Health promotion as practiced by public health inspectors: the BC experience.

Campbell, Audrey C. ; Foggin, Timothy M. ; Elliott, Catherine T. 等

Health promotion is the process of enabling people to increase control over and to improve their health. (1,2) Health promotion involves actions directed at strengthening the skills and capabilities of individuals, as well as changing social, environmental and economic conditions to alleviate their negative impacts on public and individual health. (1) There are a range of activities under the umbrella of health promotion, including policy initiatives, environmental strategies, community development, as well as the more traditional lifestyle and public education initiatives. (3) The Ottawa Charter for Health Promotion (1986) identifies five key strategies for health promotion: building healthy public policy; creating supportive environments; strengthening community actions; developing personal skills; and reorienting health services. (2)

Health protection describes the activities, many of them based on traditional mandates, of public health units/departments, especially in food hygiene, water purification, environmental sanitation, involvement with permits for facilities, and other activities in which the emphasis is on actions that can be taken to reduce or contain the risk of adverse consequences for health attributable to environmental hazards, unsafe or impure food, water, dangers in care facilities, etc. (4,5) In the province of British Columbia (BC), Environmental Health Officers (EHOs), formerly called Public Health Inspectors, are mandated to protect health by enforcing provincial regulations. They surveil and monitor activities and premises that may affect the public's health, administer provincial legislation, and intervene to minimize health and safety hazards. (6)

It is recognized that health promotion and health protection have followed two paths, yet EHOs are often invested in promoting health. Further, the importance of health promotion in the work of health protection is reflected in the strategic plan for the Health Protection Branch of the BC Ministry of Healthy Living and Sport, in which health promotion is identified as an important strategy specifically in promoting resilient communities. (7) Theoretically, the use of health promotion upstream might create conditions in which breaches of health protection are unlikely to occur, and therefore decrease the need for enforcement downstream. Further, a progressive approach to enforcement (e.g., a continuum, beginning with education and compliance promotion, progressing to warnings, and then to penalties) (8) when lapses of hygienic practice do occur, limits the impacts, economic and social, on operators, and encourages them to consult prospectively rather than to effect corrections in response to penalties.

There is literature that discusses the work of nurses in environmental health practice who have expertise in health promotion. (9-14) However, no literature has been found that specifically explores the knowledge, attitudes and behaviours of EHOs with respect to health promotion. In BC, it is uncertain whether, or how, EHOs practice health promotion, how health promotion relates to their enforcement mandate, and what factors support or hinder their involvement with health promotion. In order to assist in documenting the work of EHOs in the area of health promotion, and to support the ongoing development of this field, the study team at the BC Centre for Disease Control (BCCDC)--Environmental Health Services Division (EHSD) sought to explore the experiences of EHOs in practicing health promotion and create a roadmap for the ongoing integration of health promotion into health protection mandates.

METHODS

Sample and data collection

A convenience sample of EHOs was selected to represent different geographic locations (i.e., the five BC Health Authorities), levels of experience and authority (e.g., senior and junior EHOs, managers and consultants), and areas of work (e.g., food protection, drinking water, air quality, land use, safety or other local health-related issues). The Regional Directors of Health Protection of each Health Authority identified three EHOs who agreed to be interviewed. A nine-item, mixed qualitative and quantitative survey was developed to explore EHOs' perceived involvement in health promotion, strategies utilized, the relationship between health promotion and their enforcement mandates, effectiveness of health promotion, and barriers and enabling factors affecting implementation. The survey was first reviewed by EHOs outside of the sample and the Regional Directors of Health Protection. Participants received the survey in advance, then were contacted to discuss the purpose and methods, intended uses of the data, and provisions for confidentiality. All participants provided verbal consent, and one-to-one interviews were conducted by one interviewer in person or by telephone in August and September 2010. Data were transcribed by hand or notes were taken using a computer.

Analysis

Qualitative data contained in field notes were analyzed through the following process: familiarization with the raw data and identification of ideas and recurrent themes; selection of themes; review of the data and arrangement by theme; and data interpretation. (15) Identifying information (e.g., names, geographic area of practice) was removed. Direct quotations are included throughout the text. Quantitative data were analyzed using Microsoft Excel (version 12.2.5, 2007) to produce proportions with percentages. The draft results document was circulated to participants and feedback was requested to ensure that the data were accurate and reflected important themes.

