural problems in 

their new homeland. The table above was used to illustrate this point in which the percentage 

reporting long-lasting illness (all diseases) was lower among younger migrants than among 

Norwegians in the same age groups (16-24 year-olds, 25-44 year-olds). For older migrants 

(45-66 year–olds) the situation was reversed. 

The Norwegian report identified a total of four interventions and seven policies. Bosnian 

refugee children were the subjects of the first. By working with them and providing them with 

assistance, the aim was to help them cope with the trauma of war. 

The second project was involved with the setting up of a workshop for primary medical care; 

lay health promoters were used to forge links with the immigrant population. Priorities were 

driven by the community and focused primarily on healthy eating issues, the wider objectives 

were related to empowerment and developing social cohesion. An action research approach 

was adopted to evaluate the implementation of the project. 

The Varden Childcare Centre, the third Norwegian intervention, offered day centre facilities for 

children and parents. Although focused primarily on a specific centre, work was not confined 

within the building and outreach extended into the surrounding community. Cross-sectoral 

ways of working were employed with long term health benefits through community 

empowerment the goal. This was accompanied by an evaluation of the implementation. The 

Hasvik Self-help House was the final Norwegian nomination in the intervention section. This 

was set up to assist a small local community who were suffering economic recession as a 

result of the collapse of the fishing and associated industries in the area. The priorities were 

community-driven and covered a broad range of issues including social, economic and wellbeing. 


87

The Norwegian policies that were identified in their report are listed below: 


� Housing 

policy 

� Environmen 

t policy 

� Health and 

healthcare 

policy 

� Social 

welfare and 

social 

security 

� Lifestyle 

� Educational 

and 

vocational 

training 

� Area 

community 

policy 

Aimed at increasing public housing stock adopting a multi-sectoral 

approach through the setting up of collectives. Also covers assistance 

for homeless people 

An explicit link is made between the environment and psycho-social 

well-being 

Covers the needs of people with psychiatric disorders 

Dealing with problems arising from forced marriages amongst 

immigrant populations 

Strong focus on the health of children 

Covering the provision of economic support for single parents to 

enhance their prospects within the labour market 

Areas suffering deprivation – example given, Inner East Oslo. 

The account presented a favourable situation in terms of tackling inequality, socio-economic 

factors and their relationships to health outcomes were made explicit. The overall approach 

was orientated towards tackling problems faced by marginalized groups and communities 

rather than through influencing structural conditions. 

Portugal 

Through various local and sectoral studies in Portugal, it was possible to ascertain some of the 

health characteristics of certain groups such as drug addicts, sex workers, immigrants, 

homeless people and travellers. 

The Portuguese co-ordinator identified a total of four interventions and five policies. All of the 

interventions that were identified were aimed at improving health provision and access to 

socially excluded groups. 

Espaco Pessoa in Oporto city was an outreach support programme for male and female sex 

workers. The AUTOESTIMA programme based in Northern Portugal again focused on the 

sexual health of prostitutes with an outreach programme tailored to the special health needs of 

this ‘hard to target’ group. 

Immigrants and illegal migrants were the target group for a ‘better access to healthcare’ 

project in Quinta do Mocho and Marvilla. A set of protocols was developed to facilitate 

collaborative action between different service providers and patient satisfaction was 


88

monitored. There was a strong emphasis on priorities identified by community representatives 

and empowerment. 

Finally in Soares dos Reis, older low-income people, particularly those with mobility difficulties, 

were the subject of an effort to improve accessibility to healthcare services. 

The five policies identified within the Portuguese report were; Guaranteed Minimum Income 

(GMI); Promoting Micro-Enterprises; the Elimination of Child Labour Exploitation; Integrated 

Support for Older People; and Combating Poverty. 

Spain 

The most comprehensive effort to study health inequalities at the national level was conducted 

in 1993 when the Ministry of Health appointed a scientific commission to study social 

inequalities in Spain. The report published in 1996, considered gender, class, geographical 

and health service provision inequalities. It also reviewed some selected examples of social 

and health policy initiatives. Other potentially useful sources were reported to have been 

hampered by data quality problems, these included the Spanish Health Interview Survey and 

routine mortality statistics. Practical problems were also experienced when trying to review 

work conducted at both the regional and local levels because of the diversity of the work being 

produced by a broad range of institutions and in difficulties in trying to trace otherwise useful, 

but unpublished, work. 

The Spanish report identified two interventions and two policies. The first intervention, based 

in Ciutat Vella, a deprived inner city area in Barcelona, targeted pregnant women and women 

with young children. For this particular group accessing healthcare services was identified as 

being problematic. The project incorporated a quasi-experimental design and compared infant 

mortality rates between different areas. The project was reported to have demonstrated a 

reduction in the infant mortality rate in the area of the city where the intervention had been 

implemented. 

The distribution of healthcare services was the subject of the second intervention identified 

within this report. The example was from Barcelona where a review of services leads to 

reforms. 

The Reduction of Poverty and Social Welfare were identified within the policy section. The 

former (re) established a legal minimum wage and made provision for employment training for 

the unemployed. The latter targeted the significant proportion of the Spanish population 

composed of immigrants and their eligibility to access support services. Some interesting 

contextual remarks were made regarding the adjustment of restrictions associated with 

changes in successive governments. 

Sweden 

Ostlin and Diderichsen took much of the Swedish Co-ordinators account from a report 

(summary available: http://www.who.dk/hs/echp/index.htm) 

In 1997, the Swedish Government appointed a National Public Health Committee, charged 

with the task of defining strategies and targets that would lead the way in disease prevention 

and health promotion in Sweden. There was however a number of key events that led to the 

setting up of the Committee. The publishing of the Black Report at the beginning of the 1980s 

was cited by the author and attributed with increasing the political and scientific interest in 

social inequalities in health and its causes. In 1988 a Public Health Group was established, 

primarily to develop preventive health measures from a broad public health perspective. One 


89

of the most important achievements of this group was a proposal, which led to the 

establishment of the National Public Health Institute in 1992. 

Throughout the 1990s awareness grew that although in absolute terms health had improved 

inequalities had remained the same or were increasing. The author cited Work by 

Mackenbach J et al (1997). 

Lindholm A.L. et al conducted a study amongst Swedish politicians responsible for health and 

how they interpreted the relationship between equity and efficiency targets. In this work he 

was able to demonstrate that two thirds of his sample were prepared to sacrifice overall health 

benefits for equity. 

More recently, at the request of the Government, the Council of Social Research drew up a 

national programme of health equity research. As a result a national multidisciplinary research 

centre for health equity studies was established last year. 

The targets and strategies that were requested by the Government in 1997 should contribute 

to the reduction in health among: socio-economic groups; women and men; ethnic groups; and 

geographical regions of the country. It was required that these proposals should be 

scientifically well founded and stimulate a broad democratic process on health policy issues. 

The Commission that was set up consisted of all seven political parties in Parliament and a 

number of scientific experts and advisors from national authorities, universities, trade unions 

and non-governmental organisations. 

The preliminary proposal for objectives, targets and strategies was submitted to the 

Government on the 6 th of December 1999 and was made available for public consultation. 

National health-related policy objectives from Sweden included the: 

• Counteraction of wider disparities in income (Indicator: Gini coefficient under 0.25 (in 1998, 

0.25) 

• Reduction of political marginalization (Indicator: increase in voters in general elections in 

districts where fewer than 60% voted in 1998) 

• Increase in opportunities for integration into the labour market and reduced social 

exclusion, opportunities for continuing education, retraining and adult education (Indicator: 

40% of the labour force aged 25 plus with access to 5 plus working days of education per 

year (now 26%) 

There were 18 objectives in the Green Paper on health objectives for Sweden published by 

the National Committee for Public Health, based on the WHO Health 21 targets. Each 

objective had several general targets attached to it. These were generally not quantified. 

Relevant within the context of inequalities were: 

• strong solidarity and community cohesion (targets to reduce poverty, reduce segregation in 

housing and compensatory support for children and adolescents in socially disadvantaged 

residential areas) 

• supportive social environments for the individual (reduce isolation, loneliness and 

insecurity; increase participation in voluntary organisations and cultural activities) 

• high unemployment (good opportunities for life-long learning, low unemployment and no 

discrimination against immigrants and people with disabilities) 

(Swedish public health strategy is at http://www.fhi.se/english/pubHealth.asp) 

Examples of proposed indicators for the targets: 


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Reduced poverty 

• Distribution of economic standard (GINI co-efficient) 

• Proportion of households with a disposable income of less than 50% of average income 

• Proportion of individuals depending on social welfare/economic support for at least 10 

months per year etc 

Reduced segregation in housing 

• Quota between high income individuals in relation to low-income individuals per defined 

neighbourhood 

• Quota individuals born in Sweden in relation to individuals born abroad per parish 

• Number of homeless people etc 

Compensatory support for children and adolescents in socially disadvantaged residential 

areas 

• Number of children growing up in vulnerable residential areas 

• Resource allocation to pre-school, compulsory school, primary medical care etc in relation 

to needs 

A total of five interventions were reported within the Swedish report. Three were communitybased 

interventions, one involved the development of protective legislation in nursery schools 

and one sought to improve the financial access to healthcare services. 

Regular inspections of the work environment in nurseries and schools were instigated to 

improve the physical conditions existing within this setting. In addition to child safety a link 

was made between the physical environment and psychosocial well-being, considering the 

quality of life and morale of teachers and care staff. Legislation regulating conditions was 

used to enforce standards. 

Norsjö CVD, community intervention study examined lifestyle risk factors in a rural population 

suffering recession following economic collapse in the 1990s. The evaluation looked 

specifically at measures of equity. 

Comprehensive infant and child health screening 

Financial co-ordination between healthcare and health insurance for rehabilitation (FINSAM) 

was a programme where a decrease in absenteeism costs had been demonstrated in areas 

where organisational reforms had taken place. Cross-sectoral Cupertino between healthcare 

providers and private insurance companies. 

United Kingdom 

The national report from the United Kingdom presented a very positive picture in terms of the 

identification and monitoring of inequalities. 

Data collected and published by the Office of National Statistics (ONS). A national census 

was carried out every ten years. 

Social class routinely collated mortality statistics. An occupational mortality study was 

published every ten years, the “Decennial Supplement’, was a major source for comparing 

deaths in different groups and social classes. 

A one percent sample of the census, the ONS Longitudinal study (LS), was used for both 

unemployment and health research. The LS was started in the early 1970s by selecting 

everyone born on one of four particular days who were enumerated at the 1971 Census. 


91

Subsequent samples were drawn and linked from the 1981 and 1991 Censuses using the LS 

dates of birth. 

Routinely collected data on mortality, fertility, cancer registration, infant mortality, widow(er) 

hood and the migration of sample members were linked into the sample using the National 

Health Service Central Register (NHSCR). 

Data from a number of surveys were used to provide information about morbidity. The 

General Household Survey (GHS) was a continuous survey running since 1971. It was based 

each year on a sample of the general population resident in private (non-institutional/social) 

households in Great Britain. Interviews were obtained from about 20,000 individuals aged 16 

years and over residing in about 10.000 households. The GHS included questions on 

population and fertility, housing, health, employment and education. 

In non-census years the Labour Force Survey (LFS) provided background information on the 

age, sex and occupational structure of the workforce. The LFS first took place in 1973. 

In addition to an account of how inequalities were identified in the United Kingdom, the 

national co-ordinator provided a profile of the health service context. 

The National Health Service was created in 1948, and provided universal coverage based on 

the principles of equity and comprehensiveness. It remained free at the point of delivery with 

only a few exceptions, for example, dental, ophthalmic and prescription charges. 

The Co-ordinator from the United Kingdom submitted by far the greatest number of 

interventions for consideration - fifteen. 

Community Development for Health Improvement. This was a general description given of 

community development approaches in the United Kingdom and served as an introduction to 

several of the other interventions in the report. 

Community Health Exchange – CHEX, Scotland. This was targeted at community health 

initiatives and professionals. The aim was to provide resources to communities across 

Scotland. It disseminated good practice and supported communities to influence national and 

local policies on health inequalities. 

Community Development and Health Network Northern Ireland. This network was established 

to support community action on health issues through: self-help activities; campaigning; 

community education; health information; health rights. 

Heart of Our City Project – HOOC, Sheffield. This was launched in 1996 and covered 6 inner 

city wards of Sheffield. It was targeted at specific risk factors and supported the development 

of social networks. 

Smethwick Heart Action Research Project – SHARP. The aim of this initiative was, after the 

creation of a benchmark community survey, to develop health promotion programmes with 

black and minority ethnic community’s at all key life stages. 

Sonas – Community Health Work in the Western Isles, Scotland. This was a community 

based health project financed by the Health Education Board for Scotland between 1993 and 

1996. A number of different approaches were adopted. 

Community Action on Health, Newcastle. A planning forum of General Practitioners employed 

a community development worker to create a structure for the commissioning of primary 

healthcare facilities by local people. 


92

Advocacy/Access to Services in East London and the City. Serving an area with a large 

diverse minority ethnic population, this project sought to increase levels of community 

involvement and develop advocacy and interpretation services. A charter of access covering 

recruitment and physical access to buildings etc was developed. 

