HEALTH PROMOTION AT THE WORKPLACE

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1 ISPESL - ISTITUTO SUPERIORE PER LA PREVENZIONE E LA SICUREZZA DEL LAVORO IACP - ISTITUTO DELL APPROCCIO CENTRATO SULLA PERSONA HEALTH PROMOTION AT THE WORKPLACE DR. ALBERTO ZUCCONI Psychologist, President of IACP DR. SERGIO PERTICAROLI Director of the Documentation, Information and Training Department - ISPESL DR. FIORELLA CHIERICHETTI Researcher of the Documentation, Information and Training Department - ISPESL with the contribution of RICCARDO MONNI Journalist DR. GIANNI SULPRIZIO Psychologist, IACP Consultant Scientific Consultant of the Publication DR. FRANCIS LA FERLA International Occupational Health Expert EUROPEAN NETWORK WORKPLACE HEALTH PROMOTION 1

2 HEALTH PROMOTION AT THE WORKPLACE ISPESL - ISTITUTO SUPERIORE PER LA PREVENZIONE E LA SICUREZZA DEL LAVORO DOCUMENTATION, INFORMATION AND TRAINING DEPARTMENT via Alessandria, 220/e Roma Tel Fax IACP - ISTITUTO DELL APPROCCIO CENTRATO SULLA PERSONA WORLD HEALTH ORGANIZATION COLLABORATING CENTRE FOR RESEARCH, TRAINING AND CONSULTING IN HEALTH PROMOTION AT THE WORKPLACE IN ITALY piazza Vittorio Emanuele II, Roma - Tel Fax ENGLISH TRANSLATION BY VIP SERVICES ROME (EXCEPT OCCUPATIONAL HEALTH AND SAFETY, OTTAWA CHARTER FOR HEALTH PROMOTION, CARDIFF MEMORANDUM) 2

3 CONTENTS Preface A reflection Introduction 1. Health: a word of many meanings 2. The ecological view of health 3. The foundations of health 4. Health Promotion 5. The strategic importance of the workplace 6. If a global vision of the problem is lacking 7. Concrete examples of Health Promotion 8. Obstacles to Health Promotion 9. Conclusions References and Sources of Information Appendix Occupational Health and Safety Ottawa Charter for Health Promotion Cardiff Memorandum WHP Health Promotion at the Workplace Training course in Health Promotion 3

4 PREFACE The world of work, in the industrialized part of our planet, is undergoing an epochal and often dramatic change. The instability and variability of markets together with the effects of the technological innovation that is imposing an acceleration on processes of change, require, among other things a re-examination of the way in which the variable constituted by the individual is positioned within production systems. These changes intersect with a new vision of man as agent and protagonist of environmental modifications, within an epochal process of cultural transformation that involves the concepts of health, wellness and illness. The awareness that all components interact reciprocally world-wide is gaining ground and, brought into the pragmatic world of work, translates into the principle that wellness and output are closely interdependent. The idea that it is advisable, if not indispensable, to create work environments that promote wellness, is today progressively more understood and accepted. This consciousness, which is starting to have its effects in new legislation, is a response to the need for companies to develop an international competitiveness that translates in practice into improvement of the cost benefit ratio of investment in Health Promotion at the workplace and in actively supporting the trend to total quality in the company. The benefits for workers are considerable and measurable. They translate into a reduction in occupational risks, better health for production workers, greater job satisfaction and an overall improvement in quality of life. Within this scenario, small firms present special problems: the economic constraints to which firms with less than 50 employees are subject are considerable and greatly impede their commitment to action to promote health and safety. For that reason, a substantial government involvement in promotion of Health Promotion at the workplace in small firms is undoubtedly desirable. Governmental support could easily produce positive and measurable results, such as an eventual reduction in public expenditure, in particular on health care, and an increase in overall productivity. In the Ottawa Charter, the World Health Organization emphasizes that Health Promotion is the process that permits people to exercise greater control over their own health and to improve it. Experience does in fact demonstrate that investments that allows workers to exercise effective actions on impediments to their health and wellness leads to a reduction in disease and death rates. Health Promotion is an effective means for improving the health of workers and hence the health of a nation. Promoting health in effect means adding value to the firm s human capital. Unfortunately this concept is not yet understood or implemented by the majority of those active in the world of work. 4

