Lifestyle, Work, and Health in the EU Tutorial Group 2 PDF

EPH 2022 - Lifestyle, Work, and Health in the EU Tutorial Group 2 Chair Scribe Case 1 Carla Rueben Case 2 Rueben Carla Case 3 Daphne Elif Case 4 Elif (Carina) Claudia C...

EPH 2022 - Lifestyle, Work, and Health in the EU Tutorial Group 2 Chair Scribe Case 1 Carla Rueben Case 2 Rueben Carla Case 3 Daphne Elif Case 4 Elif (Carina) Claudia Case 5 Leila Emilia Case 6 (recap) Emma Leila Case 7 Emilia Emma Case 8 Daphne Carina Case 9 Sébastien Daphne Case 10 (wrap up) Jakira Sébastien Case 1: Inequalities in working and behaving in a healthy way Keywords: - Health determinants - How lifestyle and work affect health. - Precede and proceed model - Different ways to deal with cancer - How different education/SES plays a role in health - Views on health (screening participation) - Work policy can affect health - Exposure to harmful substances - Behavioural factors and social factors leading to worse health outcomes - What are health promoters? Learning Goals: 1. What are health determinants? Health determinants are factors that influence an individual’s or a community’s health status. Those factors could include: The socioeconomic environment is also important (e.g. social support) Access to healthcare is also important There are different health determinant models. 1. Lalonde model (four health views a. Human biology b. Lifestyle c. Social and physical environment d. Organisations 2. Model of Bloom 3. Dahlgreen and Whitehead model 2. What is the impact of SES on Lifestyle? A social normative theory: people adopt behaviours that align with the highest level they have achieved in their socioeconomic status, rather than the average. (e.g. a person with higher education but moderate income, a person will align with the higher education behaviours). - SES shapes lifestyle through predisposing, enabling, and reinforcing factors: - Predisposing: education and values are associated with SES. You could be more likely to engage in preventive behaviours. - Enabling factors: Access to health supporting resources, safe living conditions, access to healthcare. Lower SES may be exposed to food deserts or environments that discourage physical activity.  - Reinforcing factors: social norms and peer influence, smoking is less normalised in higher SES groups. Two theories: People with a low SES have a less healthy lifestyle and live and work in more disadvantaged conditions than people with a high SES The effects of unhealthy lifestyle and living conditions and working conditions on health is larger in those with a low SES 3. What is the impact of SES on someone's profession? Several factors that could play a role: - Education access (because affordability) - Job security (higher SES tend to have more security) - Lower SES individuals face worse safety (more mental and physical risks). - Unemployability Behaviour challenge (how behaviour systems work) - Capability - Opportunity: - Motivation All of these interact, and if these aren’t reinforced through someone’s work, can lead to making behaviour complex. 4. What is the impact of the lifestyle on health outcomes? - Lifestyle factors explain about 1/5th of the relation between SES and self-related health. - Bad lifestyle means worse health. - Physical inactivity can also be linked not only to poor physical health, but also to poor mental health. 5. What is the impact of someone’s profession on health outcomes? A systematic review from Dieker et al showed that work factors were more likely to contribute to health inequalities than lifestyle factors. Occupational stress which occurs when demands don’t match a person’s ability. This can lead to negative health outcomes. Health outcomes can also be promoted through health benefits or preventative measures. Vicious cycle (unemployment -> ill -> unemployment). 6. What is the link between lifestyle and profession? What are the differences? There is a link between job related stress and lifestyle choices. High strain jobs (more stress) were more likely to engage in negative coping mechanisms (more smoking, drinking, physical inactivity), and lower stress means better coping mechanisms. Social environment of the profession (peer influence) can also influence lifestyle choices. (e.g. if everyone around your work environment smokes, then people will smoke). Differences: (none apart from the obvious) 7. Based on someone’s SES, how could factors of profession affect the health outcome? Occupational stress (can vary physical or mental). Occupational stress is becoming the single greatest cause of occupational disease. All the conditions that individuals face in their workplace can be unhealthy (such as chemicals and toxins) or repetitive motions for their workplace. Also, insurance can be connected to the workplace, so individuals with a lower SES who have no work or work without health insurance could mean no treatments, screenings etc. Resource-wise (financial), provides more ability to lead a healthier lifestyle. 8. Based on someone’s SES, how could factors of lifestyle affect health outcomes? Someone with a low SES is more likely to have limited access to healthy food, physical inactivity, and other lifestyle factors. They influence health outcomes, leading to poorer health outcomes. Unsafe neighbourhoods, and individuals with a lower SES can lead to lower health outcomes. Passive outreach accesses more higher SES people 9. What is the PRECEDE and PROCEED model? A framework for health programming. Focuses on lifestyle but also looks at wider factors. Gives importance in bottom up planning. Not just focusing on an individual themselves. Has 2 phases. - Precede - Looking at socio, educational, ecological, etc. You are looking at what the problems are - Proceed: you are looking at implementing interventions. You are looking at the outcomes as well. 1. Social assessment: you are looking at a neighbourhood. This would be bigger 2. Epidemiological assessment: focus on identifying and prioritising specific health issues. You make goals.You want to know mortality rates, etc 3. Educational and ecological assessment: you look at factors behind, (predisposing, reinforcing, and enabling). Methods such as interviews can be used. a. Predisposing: individual knowledge and attitudes, draw most heavily from the intrapersonal health promotion theories b. Enabling factors are the resources and skills required to make desirable behavioural and environmental changes c. Reinforcing factors: are those that follow a behaviour that ‘determine whether the actor received positive (or negative). 4. Administrative and policy and intervention alignment: people set up goals and objectives for an intervention, based on the first 3 phases. 5. Implementation of the findings in stage 1-4  6. 6-8 is evaluating whether the policies have worked, whether there needs improvement. To see if the goals have been reached. The model is very comprehensive, looking at different factors and not merely one factor. Case 2: Good intentions Keywords: - Difficulties in changing lifestyle (barriers) - How do good health professional develop interventions to help individuals live healthier - Complex interplay of various factors - Individual and environmental level - Behavioural mechanisms - Interventions to change bad habits or decision making - Focus on determinants of behaviour - Factors that influence behaviour on an individual and societal level - Methods or theories for behaviour change - Social support in changing behaviour (community aspect) - Habits - Impact of stress, guilt and pressure - coping mechanisms (feedback loop) - Social welfare benefit - Governmental support - Predisposed issues → address root issue not the lifestyle itself Learning goals: 1. What are the determinants (factors) of health behaviour? 8 determinants: - Intention to perform the behaviour - Environmental constraints - Skills - Perceived advantages - Social pressure - Whether change is according to personal standards - Positive emotions - Capability and self-efficacy to perform the behaviour 3 factors necessary or sufficient for producing behaviour - Intention - Skills - Environment a. What are the individual and environmental determinants? Environmental/social - Perceived outcome - Relevant reference - Barriers/facilitators - Person characteristics - Action alternative Individual characteristics - Intention  - Behavioural beliefs - Self-efficacy Theory of Planned Behaviour - People are more likely to engage in a behaviour if they feel like they will be successful - Norms within the group or society change the intention - Perceived advantages and disadvantages * lack of facilities not included Intention as the starting point of behavior - Also impacted by your environment - Intention doesn’t always lead to results (but the greater the intention, the greater the results) - Self-efficacy - intention does not always drive behaviour b. How do financial factors play a role in behaviour? - If you are you often behave in less capable ways, in turn increasing poverty - Financial concerns impacts stress, leaving less capacity - Directly impacts cognitive function and ability to perform certain tasks - Impacts time 2. If there is scarcity, how does that affect your health behaviour? - Refers to money as well as time problems - Focus on healthy behaviour is limited - Operate independently, but in some cases interact synergistically and amplifies health impacts - For the Theory of Planned Behaviour: - Scarcity in terms of time impacts self-efficacy (less perceived time to perform the behaviour) - E.g. perception of not enough time to cook → falls back to the default of eating unhealthy (preferred), bad habits - Not only present ability to cope, but own perception/mindset - Self-efficacy can be had for one thing but not the other (e.g. one might have self-efficacy for exercise but not smoking) - Apply scarcity to SES in terms of lifestyle habits or behaviour: scarcity can lead barriers e.g. to eating well or exercising - E.g.: Low SES → less income (scarcity) → lifestyle habits - E.g.; High/low SES → occupation that takes a lot of time (scarcity in terms of time) → lifestyle habits 3. How can you change health behaviour and which strategies can you use? - Behaviour change interventions: e.g. Stoptober - Behaviour patterns measured in terms of prevalence or incidence - Used to promote the uptake of clinical services - Big scale interventions  - Ecological approach: different levels to which you can change behaviour - Individual, interpersonal, community, institutional/public policy level - Social, economic, cultural, physical and policy options 4. Behaviour change wheel a. What is it? 3 components - Capability, opportunity, motivation (at the centre) - Intervention functions - Education, persuasion, incentivization, coercion, training, restriction, environmental restructuring (changing the environment), modelling (demonstrating the behaviour), enablement (financial support, new technology) - Different degrees of helpfulness depending on the determinant - 2 options - Address which determinant has deficits, chose a target group - Target all 3 determinants → interact synergistically - Important to find a balance - Policy Categories: outer layer consists of 7 policy categories that can support the implementation of the intervention functions communication / marketing, guidelines, fiscal measures, regulation, legislation, environmental / social planning, service provision - Specific policies translate to specific determinants *in comparison to Precede-Proceed model - Did not give specific interventions - Does not fit into one specific step of the Precede-Proceed Model (but similarities to e.g. step 5 - into which policy category can you implement it) - Should be linked to each other *Theory of Planned Behaviour - E.g. motivation similar to social influence and efficacy b. How can you use it? - Wheel is for changing behaviour - starts with a determinant to change - Take the centre and use separately or as part of the model c. Apply this wheel to stoptober Several interventions that fit, main ones: - Environmental restructuring - Modelling - Enablement - Education - Incentivise COM (mix of all three → targeting 3 give the highest chances of it being succesful) - Motivation - Opportunity socially, - Capability 5. What are examples to promote a healthy lifestyle? - Multiple incentives - Getting money from the government Case 3: Different perspectives Keywords: Health Promotion (ethical ?) Health Promotion Policies Health Education Individual approach vs Social, economic, and physical environments Settings approach Intervention Mapping Occupational health promotion and intervention Choice to be healthy (?) Sustainable work Levels of Intervention ( Micro-Meso-Macro) Learning Goals: 1) What is health promotion? Health promotion is the process of enabling people to increase control over and to improve their health (WHO 1984). - Health promotion is the science and art of helping people change their lifestyles to move towards better optimal health (AJHP 1986). - Addresses a broad spectrum of determinants of health, including behavioral, biological, and environmental factors. - Combinations of educational, political, regulatory, and organizational supports for behavior and environmental changes that are conductive in health The emphasis of health promotion in the Western Pacific Region is on: - Strengthening health promotion capacity (financing and infrastructure); - Promoting urban health (including healthy cities and health equity through Urban HEART); - Building other healthy settings (including schools and workplaces) and healthy islands; and - Developing health literacy Ottawa Charter → ‘Health promotion is the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental, and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment Strategies for health promotion (Heart of the Ottawa Charter) - Advocacy: for health to create the essential conditions for health; Taking a stand for/ presenting issues of certain communities - Enabling: More information, education encouraging participation; all people to achieve their full health potential - Mediating: between the different interests in society in the pursuit of health. Necessary for health Ottowa charter is achievable and represents the core values Those strategies are promoted by 5 priority action areas 1) Build healthy public policy 2) Create supportive environments for health 3) Strengthen community action for health: Empowerment, Community competence, participation, Issue selection, Creating critical consciousness 4) Develop personal skills 5) Reorient health services 2) What is intervention mapping? - Systematic framework used in health promotion and PH to develop, implement, and evaluate behavior change interventions that address specific health issues - Needs assessment: identify the health issue, understand the target population, and assess the determinants (social, behavioral, environmental) influencing the problem - Identify behavioral theories (e.g. Theory of Planned Behavior) and evidence-based strategies that will guide the intervention’s activities - Develop specific intervention components and materials, messaging, and resources that are engaging, accessible, and relevant to the target audience - Plan for adoption, implementation, and sustainability: ensure intervention is adopted by stakeholders, implemented as designed, can be sustained over time identify resources and partnerships needed for implementation, train staff, consider barriers that might affect long-term program success Steps of the Process - Individual - Interpersonal - Organization - Community - Society - Supranational 6 steps of Intervention Mapping The logic Model relates to the behavioral change model Analysis of what happening to the behaviour Determinants of behavior and you also know what could change Behavioral change wheel and intervention mapping are ways to implement change. Behavior and behavioral differences between high and low SES What kind of models and steps and how can we change that Analyzing the determinants of what we want to change  3) What is the Settings Approach to health promotion? Taking a setting approach to health promotion means addressing the contexts within which people live, work, and play and making these the object of inquiry and interventions as well as the needs and capacities of people to be found in different settings. Definition of a setting (WHO) “The place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect health and wellbeing.” Aim of the setting approach: It aims to make these settings the target of health interventions, adjusting them to better support health and well-being by considering the specific context and needs of the people within each setting​ Understanding the settings - Changing the settings - Knowledge developments - Knowledge translation Healthy Settings, the settings-based approach to health promotion, involves a holistic and multi-disciplinary method that integrates action across risk factors. The goal is to maximize disease prevention via a "whole system" approach. The settings approach has roots in the WHO Health for All strategy and, more specifically, the Ottawa Charter for Health Promotion. Healthy Settings→ key principles include community participation, partnership, empowerment, and equity. Both the Ottawa Charter and WHO emphasize on Health for All - Community - Equity - Encouraging participation 4) What kind of settings are used for the health Promotion(Give examples) - Schools - Workplaces - Hospitals - Cities and communities - prisons Different kinds of interventions - There can be different groups of setting - Differences and similarities of different kinds of settings 3 Types of interventions 1. Both group and individual interventions 2. Treatment provided by professionals or peers 3. Interventions directed to increasing network size or perceived support./ directed to building social skills to facilitate the creation of support. List of healthy Settings - Healthy Aging - Healthy Cities, Healthy Homes Important to know What kind of specific health determinants and behaviors are targeted with the intervention? 5) What (ethical) viewpoints on nudging people to different views? Whether you hold individuals responsible but also what happens in society affects individual You as an individual can make great choices still individuals need resources The model is too individualized We often have the idea that individuals are in charge of their health ( this libertarian view), but there is also a social aspect. Nudging can be effective in improving individualize health 2 objection Paternalism Someone else knows what is good for you and decides for you For example medical paternalism( We assume that individuals know what is best for them so that they will choose what is good for them) Everything starts will and actions of individual him and herself Negative freedom: (Autonomy) We don't accept interference from others because it limits our freedom Positive freedom: Freedom to pursue your interests and priorities in your life. All people need to be able to reach their goals and to reach that people should be guided Case 4: Occupational health risks: Occupational exposure to paint as an exemplary case Keywords: Occupational exposure limits (OELs) Positive effect of work environment Negative aspects of the work environment Precautionary principle Occupational health services Several occupational exposure factors: physical, ergonomic, biological, chemical Control measures for chemical use Hierarchy for control measures Personal protection vs. work protection Occupational toxicology Learning goals: 1. What are the effects of work/occupation (environment) on health? a. Positive Job motivation/ career Competencies Social aspects: social connections, sense of purpose, financial stability crucial for overall well-being, mental health Growth and development Income Physical condition Access to health promotion resources or healthcare services (insurance) Sports programs,fitness programs, mental health b. Negative Occupational cancers → asbestos, physical hazards (ionisation radiation) ○ 60M are exposed to carcinogen at work. ○ Most frequent cancers: Lung, bladder, skin, liver Occupational reproductive disorders → fertility (pesticides) Occupational lung diseases ○ Pneusinosips (dust, sun) ○ Silicosis → exposure to silicone Hearing loss Sedentary lifestyle → increase risk of obesity, metabolic diseases, mental health risks Irregular hours can affect your sleep schedule → insomnia, paranomia, etc. 2. What is occupational toxicology? Occupational toxicology is the subdiscipline of toxicology that is concerned with the health effects of chemicals encountered in the workplace. The goal of occupational toxicology is to help establish safe working conditions. Toxicology = study of the nature mechanism(s) of toxic effects of substances on living organisms and other biological systems  ○ Effect on public health The entry of chemicals to water supplies The effects of toxic vapours contaminating the environment of public places and housing complexes The presence of chemicals in land where buildings or recreational activities are planned — land contamination. Instances where there would be deliberate release of toxic chemicals, either during warfare or as an act of terrorism. 