National Health Action Zones (HAZ) Programme. The principle aim of HAZs was to tackle 

inequalities in health in the most deprived areas of England through health and social care 

modernisation programmes with opportunities to address the wider determinants of health 

such as housing, education and employment. 

Scottish Community Diet Programme. This project was established in 1996 to promote and 

focus on dietary initiatives in low-income communities and bring these within a strategic 

framework. 

Montpelier’s Cuddlemum – Community Mothers Programme, Bristol. Support was provided by 

local women (‘community mothers’) supported by health visiting staff. After some basic 

training in child protection and child development families were provided with: advice; 

information on local services; assistance in dealing with statutory organisations such as 

education and housing; health education; and support to parents to play and read with their 

children. 

National Timebank Network. Time banks were based on the concept of people using their 

time as money. Credits were exchanged for time put into health or social care. Everybody’s 

time was equally valued. Communities which were ‘cash-poor, time rich’ were able to trade 

their time providing each other with valuable services – like care for elders and family support 

Citizen’s Advice Bureau Welfare Rights Services In Primary Care Settings. Welfare rights 

workers, employed by local citizens advice bureaux, worked alongside primary healthcare 

professionals in general practitioners’ surgeries and health centres. Advice on entitlements to 

state benefits for disability was given along with unemployment, carer’s allowances. Clients 

were also supported with industrial injury claims, immigration and other legal problems. 

MESMAC – Men who have sex with men – Action in the Community. Four pilot projects were 

set up across England in 1994. They were hosted by community based and statutory 

agencies, together with an integrated programme of evaluation undertaken with researchers 

from the University of Keele. 

Community Health Connections, Wales. The core aim of this community health development 

approach was to address the wider determinants of health and enhance community capacity in 

order to promote sustainable improvement in community health and well-being. 

In addition to providing a useful audit of the general policy environment (see below) the UK coordinator 

focused her attentions on five main areas of policy: 

Improving Education (Whitepaper ‘Excellence in Schools’ 1997) was the over-riding priority of 

the Labour Government. Amongst the commitments given within this white paper were: the 

investment in the fabric of school buildings; the reduction of class sizes in primary schools; 

‘Surestart’ programmes for pre-school children; the setting up of Education Action Zones; a 

healthy schools programme; and open access schemes for life long learning. 

Modernising health services (White paper ‘The new NHS - Modern Dependable’ 1997) 

included measures such as: national standards of care in national service frameworks; NHS 

Direct, a 24 hour nurse led telephone helpline; NHS internet information to link all parts of the 

service; the setting up of Health Action Zones to improve health and reduce inequality. 


93

Reducing Unemployment (‘Welfare to work’ Scheme). This included overall measures to 

reduce inequalities in income and increase the income of people that were worst off. The 

principle behind the scheme was to work for benefit payments. Measures included: new deals 

for employment helping people into work (particularly young people, the long term unemployed 

and disabled people); employment action zones; tax and benefit reforms including the working 

families tax credit; introduction of a national minimum wage; and a new occupation health 

strategy including NHS plus which provided NHS services to small and medium-sized 

enterprises. 

Various Tax reforms were identified as redistributing income in favour of the less well off. 

Measures included; Children’s Tax Credit replacing the Married Couples Allowance; the 

introduction of a lower tax band; an increased threshold for Value Added Tax registration; and 

a new minimum income guarantee for old age pensioners. 

Neighbourhood Renewal was the culmination of work undertaken by the Social Exclusion 

Unit’s policy action teams. Priorities within the most deprived areas were employment, 

educational attainment, crime reduction and health improvements. An important element of 

this scheme was the emphasis on community governance, working with and empowering local 

communities and individuals. 

The account of recent policy measures was accompanied by an historical perspective, which 

provided useful contextual information. Within this a number of key publications were 

identified including The Black Report (1980) and The Health Divide (1987). The first actions of 

the then new Labour Government were profiled. This included the establishing of an 

Independent Inquiry into Inequalities in Health, chaired by Sir Donald Acheson, which reported 

in 1998. The report made 39 recommendations including: 

� Policies which further reduce income inequalities and improve the living standards of 

households receiving social security benefits; 

� That a high priority be given to policies aimed at improving health and reducing health 

inequalities in women of childbearing age, expectant mothers and young children; 

� Health inequalities impact assessment of all policies likely to have a direct or indirect 

effect on health 

The report of the Independent Inquiry informed the consultation process and the final White 

Paper ‘Saving lives – Our Healthier Nation’ and was accompanied by a specific response from 

the Department of Health, Reducing Health Inequalities – An Action Report (Department of 

Health 1999). A wide range of supporting policies which influenced health improvement 

directly or indirectly were announced within this. Some examples were: 

� ‘new deal for communities’ to regenerate the most deprived neighbourhoods 

through economic and employment opportunities; 

� establishing Health Action Zones in the most deprived areas of the country to 

develop local strategies to improve health and reduce inequalities through partnerships 

between local agencies; 

� the initiation of a Social Exclusion Unit (SEU) prioritising community infrastructure 

and access to services; 

� various housing initiatives including ‘Affordable warmth’ – a fuel poverty programme. 

The report also highlighted a number of separate policy developments within Scotland and 

Wales and Northern Ireland. 


94

In Scotland in 1997/98 a consultation exercise into social exclusion led to establishing of a 

Social Inclusion Network drawn from statutory drawn from the statutory, community and 

voluntary sectors. 

Towards a healthier Scotland was the White Paper on health in Scotland and was published in 

February 1999. Commitments were made to develop: 

� an attack on health inequalities based upon a comprehensive and co-ordinated use of 

health and other resources and agencies capable of influencing health; 

� a focused programme initiatives for the health of children and young people; 

� major initiatives aimed at the prevention of Scotland’s two major killing diseases, 

cancer and coronary heart disease. 

Better Wales was the strategic plan of The National Assembly for Wales, and this had better 

health and well-being as one of its priorities, along with better opportunities for learning, a 

better and stronger economy, better quality of life, and better simpler government. Reducing 

inequalities in health and tackling the underlying causes of ill health was a stated commitment 

of Better Wales. 

Health and well-being was seen as a theme that cut across policy areas as part of the 

Assembly’s three major themes of sustainable development, equal opportunities, and tackling 

social disadvantage. The Assembly aimed to achieve an integrated approach where different 

policies and programmes were adding value to each other. Health impact assessment - which 

encompasses consideration of the potential effects of policies and programmes on inequalities 

in health - was being developed as a policy tool that can assist the process. 

Better Wales underpinned a number of major strategies and policy initiatives. Improving health 

in Wales: A plan for the National Health Service (NHS) with its partners set the direction for 

health services for a ten year period and was designed to meet the specific needs of Wales. 

Tackling inequalities in health was a key feature of the plan. The plan emphasised that the 

social and economic determinants of ill health were often seen as outside of the concerns of 

the NHS but it committed the NHS in Wales to play a major role with its partners in addressing 

them. 

The Assembly’s national health promotion strategy was developed in 2000 and an action 

programme to implement the strategy was launched in early 2001. The programme extended 

across the Assembly’s policy areas. It reflected the importance of action to promote healthy 

lifestyles but as part of wider action to address the socio-economic determinants of health. The 

targeting of action to address inequalities in health was one of the programme’s core themes. 

Developments that were taking place with the aim of reducing inequalities in health included 

the following examples: 

Local Health Alliances were established in all parts of Wales. Led by local authorities, they 

brought together key local partners to address local priorities to address determinants of 

health and to reduce inequalities in health. 

The Inequalities in Health Fund was launched in February 2001 and designed to stimulate and 

support local projects in deprived communities or work with disadvantaged groups within the 

population. The Fund was designed to support a large portfolio of projects that were tackling 

inequalities in health and the factors that caused it, including inequities in access to health 

services. The priority for the Fund’s first year was coronary heart disease. 

Healthy School Schemes – were being developed across Wales with an emphasis on 

targeting schools in deprived areas. The schemes were planned to assist schools to identify 


95

the priorities they wished to address and to develop and implement plans of action involving 

pupils, staff, governors and, where appropriate, their local community. 

The Assembly’s Resource Allocation Review was a significant development and examined the 

health needs associated with socio-economic disadvantage with the aim of ensuring that 

health resources were distributed so as to best reflect health needs. 

An expert-working group was developing health inequality indicators. Phase 1 of the work was 

complete and provided a list of health indicators to measure improvement in inequalities in 

health over the long term. Phase 2 was developing a list of indicators of determinants of health 

to provide short-term measures of health inequality by monitoring wider socio-economic 

determinants of health. This was being integrated with a review of health gain targets in 

Wales. 

Communities First were a major new initiative. Communities First were a non-prescriptive, 

community-centred approach to community regeneration targeted at the most deprived 

communities in Wales. It was based on the principle that regeneration and community renewal 

should meet the needs and priorities identified by those communities themselves in order for 

renewal to be sustainable. Improving health and reducing inequalities in health was an integral 

part of Communities First along with other factors that affect people’s health including 

education and training, and employment. 

The Sustainable Health Action Research Programme comprised a number of action research 

projects, which aimed to identify effective local action in tackling poor health. Communities 

were involved as active partners in all aspects of project development and implementation, 

and the identification of policy implications and recommendations. 

Community Food Initiative was launched in October 2000 and was designed to improve 

nutrition in disadvantaged areas by tackling the barriers to healthy eating as a means of 

encouraging change in eating habits. 


96

APPENDIX 3: The European Network of Health Promotion Agencies 

(ENHPA) − Member List 

AUSTRIA 

Dr. Brigitte Svoboda 

Federal Ministry of Social Security and Generations 

Radetzkystr 2 1030 Vienna 

Austria 

+43 1 71172 4378 / 4370 

+43 1 713 8614 

brigitte.svoboda@bmsg.gv.at 

brigitte.zarfl@bmsg.gv.at 

BELGIUM 

Rikkie Heeman 

Director 

Linda De Boeck, 

Flemish Institute for Health Promotion (VIG) 

Schildknechtstraat 9 B-1020 Brussels 

Belgium 

Tel: +32 2 422 4949 

Fax: +32 2 422 4959 

rikkie.heeman@vig.be 

linda.deboeck@vig.be 

BELGIUM 

Prof. Danielle Piette 

Université Libre de Bruxelles-ESP Groupe Interdisciplinaire de Promotion Santé (GIPS) 

Route de Lennik 808 - CP 596 B-1070 Brussels 

Belgium 

+32 2 555 4081/4083 

+32 2 555 4049 

danielle.piette@ulb.ac.be 

Mobile: 0476-425351 

CZECH REPUBLIC 

Lumir Komarek 

Director 

National Institute of Public Health 

Srobarova 48 

100 42 Prague 10 

Czech Republic 

Tel: +420 2 67081111 

Fax: +420 2 67311188 

e-mail: komarek@szu.cz 


97

DENMARK 

Jens Mathiesen 

Director 

Danish Committee for Health Education 

Ostbanegade 55,5 

P.O. Box 2639 DK-2100 Copenhagen 

Denmark 

+45 35 265400 

fax: +45 35 430213 

jm@sundkom.dk 

ENHPA OFFICE 

Clive Needle 

Maya Matthews 

ENHPA 

Liaison Office 

6, Philippe le Bon B-1000 Brussels 

Belgium 

+32 2 235 03 20 

+32 2 235 03 39 

enhpa.liaison@village.uunet.be 

ESTONIA 

Anu Kasmel 

Estonian Centre for Health Education and Promotion 

Ruutlit tn 24 EE 000 1 Tallinn 

Estonia 

+372 2 440 801 

+372 2 440 880 

anu@tervis.ee 

EUROPEAN COMMISSION 

Horst Kloppenburg 

Head of Unit Health Promotion/Health monitoring 

European Commission 

DG Health and Consumer Protection F/3 Health Promotion unit 

EUFO 3182 EUROFORUM L-2920 Luxembourg 

Luxembourg 

+352 4301 33282 

+352 4301 32059 

Horst.Kloppenburg@cec.eu.int 

EUROPEAN COMMISSION 

Dr. Matti Rajala 

Head of Unit – Cancer Programme 

European Commission 

DG Health and Consumer Protection F/3 Health Promotion unit 

EUFO 3182 EUROFORUM L-2920 Luxembourg 

Luxembourg 

+352 4301 38502 

+352 4301 32059 

matti.rajala@cec.eu.int 


98

FINLAND 

Dr. Harri Vertio 

director 

Finnish Centre for Health Promotion 

Karjalankatu 2 C 63 FIN-00520 Helsinki 


+358 9 725 30300 

+358 9 725 30320 

harri.vertio@health.fi 

Mobile. 050-5677558 

FRANCE 

Bernadette Roussille 

Director 

Comité Français d'Education pour la Santé (CFES) 

2 Rue Auguste Comte 92170 Vanves 

France 

+33 1 41 33 33 23 

+33 1 41 33 33 90 

cfes@imaginet.fr 

christiane.dressen@cfes.sante.fr 

GERMANY 

Dr. Elisabeth Pott 

director 

Bundeszentrale für gesundheitliche Aufklärung 

Ostmerheimerstrasse 220 51109 Köln 

Germany 

+49 221 8992 349 

+49 221 8992 359 

international@bzga.de 

GREECE 

Yannis Tountas 

director 

Institute of Social and Preventive Medicine (ISPM) 