5 The road to be travelled is long and complex. The concept of health varies from one country to another and is dependent on cultural, social, scientific, clinical and biomedical factors, while health problems themselves also vary. Although there is today already sufficient data to justify the claim that Health Promotion is economically profitable, in future it will be necessary to identify further parameters that will permit ever more accurate assessments of the impact of Health Promotion actions in terms of their costbenefit ratio. Failure to promote health today means facing higher costs tomorrow. In contrast, a very considerable competitive advantage is obtained when a coherent national Health Promotion policy with realistic objectives is established. Identification and implementation of actions that involve synergistic co-operation of all concerned is today s challenge in Health Promotion. Networking must in future become the primary means for creation of an effective policy of Health Promotion, which in its turn will produce greater motivation, more research and fruitful co-operation. Valletta (Malta), May 1999 Francis La Ferla 5

6 A REFLECTION Health Promotion is a topic that has only recently become a subject of debate in Italy. In fact it was only in its latest National Health Plan that the Ministry of Health, which is in overall charge of health matters, introduced Health Promotion as one of the fundamental components of health policy, with the assertion that health and wellness are both of great importance for ensuring that work is performed safely and focused on productivity and competitiveness. However there is no specific mention of Health Promotion at the workplace. It would therefore seem indispensable, and no longer deferrable, to introduce Health Promotion programmes into the world of work, with the aim of promoting radical change in the organization of programmes promoting the safety and health of workers and indeed in relations between employers and trade unions. The achievement of wellness at work is not only of primary importance for facilitating work and improving productivity, it is also an indispensable condition for influencing and extending positive behaviour by individual workers in the workplace to the rest of their life environment. To simplify the concept of Health Promotion and make it usable by everyone, in view of its innovative nature, it is necessary to adopt strategies that create involvement and use forms of communication that have an effective influence on motivation. The Department of Documentation, Information and Training of ISPESL, the National Contact Point of the WHP - Work Health Promotion European Network, has introduced some initiatives into the Institute s various action plans that aim to transmit Health Promotion messages. In collaboration with the Istituto dell Approccio Centrato sulla Persona, a collaborating centre of the World Health Organization (WHO), it has produced this book, complete with videotape, entitled Health Promotion at the Workplace, an innovative instrument to spread the concept of Health Promotion at the workplace, and an aid to both employers and employees. Sergio Perticaroli Rome, September

7 INTRODUCTION Our species possesses an intrinsic creative capacity which constitutes the premise for the advance of knowledge. This capability has allowed human beings to equip themselves, over time, with sophisticated instruments to monitor and take action on the reality that surrounds them: their environment. Nevertheless, they often fail to make use of instruments already in their possession to improve the quality of life. This singular inattention at times assumes such importance that those who devote themselves to the study of human behaviour are drawn to pessimistic conclusions regarding the fate of humanity. However it is equally true that the human community is capable of great comebacks, as if it were a football team that needs to be a few goals down in order to achieve a win in the last few minutes. The question of health at world level is an obvious example. The bio-medical approach, though it has proved effective in combating infectious diseases, now seems inadequate to address the current causes of disease and death in societies with a Western life style. At present, in Western societies, Italy included, the principal causes of death are associated with chronic diseases, such as those of the circulatory system and tumours (National Health Council, 1993). These diseases are classified as degenerative multifactor, in the sense that their causes are multiple and can be attributed chiefly to unhealthy life styles and inappropriate social and economic conditions (WHO, 1995). Furthermore, the contemporary human is considerably more exposed than his forebears to situations defined, even in common parlance, as stressful, and stress, if it becomes chronic, can cause severe damage to the organism and its functioning (Biondi, 1997). To problems of this type, the old medicine does not provide adequate answers. This observation must not, however, deceive us into pessimism over the future. It is already possible today to implement effective diagnosis, treatment and prevention of this worrying situation, in part thanks to a radical change in the way the scientific community looks at these questions. Let us try, for simplicity, to summarise the complex process that has given rise to this cultural change. In the traditional bio-medical model, disease is the result of single cause-effect relationships. Health is seen in a static sense: one is either healthy or ill. In this model, the mind is also viewed as separate from the body. This view, known as mechanistic is today considered obsolete. That does not mean denying the merits of the traditional biomedical view, which has saved millions of lives and still today continues to make its contribution, especially in the treatment of infectious diseases (Engel, 1977). 7