3. What are possible exposure routes of paint? (mechanism) Three major ports of entry into the body: 1. Oral (ingestion) a. food intake, accidents, smoking, eating with contaminated hands, eating food that is contaminated with toxins. 2. Dermal (skin absorption) a. paint on skin b. Eyes 3. Respiratory (inhalation) a. breathing airborne particles, spraying pesticides, working in poorly ventilated areas b. only very small particles can enter the lungs High pressure devices → injection injury 4. What are the possible health effects of solvents? Organic solvent disorder ○ Depression, anxiety, memory loss and concentration, mood swings, symptoms of dementia ○ People at risk: House painters , builders, construction workers,house painters, spray painters, boat builders, dockyard and construction workers, and dry cleaners. Fatigue, headache, dizziness → short-term effects Lung irritation, respiratory issues → long-term effects VOCs (volatile organic compounds) are gases that are emitted into the air from products or processes, they have a high vapor pressure at room temperature 5. How are these occupational exposure limits established? (Example from the lecture) Drinking and driving ○ The legal limit is different within EU countries ○ The risk may be different Dose: amount of the potentially harmful substance that is administered at one time  Exposure dose : amount of the potentially harmful substance that is present in the environment or the source from which the harmful substance enters the living organism Absorbed dose : The exact amount of the potentially harmful substance that enters the living organism and is absorbed by it Administered dose Target dose : The dose of a toxic substance that reaches a target organ Total dose : The sum of all individual doses, from all exposure routes. Toxic dose (TD) : The dose that causes adverse or harmful effects: ○ TD 0 is the maximum dose that would cause harmful effects to 0 % of the population ○ TD 10 is the dose that would cause harmful effects to 10 % of the population ○ TD 50 is the dose that would cause harmful effects to 50 % of the population ○ TD 90 is the dose that would cause harmful effects to 90 % of the population. ○ Threshold dose : The dose at which a toxic effect is first observed or detected. LD (Lethal Dose) 50 : The statistically derived dose at which 50 % of individuals will be expected to die NOAEL No-Observed-Adverse-Effect Level: the highest dose or exposure level of a substance at which there are no observed harmful effects on the test subjects NEL No-Effect Level: helps in determining a safe level of exposure or dosage for humans and animals DOSE RESPONSE CURVE Percentage response - the population, number of individuals reacting - Draw the limits 6. What is the role of occupational exposure limits in occupational health prevention? 3 steps of prevention (Literature 4.2 – page 17 - Risk management) ○ Primary prevention Elimination of toxic products, reduce noise and asbestos ○ Secondary prevention Detect people who have been exposed  ○ Tertiary prevention Minimize the consequences for people who already have the disease Focus on occupational diseases Exposure value: ○ TWAEV (Time-Weighted Average Exposure Value) - The average airborne concentration of a biological or chemical agent to which a worker may be exposed in a work day or a work week. ○ STEV (Short Term Exposure Value): The maximum airborne concentration of a chemical or biological agent to which a worker may be exposed in any 15 minute period, provided the TWAEV is not exceeded. ○ CEV (Ceiling Exposure Value) - The maximum airborne concentration of a biological or chemical agent to which a worker may be exposed at any time. 7. How do you interpret the occupational exposure limits for solvents in paint? Long-term exposure is bad for respiratory diseases Look into the concentration rather than the working hours of the painter Apply safety measures ○ Body smell detectors ○ In factories → Different smell sensors A Material Safety Data Sheet (MSDS) is a document that lists information relating to occupational safety and health for the use of various substances and products. ○ It is developed by manufacturers and includes brand-specific information such as physical data, health effects, first aid, reactivity, storage, handling, disposal, and so on. ○ Is a widely used system for cataloguing information on chemicals, chemical compounds, and chemical mixtures ○ The MSDS lists the hazardous ingredients of a product, its physical and chemical characteristics (e.g. flammability, explosive properties), its effect on human health, the chemicals with which it can adversely react, handling precautions, the types of measures that can be used to control exposure, emergency and first aid procedures, and methods to contain a spill. 8. What are possible control measures to reduce occupational exposure? What is the hierarchy between these measures? Hierarchy of Control Measures: systematic approach to minimising or eliminating workplace hazards and associated risks. - This approach categorises various control measures in order of their effectiveness, from the most effective to the least effective. 1. Elimination 2. Substitution 3. Containment 4. Work methods 5. Personal protection 1. Hazard Elimination or Substitution - Elimination completely removes the health risk. For example, removing carcinogens like asbestos or benzene from work processes. In cases where total removal isn’t feasible, methods like coating or changing particle size (e.g., pelletizing) help reduce exposure.  - Substitution replaces a hazardous substance with a less toxic one. For example, using a less toxic solvent in degreasing or switching to intermittent processes can reduce exposure. 2. Engineering Controls - Controls such as automation, enclosure, ventilation, and isolation prevent hazards from reaching workers. Improved ventilation systems (e.g., negative pressure ventilation in healthcare) effectively reduce airborne contaminants. - Isolation involves creating barriers between workers and hazards, like enclosing noisy equipment. Suppressing dust by wetting and redesigning work practices (e.g., vacuuming instead of blowing dust) further reduces exposure. 3. Redesign of Workstations and Processes - Ergonomic adjustments, such as proper equipment placement and providing rest periods, reduce repetitive strain and improve comfort, especially for computer operators. Adjustments in workstation design can help prevent visual strain and musculoskeletal issues. 4. Administrative Controls and Worker Education - Administrative controls limit exposure duration by job rotation, rest breaks, or restricted hours in hazardous areas. Rotating between physical and mental tasks helps balance workload and improves well-being. - Training equips workers to identify hazards, understand safety protocols, and follow personal hygiene practices, like using separate facilities for eating, to minimize ingestion of toxic agents. 5. Personal Protective Equipment (PPE) - PPE, such as respirators, gloves, and earplugs, is used as a last line of defence. It is critical for short-term or emergency exposures but is less effective than engineering controls. Proper selection, training, and maintenance of PPE ensure its effectiveness, though compliance may vary due to discomfort. Source: Oxford Textbook of Global Public Health  9. Apply to the case. Related to CASE 1 SEP and lifestyle ○ How professions affect health outcome Case 5 - Healthy@work: interventions at the workplace Keywords: - Interventions - Workplace interventions - Promotion and prevention of health risks - Work environment interface - MSD musculoskeletal disorders - Risk assessment and evaluation - Evidence based intervention Learning goals: 1. What are musculoskeletal disorders (MSD’s)? Injuries or dysfunctions affecting muscles, nerves, bones… tissue injuries, cause can be due to physical activity at work. Causal relationship between physical exertion at work and work-related musculoskeletal disorders (WMSD) WMSD is the most expensive form of work disability Workplace MDS’s: mostly cumulative, resulting from repeated exposure to loads at work over a period of time. Upper limbs (the hand, wrist, elbow, and shoulder), the neck and lower back are particularly vulnerable to MSDs. They are also episodic. Types: episodic,transient, persistent/irreversible, specific or non-specific. Osteoarthritis, lower back pain, strains in general. Blue-collar and white-collar workers. Blue-collar workers are 20 times more at risk. Risk for male workers is higher than female workers. Risk increases with age (55-64 years). But the type of MSD differs between these groups. ○ Sedentary injuries, lower back pain, neck pain more in white-collar workers. MSD comprises different diagnosis and they have different causes, cna be depending on your work. Incidence highest in mining etc., but highest amount of complaints among healthcare workers. Mental stress: ○ Stress and job dissatisfaction increase risk of MSD. ○ Muscular tensions increase with mental stress. ○ How you feel pain can be affected by your feelings (stressed people may experience pain more often) a. Prevention measures for MSD (at workplace)? Pre-employment examination: are applicants suitable for the intended job, are they at risk. Ergonomic designs, equipment should minimize risks Risk assessments. Medical examinations: prevent developing occupational diseases (noise, other hazards) Four directives: 1. Minimum health and safety requirements for the manual handling of loads,where there is a risk, particularly of back injury to workers i. 2. Minimum safety and health requirements for work with display screen equipment i. 3. Minimum health and safety requirements regarding the exposure of workers to the risk arising from physical agents(vibration) i. 4. Introduction of measures to encourage improvements in the safety and health of workers at work Vibrations: hand power tools all day is bad for the whole day. Rehabilitation Cognitive behavioral interventions → reduce stress, burnout b. What are risk factors of MSD? Biomechanical: correct positions, heavy lifting, repetition of work, heavy physical work, vibration, computer work, cold environment Individual: age, physical fitness, pre-existing health conditions, obesity, prior injuries, gender, smoking, high BMI, sedentary lifestyle Psychosocial: stress, job demands, low level of work satisfaction and support, low level of job control, mental strain can increase physical strain. c. What are determinants of MSD? Blue-collar employees experience more MSD Leisure activities Level of autonomy and support from co-workers Males/females are more likely to get MSD, but depends on the work you do, gender affects the job you are more likely to do, but women generally work less than men. Complaints increase with age Migrants are vulnerable population - 3D (dirty, dangerous, demanding) jobs d. Provide examples of interventions for MSDs. Education and training of employees, proper lifting techniques, awareness of symptoms, offer access to physiotherapy or health programmes. Medical support and rehabilitation Workplace made more ergonomic Regular work hours and long hours increase stress, sleep disorders and MSDs. Ensure good work-life balance. 