25, Alexandroupoleos street 115 27 Athens 

Greece 

+30 1 7482015 

+30 1 7485872 

ispm@compulink.gr 

HUNGARY 

Gabor Kovacs 

Coordinator for International Affairs 

National Institute for Health Information and Communication 

P.O. Box 278 Budapest 

Hungary 

Tel. +361 33 84 133/ext. 115 - Mobile. +362 0345 3147 

Fax. +361 266 0402 

Kovgab@medinfo.hu 


99

ICELAND 

Anna Björg Aradottir 

project manager 

Health Promotion Ministry of Health and Social Security 

Laugavegur 116 IS-150 Reykjavik 

Iceland 

+354 510 1900 

+354 510 1919 

annabara@landlaeknir.is 

IRELAND 

Katrina Ronis 

Health Promotion Advisor 

Department of Health and children Hawkins House 

Dublin 2 


+353 1 635 4000 

+353 1 635 4372 

katrina_ronis@health.irlgov.ie 

IRELAND 

Owen Metcalfe 

All Ireland Institute of Public Health 

6, Kildare street Dublin 2 

Republic of Ireland 

+353 1 66 29 287 

+353 1 66 29 286 

iph@rcpi.ie 

ITALY 

Prof. Dr. Lamberto Briziarelli 

Italian Committee for Health Education 

c/o Centro Sperimentale 

per l'Educazione Sanitaria 

Via del Giochetto 4 06100 Perugia 

Italy 

+39 075 5853315 

+39 075 5853317 

lbrizigi@unipg.it 

Claudio Calvaruso 

General director 

Ministero della Sanità Servizio Studi e Documentazione 

Piazale dell Industria 00197 Rome 

Italy 

+39 06 599 42652 

+39 06 599 42128 

studi.doc@interbusiness.it 


100

LUXEMBOURG 

Dr. Yolande Wagener 

Direction de la Santé Div. de la Medecine Preventive et Sociale 

Villa Louvigny L-2021 Luxembourg 

Luxembourg 

Tel: +352 4785544 

Fax: +352 467527 

yolande.wagener@ms.etat.lu 

NORWAY 

Heidi Tomten 

Adviser 

National Council on Nutrition and Physical Activity 

Ullevaalsveien 76 - 0033 Oslo 

Norway 

+47 22 248540 

+47 22 24 9091 

heidi.tomten@sef.no 

PORTUGAL 

Dr. Emilia Nunes Natario 

Pedro Ribeiro da Silva 

Ministerio da Saude Direccao-Geral da Saude 

Alameda D. Afonso Henriques, 45 1056 Lisbon Codex 

Portugal 

+351 21 8430500 

+351 21 8430530/1 or 

+351 1 8430620 

emiliann@dgsaude.min-saude.pt 

pedros@dgsaude.min-saude.pt 

ROMANIA 

Irina Dinca 

Youth for Youth 

Casuta Postala 66-121 

Strada cernica nr.5, sector 2 

Bucharest - Romania 

Tel: +401 315 5642 

e-mail: Idinca@ms.ro 

SLOVENIA 

Mojca Gruntar Cinc 

Head 


Trubarjeva 2 1000 Ljubljana 

Slovenia 

+386 61 132 32 45 

+386 61 323 955 

mojca.cinc@ivz-rs.si 


101

SPAIN 

Dr. Begoña Merino 

Consejar Tecnica 

Educacion para la Salud Promocion y Subdireccion General de Epidemiologia 

Paseo del Prado, 18-20 280270 Madrid 

Spain 

+34 91 5964194 

+34 91 5964195 

bmerino@msc.es 

SWEDEN 

Bosse Pettersson 

Director, Strategic Policy Development, Deputy Director-General 

National Institute of Public Health International Relations 

Olof Palmes Gata 17 S-10352 Stockholm 

Sweden 

+46 8 5661 3515 

+46 8 5661 3601 

Fax: +46 8 5661 35 05 

bosse.pettersson@fhi.se 

THE NETHERLANDS 

Gerard Molleman 

Head 

Netherlands Institute for Health Promotion and Disease Prevention 

P.O. Box 500 3440 AM Woerden 

The Netherlands 

+31 348 437630 

+31 348 437666 

gmolleman@nigz.nl 

UNITED KINGDOM 

Ceri Breeze 

director 

The National Assembly for Wales Strategy & Co-ordination Branch 

Health Promotion Division 

Ffynnon-las, Ty Glas Avenue Llanishen, Cardiff CF14 5EZ 


+44 29 2068 1214 

+44 29 2068 1297 

Ceri.Breeze@wales.gsi.gov.uk 


Peter Farley 

Health Promotion Division 

The National Assembly for Wales 

Cathays Park, Cardiff CF10 3NQ 

Wales UK 

+44 29 2082 5995 

+44 29 2082 5779 

Peter.Farley@wales.gsi.gov.uk 


102


Maggie Davies 

Programme manager 

Health Development Agency 

Trevelyan House 

30 Great Peter Street London SW1P 2HW 


Tel. +44 207 413 

Fax. +44 207 413 2045 

maggie.davies@hda-online.org.uk 


Dr. Brian P. Gaffney 

Chief Executive 

Health Promotion Agency for Northern Ireland 

18 Ormeau Avenue BT2 8HS Belfast 


+44 2890 311611 

+44 2890 311711 

b.gaffney@hpani.org.uk 


Graham Robertson 

Deputy Chief Executive 

Health Education Board for Scotland Woodburn House 

Canaan Lane Edinburgh EH10 4SG 


+44 131 536 5500 

+44 131 536 5501 

graham.robertson@hebs.scot.nhs.uk 


103

Appendix 4: National Project Coordinators 

AUSTRIA 

Andrea Lins 

Fonds Gesundes Osterreich 

Mariahilferstraβe 176 

A - 1150 Wien 

Austria 

E-mail:andrea.lins@fgoe.org 

Tel: + 43-1-895 04 00-12 

Fax: + 43-1-895 04 00 20 

BELGIUM 

Marianne Flament 

Culture et Santé 

130, Chaussée de Mons 

1070 Bruxelles 

Belgium 

Tel: + 32 2 558.88.10 

Fax: +32 2 520 51 04 

Mobile: 0477/65.62.47 

E-mail : culturesante.claes@skynet.be 

DENMARK 

Niels Kristian Rasmussen 


SvanemØllevej 25, 

DK 2100 KØbenhavn 

Denmark 

Tel: +45 3920 7777 

Fax: +45 3927 3095 

E-mail : nkr@dike.dk 

FINLAND 

Antti Uutela, PH.D. Prof. 

Laboratory Director, Head 

Health Education Research Unit 

Department of Epidemiology and Health Promotion 

Mannerheimintie 166 

FIN-00300 Helsinki 


E-mail: antti.uutela@ktl.fi 

Tel: + 358-9-47 44 8619 

Fax: + 358-9-47 44 8338 

Mobile: + 358-50-56 58 721 

FRANCE 

E-mail: Christiane Dressen cfes.etu@imaginet.fr 


104

GERMANY 

Dr. Ljiljana Joksimovic 

University Düsseldorf 

Department of Medical Sociology 

Medical Faculty 

P.O. Box 10 10 07 

D - 40001 Düsseldorf 

Germany 

E-mail: joksimov@uni-duesseldorf.de 

Tel: +49 211 81 14360/61 (Secretariat) or +49211811 - 4806 (direct) 

Fax: +49 211 81 12390 

GREECE 

Dr Dimitria Triantafyllou 

Institute of Social and Preventive Medicine (ISPM) 

25 Alexandroupoleos St. 

115 27 Athens 

Greece 

E-mail: ispm@compulink.gr 

Tel: +301-7482015 

Fax:+301-7485872 

ICELAND 

Matthias Halldorsson 

Deputy Director of Health 

Directorate of Health 

Laugavegur 116 

150 Reykjavik 

Iceland 

E-mail: matthias@landlaeknir.is 

Tel: +354 510 1900 

Fax: +354 510 1919 

IRELAND 

Katrina Ronis 

Health Promotion Advisor 

Department of Health and Children 

Hawkins House 

Dublin 2 

Tel: +353 1 635 4000 

Fax: +353 1 635 4372 

E-mail: Katrina_Ronis@health.irlgov.ie 

ITALY 

Dr. Giuseppe Masanotti 

Centro Sperimentale per 

l'Educazione Sanitaria 

Via del Giochetto 

6100 Perugia 

Italy 

E-mail: lbrizigi@unipg.it 


105

Tel: +390 75 5853346 or 5730946 

Fax: +390 75 5853317 

LUXEMBOURG 

Dr. Yolande Wagener 

Ministry of Health 

Dept. Of Prevention 

22, Rue Goethe 

Luxembourg 

E-mail: yolande.wagener@ms.etat.lu 

Tel: +352/478 55 44 

Fax: +352/291 121 

NORWAY 

Elisabeth Fosse 

Research Centre for Health Promotion 

University of Bergen 

Christiesgt. 13, 

N-5015 Bergen 

Norway 

E-mail: elisabeth.fosse|@psych.uib.no 

Tel +47 55 58 27 58 

Fax +47 55 58 98 87 

PORTUGAL 

Pedro Ribeiro da Silva 

Manuela Cabral 

Direccao General da Saude 

Alameda D. Afonso Henriques 45-7° 

1056 Lisbon Codex 

Portugal 

E-mail: pedros@dgsaude.min-saude.pt 

Tel: +351 21 843 05 30 

Fax: +351 21 843 05 00 

SPAIN 

Dr. Esteve Fernández 

Institut Català d'Oncologia 

Servei de Prevenció i Control del Càncer 

Av. Gran Via s/n Km 2,7 

08907 L'Hospitalet (Barcelona) 

Barcelona 

Spain 

Tel +34 93 260 77 88 

Fax +34 93 260 79 56 

E-mail: efernandez@ico.scs.es / fernandeze@globalink.org 


106

SWEDEN 

Malin Rydberg/ Nina Bergman 


103 52 Stockholm 

Sweden 

E-mail: malin.rydberg@fhi.se 

nina.bergman@fhi.se 

Tel: +46 8 56613579/3515 

Fax: +46 8 5661 35 05 


Joop Ten Dam 

Netherlands Institute for Health Promotion 

and Disease Prevention (NIGZ) 

P.O.BOX 500 

3440 AM Woerden 

Nederland 

E-mail: Jtendam@nigz.nl 

Tel: +31 348 437 600 or 631 

Fax: +31 348 437 666 


Marion Drinkwater 

Sandwell Health Authority 

Kingston House, 438 High Street 

West Bromwich, West Midlands B70 PLD 


E-mail: Marion.Drinkwater@sandwell-ha.wmids.nhs.uk 

Tel: +44 121 500 1567 

Fax: +44 121 500 1501 


107

APPENDIX 5 – National reports: contact persons and organisations 

AUSTRIA 

Wolfgang Gulis 

Verein Zebra , 

Pestalozzistraße 59/II, 

A-8010 Graz, 

Tel: 0043-316-83 56 30, 

Email: zebra@zebra.or.at 

Mag. Doris Gartner 

Fem Süd health centre for women – parents – girls 

Kundratstraße 3 

A-1100 Wien 

Tel: 0043-1-601 91-5201 

Email: femsued.post@kfj.magwien.gv.at 

Dr. Tina Svoboda 

MA-L/II Dezernat für Gesundheitsplanung 

Schottenring 24 

A-1010 Wien 

Tel: 0043-1-53114-76051 

Heinz Eitenberger 

PGA Wien – Verein für 

Prophylaktische Gesundheitsarbeit 

Kaplanhofstraße 1 

A-4020 Linz 

Tel: 0043-732-77 12 00-0 

Dr. Herwig Zott 

„Stadtteilverein Liefering” 

Tel: 0043-699-111 64 919 

Dr. Tom Schmid 

Sozialökonomische Forschungsstelle 

Maria-Theresienstraße 24 

A-1010 Wien 

Tel: 0043-1-319 57 50 

Email: s.f.s@chello.at 


108

BELGIUM 

Nans Antheunis 

Vzw Wijkgezondheidscentrum De Ridderbuurt 

Riddersstraat 163, B-3000 Leuven 

Tel: 016/23 09 03 - Fax: 016/23 09 03 

E-mail: wgc.ridderbuurt@pandora.be 

Dr. Stef Bruggeman 

Vereniging voor Wijkgezondheidscentra (VWGC) 

Gustave Schildknechstraat 9, B-1020 Brussel 

Tel: 02/422 49 49 - Fax: 02/422 49 59 

E-mail: stef.bruggeman@vig.be 

Rudy De Cock – « Kind en Gezin » 

Hallepoortlaan 27, B-1060 Brussel 

Tel: 02/533 13 29 – E-mail: rudy.de.cock@kindengezin.be 

Bruno Buytaert – VIG – Coördinator Locale Gemeenschappen 

Gustave Schildknechstraat 9, B-1020 Brussel 

Tel: 02/422 49 49 - Fax: 02/422 49 59 

E-mail : Bruno.buytaert@vig.be 

Hans Verrept 

Coördinatiecel Interculturele Bemiddeling 

RAC, Vesaliusgebouw 2.30 

1010 Brussel 

Tel : 02/210 42 13 - Fax : 02/210 47 71 

ASBL les Pissenlits 

Avenue Clémenceau, 94 

1070 Bruxelles - Tél : 02/521.77.28 

Forest Quartiers Santé 

Rue du Curé, 7 

1190 Bruxelles - Tél : 02/333.07.86 

Dr Vanmeerbeek 

Centre de Santé 

Rue Malgarny, 2 

4420 Tilleur - Tél : 04/233.14.79 

Dr Roger Lonfils 

Sous-directeur 

Direction Générale de la Santé 

Boulevard Léopold II, 44 

1080 Bruxelles - Tél :02/413.26.10 


109

Anne Hercovici 

Présidente – CPAS d’Ixelles 

Chaussée de Boondael , 92 

1050 Bruxelles - Tél : 02/641.54.01 

Dr Myriam De Spiegelaere 

Observatoire de la Santé du Brabant 

Avenue Louise, 183 


Tél : 02/552.01.45 

Dr Michel Roland 

Maison Médicale « Santé Plurielle » 

Rue de la Victoire, 110 

Tél :02/537.71.24 

Dr Pierre Drielsma 

Fédération des Maisons Médicales 

Boulevard du Midi, 25 bte 5 


Tél : 02/514.40.14 

Francine Boudru 

CIRE-ISM 

Rue du Vivier, 80-82 


Tél :02/629.77.27 

Agnès Claes 

Cultures et Santé 

Chaussée de Mons, 130 


Tél : 02/558.88.12 

DENMARK 

Project job maintainment: 

Planlægger Lotte Junker, 

Ringkøbing kommune, 

Rådhuset, 

Ved Fjorden 6, 

DK 6950 Ringkøbing, 

Denmark. 