8 DISEASE-CENTRED MEDICINE OR PERSON-CENTRED MEDICINE? In assessment of the cost-benefit ratio present in the traditional biomedical model, its limitations appear alongside its undoubted strong points. Development of medicine centred on the disease, this last defined in purely biological terms, has led in practice to a failure to consider the person except in relation to the disease, therefore the person as patient, assigned a passive role by the doctor as a subject for diagnosis and therapy. Many writers have criticised the disease-centred model and suggested a change of perspective to person-centred medicine or medicine centred on the patient or client" (Rogers, 1942, 1951; Szasz, 1956; Balint, 1957; Jaspers, 1959; Illich, 1976; Byrne, Long, 1976; Brown et al., 1986; Levenstein et al., 1986; Stewart et al., 1986; Stewart, Roter, 1989). At the root of the proposal for person-centred medicine there is the concept of the client or patient/customer seen as partner, or active agent to be involved in the process of recovering psycho-physical equilibrium and development of the individual s potential. The feelings, cognition and expectations of the patient/client thus become variables of significance for attainment of the therapeutic objectives. This fact should not astonish us. The history of scientific progress shows us the continual modification of models or paradigms by which we generate representations of reality: paradigms thus understood as new instruments for observation, that allow us to extend our knowledge. When and to the extent that current theories do not offer effective instruments for addressing new problems, the scientific community formulates new theories (Kuhn, 1973). In line with this affirmation, awareness of the deficiencies of the traditional biomedical model has led to the formulation of a wider view based on a new model, the so-called biopsycho-social paradigm (Engel, 1977), which radically enlarges our vision of reality with the aid of general systems theory. According to the new perspective, a person s state of health is the result of numerous interacting factors: BIOLOGICAL: genetic factors, attacks by viruses, bacteria etc.. PSYCHOLOGICAL: beliefs, attitudes, behaviours etc. SOCIAL: education, wealth, social class, type of work, type of society in which the individual lives etc. Thus the deterministic principle of the univocal relationship between effect and single cause fails: health and disease are considered as the resultants of a process within which the 8

9 biological, psychological and social variables interact. In consequence, the health field becomes interdisciplinary. In addition to medicine, various other disciplines such as biology, psychology, sociology, economics and politics contribute to formulate hypotheses and policies for health. From the concept of prevention and treatment of disease, strategies for action have shifted to the concept of Promotion of Health and Wellness. 9

10 1. H EALTH: A WORD OF MANY MEANINGS If, on the streets of any city, we were to ask a hundred individuals what the word health means to them, we should probably get a hundred different and conflicting answers. In fact, the meaning of the word health, and the behaviours and convictions associated with it, vary between individuals and cultures according to the social context concerned, level of education, work or profession of the individual, and the prevalent culture. To check the truth of these statements, we invite you to perform the following simple exercise, at home or at work. EXERCISE: WHAT DOES BEING HEALTHY MEAN TO ME? SELECT ONLY ONE DEFIN ITION: W AKING IN THE MORNING, RESTED AND FULL OF ENERGY BEING DECLARED DISEASE-FREE IN THE LAST MEDICAL CHECK-UP FEELING IN FORM AND M OTIVATED AT WORK AND IN LEISURE ACTIVITIES FEELING ABLE TO FACE CHANGES IN MY OWN LIFE WITH CONFIDENCE IN MY OWN RESOURCES FEELING IN PSYCHO-PHYSICAL EQUILIBRIUM AND HAVING A MEANIN GFUL RELATIONSHIP WITH MYSELF AND OTHER PEOPLE. PROPOSE THE SAME QUESTIONS TO YOUR NEIGHBOURS, FRIENDS AND COLLEAGU ES TO VERIFY THE RESULTS. The difficult paradigm changes to which the scientific community is occasionally subject are often not immediately adopted into public opinion. Because of the difficulty of adjusting to sudden changes and inadequate communication between the scientific community and the general public, the latter continues, for some time, to accept obsolete scientific ideas as true. And so, most people still today hold that being healthy means not having a disease. This should not surprise us, considering that this interpretation corresponds to the view that medicine offered until recently, although today it is considered obsolete from the scientific point of view. Medical science, like all other 10