RESULTS

Three EHOs from each of BC's five Health Authorities participated. The sample included one manager from each Health Authority, consultants, and EHOs with a range of years in practice from 2 to 20+. Respondents worked in various areas, including drinking water, food safety, land use, etc.

Fourteen of the fifteen respondents (93%) indicated that they did practice health promotion. A few commented that "EHOs have been doing health promotion all along, in a subtle way" before it was called health promotion. One respondent explained that her work involved helping individuals/businesses "come up with solutions on their own." The most commonly utilized strategies for health promotion were building healthy public policy (13/14, 93%) and developing personal skills (13/14, 93%). Twelve (86%) were involved with creating supportive environments for health, and a few respondents stated that this is what EHOs do during their routine inspections (e.g., food premises). Strengthening community action and reorienting health services were practiced by 9/14 (64%) and 6/14 (43%), respectively. A wide variety of examples were provided, illustrating the diverse health promotion activities of EHOs (Table 1). The one EHO who did not feel s/he utilized health promotion indicated that the nature of the work made it difficult: "our side of things is health promotion, but it is hard because the other side is business-oriented. You can only do so much education."

The relationship between health promotion and enforcement was explored among 13 respondents, as 1 EHO did not practice health promotion, and 1 respondent was a consultant who did not feel s/he was involved with enforcement in his/her current work (Table 2). The majority of respondents felt that they used health promotion "as a part of enforcement"; they first tried to educate and create environments that supported individuals/businesses in making required health and safety choices, and then applied enforcement measures if this did not work. Note that enforcement was recognized as an important and valuable tool: "there is stigma that the EHO's job is as an enforcer. Whenever I have to use enforcement it is critical ... we need to have this tool, it is a valuable tool to protect health. Enforcement and health promotion together make this job a great job." Other relationships between health promotion and enforcement were identified, including using health promotion as an alternative approach to enforcement, as an 'add-on' to enforcement, and separately from enforcement. Some respondents reported that the model they used was situation-dependent. The majority (69%) did not feel that their enforcement mandate limited their use of health promotion, however some explained that being perceived as enforcement officers posed challenges for using health promotion. One respondent commented that the "[enforcement mandate] can restrict the use of health promotion, because of the perception that we are not here to necessarily help but to be the legal technicians that give out tickets." One respondent reported that the use of health promotion in connection with enforcement varied depending on the situation: "there is some very old legislation that doesn't allow us to use a lot of health promotion-type discretion because it is very black and white and very prescriptive, whereas the more recent legislation does open it up."

Several factors influenced EHOs' perceived abilities to practice health promotion. Respondents largely felt that their training (particularly to qualify as an EHO, but also during the duration of their employment) enabled them to use health promotion (13/15, 87%). Training provided theoretical information about health promotion, and equipped them with a comprehensive base of knowledge in environmental health which they felt was necessary to engage in health promotion activities (i.e., educating individuals and communities, and providing the rationale for required environmental changes). One senior EHO highlighted the importance of the academic experience in providing opportunities to gain comfort with public speaking: "we know why you should do it, the health reasons behind it, but you have to be comfortable getting up in front of a group and saying it." A few respondents felt that the curriculum of current training programs addresses health promotion to a greater degree than occurred in the past.

Most respondents felt that their relationships with local governments, and individuals and firms over which they had regulatory authority, enabled them to use health promotion (14/15, 93% and 12/15, 80%, respectively). Examples were given of strong relationships with local governments, and involvement with community groups. However, for some EHOs, this varied. Some described difficulties in attempting to engage in community outreach due to some members of the community perceiving that EHOs would enforce policies that were unfavourable to them.

The majority of respondents (12/15, 80%) felt that the increased use of health promotion would increase the effectiveness of their work. Further, one respondent in a management position suggested that it was important to broadly increase the health promotion profile of health protection activities. Among those who did not feel that health promotion would increase the effectiveness of their work, one commented "as much as you try to use health promotion, you still always have this legislative expectation and legal obligation that you have to enforce, and I don't necessarily think that health promotion in the line that we are working in would help. You do try, but in the end people always say that you enforce the law: it is there, enforce it."

Respondents suggested a variety of strategies to facilitate their involvement with health promotion. Many identified that more training was needed. It was suggested that training should be ongoing, and be available to all EHOs (managers, field staff, specialists, etc.). Comments were made that health promotion is very theoretical, and that guidance on practical implementation is lacking; as one EHO requested, "tell us what we can actually do." Components of training should include: the theoretical basis for health promotion; examples of how health promotion has been implemented elsewhere (provincially, nationally and internationally) and impact; how health promotion can be operationalized in BC; and how health promotion strategies can complement enforcement activities. Suggested structures and venues for delivery included hands-on 'implementation-focused' workshops; annual education days in which speakers are brought in ("mini-conferences"); and the use of regular staff meetings to deliver information.

