BMC Public Health 2008, 8:284 http://www.biomedcentral.com/1471-2458/8/284 media and communities to achieve "healthy public policy" [5] which creates environments supportive of health, (such as safe walking and cycling routes), supporting peo- ple in developing personal skills (by providing informa- tion on healthy lifestyles and disease management, enhancing health literacy and life skills), reorienting health services so that they focus on preventing disease/ encouraging health in addition to curing existing condi- tions [5] and strengthening community action by involv- ing communities in socio-political activities that impact on their own health [5,6]. The principles and practice of health promotion specifi- cally within hospitals has been further developed in The Budapest Declaration on Health promoting Hospitals, 1991 [7] and The Vienna Recommendations on Health Promoting Hospitals, 1999 [8]. These recommendations are embodied in the guidelines developed by the World Health Organisation Health Promoting Hospitals (WHO HPH) project/network [3,4]. One of the core aims of the WHO HPH network is to facilitate change within the qual- ity management of hospitals, with health promotion a core quality dimension [9]. To this end the WHO HPH network has recently developed a strategic and quality framework for health promoting hospitals [4]. This high- lights areas which all health promoting hospitals should have as part of their quality development strategy that would benefit key stakeholders: patients, staff and com- munities (see table 1 for the development strategy aimed at patients). The first three strategies (PAT 1 to PAT 3) should be delivered by all health promoting hospitals as they aim to further develop the health promoting quality of the hospital services and setting, whereas strategies PAT 4 through to PAT 6 are viewed as additional health pro- motion strategies which hospitals can offer. Key to the concept of health promotion is "empower- ment" of individuals, social groups and communities: "a process through which people gain greater control over decisions and actions affecting their health" [10]. Health promotion interventions within healthcare can empower people through "self-reproduction": supporting patients to take responsibility for self-care physically, mentally and socially; through "co-production": collaboration of the patient in their therapy; empowering health promotion services for illness management (usually part of integrated care and beyond the hospital boundaries); and empower- ing health promotion services for lifestyle development: people are empowered to live healthy lives by preventing risk (e.g. not smoking or excessive alcohol intake) or enhancing lifestyles (e.g. becoming more physically active). This latter aspect of empowerment relates to the concept of "health education" which can be defined as "an activity that seeks to inform the individual on the nature and causes of health/illness and that individual's personal level of risk associated with their lifestyle-related behaviour.... [it] seeks to motivate the individual to accept a process of behav- ioural-change through directly influencing their value, belief and attitude systems, where it is deemed that the individual is particularly at risk or has already been affected by illness/dis- ease or disability" (p. 313 [6]). It is the provision of health promotion services for life- style development (health education) to patients within hospitals which is of interest in this study (Table 1, strat- egy PAT 5). Specifically, the strategy for health promoting lifestyle development aims at "improving the outcome of hospital interventions by empowering patients to build up spe- cific health literacy (knowledge, skills and preferences) for developing and maintaining health promoting life styles" ([4] p.30). The strategies should be viewed as a coherent pro- gramme of development as they are inextricably linked Table 1: Core health promotion strategies aimed at patient in Health Promoting Hospitals [4] Health promotion by .... Health promoting quality development of treatment care by.......... Strategic positioning Empowerment of stakeholders for health promoting self-reproduction/self management Empowerment of stakeholders for health promoting co-production Health promoting & empowering hospital setting for stakeholders Empowering illness management (patient education) for stakeholders Empowering lifestyle development (health education) for stakeholder Participation in health promoting & empowering community development for stakeholders Health promotion for Patients PAT 1: Health promoting living in the hospital for patients PAT 2: Health promoting co-production of patients in treatment PAT 3: Health promoting hospital setting patients PAT 4: Health promoting illness management for patients PAT 5: Health promoting lifestyle development for patients PAT 6: Health promoting community setting for patients Six strategies have also been developed for staff and communities, resulting in 18 HPH core strategies. The first three strategies are quality development strategies and the strategic positioning rows refer to additional health promotion strategies that hospitals can offer. Page 2 of 10 (page number not for citation purposes)