11 sciences, changes paradigms and frames of reference over time, and progressively more rapidly as research tools progress. The word malaria is revealing in this regard. The term was coined in the past as a result of the conviction that the disease was contracted by breathing in foul air resulting from the decomposition of organic matter in marshes. Only with the progress of experimental science was it found that the disease was not caused by unpleasant smells but was transmitted by mosquito bites. However, if you consult a dictionary, you will find that the two definitions still coexist. For example, the Nuovo Zingarelli states: MALARIA [From malo (bad) and aria (air)] s. f. 1. (rare) Unhealthy air of the Maremma district and of swampy places. 2. Parasitic disease produced by plasmodia which, when introduced into the human organism by mosquitoes of the Anopheles type, reproduce within the red corpuscles causing typical fever symptoms, with destruction of the red corpuscles and consequent anaemia. IN MEDICINE, TOO, OPINIONS CHANGE OVER TIME The medical community has become increasingly aware that traditional medicine is practically impotent in the face of the great killers of our time, the degenerative chronic diseases (cardiovascular diseases, neoplasias, diabetes mellitus) which are caused not by one single factor but by a combination of factors, including life style and environmental conditions. Because of this impotence, and of the parallel increase in chronic diseases, costs for the resultant medical treatment account for an ever higher proportion of health expenditure in advanced industrial societies (Sheridan, Radmacher, 1992). However, in spite of the exponential growth in health expenditure in all Western nations, the results are disappointing. From observation of this worrying situation there has emerged a new awareness that has led to affirming the necessity of a change in viewpoint (that is the paradigm) from which health problems are examined. And so, from a mechanistic view based on a deterministic approach, we are moving to a total ecology viewpoint. 11

12 2. THE ECOLOGICAL VIEW OF HEALTH BETTER UNDERSTANDING OF COMPLEXITY. WHAT HUMAN ECOLOGY MEANS. THE ACTIVE ROLE OF THE CITIZEN. THE OTTAWA CHARTER. We have long learned to consider plants and animals as elements of an interconnected system that we call ecological. For a better understanding, we once again turn to a dictionary. The Nuovo Zingarelli defines ECOLOGY as follows: Branch of biology that studies the mutual relationships between living organisms and surrounding environment, spec, to limit or eliminate its harmfulness: human, animal, plant ecology; marine ecology. Perhaps it was due to presumption that we were late in including the human being in this complex network of relationships. Today, we use the term human ecology to express the concept that, if everything is in relation, then the human being cannot be considered as merely an external observer of the system of which it forms part, but also as a component of it, interacting with the other parts. And not only so: general systems theory holds that every organism can be considered a complex system that interacts with other organisms in a complex manner. The perspective opened up by this theory leads to the view that all living organisms are components of more extensive systems (for example: INDIVIDUAL FAMILY SOCIETY) while internally they are composed of subsystems (for example: INDIVIDUAL NERVOUS SYSTEM BRAIN). Furthermore, any impact on a component element has an influence on the entire system; in the example, an impact on an individual influences society as a whole. The box illustrates this concept. 12