Another common suggestion is that health promotion needs to be included in the goals and plans of health protection policies and programs, at all levels. One respondent suggested "the Ministry needs to specify a mandate for [health promotion], an expectation that the Health Authorities will do it, and accountability.this will then be integrated into the Health Authority's 'strategic plans' and then into 'program plans'." Another respondent proposed that "we need a system and acknowledgement for measuring health promotion activities ... it would need to be built into our current workplans ... there is no way to measure [health promotion] right now." Further, that the "accountability frameworks and expectations need to be as uniform as possible across BC's Health Authorities."

A number of respondents commented that a lack of resources (e.g., time, personnel, money) is a barrier to engaging in health promotion. One respondent said "[we need] more time; we are stretched so thin, at times it becomes very trying to do your job the way it needs to be done, including education. When you have limited time and are asked to do more with less, it becomes difficult, almost impossible." Another respondent suggested that there needs to be a greater allocation of financial resources for health promotion, beyond what is necessary to meet the core health protection programs.

Box 1. Tools that facilitate the use of health promotion by
EHOs

* Consistent and clear mandate for health promotion and supervisory
guidance

* System of acknowledgement and/or accountability

* Education about health promotion in EHO training programs and
professional development

* Practical information on how to engage in health promotion in the
BC context

* Resources (e.g., time, finances, personnel)

* Strong relationships with local government and community groups

Other suggestions included ongoing relationship building with individuals, businesses and communities. One respondent commented that there is a long history of enforcement with individuals and firms, and there is a need to "build relationships to move towards health promotion." It was also suggested that partnerships with communications staff within the Health Authorities should be developed further, in order to facilitate the production of health promotion information and tools. Finally, the importance of having EHO input into the type of health promotion they should be doing was highlighted. In other words, if EHO staff could do things that interest them, this would facilitate buy-in.

DISCUSSION

This study has provided initial insights into the perspectives and behaviours around health promotion for a convenience sample of Health Protection Officers in BC.

The majority of EHOs in our sample do practice health promotion, and utilize a wide variety of strategies to both effect change in the environment and provide individuals and communities with information and support skill development. Box 1 outlines tools that facilitate EHOs' use of health promotion. It is interesting to note that building healthy public policy is widely practiced, illustrating involvement with policy and advocacy to promote healthy lifestyle conditions and remove impediments to individuals and communities making healthy choices.

Attempts are often made to use health promotion strategies first to support necessary behaviour change, with enforcement applied when these efforts are not successful. However, the relationship between health promotion and enforcement was often situationspecific. Ongoing relationships with government, individuals and firms enable health promotion, but given the wide range of situations that EHOs encounter, their ability to apply health promotion varies. Most EHOs felt that the increased use of health promotion would increase the effectiveness of their work, with calls for practical training, clear expectations and accountabilities, the inclusion of health promotion in program planning, greater resource allocation, and the further development of partnerships.

The importance of consistency of expectations across the provincial health authorities with respect to health promotion, and guidance on when and how to apply it is a concern worth noting. The development of an evaluation process is also an important challenge. Further, the question of how health promotion experts within the health authorities can support health protection staff is a key question for consideration.

Our study was limited by the fact that participants were selected by the Regional Directors of Health Protection, which may introduce bias (e.g., if those selected were more likely to be involved with, or have an interest in, health promotion). The study authors hold leadership and learner roles within the BCCDC-EHSD; as such, they are aware of the roles and areas of work of EHOs, but are not EHOs themselves. Although our study involved a small, convenience sample, this is appropriate for this novel exploratory study. The important issues raised should be examined with a larger sample.

Acknowledgements: The authors thank Lynn Wilcott, BC Centre for Disease Control; Anne Thomas, Vancouver Island Health Authority; Lucy Beck, Northern Health Authority; Tim Shum, Fraser Health Authority; Richard Taki, Vancouver Coastal Health; Ken Christian, Interior Health Authority; Sophie Verhille, National Collaborating Centre for Environmental Health.

Conflict of Interest: None to declare.