Alcohol problems in families with children: 

Socialrådgiver Britta Andergren Nielsen, 

Alkoholrådgivningen i Grenå, 

Kløvervang 1, 

DK 8500 Grenå - Denmark 


110

Social-psychiatric outreach to the homeless and the mentally ill: 

Dr. Preben Brandt, 

Chief physician 

Frederiksborggade 42, 1 

DK 1360 Copenhagen K. 

Denmark 

GERMANY 

Unemployment And Health – 

pilot project of the State of Brandenburg 

Ms. Bolz, 

Koordinatorin Prignitzer Servicestelle 

Arbeit und Gesundheit, 

Heinrich-Heine-Platz 4, 

D-19322 Wittenberge 

Germany 

Transnational Aids/Std Prevention 

Among Migrant Prostitutes In Europe (Tampep) 

Veronica Munk, 

Amnesty for Women, 

Grosse Bergstr. 231, 

D-22767 Hamburg 

Germany 

Health Promotion In A City District 

Dr. Dorothee Fischer/ Dr. Rotraut Reinhardt-Bertsch, 

Gesundheitsamt der Stadt Stuttgart, 

Bismarckstr. 3, 

D-70176 Stuttgart. 

Germany 

Health Promotion In A City District 

Prof. Hans Wieland/Dr. Claudia Fleischle-Braun, 

Institut für Sportwissenschaft, 

Universität Stuttgart, 

Allmandring 28, 

D-70569 Stuttgart 

Germany 

Economic Nutrition 

Christiane Deneke, 

Zentrum für Angewandte 

Gesundheitswissenschaften 

Fachhochshule Nordostniedersachsen, 

Wilschenbrucherweg 84a, 

D-21335 Lüneburg - Germany 


111

Health Promotion For Young Adults 

Participating In Vocational Trainees 

Dr. Harald Barkhoff, 

Arbeitsgemeinschaft Prävention 

und Gesundheitsförderung, 

Wächterstr. 67, 

D-72074 Tübingen 

Germany 

Prof. Dr. Johannes Siegrist 

Heinrich Heine University Düsseldorf 

Department of Medical Sociology 

P.O. Box 10 10 07 

D-40001 Düsseldorf 

Germany 

Tel.: +49 211 811 4360/61 

Fax: +49 211 811 2390 

E-mail: siegrist@uni-duesseldorf.de 

Dr. Andreas Mielck 

Institut für Medizinische Informatik und Systemforschung (MEDIS) 

Postfach 1129 

85758 Neuherberg 

Germany 

Tel.: +49 89 3187 4460 

Fax: +49 89 3187 3375 

E-mail: mielck@gsf.de 

GREECE 

Nutrition programme – primary school children - Crete 

Professor Antonis Kafatos and Dr. Yannis Manios, 

Preventive Medicine and Nutrition Clinic, 

Medical School, University of Crete, 

T.Θ. 1393, Heraklion, Crete, 

Greece. 

Tel: ++30 81 394595, 394601-3 

Fax: ++30 81 394604 

E-Mail: kafatos@med.uoc.gr 

CVD prevention – elderly volunteers 

Dr. Emmanuel Velonakis and Dr. Panagiota Sourtzi, 

Hellenic Association of Gerontology and Geriatrics, 

23 Kanningos Str., 106 77 Athens, 

Greece. 

Tel: ++30 1 3811612 

Fax: ++30 1 3840317 

E-Mail: hagg@compulink.gr 


112

Delinquency/ drug prevention – Primary school in Piraeus 

Ioanna Kyritsi, 

Therapy Center for dependent individuals (KETHEA), 

24 Sorvolou Str., 

116 36 Athens, Greece. 

Tel: ++30 1 9241993-6 

Fax: ++30 1 9241986-7 

E-Mail: prev@kethea.gr or admin@kethea.gr 

FINLAND 

Prof. Pekka Puska, 

Vice-Director General, MD, Ph.D., 

National Public Health Institute (KTL), 

Mannerheimintie 166, 

FIN-00300 Helsinki, 

Finland, 

Tel. +358-9-47 44 8336, 

E-mail: pekka.puska@ktli.fi 

Maila Upanne, 

Licentiate in psychology, 

Development manager, 

National Research and Development Centre 

for Welfare and Health, Finland (STAKES), 

P.O. Box 220, 



Tel. +358-9- 3967 2121, 

E-mail: maila.upanne@stakes.fi 

Rainer Anttila, 

Licentiate in Health Sciences, 

Manager, 

LIKES-Foundation for Sport and Health Sciences, 

Rautpohjankatu 10, 

FIN-40700 Jyväskylä, Finland, 

Tel. +358-14-601 572, 

E-mail: rantti@maila.jyu.fi. 

Dr Juha Teperi, 

Director, MD, Ph.D., 

Head of services, 


for Welfare and Health, STAKES, 

P.O. Box 220, 



Tel. +358-9-3967 2263, 

E-mail: juha.teperi@stakes.fi 


113

Dr Seppo Koskinen, 

senior physician, MD, Ph.D., 

National Public Health Institute, KTL, 




Tel. +358-9-47 44 8762, 

E-mail: seppo.koskinen@ktl.fi 

Dr Antti Reunanen, 

laboratory director, MD, Ph.D., 





Tel. +358-9-47 44 8772, 

E-mail: antti.reunanen@ktl.fi 

Dr. Ahti Anttila, 

senior researcher, Ph.D., 

Finnish Cancer Foundation, 

Liisankatu 21 B, 

Fin-00170 Helsinki, 


Tel. +358-9-1353 3210, 

E-mail: ahti.anttila@cancer .fi 

Dr. Arja R. Aro, 

senior researcher, Ph.D., Dr. Sc., 





Tel. +358-9-47 44 8264, 

E-mail: arja.aro@ktl.fi 

Ms. Ulla Salomäki, 

Project leader, 

Finnish Centre for Health Promotion, 

Karjalankatu 2 C 63, 


Finland, Tel. +358-9-7253 0326, 

E-mail: ulla.salomaki@health.fi 


114

Prof. Vappu Taipale, 

Director General, MD, Ph.D., 


for Welfare and Health, STAKES, 

P.O. Box 220, 



Tel. +358-9-39671, 

E-mail: vappu.taipale@stakes.fi. 

ITALY 

Dr. Ismail Zahra 

Experimental Center for health education 

via del Giochetto 4 

06100 Perugia 

Italy 

tel: +390 75 5853346 or 5730946 

Fax: +390 75 5853317 

e-mail csesi@unipg.it 

"unità mobile donna" 

Dr. Maura Muneretto 

Parsec 

piazza Orazio Marucchi n. 5, Roma 

Tel: +390 6 86 20 99 91 

Fax:+390 6 86 11 067 

e-mail parsec@flashnet.it 

"health culture and immigration" 

Istituto Ospitaliero Dermosifilopatico 

di Santa Maria e San Gallicano 

Via San Gallicano 25/A 

00123 Roma 

Tel: 0658543741 - 0658543612 

Fax: 0658543740 


115

IRELAND 

Irish National Cancer Registry 

Dr Harry Comber 

Director 

Irish National Cancer Registry 

Boreenamara Road 

Cork 


Tel: 021 4318014 

Fax: 021 4314016 

Email: h.comber@ncri.ie 

Survey of Lifestyles, Attitudes and Nutrition (SLÁN) 

Prof. Cecily Kelleher 

Head of Department 

Department of Health Promotion 

National University of Ireland 

Galway 


Tel: 091 524411 

Email: cecily.kelleher@nuigalway.ie 

Sharon Friel 

Assistant Academic Director 



Galway 


Tel: 091 524411 

Email: sharon.friel@nuigalway.ie 

Saoirse NicGabhainn 

Assistant Academic Director 



Galway 


Tel: 091 524411 

Email: saoirse.nicgabhainn@nuigalway.ie 

NORWAY 

“Help to children who have experienced war” 

Contact organisation: Centre for Crisis Psychology, 

Fabrikkgt. 5, 

N-5059 Bergen 

NORWAY 

E-mail: atle.dyregrov@psych.uib.no 


116

“Workshop for Primary Medical Care” 

Contact organisation:Primærmedisinsk verksted 

Sverresgt.4, 

N-0652 Oslo 

NORWAY 

E-mail: posmaster@pmv-senter.org 

Varden Child Care Centre 

Varden barnestasjon, 

Ringkollgrenda 4 c 

N-3227 Sandefjord 

NORWAY 

Tel: +47 33 47 28 47 

“The Project House for Help and Self help in Hasvik” 

Contact Person: Hanne Nilssen, 

N-9590 Hasvik 

NORWAY 

Tel: +47 78 45 12 98 

Espen Dahl 

Fafo Institute for Applied Social Science 

Address: PO-Box 2947 Tøyen 

N-0608 Oslo 

Norway 

Telephone: +4722088600 

Fax: +4722088700 

E-mail: Espen.Dahl@fafo.no 

Marit Rognerud 

The National Institute for Public health 

Address: Statens institutt for folkehelse, 

Postboks 4404 Nydalen 

N-0403 Oslo 

Norway 

Telephone: +47 22 04 22 00 

Fax: 22 35 36 05 

E-mail: marit.rognerud@folkehelsa.no 

PORTUGAL 

Espaço Pessoa 

Jorge Martins 

Address: Travessa das Liceiras, nº 14/16 

4000 Porto 

tel: 00351222008377 

fax: 00351222085869 


117

Autoestima 

Carlos Daniel 

Address: Rua José Espregueira 96 

4901-871 Viana do Castelo 

tel: 00351 258 829646 

fax: 00351258811714 

Quinta Do Mocho 

Rosário Horta 

Address: Centro de Saúde de Sacavém 

Rua Filinto Ramalho nº 10, 2º 

2686 Lisboa 

tel: 00351219419634 

fax: 00351219413457 

Soares Dos Reis 

Miguel Miranda 

Address: Centro de Saúde Soares dos Reis 

Rua Bartolomeu Dias 316 

4430-040 Mafamude 

tel: 00351223717571 

fax: 00351223704847 

SPAIN 

Report of the Scientific Commission 

for Research on Social Inequalities in Health: 

President: Prof. Vicenç Navarro 

Universitat Pompeu Fabra 

Social and Policy Sciences Dept. 

Ramon Trias Fargas 25-27 

08005 Barcelona, Spain 

Vice-president: 

Prof. Joan Benach 

Universitat Pompeu Fabra 

Experimental and Life Sciences Dept. 

Dr Aiguader 80 

08003 Barcelona, 

SPAIN 

Email: joan.benach@cexs.upf.es 

National Health Interview Survey 

Subdirector General de Epidemiología, 

Promoción y Educación para la Salud: 

Dr Enrique Gil López 

Ministerio de Sanidad y Consumo 

Paseo del Prado 18 

28014 Madrid 

Tel: +34 91 596 40 60 


118

Mother and child health programme in an inner city area & 

Primary Healthcare reform in Barcelona. 

Municipal Institute of Public Health of the Barcelona City Council 

Persons in charge: 

Dr. Joan Ramon Villalbí (past-director) 

Email: jrvillal@imsb.bcn.es 

Dr. Antoni Plasència (director). 

Email: aplasenc@imsb.bcn.es 

Dr. Carme Borrell (health information service). 