13 MACROSYSTEM (C ULTURE, SHARED BELIEFS, SOCIAL EXPECTATIONS, ETC.) EXOSYSTEM (GOVERNMENT AGENCIES, ECONOMIC SYSTEM, RELIGIOUS ORGANISATIONS, ETC.) MESOSYSTEM (ALL THE SYSTEMS OF DAILY LIFE INTERACTING WITH EACH OTHER) MICROSYSTEM (FAMILY, FRIENDS, W ORKPLACE, ETC.) PERSON (THE VARIOUS SYSTEMS: SKELETAL, IMMUNE, CARDIO-CIRCULATORY, RESPIRATORY, C OGNITIVE, EMOTIONAL, ETC.) Adapted from Cowan and Egan, 1979 To simplify our discourse., let take the following example. If the percentages of atmospheric pollutants increase in a given city, not only will the damage to the respiratory tracts of the individual inhabitants increase, together with asthma and bronchitis, but so will absenteeism due to sickness; the productivity of workers and firms will decline and health expenditure will increase. The most vulnerable categories, such as children and the elderly, will suffer most. However the consequences resulting from the reduction in the quality of life are still more extensive, affecting all the components of the city system, including commerce, tourism and legislation. In a strictly human ecology perspective, the implications of complexity theory are translated operatively into the so-called bio-psycho-social paradigm. According to this paradigm, the emergence of any illness can be correlated with numerous factors of various provenances, for example the spheres of genetics, psychology and social and environmental sciences, which interact mutually and continuously in a complex manner. Much research work seems, in fact, to indicate the existence of common denominators between persons, properties shared by other individuals which may indicate a greater propensity to suffer from chronic stress, to contract diseases more easily, to recover more 13

14 slowly and die earlier than the average. Specific studies have made it possible to classify these common denominators (Kobasa, 1979; Stroebe e Stroebe, 1995). They are: Pessimism Low self esteem Fear of change COMMON DENOMINATORS Poor rapport with one s own emotions and limited ability to express them Difficulty in asking for help when needed Few friends or relatives to turn to in case of need Unhealthy life styles, such as tobacco, alcohol, pharmaceutical or drug abuse Little or no physical exercise This knowledge makes it possible to act on such variables through programmes that help individuals to reduce their own risk level and become more resistant (Meichenbaum, 1985; Maddi, 1987). The World Health Organization (WHO) has made a great contribution to addressing these questions by making available expertise in various disciplines. The results of parallel investigations constitute the basis of an agreement signed by all countries in Ottawa in The Ottawa Charter (see further on) describes the strategy the WHO proposes to tackle the health emergency in the third Millennium. It expresses the hope that citizens in each country will take an active role in promoting their own health, rather that passively delegating its protection to the health care system. In that document, the WHO stresses the need to view health as the resultant of all the components of social relationships, and therefore not as the exclusive province of health policies and organisations. 14

15 3. THE FOUNDATIONS OF HEALTH THE FACTORS THAT DETERMINE HEALTH AND WELLNESS. THE ADVANTAGES AN ECOLOGICAL VIEW OF HEALTH OFFERS THE INDIVIDUAL, THE COMMUNITY AND THE NATION. A PERSONALISED TEST. Besides the factors already mentioned, there are others that play a significant role in creation of health and wellness in the individual. These include the elements that connote and configure the surrounding social reality, but also other variables such as social class, gender, occupation, economic and environmental conditions, geographical location and the laws and organisation of the community and country in which the individual lives. There is, for example, a proven as well as easily guessed correlation between health and income. Economic and social disadvantages generate poor housing conditions and uncertainty over job retention, as well as naturally favouring the emergence and amplification of many environmental stressors ( ). Specific classes of variables with a considerable impact on health include conditions in the workplace, housing environment, the way in which social and health services are organised and in the broader sense, the structure of all macrosystems, such as the political and social structure of a country, the messages received from mass media, management of the environment and natural resources and the dominant culture; in short all aspects of a society (see Figure 1). Consequently we can say that Health is socially constructed (Ingrosso, 1994). Stressors are defined as environmental, social or personal factors that can generate stress. 15