2. What are the different types of prevention measures? / What are classifications of prevention? Prevention - Measures adopted by or practised on persons not currently feeling the effects of a disease, intended to decrease the risk that that disease will affect them in the future. The type of prevention depends on the preference, budget, need assessment performed, analysis of the problems, the priorities and risk factors.  Primary, prevent disease before it occurs Secondary, individuals have disease but don’t experience symptoms and aim is to prevent more suffering Tertiary, individuals are suffering with disease, but prevent further suffering Focuses only on prevention, not health promotion Makes it seem like primary prevention is more important than others Other classification: Universal (primary): general and for everybody (smoking cessation, immunization) ○ MSD prevention: e.g. computer reminds of a break, smart watch, company invests in proper chairs, Selective: advisable for population sub-groups, like age, occupation (flu shots for elderly) ○ MSD prevention: ergonomic mouse Indicated (secondary): should be applied for those who are at higher risk (managing high cholesterol and hypertension) ○ Sounds similar to treatment Tertiary: Preventing worse, managing disease ○ provide work, despite the illness, or adjust the work to be suitable for these people. 3. Fill out the table. Prevention The intervention Universal/Primar Selective Indicated Tertiary aimed at: y Work Reducing Stress-mana Cognitive Psychothera environment: workload gement therapy py Interface: Encouraging Team-buildin Advising for Mediation environment g employees, for hostile psychologist workplaces Individual/team: Job control Task Vocational Conflict distribution rehabilitation managemen t  PRIMARY SECONDARY TERTIARY Individual (or group of Lifestyle-programme Cognitive therapy Psychotherapy individuals) Didactic stress Relaxation management Tai Chi Interface Time-management Stress management Specialised counselling individual/organisation Participative leadership Coping strategies Employee assistance Training Coaching and programmes consultation Organisation/department Job redesign Conflict management Institutionalised Task enrichment Flexible work occupational healthcare Improving job control schedules Vocational Organisational procedures rehabilitation 4. What kind of prevention measures to prevent health risks at workplaces? a. What are evidence-based interventions? b. What kind of factors can interventions be focused on? c. Advantages and disadvantages of the mentioned interventions? Some prevention/intervention are seen as more important than others. Improved employee health, increase productivity Costs of implementing environment change, time management. Most interventions could be cost-effective d. How to select workplace interventions? What kind of phases to implement workplace interventions? Risk assessment, what are risk factors, what needs to be tackled. E.g. If back pain is a common issue your intervention would perhaps focus on an ergonomic solution. Cost-benefit analysis Surveys, interviews to identify hazards Determine the social determinants of diseases PDCA 5. Select and describe a suitable intervention for Eurocity. Implement something to reduce the strain on nurses, ergonomic equipment, mandatory training for proper lifting method Tackle harassment, anti harassment policies Guard, conflict management, training how to deal with violent people Employer should be against violence, protect safety of employees Case 6: Wrap up & reflect - Prepare short presentations in which you summarize the core and main messages - Focus on one case and make connections between the topics of case 1-5 - Include one critical question or statement - Keep the macro-meso model in mind Group 1 (case 1) : Claudia, Sébastien, Carina EPH 2022 - Case 1 - Presentaciones de Google Group 2 (case 2) : Rueben, Emilia https://docs.google.com/presentation/d/1jmIpnd3nqYUi76VuNHUQdeeR8EwWOjqmZCTwW 14lQG0/edit?usp=sharing Group 3 (case 3): Emma, Carla https://docs.google.com/presentation/d/1AaASPHbeWH65-NyriHV1IBYT6QG3msMSauu1R 6F-Ozc/edit#slide=id.g315f024d265_0_0 Group 4 (case 4): Jakira, Elif https://www.canva.com/design/DAGWxPK9mLk/QcC9DOsOsq1yzqxdnCwQ_w/edit?utm_co ntent=DAGWxPK9mLk&utm_campaign=designshare&utm_medium=link2&utm_source=shar ebutton Group 5 (case 5): Leila, Daphne https://docs.google.com/presentation/d/1qj0JMUFwNyX0nZvcg-XM3BuN1fWYEePHybZNRY wPC8A/edit?usp=sharing Case 7 - EU law and policies for occupational health and safety Summary: - Case is about EU law and different policies - how to protect EU employees’ health Key words: - Soft policies - campaigns - Hard vs. soft law - Legislation - Framework Directive 89/391/EEC in 1989 - Safety - Goal-oriented directives (such as the Framework Directive 89/391/EEC in 1989 - Prescriptive Directives (such as some of the individual directives) - Luxembourg Declaration on Workplace Health (this is an example of a soft policy)  - Subsidiarity - Two different campaigns: - Prevention of musculoskeletal disorders - Risks and opportunities of the digitalization of work - Occupational health-route (DG EMPL) - public health-route (DG Santé) - ‘Acquis’ -> property status - OHS (Occupational Health and Safety) Learning goals we come up with on our own: 1. What is hard law and what is soft law? a. What is the distinction between goal-oriented directives and prescriptive directives? b. What is the subsidiarity legislation? 2. How have workers’ rights changed in line with the different policies (the Treaty of Rome (1957), Single European Act (1987), etc.) 3. What are the two campaigns in the text: a. Prevention of MSD (lighten the load) b. Risks and opportunities of the digitalization of work (safe and healthy work in the digital age) 4. What are the ‘occupational health-route’ (DG EMPL) and ‘public health-route’ (DG SANTÉ) and how do they improve workers' health? Learning goals provided by the tutor: 1. What kind of legislation exists in Europe with regards to occupational health and safety (OHS)? - Directive 89/391/EEC OSH Framework directive - aim: encourage the improvement in safety and cultivate an environment of prevention in the working environment - Encompasses all sectors of activity - public and private(no armed forces, no police no civil protection forces) - Covers all risks posed to workers safety and health - physical, - Avoiding risk - Obligations to employers(aritcle 8): risk evaluation, protective measures, task allocation, consultation and prevention, emergency preparedness(having first aid/fire extinguishers, signs for fire exits, training employees on what to do when an emergency breaks out), accident records, worker involvement, training - Obligations for workers(article 13): proper equipment use, hazard reporting, cooperation - Fact sheet 80&81- addresses the issue of risk assessment in the EU  2. What other policy tools are used by the EU with regard to OHS? (guidelines, standards and softer tools like campaigns) The Strategic Framework on health and safety at work 2021- 2027 The EU Strategic Framework on Health and Safety at Work 2021-2027. Announced in the European Pillar of Social Rights. Aim to identify priorities, inform the development of OSH practice and policy (in digitalisation, green job, psychosocial risks), easy-to-use resources for prevention. Three aims: 1. Anticipating and managing change in the context of green, digital, and demographic transitions. 2. Improving the prevention of work-related accidents and diseases, striving towards a Zero approach to work-related deaths. 3. Increasing preparedness to respond to current and future health crises. osha.europa.eu - this website provides of an overview of all healthy europe campaigns 3. Which EU regulation relates to indirect effects on health? (example -> DG Santé) - Reach regulation - limits the exposure to harmful chemicals to employers and workers - Work-life balance safety - Luxembourg declaration on workplace health promotion 4. How are the OHS regulations and policies implemented in the different MS? Which factors affect this implementation (descriptive legislation vs goal oriented legislation) - OHS legislations have to be transposed into national law of member states. The implementation differs based on different factors - Descriptive legislation (germany) - Goal oriented legislation (scandinavian countries) Chapter 3 EASHW report 5. What are the two campaigns in the text: a. Prevention of MSD (lighten the load) i. Raise awareness for MSD and the need to create a culture of prevention ii. Workplace risk assessment: preparing assessment and implementation of preventative approach: workplace factors(ergonomics), work organisation, psychosocial factors, worker training b. Risks and opportunities of the digitalization of work (safe and healthy work in the digital age) i. Safe and healthy work on the digital age  ii. Digital platform work, automation of tasks, remote work, AI and worker management, smart digital systems iii. Aim is to raise awareness about the impact of new digital technologies on work and workplace 6. What is the effectiveness of these policies and tools? Which policies are most effective? Hard or soft? Or do they complement each other? Different results in different MS: - Greece, Ireland, Portugal, Spain, Italy, Lux there were considerable consequences since these countries had inadequate national legislation on health and safety. - Austria, France, Germany, UK, NL, and Belgium, the directive refines existing national legislation. - Denmark, Finland and Sweden, no major adjustments, since there already was national legislation in place in line with the directive. Hard policies: provide a minimum set of rules that everyone needs to follow in each country. Can be inflexible a slow to adopt Soft policies: suggested but not enforced. Good for rising awareness but lack legal authority 7. What is the added value of these harmonized EU legislation? Is occupational health indeed an international issue that exceeds international boundaries? - Consistency: Harmonized legislation ensures a uniform level of worker protection across member states, reducing disparities - Yes it is, considering there