Email: cborrell@imsb.bcn.es 

Address:Plaça Lesseps, 1 

08023 Barcelona, 

Spain 

SWEDEN 

Norsjö CVD community intervention study – 

Lars Weinehall 

Department of Public Health and Clinical Medicine 

Umeå University, SE-901 85 Umeå, 

Sweden 

Phone int+46 90 785 27 69 

Fax int+46 90 13 89 77 

E-mail: Lars.Weinehall@epiph.umu.se 

Integrated community efforts for youth health behaviour – 

Torbjörn Erneholm 

Tjörn Vårdcentral 

Syster Ebbas Väg 4 

471 94 Kållekärr 

Phone: +46 304 67 98 17 

Fax: +46 304-66 82 33 

Email: torbjorn.erneholm@vgregion.se 

Comprehensive Infant and child health screening – 

Lena Ekenvall 

Yrkesmedicinska enheten 

Norrbacka 

171 76 Stockholm 

Phone:+46 8 517 730 86 

Fax:+46 8 33 43 33 

E-mail: lena.ekenvall@smd.sll.se 


119

Financial coordination between health care and health insurance for 

rehabilitation(FINSAM) – 

Hans Folkesson 

Riksrevisionsverket 

Box 450 70 

104 30 Stockholm, Sweden 

Phone: +46 8 690 40 00 

Fax: +46 8 690 41 00 

E-mail: hans.folkesson@rrv.se 


Dr John Middleton 

Director of Public Health, 

Sandwell Health Authority, 

Kingston House, 

438 High Street, 

West Bromwich, B70 9LD 


Tel: 0121 500 1661 

E-Mail: john.middleton@sandwell-ha.wmids.nhs.uk) 

Sir Donald Acheson 

University College London, 

1-10 Torrington Close, 

London, WC1E 6BT 


Tel: 0207 3911706 

Ceri Breeze 

Head of Strategy & Co-ordination 

National Assembly for Wales, 

Health Promotion Division, 4 th Floor, 

Cathays Park, Cardiff, CF10 3NQ 


Tel: 02920 823214 

Graham Robertson 

Director of Programmes & Communication 

Health Education Board for Scotland, 

Woodburn House, 

Canaan Lane, 

Edinburgh, EH10 4SG 



120

Jenny Douglas 

Senior Lecturer in Health Promotion, 

The Open University, 

Warton Hall, 

Milton Keynes, MK7 6AA 


Tel: 01908 274066 

Lee Adams 

Director, 

Wakefield Health Action Zone, 

Wakefield & Pontefract NHS Trust, 

Fieldhead Hospital, 

Wakefield, WF1 3SP 


Tel: 01924 814400 

Tim Sands 

Head of Health Action Zone Development, 

NHS Executive, Quarry House, 

Quarry Hill, 

Leeds, LS2 7UE 


Tel: 0113 254 5069 

Emma Witney 

Programme Manager – 

Community, Health Education Board for Scotland, 

Woodburn House, 

Canaan Lane, 

Edinburgh, EH10 4SG 


Tel: 0131 536 5560 

Chris Roberts 

Head of Evaluation, 

National Assembly for Wales, 

Health Promotion Division, µ 

4 th Floor, 

Cathays Park, 

Cardiff, CF10 3NQ 


Tel: 02920 681214 


121

Fran Fahy 

Portfolio Director, 

Strategic Health Improvement, 






Tel: 0121 500 1662 

E-Mail: fran.fahy@sandwell-ha.wmids.nhs.uk) 

Sophia Christie 

Portfolio Director - Policy Implementation, 

Sandwell Health Authority, Kingston House, 



Tel: 0121 500 1634 


E-Mail: sophia.christie@sandell-ha-wmids.nhs.uk) 

Aldo Mussi 

Acting Community Development Manager, 






Tel: 0121 500 1621 

E-Mail: aldo.mussi@sandwell-ha-wmids.nhs.uk) 

George Davey Smith 

Professor of Clinical Epidemiology, 

University of Bristol, 

Canynge Hall, 

Bristol, BS8 2PR 


Tel: 0117 954 6800 

Dr D. Player 

UK Public Health Association, 

7 Ann Street, 

Edinburgh, EH4 1PL 


Tel: 0131 332 1088 

Zena Peatfield 

Social Exclusion Unit, 

Cabinet Office, 

Horse Guards Road, 

London, SW1P 3AL 

Tel: 0207 270 1234 


122

Professor Raj Bhopal 

Professor of Public Health Sciences, 

University of Edinburgh, 

Teviot Place, 

Edinburgh, EH8 9AG 


Tel: 0131 650 3216 

Jeni Bremner 

Health Policy Officer, 

Local Government Association, 

Local Government House, 

Smith Square, 

London, SW1P 3HZ 


Dr Michaela Benzeval 

Health Variations Programme, 

Lancaster University, 

Bailrigg, 

Lancaster, LA1 4YW 


Tel: 020 7882 5439/01524 65201 

Professor Stephen Platt 

Director, 

Research Unit in Health & Behavioural Change, 

University of Edinburgh Medical School, 

Teviot Place, 

Edinburgh, EH8 9AG 


Tel: 0131 650 6192 

Janet Muir 

CHEX, 

Scottish Community Development Centre, 

Suite 329, Baltic Chambers, 

50 Wellington Street, 

Glasgow, G2 6JH 


Tel: 0141 248 1990 

Ruth Sutherland 

Northern Ireland Community Development and Health Network, 

Ballybot House, 

22 Cornmarket, 

Newry, County Down, BT35 8BG 

Tel: 01693 64606 


123

Martine Standish 

Sheffield Health Authority, 

5 Old Fulwood Road, 

Sheffield, S10 3TG 

Tel: 0114 271 1100 

Norma Neil 

Sonas, Community Health Project, 

42 Winfield Way, 

Balivanich, Benbecula, Western Isles, 

Scotland, HS7 5LH 


Tel: 01870 602588 

Dr Philip Crowley 

Community Action on Health, 

14 Great North Road, 

Newcastle upon Tyne NE2 4PS 


Tel: 0191 261 6358 

Barbara James & Anjum Fareed 

East London and The City Health Authority, 

Aneurin Bevan House, 

81 Commercial Road, 

London, E1 1RD 


Tel: 020 7655 6600 

Michael Swaffield 

Health Action Zones, 

NHS Executive, 

Quarry House, Quarry Hill, 

Leeds, LS2 7UE 


Tel: 0113 254 5069 

Bill Gray 

Scottish Community Diet Project, 

Scottish Consumer Council, 

Royal Exchange House, 

100 Queen Street, 

Glasgow, G1 3DN 


Tel: 0141 226 5261 


124

Anita Underwood 

Montpelier Health Centre, 

Bath Buildings, Montpelier, 

Bristol, BS6 5PT 


Tel: 0117 942 6811 

Sarah Burns 

New Economics Foundation, 

Cinnamon House, 

6-8 Cole Street, 

London, SE1 4YN 


Tel: 0207 4077447 

Tom Doyle 

MESMAC, 

PO Box 417, 

Leeds, West Yorkshire, LS1 5PN 


Tel: 0113 244 4209 

Maria Finnemore 

Community Health Connections, 

Meddygfa Pen-y-Groes, Hoel y Bont, 

Pen-y-Gres, Llanelli, 

Carmarthenshire, Wales. 


Tel: 01269 824858 


125

Annex 1: Inventory of indicators from surveys and registries 

AUSTRIA 

• Mortality Registry, is linked to population census data (censuses took place in 1981 

and 1991) 

health measures: mortality by cause of death 

SES-measures: educational level 

• Cancer Registry, since 1985, (no further information found). 

health measures: type of cancer 

SES-measures: socio-demographic variables (no further information found) 

• Microcensus - Working Conditions (Mikrozensus – Arbeitsbedingungen (MA)), 

Austrian Central Statistical Office (Österreichisches Statistisches Zentralamt), special 

program within the regular microcensus which is conducted every 5 or 10 years in a 

representative sample of 1% of the households of the Austrian population, started in 1980, 

also in 1985 and 1994, +16y. 

BELGIUM 

health measures: perceived health status, prevalence of selected diseases, health complaints, 

disabilities, accidents (at home and during leisure time), BMI, working conditions (workload, 

…), smoking behaviour 

SES-measures: household income 

• National Health Survey (Gezondheidsenquête), Scientific Institute for Public Health 

(Wetenschappelijk Instituut voor Volksgezondheid (WIV)). First undertaken in 1997, 

meant to be conducted every 4 years, covers all three regions in Belgium (Flanders, 

Wallonia, Brussels), n 10 =+/-10.000, +15y. 

health measures: perceived health status, chronic diseases, disabilities, dental health, alcohol 

and tobacco consumption, physical activity, food consumption, accidents, use of seat belts, 

use of contraceptives and other medicines, mental health, frequency of social contacts, 

cholesterol, blood pressure, knowledge and attitudes towards AIDS, vaccination, screening for 

cancer, use of health services (healthcare expenditure, visits to physician, visits to specialist), 

access to healthcare 

10 Note: n is the actual number of respondents and not the number of the targeted sample population (=people 

being mailed a survey). 


126

SES-measures: educational attainment, household income, nationality 

• Child Mortality Registry, Centre for Perinatal Epidemiology (Studiecentrum voor 

Perinatale Epidemiologie (SPE)). This registry contains all births in Flanders and also all 

deaths of children less than 1 year old. Although the registers exist for a longer time, 1998 

was the first time socioeconomic data were to be mentioned on birth certificates. 

health measures: child mortality, congenital deviances 

SES-measures: educational level and occupational class of parents 

• Household Budget Survey (Huishoud Budget Enquête), Scientific Institute for Public Health 

(Wetenschappelijk Instituut voor Volksgezondheid (WIV)), part of DAFNE I in 1987-88, covers 

all regions, n=3.235. 

health measures: food consumption 


• Occupational Accidents Statistics (Statistiek van de Arbeidsongevallen), National 

Institute for Statistics (NIS), national (Flemish and Walloon region) since 1971, cover all 

accidents in and around the workplace. 

health measures: nature and location of the injury, duration of work disability, type of accident 

SES-measures: occupation, nationality 

Other interesting databases in Belgium that are not mentioned here because (the last 

time) they were conducted (was) before 1994, include: the Belgian Interuniversity 

Research on Nutrition and Health (BIRNH, 1980-85). 

DENMARK 

• Statistics on Mortality and Occupation (Dodelighed og Erhverv (DE)), Danish Central 

Bureau of Statistics (Danmarks Statistik), based on a computerized linkage of census 

registers with death registers in order to gather information on how occupation affects 

mortality. Covers all workers in all sectors of activity. First census in 1970, death registers 

are updated each year. 

health measures: cause of death 

SES-measures: occupational class, educational level, housing conditions, geographic area 

• Danish Cancer Register (Cancerregisteret (CR)), Danish Cancer Society, covers all 

cancer cases in Denmark since 1943. 

health measures: details of cancer diagnosis and treatment 

SES-measures: occupation 


127

• Danish Health and Morbidity Survey (1994) (Sundhed og Sygelighed I Danmark), 

Danish Institute of Clinical Epidemiology (DICE), also 1986-1987 (‘Health and Activity 

Limitations Survey’) and specific topics in 1991, nationally representative, part of the WHO- 

EUROHIS Project, n=4.668,+16y. 

health measures: perceived general health, perceived quality of life, chronic diseases, functional 

disabilities, physical activity, accidents, dietary, alcohol and smoking habits, attitudes towards 

health, use of health services, housing conditions and risks at home, work environment and 

risks at work, social network 

SES-measures: occupation, educational level 

• General Health Survey in Greenland (1999) (5 subprojects), Centre for Circumpolar 

Health Research, also in 1994, n=+/-2.000 adults. 

health measures: self-related health, chronic diseases, alcohol and tobacco consumption, dietary 

habits, village health 

SES-measures: socioeconomic background, job situation, degree of western acculturation 

• Dietary Habits in Denmark, 1985 and 1995, n=1.837, 1-80y. 

FINLAND 

health measures: food consumption (no further information found) 

SES-measures: educational level, occupation 

• Mortality Registry, is linked to census data (censuses are conducted every 5 years), 

since 1971, by means of personal identification codes. 


SES-measures: occupational class, educational level 

• FINMONICA Stroke Registry, National Public Health Institute of Finland (KTL), Dpt. of 

Epidemiology and Health Promotion, registers all stroke events. This registry is linked to 

other data files by means of personal identification codes. 

health measures: stroke mortality, stroke incidence and prognosis 

SES-measures: educational level, income 

• Finnish Cancer Registry, Cancer Society of Finland, covers all cancer cases diagnosed 

in Finland since 1953 (from hospitals, laboratories and private physicians). 

health measures: detailed information on cancer: primary site, histology, stage, treatment 

SES-measures: occupational class 


128

• Health Behaviour among Finnish Adult Population (AVTK), National Public Health 

Institute of Finland (KTL), Dpt. of Epidemiology and Health Promotion, nationally 

representative, annual since 1978/1979, n=+/- 3.500, 15-64y. 

health measures: see Finbalt Health Monitor 

SES-measures: see Finbalt Health Monitor, also occupational class 

• Adolescent Health and Lifestyle Survey, bi-annual since 1977, national, 12-14-16-18y. 

health measures: perceived health status, health behaviours and lifestyle (no further information 

found) 

SES-measures: socioeconomic background (no further information found) 

• Finnish Survey on Living Conditions (1994), Statistics Finland, also 1978 and 1986-87, 

national, n=+/-10.000, +15y. 

health measures: perceived general health, disabilities, chronic diseases, living conditions 

SES-measures: educational level, occupational class, income 

• Quality of Working Life Survey (Työelämän Laatu (TL)), Statistics Finland, nationally 

representative sample of working population aged 15-64y. First time conducted in 1977, 

also in 1984, 1990 and 1997, n=+/-5.000. 

health measures: working conditions (content, shift hours), physical environment problems 

(climate, noise, chemicals, smoke, …), psychosocial environment (pressure, support, 

decision-latitude, …), health (stress symptoms, pain) 

SES-measures: education, occupation, wage, socio-economic class 

• Dietary Survey of Finnish Adults, National Public Health Institute (KTL), Dpt. of Nutrition, 

conducted in 1992 and 1997, n=1.861, 25-64y. 