16 LEVELS OF INFLUENCE ON HEALTH ECONOMIC SYSTEM (PRODUCTION, DISTRIBUTION AND EMPLOYMENT) NATIONAL POLICIES ON FOOD PRICES, TAXES ON GOODS (E.G. TOBACCO, ALCOHOL) CULTURE AND SOCIETY WORK ENVIRONMENT HOUSING ENVIRONMENT HUMAN RIGHTS AND SOCIAL JUSTICE (E.G. CLASS, RACE, AGE, SEX) SOCIAL SERVICES LEISURE FACILITIES GENETIC AND PSYCHOLOGICAL FACTORS. FAMILY AND PERSONAL LIFESTYLE COMMUNITY SUPPORT HEALTH SERVICES SOCIAL CHANGE, MIGRATION, INNER CITY DECAY INCOME EDUCATIONAL OPPORTUNITIES ENVIRONMENT AND NATURAL RESOURCES NATIONAL POLICY ON HEALTH AND SOCIAL SERVICES COMMUNICATIONS, MEDIA, ADVERTISING AND HEALTH EDUCATION FIGURE 1 Addressing the topic of health from this viewpoint means applying a systems approach to the problem. It is clear that a systemic, and therefore ecological, viewpoint applied to health offers new and important opportunities not only to individuals but also to social organisms, independently of their size and complexity. Furthermore, since the process of expansion of knowledge made available by the bio-psycho-social paradigm includes previous discoveries and applications in a broader vision, adoption of this new viewpoint does not invalidate the knowledge derived from traditional biomedical experience. In consequence, it can be said that the transition from the old to the new paradigm does in fact bring about the gain comprised by the many additional benefits. Individuals who have developed this new perspective discover that they have great power over their own selves. They can, in fact, influence their own state of health (understood, we repeat, not as the simple absence of diseases but as development of their own human potential) through changes in lifestyle, that is, through conscious decisions aimed at improving their relations with others and themselves. One example will suffice. If, to adapt to the stressful conditions of the environment in which we work, we force ourselves to passively submit to discomfort, it is probable that continuation of the state of deprivation beyond our tolerance limit will provoke violent and aggressive reactions to the people and things around us, with an end result adverse to both ourselves and the environment in which we work. A proactive approach to the problem, based on an ability 16

17 to express our needs assertively and discuss effective agreed solutions, will most probably lead to satisfactory solutions and make us a point of reference for others. For the community, adoption of a bio-psycho-social viewpoint means logical and effective overall planning in the common interest. For example, if the authorities of a small resort town approved the establishment of a polluting industry in order to create more jobs and obtain more revenues from increased circulation of cash or taxes, but ignored the consequent damage to environment, health and image, in the long run they would do themselves harm by not foreseeing the adverse effects of the factory on the tourist trade. By adopting a broader view, the same authorities could promote employment programmes aimed at developing and exploiting local resources, for example by creation of farm holiday facilities. For a country, taking decisions in awareness of the human ecology implications means, in the first place, not wasting human and financial resources. This means setting priorities and deciding on investments to achieve an optimum cost-benefit ratio. Every country has instruments to promote health and wellness, but to employ them it must first have a knowledge of their efficacy. As an example, take a country whose government the expression of the collective will mediated by parliament is responsible for education and health policy, for administration of part of the communications systems, and for national defence, and has legal and fiscal instruments available to guide the decisions of the public administration and of the private sector. That government has sufficient power to plan and implement Health Promotion policies. If it does not do so, it is probably because it still has little faith in them. EXERCISE: A PERSONALISED TEST TAKING YOUR CUE FROM THE FIGURE 1, OR ADDING OTHER VARIABLES AT WILL, ATTEMPT TO CREATE YOUR PROFILE, ESTABLISHING A HIERARCHY OF IMPORTANCE FOR THE ELEMENTS WHICH, IN YOUR OPINION, HAVE AN ADVERSE EFFECT ON YOUR HEALTH, EXPLAINING WHY. 17

18 4. H EALTH PROMOTION HOW IT IS DONE. WHERE IT IS DONE. HOW IT CAN BE LEARNED. As already said, Health Promotion establishes a systems view of total ecology which, when compared to the previous model, appears as veritable conceptual revolution, presenting health and wellness as the resultants of interactions between biological, personal, social and environmental factors. It follows that initiatives in this sphere must be systemic. For this reason Health Promotion cannot but view citizens as pro-active, rather than passive, elements. It is therefore best to start at the bottom. Ordinary people must be invited to use their own personal power to promote their own health and their own wellness. The reason for this strategy is clear: the power that results for exerting greater and more direct control over oneself must be exercised by each of us, consciously, in our daily lives. HOW IS HEALTH PROMOTION CARRIED OUT? The World Health Organization emphasises that the prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned: by governments, by health and other social and economic sectors, by nongovernmental and voluntary organization, by local authorities, by industry and by the media (International Conference on Health Promotion, 1986). The problem, in short, involves everyone and the solution depends on all the components of society. So delicate a problem as health can be effectively addressed and resolved only if all stakeholders become aware of it and function together as active elements in its solution, rather that constituting merely one of the elements of the problem. WHERE IS IT CARRIED OUT? As we have already said, Health Promotion can be carried out at all levels and in all sectors of society. However it is reasonable to think that efforts should be concentrated in those areas and on those projects that guarantee an optimal cost-benefit ratio. Since it involves a global cultural revolution, Health Promotion should also be conceived as a vast effort to promote change in the ideas, habits and laws that govern our society. The role played by the means of communication would therefore seems to be essential, as they are the primary route for presentation of the new, advantageous models of behaviour to the general public. It is likewise essential to train and retrain the professionals involved in various aspects of health protection and human resources management, and also to create a new professional role, that of Health Promoter. It would also seem necessary to restructure training curricula and continuing education courses for doctors, psychologists, teachers, social assistants and social workers in general. But the same also applies for other professions that 18