is a campaign regarding digital aspects of work, traveling for work. It's good to know that workers are protected across international boundaries Case 8 - Policy and regulation the EU on lifestyle Keywords: - Smoking - tobacco - Policies on lifestyle - Directives - 2006 EU alcohol strategy - 2014 Tobacco products directive (2014/40/EU) - Advertising directive (2003/33/EC) - Alcohol - Nutrition - Physical activity - Pressure from lobby groups - Country specific policies / one-si ze-fits-all approach  - Taxes depending on EU-member state Learning Goals 1. What are the current directives on tobacco, alcohol, nutrition and physical activity? - Tobacco: - Tobacco Products directive (2014/40/EU): manufacturing, presenting, product regulation (ban cigarettes with certain flavours), regulations on E-cigarettes - Limiting advertisements on tobacco products - Definition Directive: hard law published by the EU. “A "directive" is a legislative act that sets out a goal that EU countries must achieve.” - Alcohol - It’s currently included in the “Europe's Beating Cancer Plan 2021” - Past: “EU Alcohol 2006-2012” was stopped. Supposedly because of lobbying. - There were multiple attempts to introduce new Alcohol directives, but they were all stopped - 2024: proposition of putting health labels - Consumer product information - 1993: mandatory labelling of products with < 1.2% alcohol - 2005: mandatory labelling of allergens - Labelling of ingredients and nutritional value on alcoholic beverages There are not many mandates on public health, the EU has to use the internal market or mandates on other topics 5. What are commercial determinants of health? (CDoH) Commercial determinants of health (CDoH) describe the population health consequences arising from for-profit actors and activities, as well as the social structures that sustain them. Approaches and strategies to mitigate the harmful health effects of CDoH: ○ Behavioral change: Modify behavior of consumers to reduce exposure to harmful effects of commercial practices. i. It is the most widely used ii. Interventions aim to educate people on the risks from consuming tobacco, alcohol, and highly processed food products and to encourage alternative behaviours to mitigate those risks. ○ Regulation of market and nonmarket business practices: Use regulation to change behaviors of commercial actors. ○ Fiscal policy strategies: Use public spendings, taxes, financial incentives, and subsidies to alter commercial practices. ○ Consumer and citizen activism: Mobilize populations to put pressure on elected officials or businesses to take actions that reduce harmful practices. ○ Litigation and other legal remedies: Use the courts and legal system to force commercial actors or government to end harmful practices and determine liability. Market strategies are actions that businesses take to maximize return on investment, revenues, profits, shareholder value, and market share. Nonmarket strategies are actions that businesses take to exert political and economic influence in ways that create and sustain favorable operating environments. - Overall the CDoH negatively affect health (e.g. 80% of supermarket food is found unhealthy)  Case 9: Everything is connected to everything else Problem definition/what this case is about: Health inequalities within EU countries/citizens and how this is connected to the EU’s mandate Keywords: - Diderichsen (and colleagues) theoretical framework on differential vulnerability and susceptibility - Ecological model (beginning of the case) - Explains how things are interconnected -> what this case is about - Implementation variability - OSH directives - Diverse national policies - Socioeconomic disparities - Historical health influences - Medical anthropology Learning goals: 1. Why is it difficult for MS to adopt the 24 OSH directives? - Limited resources of countries - OSH are not the priority with regard to more important issues - Cultural differences between countries - Weak enforcement mechanisms - Easier to implement the directives among bigger companies within countries - So harder for smaller companies 2. How do the differences in legislation regarding MS lead to unequal health outcomes? - Soft law leads to unequal health outcomes, because bigger/more wealthier countries with the resources are more likely to adopt the soft laws instead of the less wealthier countries - Differences in how the MS adopt the directives, leading to different rules, leading to different health outcomes, so inequality - Different kind of risks in the different MS, so the MS only include laws that address their own issues Martijn: - Differentiated policy implementation -> DPI - Source 3: Differentiated policy implementation in the European Union - Important to look into this source (page 17) - Particularly “patterns and drivers of DPI in the EU” (page 28) 3. What is the Diderichsen theoretical framework on differential vulnerability and susceptibility? - Differential exposure: how risks are distributed unevenly among social groups - Differential effect: how social positions interact with risk factors, so making some groups more vulnerable than other groups - Differential vulnerability and susceptibility - Theoretical framework of 8 questions to help a dialogue between researchers and policy-makers: 1. What prevalent exposures are both unequally distributed across socioeconomic positions and have substantial causal health effects supported by robust epidemiological evidence? 2. What are the major causes of the unequal consequences of disease? 3. What and who drives the unequal distribution of exposures, such as those in question 1? 4. What and who drives the inequalities in the consequences of disease? 5. What is the intervention evidence on policies that reduce inequalities in disease incidence? 6. What intervention evidence is there for effective policies that might reduce inequality in disease consequences? 7. What is the implementation evidence that the preventive policies actually reduce unequal exposures? 8. Are clinical interventions being implemented equitably to reduce inequalities in disease consequences and why (not)? - Different policy strategies when you want to reduce disparities - 3 strategies: (source: Differential vulnerability….. Finn Diderichsen et al.) - High risk strategy: focus on individuals at a high risk - Downside: benefits those with better access to resources (for example from a higher SES) - Population strategy: applies to the entire population (for example tobacco taxes and pollution laws) - Downside: could widen inequalities, maybe less effective for the most disadvantaged group - Vulnerable population approach: target group is those with a high vulnerability - Impact of preventative program: - Differential exposure: How well programs reach different population groups - Differential effectiveness: how interventions affect exposure to risks in different groups - Differential capability: - Differential susceptibility: a. Can the Diderichsen framework be applied to reduce health differences between and within EU member states? - Yes, identifying different issues and implement preventative strategies - Between MS: important to identify disparities and try to reduce these disparities - Make sure there are targeted interventions for most vulnerable group - Identification of the root issue is most of the important parts of the framework - DPI: Differentiated Policy Implementation - How can DPI be conceptualized, and how does this concept relate to and add to the field of EU implementation studies? - What is the relationship between differentiated integration and DPI in the EU? - What patterns and causes of DPI can be observed? - What are the consequences of DPI for the effectiveness and legitimacy of the European Union? b. If yes, how should EU health policy change going forward? - See question 3a. c. If not, what other frameworks or approaches can be used to advise health commissioners? - / -> because the answer was yes 4. Propose strategies to improve the implementation of EU health directives to ensure more equitable health outcomes across the member states? (consider both national and EU level interventions) - Combination of the strategies (high-risk strategy, population strategy, vulnerable population) - Sometimes interventions are effective for the whole group, but can make the gaps between groups even more bigger Tutor: - Is increasing taxes on tobacco effective and does it lower inequalities between high and low SEP? - Evidence is that taxes are effective and reduces inequalities in health outcomes, but perhaps it increases other inequalities Diderichsen F. (2021). How did Sweden Fail the Pandemic?. International journal of health services : planning, administration, evaluation, 51(4), 417–422. https://doi.org/10.1177/0020731421994848 Case 10: Wrap up Presentation distribution: Case 7: Sébastien, Emilia, Daphne, Carina https://www.canva.com/design/DAGZAYjnqXY/jMlKHZM7kEeP27w-n2iY1w/edit?utm_conten t=DAGZAYjnqXY&utm_campaign=designshare&utm_medium=link2&utm_source=sharebutt on Case 8: Leila, Claudia, Jakira, elif ​https://docs.google.com/presentation/d/1yLP_whV4OXNG0FvTGOosXVLpYHFUA92Rifw2u BzugmE/edit?usp=sharing Case 9: Rueben, Carla, Emma https://docs.google.com/presentation/d/1ZT3WS7r6uyQ4efeZ_zSddQPNc-NET4S1cIkdskTe Jhg/edit?usp=sharing → Every group should present two (new) examples of how determinants of individual health at the micro, meso or macro level Wrap Up of the Course Lifestyle, Work and Health in the EU (2425-EPH2022) Case 1 + Lecture 1 - Lifestyle definition (Matt Commers lecture): A set of health-related behaviours specific to an individual or social group that emerges through a complex interrelationship among voluntary (chosen), biological, and environmentally-induced factors Precede-proceed model  - Definition: preceed = stages 1-4, proceed = stages 6-8, stage 5 is implementation - Why was it developed? There was no standardisation, no regular process of implementation, HARMONISATION, now you cannot do anything without it, increased credibility and validity (operationalisble) - Strengths: comprehensive framework, covers all stages of planning/implementation and action; evidence based approach, data driven; involves the community; flexible → applixcable in different contexts (eg. home, hospital, etc): can look at multiple factors at the same time - Weaknesses: resource intensive ( need time and expertise) for the preceed part; depends on accuracy of the data; complex - What is used for? To design, implement and evaluate health programs - Bottom up planning: not just looking at the individual themselves, but also looking at the environment of the individual; working with the community (bottom up approach/participatory approach) - Precede: predisposing, enabling, and reinforcing constructs in an attempt to understand the community:; looking at the health determinants and the risk factors (predisposing, genetics, behavioural) - Proceed: implementation in which you are engaging the community and also evaluating the intervention in the real life setting (evaluating the intervention) - Main goal: improving the quality of life - Application example: diabetes → 4 interventions - Community, healthcare workers home visits - Need to know terms: predisposing, enabling, and reinfrocing Five important approaches:  1) Socio-ecological: particular emphasis on the impact of physical, social and political environments on population health. 