Received: March 3, 2011 Accepted: July 6, 2011

REFERENCES

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(2.) World Health Organization. Ottawa Charter for Health Promotion. Ottawa, ON: WHO, Health Canada, CPHA, 1986. Available at: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf (Accessed July 12, 2010).

(3.) Centre for Addiction and Mental Health. Health Promotion Resources. Available at: http://www.camh.net/About_CAMH/Health_Promotion/ Health_Promotion_Resources/index.html (Accessed August 9, 2010).

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Correspondence: Dr. Audrey Campbell, Public Health & Preventive Medicine Residency Program, School of Population & Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, E-mail: campbeac@interchange.ubc.ca

Audrey C. Campbell, MD, MHSc, [1] Timothy M. Foggin, MD, MPH, [1] Catherine T. Elliott, MD, MHSc, [2,3] Tom Kosatsky, MD, MPH [2,3]

Author Affiliations

[1.] School of Population & Public Health, University of British Columbia, Vancouver, BC

[2.] British Columbia Centre for Disease Control, Vancouver, BC

[3.] National Collaborating Centre for Environmental Health, Vancouver, BC

Table 1. Examples of Health Promotion Activities Practiced by EHOs in
BC

Health Promotion          Examples From EHO Respondents
Strategy

Building healthy public   * Sitting on local/regional/
policy                    provincial committees looking
                          at building policies, and
                          watershed protection.

                          * Working on the development,
                          revision and expansion of
                          bylaws (e.g., smoking, noise
                          and pesticide use). For
                          example, expanding the
                          provincial health regulations
                          on smoking in public places
                          (i.e., expanding areas where
                          smoking is banned, such as
                          beaches and buffer zones
                          around entrances).

                          * Working with organizations
                          to develop internal policies
                          (e.g., pest management in a
                          housing co-operative).

                          * Sitting on an airshed
                          coalition group as the
                          representative of public
                          health protection and the
                          health authority.

                          * Providing information at
                          municipal council meetings and
                          advocating for the passage of
                          pesticide bylaws.

Creating supportive       * Conducting routine
                          inspections of restaurants.

environments              * Working with farmers'
                          markets to ensure that food is
                          safe.

                          * Showing interest in bringing
                          healthy and safe local foods
                          into restaurants, and
                          encouraging healthier food
                          choices on menus.

Strengthening community   * Along with the Medical
action                    Health Officer (MHO), visiting
                          local municipalities to liaise
                          with communities and
                          identifying a designate in the
                          community to work with the
                          health authority; holding
                          sessions where issues were
                          raised and questions were
                          answered (re: the Public
                          Health Act).

                          * Facilitating
                          multidisciplinary stakeholder
                          meetings to develop emergency
                          response plans in preparation
                          for mass gatherings.

Developing personal       * Teaching FOODSAFE [a
                          comprehensive BC food hygiene
                          training program designed for
                          the food service industry].16

skills                    * Teaching MarketSafe [a food
                          safety training program for
                          farmers and producers who
                          make, bake or grow products to
                          sell at farmers' or other
                          temporary markets]. (17)

                          * Delivering presentations for
                          water system operators.

                          * Establishing information
                          booths at malls with the theme
                          "holiday food safety"
                          (offering information on how
                          to cook turkey properly,
                          providing thermometers).

                          * Providing handwashing
                          education in schools re: H1N1
                          prevention.

                          * Providing handwashing
                          education in restaurants.

                          * Delivering disease
                          prevention messages through
                          media interviews.

                          * Delivering education in
                          diverse community settings
                          (e.g., schools, seniors
                          fairs).

Reorienting health        * Encouraging a focus on
services                  preventing West Nile virus,
                          not just focusing on
                          recognition and treatment (a
                          'traveling road show' about
                          West Nile Virus).

Table 2. Interaction Between Health Promotion and
Enforcement as Described by Environmental Health
Officers (n=13) in British Columbia

Category                           Total (%)

Relationship between health
promotion and enforcement

  Health promotion as a part of    12 (92%)
  enforcement

  Health promotion as an            5 (38%)
  alternative approach to
  enforcement

  Health promotion as an 'add-      5 (38%)
  on' to enforcement

  Health promotion separately       3 (23%)
  from enforcement

Effect of enforcement mandate
on use of health promotion

  Enforcement mandate does not      9 (69%)
  limit use of health promotion

  Enforcement mandate does limit    2 (15%)
  use of health promotion

  Effect of enforcement mandate     2 (15%)
  on health promotion depends on
  the situation