19 have a significant role in society, from engineers to economists, from architects to magistrates, managers in both public and private sector, trade unionists and politicians at both national and local level. It is obvious that each of them has the power to work for or against the success of what we do not hesitate to call The Challenge of the New Millennium in Health Promotion. WHERE CAN IT BE LEARNED? PROVISION OF TRAINING ITALY IS RATHER BEHIND OTHER EUROPEAN COUNTRIES IN ITS PROVISION OF TRAINING IN THE FIELD OF H EALTH PROMOTION H OWEVER, SOME IMPORTANT MEASURES HAVE BEEN TAKEN RECENTLY, FOR EXAMPLE: THE UNIVERSITY OF SIENA HAS FOR SOME YEARS OFFERED A ONE YEAR COURSE IN H EALTH PROMOTION, OPEN TO ALL GRADUATES. ISPESL HAS JUST RECENTLY COMMISSIONED IACP TO PRODUCE TRAINING PACKAGES FOR H EALTH PROMOTERS, AN EMERGING PROFESSION IN ALL INDUSTRIALISED COUNTRIES. IACP OFFERS CONSULTANCY AND TRAINING SERVICES IN HEALTH PROMOTION TO PUBLIC AND PRIVATE SECTOR FIRMS, AND COURSES TO PROFESSIONALS WHO INTEND TO ENTER THE SECTOR. THE UNIVERSITIES OF ROME, FLORENCE AND TURIN HAVE INTRODUCED PH. D. COURSES IN H EALTH PSYCHOLOGY, OPEN TO MEDICAL DOCTORS AND PSYCHOLOGISTS. 19

20 5. THE STRATEGIC IMPORTANCE OF THE WORKPLACE HOW TO ACHIEVE A VIRTUOUS COST-BENEFIT CIRCLE. HEALTHY AND UNHEALTHY COMPANIES. SUCCESS STORIES. EXERCISE: EXAMINE YOUR OWN WORKPLACE. At this point we should be able to recognise that the commitment to health is both a collective and an individual responsibility. We should keep in mind that some social environments lend themselves to effective Health Promotion action, due to advantages deriving from easy access to a large part of the population. Schools, for example, constitute a particularly fertile soil, since it is there that new citizens are formed. Even more important, however, is the workplace. Like the school, it is a location where a large part of the population, in this case the adult population, is already assembled and organised. But it is more than that, since it is known that a great number of diseases and accidents are contracted or happen in the workplace. Health Promotion programmes in offices and factories, if well conducted, can be a profitable investment. It has in fact been shown that a well conducted programme of Health Promotion at the workplace can produce a saving equal to one and a half times the investment (La Ferla 1992). THE STRONG POINTS OF HEALTH PROMOTION PROGRAMMES AT THE WORKPLACE Promotion of health is literally promotion of social change. Resources for promotion of change must be focussed on objectives that offer the greatest possibilities of success and an optimal cost-benefit ratio. There are additional benefits to be found in the positive effects that changes in the lifestyle of employees may have on their families. Becoming aware of the dangers associated with unhealthy lifestyles, they will in turn be able to influence close relatives o adopt a healthier life style. Some of the advantages associated with Health Promotion programmes in the workplace are listed below. 20

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