2) Population-centered: rather than focused on individuals, it is a public health theoretical framework, with health behavior change embedded within it. 3) Participatory: involving citizens in identifying, assessing, and addressing their community’s health and quality of life issues. 4) Quality of life focused: rather than behavior change or even health oriented. 5) Grounded: on experience from the field with ongoing revisions and refinements. 8 phases ○ 1-4: precede Preparatory Looking at what planning needs to be done ○ 5-8: proceed Implementation Focus on action and evaluation (going from planning to practical) ○ Phase 8: “big picture” evaluation ○ They want an “evaluation” after each phase to ensure that it remains on track Predisposing factors: factors that incline individuals for a particular behavior. ➔ Knowledge ➔ Beliefs ➔ Values ➔ Attitudes ➔ Confidence ➔ Capacity Enabling factors: resources, and capabilities that make it possible for individuals to perform. ➔ Availability of health resources ➔ Accessibility to health resources ➔ Community/government/law priority and commitment to health ➔ Health related skills Reinforcing factors: rewards and feedback that influences the persistence of a behavior. ➔ Family ➔ Peers ➔ Teacher ➔ Employees ➔ Health providers ➔ Community leaders ➔ Decision makers  ​Explanations for socioeconomic health inequalities - Less money - Chronic stress (direct health consequences such as cardiovascular disease, sleeping problems, anxiety + prefrontal cortex works less well, which causes problems with planning, setting priorities, and impulse control). - Different social networks (less healthier behaviors, less resources, less social support) - Perception of lower status (relative depravation, demotivates to take control, lease to lower self0efficacy, self-stigmatization) - Growing up, living, and working in less health environments Causation Selection process: When you have lower health, you might continue to get lower health due to not being able to increase your SEP. Indirect selection = other factors e.g. genes Selection = you get a less good job due to less good health Mediation = someone’s SEP influences their work characteristics and health Moderation = e.g. work characteristics influence someone’s health depending on someone’s socioeconomic position ​How to decrease health inequalities? Individual level solution: - Redistributing the crates. - Helping people find the crates (improving reach). - Helping people get on the crates (improving support). Population level solutions: - Finance systems for crates. - Regulations that ban or limit fences. - Restricting the influence of the fence industry. Both types of solutions are needed to decrease inequalities We need not only individual level solutions, but also population level solutions. Different ways to decreases SES inequalities, we can 1. Create mental space 2. Remove barriers  3. Make it more attractive 4. Need more active promotion. ​1. Group support - Creating social support is important for people with a lower SEP. - Therefore, group support is preferred, this can also be offered at the workplace. - For group support there should be clear guidelines for people who relapse 2. Professionals - Professionals need the right attitude, knowledge, and skills. - Besides training for smoking cessation and training in motivational interviewing they also need: training in dealing with resistance, and training in communicating with low-literate people. - Very important is a non-judgmental and respectful attitude 3. Connecting - Interventions should connect well with the target group, for example by involving them in the development of the intervention. - Connecting is easier with a group with similar people, e.g. colleagues. - Professionals (and interventions) should be flexible and have a learning attitude. - Using experts by experience in the intervention can help to increase the connection 4. Materials - Materials should be simple and also suitable for people with low-literacy, for example picture books or audiobooks. - Develop materials together with the target group and test materials. - Consider whether a work book, powerpoint or homework are really needed 5. Incentives - Use (financial) incentives for quit success! - The incentives cannot be a replacement for good support, they are extra. - A large randomized study at Maastricht University in workplaces showed that a - Financial incentive of 350 Euro increased quit success significantly. It was also effective among people with a lower income and lower educational level, possibly even more effective. - Also non-monetary incentives are an option: an applause, certificate, pin or coin if you have not smoked in the past week/month/year. 6. More intensive - Support for people with a lower socioeconomic position should be more intensive than regular smoking cessation support, especially at the start. - For example a combination of weekly group meetings, individual support and WhatsApp contact. - Support is offered ideally a year long (regular programs are often 8-10 weeks) 7. Stress and help - It is important that participants learn to deal with stressful situations during the intervention. - Professionals should be able to listen well and should have attention for other problems that people may have. - Besides listening they should also use warm referrals to someone who can help with the other problems. Important notes for case 1: - Work factors: explain 1/3 of socioeconomic inequalities - E.g. People with low SES have more stress = bad health - This means that work-related factors, such as employment status, job type, job security, income, working conditions, and occupational stress, account for about one-third (33%) of the differences in health, wealth, or other socioeconomic outcomes between different groups of people. For example, people in low-income or unstable jobs may face higher levels of stress, have less access to healthcare, or experience worse health outcomes, contributing significantly to overall socioeconomic inequalities. - Lifestyle: explain 1/5 of socioeconomic inequalities - This suggests that lifestyle choices, such as diet, exercise, smoking, alcohol consumption, and other health behaviors, account for about one-fifth (20%) of the differences in health or socioeconomic outcomes across different populations. For instance, people from lower socioeconomic backgrounds may be more likely to engage in behaviors that negatively impact health, such as smoking or poor nutrition, due to factors like stress, lack of education, or limited access to healthier options. - Attributable to genetics Health inequalities and unemployment: Three ways in which unemployment affects health: 1. Financial problems result in lower living standards, which may in turn reduce social integration and lower self-esteem. 2. Unemployment can trigger distress, anxiety, and depression not only among the unemployed themselves but also among their partners and children.  3. Unemployment can impact on health behavior, being associated with increased smoking and alcohol consumption and decreased physical exercise. Overall conclusions: - There are large health inequalities among people with a lower socioeconomic position having more diseases, living shorter, and shorter in good health - Unemployment and precarious work are more common among people with a lower socioeconomic position and are unhealthy. This can cause a negative spiral of vulnerabilities. - We should not only focus on making effective health promotion interventions, but also on making sure that everyone can reach those interventions. - A lot of things should be considered when tailoring or developing health promotion interventions. You cannot think of all those things yourself, so ask the people themselves to give you input (qualitative research) and/or to help you developing (co-creation). - We should look at both individual level solutions and population level solutions and we need them both at the same time (a comprehensive approach). We also need to consider politics, finances, systems, and the environment, not just the individual health behavior. Case 2 Defining health behaviours: Health behaviors are actions taken by individuals that impact their health status, either positively or negatively. Examples include behaviors that promote health, like balanced eating and regular exercise, as well as those that increase health risks, such as smoking, excessive alcohol consumption, and unprotected sexual activity​ - Used when: neeed to evaluate an intervention - Steps 1-4 are preceed  - Step 5 is proceed 1. First step typically done by epidemiologists 2. Step two: of the existing problem, what is the cause? 3. Step three: if you know the causing behavior the next step is to understand the determinants of the behavior. Why is it, that people behave in such a way? E.g. knowledge gap in COVID crisis. 4. Step four: Intervention for this behavior 5. Step five: implementation Theory of planned behaviour - Aims to understand the behaviour of an individual - What influences the behaviour? Main question. Answer Intention - People are more likely to engage in a behaviour if they will be successful → intention: - Attitudes: beliefs about the outcome of the behaviour. - Subjective norms: perceived social pressure to (not) perform the behaviour. (e.g. no one around you goes to the gym, why should I) - Perceived control: the perceived ease or difficulty of performing the behaviour - Eg. exercise → a person is overweight and wants to go to the gym The model does not take into account factors outside of intention. - Eg. Someone planning to increase their physical activity might have a positive attitude toward exercise, feel encouraged by friends (social norms), and believe they have the time and ability (perceived control) to work out Influence on behavior  - Economic environment o Energy dense food is cheaper - Cultural environment o Healthiness or preferred foods differ across countries - Policy environment o E.g. Cycling plan (money support if you buy a bike) - Physical environment o Portion size o Neighborhoods you grow up in - Social environment o Modelling (we sometimes model other people’s behavior, sometimes we are even unaware of that!) - Obesogenic environment o Different types o Different levels Health belief model - Definition: proposes that behaviour is influenced by personal beliefs about health resists, perceived benefits and barriers, and self efficacy - eg. A person may start using sunscreen after understanding their personal risk of skin cancer and the benefits of prevention. They perceive the severity and susceptibility as high, and the barriers (such as cost or inconvenience) as lower Factors Influencing Behavior and Behavior Change According to the health belief model, two major factors influence the likelihood that a person will adopt a recommended health protective behavior. 