FRANCE 

health measures: food group and nutrition consumption 

SES-measures: educational level, household income 

• Health in France (1994-1998) (La Santé en France), High Committee of Public Health 

(Haut Comité de la Santé Publique), INSEE and INSERM, large national (but excluding 

non-natively French people) cohort study since 1954, n=?. 

health measures: cause-specific mortality, health status and diseases, cancer, AIDS, physical 

disabilities, mental health, consumption of alcohol, tobacco and drugs, accidents (at home, at 

work and on the road), sexual behaviour, physical environment, work environment 

SES-measures: occupational class 


129

• Permanent Demographic Sample (Échantilon Démographic Permanent (EDP)), Institut 

National de la Statistique et des Etudes Economiques (INSEE). This is a registry of a 

sample of the (native-born French) population (all people born on four specific dates of the 

year) that contains information from the population censuses since 1968 (other census 

were in 1975, 1982, 1990) and data on civil status (including eventual death). There is no 

information about the cause of death. 

health measures: mortality 

SES-measures: educational level (highest degree obtained), occupational status and class 

• Continuous Surveys of Living Conditions of Households (Enquêtes Permanentes sur 

les Conditions de Vie des Ménages), Institut National de la Statistique et des Etudes 

Economiques (INSEE). This is an annual series of surveys in a representative sample of 

French people aged 15 and over, n=+/-11.000 individuals in +/-5.800 households. There 

are three waves each year that cover different aspects of living conditions. 

health measures: perceived health status, chronic conditions, functional disabilities, housing 

conditions, physical environment, social relations, social support 

SES-measures: occupational class (head of household), household income and composition 

• Decennial Survey of Health and Medical Care (Enquête Decennale sur la Santé et les 

Soins Medicaux), Institut National de la Statistique et des Etudes Economiques (INSEE) 

and CREDES, carried out in 1980-81, 1991-92 and is planned to be continued, n=+/- 

20.000. 

health measures: perceived health, disability, smoking behaviour (no further information found) 

SES-measures: educational level, occupation, income 

• VIGILANCE database (PERCEVAL) (Système de vigilance de maladies dues au travail), 

National Institute for Research and Safety (Institut National de Recherche et de Sécurité 

(INRS)), covers the cases of occupational pathologies reported to INRS since 1985. 

health measures: disease specifications, symptoms, occupational hazards 


Other interesting databases in France that are not mentioned here because (the last 

time) they were conducted (was) before 1994, include: the Medical Monitoring of 

Hazards (Surveillance Médicale des Risques, 1987). 


130

GERMANY 

• Social Insurance and Pension Registries, owned by insurance companies, are the only 

source of mortality data nationwide (no further information found). 


SES-measures: occupational status, educational level 

• Micro-Census (MC) (Mikrozensus), National Institute of Statistics (Statistisches 

Bundesamt), carried out every year since 1957 in years not covered by the general 

census, n=+/-800.000 individuals in +/-350.000 households, +15y. Supplementary 

questionnaire on health issues every second year. 

health measures: diseases, disabilities, BMI, accidents, use of health services (medical 

consultation), working conditions (shift work), smoking behaviour 

SES-measures: occupational status, income, nationality 

• German Socioeconomic Panel (Das Sozio-oekonomische Panel (SOEP)), annual 

representative longitudinal study of private households in the entire federal Republic of 

Germany, including recent immigrants, since 1984, 1989, 1994, n=+/-20.000 individuals in 

+/-12.000 households. 

health measures: health (no further information found) 

SES-measures: education, occupation, income 

Other interesting databases in Germany that are not mentioned here because (the last 

time) they were conducted (was) before 1994, include ‘Health 1990’, ‘Youth Health 

Survey (1992-1993)’ and some surveys from the former West Germany: the German 

National Health Survey (NHS), the German National Food Intake Survey and from 

the former East-Germany: Eastern Germany Health Survey (Gesundheitssurvey, 

1991). 

GREECE 

• Greece Household Budget Survey, since 1974, part of DAFNE I & II in 1987-88 and 

1993-94, n=+/-6.500 households. 



Other interesting databases in Greece that are not mentioned here because (the last 

time) they were conducted (was) before 1994, include the Greek National Perinatal 

Survey (1983). 


131

IRELAND 

• Irish National Cancer Registry, National Cancer Registry Board, registers all cancer 

cases diagnosed in Ireland since 1994 (from hospitals and other healthcare facilities). 

health measures: detailed information on cancer: primary site, histology, stage, treatment 

SES-measures: occupational status 

• Survey of Lifestyles, Attitudes and Nutrition (SLAN), conducted in 1998, n=+/-6.000, 

+18y. 

health measures: perceived general health, BMI, dietary and smoking behaviour, alcohol 

consumption, physical activity 

SES-measures: occupational status 

The Mortality Registry for Ireland cannot satisfactorily be linked to socioeconomic 

measures. Other interesting databases in Ireland that are not mentioned here because 

(the last time) they were conducted (was) before 1994, include the Irish National 

Nutrition Survey (1990). 

ITALY 

• Register of Death Causes (Certificazione Cause di Morte (CCM)), National Statistics 

Institute (Instituto Nazionale di Statistica (Istat)), records the medical causes of death for all 

persons that have died in Italy since 1900. It covers the whole Italian population and is 

updated continuously by local administrations that supply information from death 

certificates to Istat. It is impossible to carry out statistical analysis because this information 

is not linked with any code number; moreover information is often inaccurately gathered. 


SES-measures: occupation at the moment of death 

• Survey on Health Conditions of Population and Use of Health Services (Indagine 

Statistica sulle condizione di saluta della populazione e sul ricorso ai servizi sanitari 

(RCSRSS)), National Statistics Institute (Instituto Nazionale di Statistica (Istat)), since 1980 

(‘Health Survey’), 1983, 1986-87, 1990-91 (‘Multipurpose Survey’), annual since 1993 

(‘Aspects of Daily Life’ (Aspetti della Vita Quotidiana)), part of WHO EUROHIS Project 

1996-97, nationally representative sample of n=+/-50.000?, +14y. 

health measures: perceived health status, (chronic) diseases, invalidity, accidents at home, BMI, 

use of healthcare services (hospitalisations, medical examinations), smoking and drinking 

behaviour, food consumption, use of medicines, physical activity, social contacts 

SES-measures: level of education, occupational class 


132

• Observatory on Youth and Alcohol (Osservatore permanente di giovani y alcol), 

National Statistics Institute (Istat), since 1989, also 1994 and 1997. 

health measures: smoking and drinking behaviour of youngsters and their parents, conflicts with 

parents 

SES-measures: level of education, occupational level 

• Cancer Registry of: Liguria, Lombardy, Piedmont, Romagna, Umbria, Tuscany, 

Ferrara, Latina, Macerata, Modena, Parma, Ragusa, Sassari, Trieste and 

Venezia. This network of registries systematically records and analyses 

incidence, mortality, survival and prevalence data. For the moment, it covers more than 

20% of the Italian population. 

Health measures: detailed information on cancer: primary site, histology, 

treatment 

SES measures: none, but the registries are linked with other databases 

Other interesting databases in Italy that are not mentioned here because (the last 

time) they were conducted (was) before 1994, include the Youth and Health (1993) 

survey. 

LUXEMBURG 

• Child Mortality Registry, (no further information found). 

health measures: child mortality 

SES-measures: socioeconomic status (no further information found) 


• Permanent Survey of Living Conditions (Permanent Onderzoek naar de Leefsituatie 

(POLS)), Central Bureau of Statistics (CBS). Large, continuous survey of different aspects 

of living conditions in The Netherlands, random sample of non-institutionalised population. 

Measured through a basic questionnaire and several modules on specific topics which are 

based on previously existing surveys. For these modules between 3.000 and 10.000 

individuals have responded to the questionnaires. These surveys, which were integrated in 

1997, are the Netherlands Health Interview Survey (Gezondheidsenquête (GE), annual 

since 1981, +/- 8.000 individuals living in +/- 3.500 households, +16y, part of the WHO- 

EUROHIS Project), the Continuous Survey on Living Conditions (Doorlopend 

Leefsituatieonderzoek (DLO), annual since 1989, +/- 4.000 individuals, +18y. Previously 

(1974-1989): Continuous Quality of Life Survey (CQLS), +13y), Survey on Housing 

Needs (Woningbehoefte Onderzoek (WBO), every 4 years since 1977, +/- 60.000 

individuals, +18y) and some others. 


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health measures: perceived general health, functional disabilities, chronic conditions, symptoms, 

dental health, use of health services (visits to general practitioner, dentist, specialist, hospital, 

alternative and other health services), use of medicines, housing conditions, living 

environment, working environment (shift work, noise, smell, danger, physical strains, 

monotony, job satisfaction), smoking behaviour, food and alcohol consumption, TV-watching, 

fysical activity, frequency of social contact, mental health, well-being, importance of 

prevention, vaccination and screening behaviour 

SES-measures: level of education, occupation, health insurance, household income, material 

belongings, ethnicity, geographic area, degree of urbanization 

• Second General Practice Inquiry (1999) (Tweede Nationale Studie naar Ziekten en 

Verrichtingen in de Huisartspraktijk), Landelijk Informatienetwerk Huisartsenzorg (LINH), 

first inquiry undertaken in 1987-1988, nationally representative sample of 160 general 

practitioners covering about 400.000 people (5% of which are surveyed). 

health measures: perceived and diagnosed somatic and psychological morbidity, use of general 

practitioner, specialist and self-care 

SES-measures: occupation, educational attainment, migrant group 

• Socio-economic Panel Survey (Sociaal-economisch Panelonderzoek (SEP), Central 

Bureau of Statistics (CBS), annual since 1984, longitudinal study of +/- 5.000 households, 

+16y. 

health measures: food consumption, housing conditions 

SES-measures: educational level, income, occupation, material belongings 

• Supplementary Survey on the Use of Services (Aanvullend Voorzieningengebruik 

Onderzoek (AVO)), Sociaal en Cultureel Planbureau (SCP), every 4 years since 1979, 

n=+/-15.000 individuals in +/- 6.000 households, +6y. 

health measures: housing conditions, use neonatal care, home care, services for handicapped 

people and other health services 

SES-measures: income 

The Mortality Registry for The Netherlands cannot be linked to census data at the 

individual level, but only at the aggregate level for cities or provinces. 

Other interesting databases in The Netherlands that are not mentioned here because 

(the last time) they were conducted (was) before 1994, include the Dutch National 

Food Consumption Survey (Dutch Nutrition Surveillance System, 1992). 

NORWAY 

• Census Based Follow-Up Mortality Study (CEBA), Statistics Norway, system consists of 

linking data from censuses and cause of death data to facilitate the study of socio- 


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economic differentials in mortality using the national 11-digit personal identification 

number. Censuses started in 1960, are conducted every 10 years and cover the complete 

Norwegian population. 


SES-measures: educational level, occupational class, income 

• Cancer Registry of Norway (Kreftsregisteret (CARE)), Institute of Epidemiological Cancer 

Research, covers all cancer cases diagnosed in Norway since 1953 (it is compulsory in 

Norway to report new cancer cases). 

health measures: detailed information on cancer: primary site, histology, stage, treatment, cancer 

mortality 

SES-measures: none, but the registry can be linked with other databases 

• Norwegian Women and Cancer Study (NOWAC), University of Tromso, Institute of 

Community Medicine (Institutt for Samfunnsmedisin (ISM)), a series of nation-wide surveys 

mainly focussed on cancer and oral contraception, targeting women in different age groups 

(sub-cohorts A, B, C and D). The first study in 1991-92 was the ‘Women, Lifestyle and 

Health’ (n=57.604, 34-49y), the ‘Women and Cancer – Young Women’ formed sub-cohort 

B in 1995-96 (n=+/-6.600, 30-44y), sub-cohort C is 1996 ‘Women and Cancer- Middleaged 

Women’ survey (n=+/-31.000, 45-69y) and in 1998 sub-cohort D was formed by 

surveying sub-cohort A again (n=+/35.000). The indicators used in the different surveys 

are broadly the same. Follow-up with regard to cancer incidence and cause-specific 

mortality will be based on record linkage by the unique national identification number to the 

Norwegian Cancer Registry and the Death Certificate Register. This study is part of the 

EPIC project (see European-wide part). 

health measures: perceived health status, use of oral contraception or hormonal replacement 

therapy (HRT), dietary habits (focus on fish and cooking methods), smoking, alcohol use, 

physical activity, sun tanning and bathing behaviour, attempts to change dietary behaviour, 

perceptions of diet’s importance to health. 