1. First, individuals must feel personally threatened by the disease (i.e., they must feel personally susceptible to a disease with serious or severe consequences). 2. Second, they must believe the benefits of taking the preventive action outweigh the perceived barriers to (and/or costs of) preventive action. ANGELO FRAMEWORK It is an example of an ecological approach to obesity related behaviors - Targets Micro-Macro level settings of Physical, social, cultural and political environments that influence the behaviors related to obesity. - Micro level → SETTINGS for the food environment these are: homes, workplaces, schools, and neighborhoods - Macro level → SECTORS for the food environment: healthcare systems, food production, and urban and rural development. - For each of the categories (socio-cultural, economic, political…) we can find MICRO and MACRO levels that have to be addressed. ANGELO (obesity) uses four broad ‘domains’: Physical, Economic, Legislative and Socio-cultural, as well as two ‘scales’ of intervention: ‘Macro’ for the national, regional or sectoral level and ‘Micro’ for the local neighbourhood/community/institutional level. Social-cognitive theory: From the perspective of social cognitive theory, the initiation and persistence of an adaptive behavior depends on beliefs of self-efficacy and outcome expectancies. That is, in order to perform a given behavior individuals must 1. believe in their capability to perform the behavior in question under different circumstances and  2. they must have an incentive to do so (i.e., expected positive outcomes of performing the behavior must outweigh expected negative outcomes). Incentives may involve physical outcomes, social outcomes, or self-sanctions COM-B Model At the centre of the BCW is the COM-B model, which stands for Capability, Opportunity, and Motivation as the primary factors that drive Behavior. For behavior change to occur, all three components must be addressed: Capability (C): This refers to an individual’s ability to engage in the behavior, both physically (e.g., strength, stamina) and psychologically (e.g., knowledge, skills). ○ Example: To encourage people to cook healthy meals, they must know how to prepare nutritious recipes (psychological capability) and have the necessary kitchen skills (physical capability). Opportunity (O): These are external factors that allow or enable the behavior. Opportunity can be physical (e.g., availability of resources, access to facilities) or social (e.g., cultural norms, social influences). ○ Example: If a community has a gym nearby, individuals have the physical opportunity to exercise. Social support, like friends joining workout sessions, provides social opportunity.  Motivation (M): This involves both reflective motivation (conscious intentions, beliefs, attitudes) and automatic motivation (emotions, impulses, habits) that drive behavior. ○ Example: A person’s belief in the importance of exercise (reflective) and the habit of going to the gym regularly (automatic) can motivate them to exercise consistently. Key Insight: To change behavior, interventions need to enhance capability, create opportunities, and build motivation simultaneously. What are the 3 types of scarcity? S ​ carcity is the feeling of having less than is needed, an assessment that takes into account the resource's amount and the demands placed upon it. → difficult to define in any fixed way because it is socially contextualized and relative Because income and time are resources linked to social structure, both types of scarcity are socially patterned: - time scarcity: most prevalent among low SEP; little to no time due to inflexible working hours for example - Resource scarcity: When people have limited financial resources - Joint scarcity: simultaneous occurrence of resource scarcity and time scarcity, where limited resources and time constraints exacerbate each other Our key results are as follows: (a) both income and time scarcity constraint healthy behaviours, particularly physical activity (b) the health influence of income scarcity strengthens if it persists, whereas the influence of time scarcity appears to be more immediate, showing only a weak increase with longer spells (c) time scarcity amplifies income-based constraints on healthy behaviours. Although time and income scarcity operate independently to constrain healthy choices, when they combine (one in ten people) they synergistically add to the risk. Case 3 Ethics and Health promotion - paternalism: someone higher up knows what’s better for you and will try and push you towards the healthier behaviour (e.g. Doctors) - manipulation: altering the decisions that the people make (contradictory) What is nudging? - nudging: a (un)friendly push to Strive people towards a (un)healthy behaviour - eg. Position of the snacks at the checkout in the grocery store - Nudging refers to subtle interventions that encourage people to make certain choices without restricting their freedom. A "nudge" gently steers individuals toward healthier or more beneficial options by designing the environment or presenting choices in a way that promotes better decision-making. - Negative nudging affects you psychologically → seeing healthy products that a person could not afford and could negatively impact someone. 🦅🦅🦅 What is banning? - Ethical aspect: FREEDOMMMM - restricting access to a product: people should have a choice in accessing - Eg. In NY they were trying to ban a 2L bottles of soft drinks —> as a result people stopped What is coercion? - bad nudging - can be criminal - compelling a person to do something FORCIBLY or THREATS  - Eg. Your kid cannot go to school if they are not vaccinated (in France nationwide) What is positive and negative freedom? - negative freedom - interfering with the individual freedom as little as possible - positive freedom - reaching the freedom of others through enabling them to realize their (health behavior related) potential and capabilities via societal collective action What is an (adapted) intervention mapping approach? 1. Need assessment: check whether there is a public health need for an intervention a. problem identification b. =>The program-planning group analyzes health issues by examining related behaviors, environmental conditions, and factors influencing these behaviors and conditions. This helps clarify which behaviors and environmental conditions need change and guides planners in defining specific goals and outcomes in the next step. c. high healthy behaviour 2. Identification of program outcomes and objectives a. environmental and/or behavioural b. risk awareness -> before we outline the outcomes, we need to see the possible risks that are present c. high self efficacy 3. Selection of theoretical methods and practical strategies for program design a. what frameworks we can use b. What is available knowledge? 4. Planning the evaluation a. integrate the community (community based project) b. co-creation c. setting d. What are the ethical concerns? 5. program implementation plan a. planning how the program will be delivered and maintained b. dynamics (how the intervention is working in different settings) c. promotion (how to make it attractive, how to support individual needs) 6. evaluation plan  a. assessing the intervention’s effectiveness and making improvements b. ethics c. risk assessment and evaluation (is there anything that needs to be *If we want to come up with the perfect intervention, we need to understand the behaviour of people and their intentions behind it (look at the cognitive models) PLAN -DO-CHECK-ACT Building capabilities (health promotion programs) - What do we do when people don't have the knowledge on (un)healthy behavior? -> focus needs to be on education - Parents trying to do good for their child: they take them to gym and afterwards to Mcdondals as a reward - sex education program (in the Dutch schools) - self efficacy -> focus on enabling people - stoptober - setting realistic goal (be specific about the date) - Social, political, cultural, and physical circumstances that affect behaviour -> focus on circumstances (nudging the barriers) - combination of individual approach with sociocultural, political, and physical environment - People don't understand the risks -> focus on risk communication - make the examples more personal - a vivid and emotional example affects risk perceptions disproportionately - People are social beings -> focus on influence of others - they pay attention to what others do - they pay attention to what others find appropriate behaviour - they receive social support for certain behaviour What is health promotion? - WHO Definition: The process of enabling people to increase control over their life, and to improve their health - AJHP Definition; the science and art of helping people change their lifestyle to move toward a state of optimal health Settings approach - population based approach - individual approach - community based approach - life course approach - preventive approach - behaviour change approach - Health education approach - policy instruction approach Case 4 What is a hazard and what is risk? - Hazard: anything physical or psychological that can be perceived/has the ability to cause harm - Risk: the probability of the hazard causing harm - Hazards can be taken precautions against, toxic and hazards don’t have to be risks if the dose is managed. Risks can be managed by introducing interventions to reduce the probability of the risk as close to 0% as possible. Elimination and substitution of hazards is very expensive. What is risk assessment? - there is a 4 step plan to evaluate the the possible risk factors and how that intervenes with employees’ health and company in the long term, used to introduce the interventions: 1. Hazard