SES-measures: years of schooling, education, occupation, income, number of persons in the 

household 

especially linked with: cancer incidence, cause-specific mortality 

• National Health Survey (Helseundersokelse (HESY)), Statistics Norway, conducted in 

1968, 1975, 1985 and 1995, nationally representative sample of n=+/-13.000 in +/-5.000 

households. Can be linked to other data sources through identification number. 

health measures: perceived health, prevalence of diseases, disabilities, dental health, mental 

health, working conditions (noise, pollution, shift work), use of health services 



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• Survey of Living Conditions on Health, Care and Social Contact (Multi-Purpose 

Survey), Statistics Norway, 1992-94 and 1998, n=+/-5.000, +16y. 

health measures: obesity, smoking behaviour, social relations (no further information found) 

SES-measures: level of education 

• Level of Living Survey (1995) (Levekärsundersokelsen), Statistics Norway, also in 1980, 

1983, 1987, 1991, nationally representative sample of n=+/-4.000 individuals, +16y. 

health measures: physical working environment (exposure to climatic or ergonomic problems, 

polluted air or risky working conditions), organizational working conditions (shift work, stressful 

working conditions, control over workplace), health (chronic illness, nervous conditions, 

disability), life style variables, housing conditions, social relations, violence and security 

SES-measures: socio-economic status, income and financial resources, education, type of 

residence 

• NORKOST, National Nutrition Council, 1993-94, n=3.144, 16-79y. 

PORTUGAL 

health measures: food intake 

SES-measures: education, occupation 

• National Health Survey, Ministry of Health, 1987 and 1995-96, part of WHO-EUROHIS 

Project, n=+/-24.000, +18y. 

health measures: perceived health status, BMI, smoking behaviour (no further information found) 

SES-measures: level of education 

• Survey on Health Conditions of Population (2000) Observatório Nacional de Saúde 

Health measures: mortality, morbidity, woman and child health, accidents 

SES-measures: scolarity 

• Homeless in Lisbon Survey (1999) Laboratório Nacional de Engenharia Civil 

Health measures: major health problems of homeless population 

SES-measures: number, sex, age of homeless population 

• Survey on scholarity of migrant children between the ages of 6 and 17 (1997) 

Secretariado Coordenador dos Programas de Educação Multicultural 

SES-measures: reasons for dropping out of school, ethnicity, educational level 


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• Permanent Demographic Sample (1998) Ministério da Administração Interna 

Health measures : mortality 

SES-measures : country of origin, ethnicity 

• Survey about Gypsies (1998) Comissariado para a Integração e Minorias Étnicas 

Health measures: health problems, disabilities 

SES-measures: housing, nomadic lifestyle, education, family 

• Survey on Population Older than 65 (1999) Ministério do Trabalho e da Solidariedade 

SPAIN 

SES-measures: dependency, ageing 

• National Health Interview Survey (Encuesta Nacional de Salud), Ministry of Health and 

Consumer Affairs (Ministerio de Sanidad y Consumo). Since 1987, also in 1993, 1995 and 

1997, covering entire Spain, representative sample of n=± 6400, +16y 

Contact: Centro de publicaciones del Ministerio de Sanidad y Consumo 

Tel: +00 34 91 596 40 60 

Health measures: perceived health status, chronic diseases, psychological symptoms, BMI, 

smoking behaviour, alcohol consumption, physical exercise, sleeping habits, preventive 

activities, use of health services (visits to GP and hospital) 

SES-measures: occupation, level of education, house tenure, household income (corrected for 

the size of household) 

• Continuous Household Budget Survey (Encuesta Continua de Presupuestos 

Familiares), National Institute of Statistics (Instituto Nacional de Estadística), since 1984 

and trimestral since 1985, part of DAFNE II in 1990-1, n= ± 20.000 households 

Contact: Instituto Nacional de Estadística 

Tel: 00 34 91 583 91 00 

Health measures: consumption of alimentary tobacco products 

SES-measures: level of education, employment status, socio-economic status 


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• Survey of Disabilities, Deficiencies and Health Status (1999) (Encuesta de 

Discapacidades, Deficiencias y Estado de Salud), National Institute of Statistics (Instituto 

Nacional de Estadística), first undertaken in 1986 n=±79000 household 

Contact: Instituto Nacional de Estadística 

Tel: 00 34 91 583 91 00 

Health measures: prevalence of chronic diseases, accessibility and use of health services, 

appreciation of health status 


• Catalan Health Interview Survey (1994) (Enquesta de Salut de Catalunya), 

Department of Health and Social Security of Generalitat of Catalonian (Departament 

de Sanitat i Seguretat Social de la Generalitat de Catalunya). Cross- sectional 

survey, n= ± 12500, +15y 

Contact: Servei Català de la Salut 

Tel: +00 34 93 430 85 85 

Health measures: perceived health status, chronic diseases, disabilities, smoking behaviour, 

alcohol consumption, physical exercise, sleeping habits, preventive activities, use of health 

services, quality of life 

SES-measures: occupation, level of education, household income 

• Basque Health Survey (Encuesta de Salud del País Vasco), Department of health of 

Basque Government (Departamento de Sanidad del Gobierno Vasco), since 1986, 

also 1992 and 1997 n= ± 4.000 households, +15y. 

Contact: Departamento de Sanidad del Gobierno Vasco 

Tel: +00 34 94 501 91 92 


smoking behaviour, alcohol consumption, physical exercise, hours of sleeping, preventive 

activities, use of health services (visits to GP and hospital) 

SES-measures: occupation, level of education, house tenure, household income (corrected for 

the size of household) 

• Navarra Health Survey (Encuesta de Salud de Navarra), Department of health of Navarar 

Government (Departamento de Sanidad del Gobierno de Navarra), since 1990, also 2000 

n= ± 1500, +15y. 


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Contact: Isabel sobejano Tornos 

isabel.sobejano.tornos@cfnavarra.es 


smoking behaviour, alcohol consumption, physical exercise, sleeping habits, preventive 

activities, use of health services (visits to GP and hospital), quality of life 

SES-measures: occupation, level of education 

• Canarian Health Survey (Encuesta de Salud de la Comunidad Autónoma de Canarias), 

Health Canarian Service (Servicio canario de Salud), since 1990, also 1997 n= ± 2800, 

+15y. 

Contact: Servicio Canario de Salud 

Tel: 00 34 22 47 47 15 


smoking behaviour, alcohol consumption, physical exercise, preventive activities, use of health 

services (visits to GP and hospital) 

SES-measures: occupation, level of education, profession, house tenure 

Other interesting databases in Spain that are not mentioned here because (the last time) they 

were conducted (was) before 1994, include the Assessment of Nutritional Status of 

Catalonia’s Population (1992-93), and the Food Habits in Basque Country (1990) survey. 

The Mortality Registry for Spain cannot be linked to census data at the individual 

level, but only at the aggregate level for cities or provinces. 

SWEDEN 

• Cause of Death Registry (Dödsorsaksregistret), Statistics Sweden (SCB), since 1961, 

linked to census data and the ULF by means of personal identification codes. Censuses 

are conducted every fifth year since 1960. 


SES-measures: occupational class, educational level 

• Swedish National Survey of Living Conditions (Undersökningen av 

Levnadsförhållanden, ULF), Statistics Sweden (SCB), annual since 1975, nationally 

representative sample of n=+/-12.500 individuals, 16-84y. Based on the ULF, the 


139

Immigrant Survey of Living Conditions was carried out in 1996 (n=1.890, aged 27-60 

y). 

health measures: perceived health status, chronic diseases, functional disabilities, use of 

healthcare, dental health, dietary and smoking habits, use of medicine, working environment, 

housing conditions, social relations (contacts with family and friends, social support). 

SES-measures: educational level, occupational class, individual and household income, area of 

living 

especially linked with: Swedish Causes of Death Register, income, housing allowance and many 

more 

• Household Market and Non-market Activities (1998), Göteborg University, Department 

of Economics, since 1984, meant to be bi-annual, n=2.347 individuals in Swedish speaking 

households 

health measures: perceived health status, housing conditions 

SES-measures: education, employment, household income 

Other interesting databases in Sweden that are not mentioned here because (the last 

time) they were conducted (was) before 1994, include the Swedish National Dietary 

Survey (HULK, 1989) and Risks 1988. 


• Longitudinal Study (LS), Office for National Statistics (ONS), No new data are gathered 

by the LS, it instead provides a link between data from the decennial Census of population, 

the National Cancer Registration Scheme, death and birth registrations and the National 

Health Services Register. All people born on one of four dates each year were selected 

from the 1971 Census, with new births occurring and immigrants having these dates as a 

birth day joining the LS after 1971. The study covers about 500.000 people (1%) of the 

population of England and Wales and events are recorded continuously as they occur. 

health measures: cause of death, occurrence and type of cancer 

SES-measures: educational qualifications, social class (based on occupation), housing tenure, 

access to cars 

• Occupational Mortality Decennial Supplement (OMDS), Office for National Statistics 

(ONS), providing a link between the decennial Census of population (which is conducted 

every 10 years since 1851 for England and Wales and sometimes for Scotland) and death 

registration by occupation and cause of death, referring to deaths occurring in the five 

years surrounding the Census. These two sources however are sometimes inconsistent, 

which led to the creation of the Longitudinal Study. 

health measures: cause of death 



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• 1970 British Cohort Study (BCS70), International Centre for Child Studies. This is a 

national longitudinal study that began with a cohort of babies born in April 1970. Follow-up 

studies have been conducted in 1975, 1980, 1986 and 1996. The scope of the inquiry has 

broadened from a strictly medical focus at birth to an evaluation of the health, care, 

edcuation, social and family environment, n=+/-11.500. 

health measures: perceived health status, medical history, chronic illnesses and disabilities, 

mental health, blood pressure, BMI, vision and locomotory functioning, physical activity, 

dietary behaviour, smoking, alcohol and drug consumption, sexual behaviour, self-esteem, 

friends and social behaviour, attitudes to health 

SES-measures: children’s educational achievement, parents occupation, parents educational 

level, family finances, household amenities 

• Health and Lifestyles Survey (HALS I & II), Social and Community Planning Research, 

national representative longitudinal survey, covering England, Scotland and Wales. First 

survey in 1984-85, follow-up in 1991-92, n=+/- 9.000 (1 st ) and 5.000 (2 nd ), +18y (1 st ) and 

+25y (2 nd ). 

health measures: perceived health, disabilities, physiological measures (blood pressure, BMI, 

respiratory function), mental health (cognitive functioning, personality and psychiatric status), 

dietary behaviour, smoking, physical activity, hours of sleep, alcohol consumption, visits to GP 

and hospital, beliefs about and attitudes towards health and disease, intentions and reasons 

for behaviour change, social support, housing conditions, working conditions 

SES-measures: educational level, occupational class, household and personal income, socioeconomic 

group 

especially linked with: causes of death registry 

• Health Survey for England (HSE), Department of Health, annual since 1991 (core topics 

and varying non-core topics), nationally representative survey, +16y plus up to 2 children 

aged 2-15y per household, n=+/- 20.000. There is an interviewer survey part and a nurse 

visit. 

health measures: general health, smoking and drinking behaviour, blood pressure, cholesterol, 

prescribed medication, housing conditions (non-core: eating habits, physical activity, 

contraceptive use, accidents, chronic diseases, physical disabilities, social support) 

SES-measures: household income and composition, occupational status, material belongings, 

ethnicity, area of living 

• Welsh Health Survey (1998), National Assembly for Wales, cross-sectional representative 

study of the health and well-being of adults (+18y) in Wales, n=+/-30.000. 


141

health measures: perceived physical and mental health, specific illnesses, disabilities, accidents, 

BMI, physical exercise, dietary behaviour, alcohol consumption, smoking, use of and 

satisfaction with health services. 

SES-measures: social class (based on occupation), employment status, ethnicity, house tenure 

• Scottish Health Survey (1995), Scottish Office, Dpt. of Health, cross-sectional 

representative survey of adults (16-64y) living in private households in Scotland, meant to 

be repeated every three years, n=+/-8.000. 

health measures: perceived general health, mental well-being, dental health status and care, 

prescribed medicines, accidents, BMI, blood pressure, cholesterol, lung functioning, use of 

health services, physical activity, dietary behaviour, alcohol consumption, smoking, attitudes 

towards changing health behaviour. 