identification 2. dose-response assessment 3. exposure assessment 4. risk (intervention) characterisation What is occupational health? - Definition: prevention of (work) diseases, fostering health and well being & sociomedical counselling What is toxicology? How is toxicology measured? Environmental and Biological Monitoring? Case 5 What is MSD and what are the risk factors? What are the levels of prevention + their critics? Name and describe the current EU policies - What are their limitations? Case 7 Group 2: Case 8 https://docs.google.com/presentation/d/1ZT3WS7r6uyQ4efeZ_zSddQPNc-NET4S1cIkdskTe Jhg/edit?usp=sharing case 9 Case 1: topics: 1. Relation between socioeconomic position and lifestyle  2. Focus on the learning goal how SEP is related to work characteristics → how are lifestyle and work characteristics related to health? - Socioeconomic position can also influence health (through lifestyle and work characteristics), higher influence through work characteristics than lifestyle - Literature suggests to focus on work characteristics to improve health of an individual 3. PRECEDE-PROCEED model - Know the different phases of the model - Probably about applying the model rather than knowing every phase by heart - Strengths: recognizes wider factors like SEP, participatory approach, importance on bottom-up planning (working with groups and communities) - Weaknesses: be careful, who you target and how? - this can increase inequalities, requires more resources, no guarantee that it will solve the problem 4. Work-related disease vs occupational disease Examples: - Occupational: main reason for the disease is the work, hearing loss, lung cancer - work-related: multiple different reasons for the disease, work-related reason is one of them, MSDs Case 2: 1. Determinants of behavior - Source theory at glance - Fishbein's eight variables that predict intentional, deliberate behavior - What’s Intention, what are the skills, … ————————————————————————————————————————— Eight Key Variables Influencing Behavioral Performance  1. Intention: A strong positive intention or commitment to perform the behavior is essential for action. 2. Environmental Constraints: The absence of environmental barriers or constraints that prevent the behavior from occurring is necessary. 3. Skills: The individual must possess the necessary skills to carry out the behavior effectively. 4. Anticipated Outcomes (Attitude): The person must believe that the benefits (positive outcomes) of performing the behavior outweigh the costs (negative outcomes), indicating a positive attitude toward the behavior. 5. Norms: There should be a perception of greater social pressure (normative influence) to perform the behavior rather than to avoid it. 6. Self-Standards: The behavior must align with the person’s self-image and personal standards, avoiding any negative self-sanctions. 7. Emotion: The emotional reaction to the behavior should be more positive than negative. 8. Self-Efficacy: The individual must feel capable (self-efficacy) of performing the behavior under various circumstances. ————————————————————————————————————————— - How does human behavior work? - First understand how human behavior works (through Theory of Planned Behavior and Fishbein’s variables), secondly, how we can change the behavior (behavior change wheel) a 2. Theory of Planned Behavior (+ reasoned action)  3. Health belief model 4. Behavior change wheel How to apply the model: Step 1: Describe the behavioral goal (example of physical activity) Step 2: Describe determinants of the behavioral goal (achieved through COM-B system, Capability, Opportunity, Motivation), psychological capability: knowing how to do certain exercises Step 3: Select the intervention functions (see table 2) Step 4: Select policy categories (see table 3) 5. Scarcity + impact on healthy behavior - Understand scarcity theory - Impact on behavior through income scarcity → helps us to understand why people behave in a certain way due to financial constraints, difficulty to make healthy choices - Time scarcity → affects us as students, upcoming exams as an example - Focus on surviving, scarcity imposes as a mental burden that can lead to poor decision-making, impulsivity, and priority on immediate needs over long-term health benefits - Troelstra article: example of stoptober Case 3: 1. Health Promotion - Ottawa charter + strategies 2. Intervention mapping - Understand that it is a systematic approach to design an intervention - Six steps - Alternative to the behavior change wheel, intervention mapping more about bottom-up planning - One weakness of intervention mapping compared to the behavior change wheel is that the BCW has a explicit step for policies (regulations, need for hard policy tools) 3. Settings approach - Know examples for the settings approach - In general, know other approaches in health promotion - Examples for each approach 4. Nudging - Friendly pushing - Example of the supermarket layout with fruit choices in the entry area - Helps people to make healthier choices - Keep in mind the ethical considerations - pros and cons for nudging Case 4: 1. Occupational health risks (the example of paint) 2. Uptake routes of paint - Inhalation, absorption - Possible health risks and hazards (short-term and long-term) 3. Occupational exposure limits - Toxic dose, lethal dose - Hierarchy of control measures to reduce occupational exposure 4. Precautionary principle 5. Risk assessment - Steps to identify risk hazards - Evaluate and prioritize the risks - Decide on preventive actions - Take actions - Monitoring and reviewing Case 5: 1. Interventions at the workplace 2. Types of preventions - Universal, selective, indicated - Multilevel interventions - Primary, secondary, tertiary - Look at the table for examples 3. Workplace interventions - environmental interventions, worker-focused, and interface improvement - Know how to select interventions 4. Intervention process (Eurofund, 2014) - Preparation phase - Risk assessment phase (screening phase in Nielsen’s and Lamontage model) - Development of an action plan - Implementation - Evaluation phase 5. MSDs - Definition - Risk factors - Da Costa source, different distinction between the evidence of risk factors for MSDs - Interventions, examples (Staal source), workplace interventions Pieper source (more research needed)  - Workplace interventions: exercise , ergonomic desks can decrease pain for employees (moderate evidence), mental: job stress management Case 7: 1. Existing legislation on occupational health and safety - Evaluation of the current process - Goal-oriented approach (more included in the framework directives) - Prescriptive approach (more included in specific requirements, individual directives, inconsistent, difficult to implement, lots of variety in implementation process) - Member states have different preferences which approach to focus on - Conclusion: Using more goal-oriented approach is aligning more with the EU idea of legislation - more freedom for the MS → Objectives, periods should be covered, but how to implement is up to the MS - Disadvantage goal-oriented: when there is no defined pathway, it's hard to evaluate if the goal is achieved in the right way 2. EU framework directive (hard policy) - Outlines what employees must do, obligations of employers and employees - Need to evaluate all the risks for the workers in a job, consult workers when introducing a new technology - Employee has obligations as well, like informing immediately the employer when there's a emergency situation - Know the directives about specific/individual topics as well: Science, personal protective equipment → in general more prescriptive, individual 3. Soft policies - Guidelines, recommendations - EU strategic framework on health and safety at work - Clips of the campaigns 4. Routes for health policy - Occupational and public health route 5. Harmonized EU - Arguments for harmonized EU legislation Case 8: 1. TFEU - Research funding from the EU - Regulations on the internal market  2. Commercial determinants - Not often recognized - Huge influence on the behavior of an individual (scientific evidence for that) - Hard policy tools are effective in tackling these - Example: Advertising of unhealthy products (alcohol, McDonalds) 3. Current policies on tobacco, alcohol, physical activity - Tobacco Products Directive - Soft policies: smoke free environment - EU policies on alcohol consumption (no directive) - Physical activity: reformulation (remove fats, sugars from certain products) → healthier diets 4. Harmonization in policies about lifestyle Case 9: 1. Differentiated Policy Implementation - Difference DPI vs DI - Drivers of DPI 2. Diderichsen’s model - No visual framework Questions 1. History Exam Recap Lectures Health determinants: factors that influence an individual’s or a community’s health status Lifestyle: a set of health related behaviours specific to an individual or social group that emerges through a complex interrelationship among voluntary (chosen), biological, and environmentally-induced factors How does SES impact lifestyle? Green says that all interaction on the association between lifestyle and health evolve around SEP. Social normative theory: people will adopt behaviours that align with the highest level they have achieved in their SES (e.g. someone with high education but moderate income will align with higher education).  SES shapes lifestyle through 3 factors (also part of Preceed-proceed model) ○ Predisposing: education and values are associated with SES. How do you position yourself mentally. You could be more likely to engage in preventative behaviour. ○ Enabling: More on a resource perspective. How can one have access to health-supporting resources (safe living conditions, access to healthcare). Low SES may be exposed things such as environments that discourage physical activity, and high SEP can hire personal trainers and doctors). ○ Reinforcing: These are the social norms and the peer influence. This highly depends on context, and for example smoking to more normalised in higher SES groups. From this, we kind of get two theories: ○ People with a low SES have a less healthy lifestyle and live and work in more disadvantages conditions than people with a high SES ○ The effects of unhealthy lifestyles and living conditions, and working conditions on health are larger in those with a low SES. How does SES impact someone’s profession? For example, education access due to affordability Job security, which is usual for higher SES More mental and physical risks for lower SES unemployability What is the impact of lifestyle on health outcomes? More risky behaviour can realte to and create non-communicable disease burd