SES-measures: social class (based on occupation) 

• General Household Survey (GHS), Office for National Statistics (ONS), annual since 

1971, covering Great Britain (except Northern Ireland), n=+/-9.000 households, +16y. Not 

all topics are covered every year. In Northern Ireland, the Continuous Household 

Survey, that started in 1983, is based on the GHS (n=+/-3.000). In 1997, a follow-up study 

of 1994 GHS was conducted for a sample of people aged 65 and over. 

health measures: perceived health status, disabilities, dental health, leisure activities, smoking, 

alcohol consumption, mental health, use of contraception, use of health services (GP, hospital, 

other health and social services), housing conditions 

SES-measures: educational level, occupational class, household income and composition, 

material belongings 

• Data on Occupational Accidents (DOA), Health and Safety Executive, national (covers 

England, Wales and Scotland) since 1986, contains information on fatal accidents and 

accidents resulting in major injuries or absence from work for more than three days, 

(obligatorily) reported by employers. 

health measures: nature and severity of the injury 


• National Diet and Nutrition Survey Program, Office for National Statistics (ONS). This is 

a joint initiative by the Ministry of Agriculture, Fisheries and Food (MAFF) and the 

Department of Health to provide a comprehensive overview of the dietary habits and the 

nutritional status of the population of Great Britain. Several age groups are studied in this 

program: 1,5 to 4 years (1992-93), 4 to 18y (1997, n=+/- 2.700), 19-64y (Dietary and 

Nutritional Survey of British Adults (DNSBA), 1986 and 1990), +65y. 

health measures: dietary habits (food and nutrient intake and use of food additives), physical 

activity, blood pressure, BMI, oral health status and care 

SES-measures: occupational class, social class (Registrar General’s Scheme) 


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• Survey of Health and Well-Being of Adults, Office for National Statistics (ONS), first 

undertaken in 1994, repeated in 2000, covers Great Britain, n=15.550 individuals 

health measures: general health problems, a range of mental health problems, such as anxiety 

and depression, alcohol and drug dependency, psychosis and personality disorder; use of 

health services, social support, key life events 

SES-measures: educational attainment, income, housing conditions 

• Mental Health of Children and Adolescents in Great Britain (1999), Office for National 

Statistics (ONS), also in 1993, 1994, 1997, was called Survey of Psychiatric Morbidity 

before. Aim to provide information on the prevalence of psychiatric problems among 

people in Great Britain and their use of services. The subsequent surveys differed in the 

subpopulations and number of people being studied: adults living in private households, 

people living in institutions for mental illnesses, homeless people, and prisoners. The 1999 

edition interviewed n=+/- 10.000 children (5-15y) and one of their parents living in private 

households. 

health measures: general health, mental health (emotional disorders (anxiety, depression, 

obsession), hyperactivity disorders and conduct disorders (antisocial behaviour etc.)), use of 

health services (in general and specifically for mental health problems) 

SES-measures: parental educational level and employment 

• Northern Ireland Health and Activity Survey (1994), Policy Planning and Research Unit, 

studies Northern Irish adults (+16y), n=1.020 

health measures: general health, physical activity, dietary behaviour, blood analysis, measured 

physical fitness, attitudes towards health, activity and physical fitness 

SES-measures: educational attainment, social class 

• Adult Dental Health Survey (ADH), Office for National Statistics (ONS), conducted 

nationally in Great Britain in 1988 and 1998 for adults aged 16 and over living in private 

households, n=+/-6.000. 

health measures: self-reported health status of natural teeth and supporting tissues, medical 

dental examination, use of dental care, oral hygienic behaviour, attitudes and knowledge 

towards dental treatment 

SES-measures: educational level, personal and household income, material belongings, 

employment status 

• Health Education Monitoring Survey (HEMS), Office for National Statistics (ONS), 

covers England, n=5.800, adults aged 16 and over, first conducted in 1995, also in 1996 

and 1998. Also called ‘Health in England’. 


143

health measures: knowledge, attitudes and behaviours towards (quitting) smoking, drinking, 

nutrition, physical activity, sexual health and behaviour in the sun; social support, community 

involvement, neighbourhood characteristics (social capital). 

SES-measures: social class (based on current or last job), employment status, highest 

educational level, ethnicity, gross household income, housing tenure, area deprivation. 

Other interesting databases in the UK that are not mentioned here because (the last time) they 

were conducted (was) before 1994, include: National Survey of Activity and Health 

(England, 1991), Allied Dunbar National Fitness Survey (England, 1990 and 1992), 

National Survey of Sexual Attitudes and Lifestyle (Great Britain, 1990), Health State 

Valuations (England / Great Britain, 1985, 1989, 1993). 

The very interesting follow-up study Social Variations in Health in Early Old Age (England 

and Scotland, 1998) was withdrawn because it had too few respondents and 

representativeness could not be guaranteed. 

Accession countries 

ESTONIA 

• Health Behaviour among Estonian Adult Population (1996), National Public Health 

Institute (Finland), bi-annual since 1990, set up based on the ‘Health Behaviour among 

Finnish Adult Population’ and part of the FINBALT Health Monitor, n=+/-1.500, 16-64y. 

HUNGARY 

health measures: see FINBALT Health Monitor 

SES-measures: see FINBALT Health Monitor 

• Health Interview Survey, Hungarian Central Statistics Office, based on the ‘Health 

Behaviour among Finnish Adult Population’, 15-64y. 

health measures: smoking behaviour (no further information found) 


• Hungarian Household Panel (HHP) Survey, TARKI Social Research Centre and others, 

annually 1991-1997, nationally representative sample of n=+/-2.600 households, part of 

(DAFNE I) in 1990-91. 




144

• TARKI Household Monitor Survey, continuation of Hungarian Household Panel without 

its longitudinal character. Purpose is the quick assessment of changes in the stratification 

of society and in social inequalities. 

health measures: (no further information found) 

SES-measures: (no further information found) 

The Mortality Registry for Hungary cannot satisfactorily be linked to socioeconomic 

measures. 

CZECH REPUBLIC 

• Czech Republic’s Health Interview Study (HIS), 1993, 1996 and 1999, part of WHO 

EUROHIS Project 1996-97, n=2.400, +15y. 

health measures: perceived general health, BMI (no further information found) 


• Data on Occupational disease (Nemoci z Povolani (NP)), State Health Institute (Statni 

Zdravotni Ustav), covers all occupational diseases reported by doctors, nationally since 

1991. 

SLOVENIA 

health measures: disease specification 


• No information sources were found 

EUROPEAN-WIDE 

• Health Behaviour among School-Aged Children (HBSC Study), WHO, every 4 years 

since 1983-1984, obliged are the age groups 11-13-15y, increasingly more countries are 

participating, including Austria, Belgium (Flanders and Wallonia), Czech Republic, 

Denmark (+Green-land), Estonia, Finland, France (in 1998 only 2 regions), Germany (in 

1998 only 1 region), Greece, Hungary, Ireland, The Netherlands, Norway, Portugal, Spain 

(not in 1998), Sweden, United Kingdom (England, Wales, Scotland and Northern Ireland), 

ntotal=+/-123.000 children from 28 countries (including non-EU countries). Core 

questionnaire is the same in all participating countries, in-depth focus questions are 

optional and change every survey, extra national questionnaires can be added. Here we 

consider the core questionnaire. 


145

health measures: perceived health status, medical complaints, smoking, alcohol abuse, physical 

activity, food consumption, knowledge of AIDS, sexual behaviour and use of contraceptives, 

dental health, use of medicines, use of seat belt, mental health (self-concept, body image), 

peer and family relations 

SES-measures: type of education, occupation of parents, nationality 

• Monitoring Trends and Determinants in Cardiovascular Disease (MONICA Project), 

WHO and 39 collaborating centres, monitors information in 26 countries including Belgium, 

Czech Republic, Denmark*, Finland, France, Germany, Hungary, Italy, Spain, Sweden, 

United Kingdom*, first survey period was 1979-1989, the final surveys were conducted in 

1989-1996, 35-64y (optional also 25-34y), ntotal=+/- 300.000. Some countries gather only 

regional information. 

health measures: coronary and stroke event registration, smoking and food habits, physical 

activity, blood pressure, cholesterol, BMI, use of contraceptives, awareness of high 

cholesterol, knowledge of and attitude towards risk factors for stroke (for * selected countries) 

SES-measures: educational level, occupational class (for * selected countries) 

• Eurobarometer studies, since 1970 the European Commission conducts, at a rate of +/- 

2 times a year, surveys on opinions and attitudes of Europeans. These are mainly opinions 

regarding institutions and policies of the EU, but there are also special surveys 

investigating opinions on broader topics, including health. The study population consists of 

n=+/-1.000 people aged +15y in each EU country, and they are presented the same (but 

translated) questionnaires. Relevant topics are “Europeans and the Prevention of Cancer”, 

“European Survey on the Work Environment”, “Passive Smoking”, “Environmental 

Problems and Cancer”, “Drugs, alcohol and cancer”, “Europeans and Safety, Hygiene and 

Health Protection at work”, “EU citizens and Health Issues”, “Women and Breast Cancer” 

and ”Europeans, Health and the Healthcare System”. 

health measures: cardiovascular disease, AIDS, cancer, smoking and dietary behaviour, use of 

drugs and alcohol, physical activity, vaccination and cancer screening behaviour, working 

conditions, knowledge and attitudes regarding cancer 

SES-measures: educational level, occupational class, household income and composition (not 

always measured) 

• European Community Household Panel Study (ECHP), Eurostat, is a annual multidimensional, 

multi-purpose, longitudinal panel survey that covers all EU member states 

(except Sweden) since 1994. The same nationally representative sample (‘panel’) of n=+/- 

130.000 individuals in n=+/-60.000 households are interviewed over several consecutive 

years. 


146

health measures: perceived general health, mental health, chronic conditions, illnesses, 

disabilities, housing conditions, social relations, use of health services (visits to GP, specialist, 

dentist, hospital stays) 

SES-measures: household income and composition, personal income, material belongings, 

occupational status, educational level, migration status 

• European Prospective Investigation into Cancer and Nutrition (EPIC), Multi-centre 

prospective cohort study (life-time follow-up) designed to investigate the relation between 

diet, nutritional and metabolic characteristics, various lifestyle factors and the risk of 

cancer. Nine countries are participating: Denmark (n=+/-50.000), France (n=+/-80.000), 

Germany (n=+/-50.000), Greece (n=+/-30.000), Italy (n=+/-42.000), The Netherlands (n=+/- 

40.000), Spain (n=+/-41.400), Sweden (n=+/-31.000), United Kingdom (n=+/-59.000), and 

recently Norway joined the project, ntotal=+/-520.000. Project started in 1990, countries 

stepped in between 1991-94. Age: 35-40y to 60-74y. 

health measures: mortality, cancer incidence, previous and current illnesses and health problems, 

dietary behaviour, physical activity, consumption of alcohol and tobacco, use of contraception, 

current medication 

SES-measures: educational level (not for all countries) 

• FINBALT Health Monitor, National Public Health Institute (Finland), collaborative 

monitoring system in Estonia, Finland, Latvia and Lithuania set up based on the ‘Health 

Behaviour among Finnish Adult Population’ since 1990 (countries stepped in gradually), biannual, 

15-64y, representative samples of national population, core and extended part. 

health measures: perceived health status, health complaints, mental health, blood pressure, 

cholesterol, smoking, exposure to passive smoking, dietary habits, physical activity, alcohol 

consumption, use of medication, traffic safety, dental health, behaviour change intentions and 

attempts (optional), use of health services (visits to the GP), exposure to health promotion 

interventions (optional), opinion on health and health policy (optional). 

SES-measures: years of schooling, occupation (recommended) 

• Socioeconomic inequalities in the health of children and adolescents in Nordic 

Countries (1996), Nordic School of Public Health, postal survey carried out in the 5 Nordic 

countries (Denmark, Finland, Iceland, Norway, Sweden). Sent to parents of n=+/-15.000 

children (+/- 3.000/country) aged 2-17, in part a replication of a survey in 1984. 

health measures: reported chronic conditions and illness symptoms, stature 

SES-measures: educational attainment and occupation of both mother and father, family income 

• Data Food Networking (DAFNE), European food data bank based on Household Budget 

Surveys, information from: Belgium*, Germany, Greece*, Hungary*, Ireland, Luxemburg*, 

Norway, Spain* and the UK, up till now 2 periods of the project (DAFNE I & II). 


147


SES-measures: educational level (only in * countries) 

• IEFS Pan-EU Surveys of Consumer Attitudes to Food-related issues, Institute of 

European Food Studies (IEFS), is a series of cross-sectional studies in the 15 member 

states of the EU, with nationally representative samples of n=+/-1.000 adults (+15y) from 

each country. The Pan-EU Survey of Consumer Attitudes to Physical Activity, Body 

Weight and Health (ntotal=14.331) was conducted in 1997. It was precedent in 1995-96 by 

the Pan-EU Survey of Consumer Attitudes to Food, Nutrition and Health 

(ntotal=15.239). 

health measures: level of physical activity, smoking behaviour, BMI, attitudes towards healthy 

eating, physical activity, body weight and health, availability of information about diet, 

perceived influences on food choice and physical activity 

SES-measures: level of education, occupational status 

Some very interesting European-wide health monitoring initiatives could not 

satisfactorily be linked to socio-economic measures, like the Health Surveillance 

System for Communicable Diseases (HSSCD, European Centre for the 

Epidemiological Monitoring of AIDS (CESES)), the European Home and Leisure 

Accident Surveillance System (EHLASS) the European School Survey Project on 

Alcohol and Drugs (ESPAD Survey), and the Panel Comparability Project (PACO, 

international comparative database integrating data from various national households 

panels). 


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Annex 1: Inventory of indicators from surveys and registries

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