Opinion on the Communication from the Commission and a proposal for a European Parliament and Council Decision on a programme of Community action on health promotion, information, education and training within the framework for action in the field of public health (95/C 210/13)

On 20 September 1994 the Council of Ministers decided to consult the Committee of the Regions, under Article 198c of the Treaty establishing the European Community, on the above-mentioned Communication and proposal.

The commission on Economic and Social Cohesion, Social Policy and Public Health, which was responsible for preparing the Committee's work on the subject, adopted its Opinion on 12 October 1994; the Rapporteur was Mr Peter Soulsby. The enclosed supplementary Opinion (CdR 247/94) was adopted by the commission on Education and Training on 24 October 1994; the Rapporteur was Mr Séan O'Neachtaín.

At its 5th plenary session (meeting of 16 November 1994) the Committee of the Regions adopted the following Opinion.

1. Introduction

1.1. The Committee of the Regions (COR) welcomes the opportunity to comment on this important new area of competence and proposals which seek to adopt a programme of Community action within the overall framework for action in the field of public health. The COR is aware of the importance of regional and local factors on the health of the Community. It is anxious, therefore, that the Commission recognizes the crucial role of local and regional authorities which addresses the fundamental determinants of poor health by providing a safe and healthy environment in which people live, work and play, and the extent to which this underpins attainment of an acceptable standard of public health by other means, such as health promotion.

1.2. The emphasis which the Commission gives to preventative rather than curative action alone is particularly welcome. The COR recognizes, therefore, the importance of an appropriate framework of health promotion, information, education and training but stresses the importance of combining this activity with other activities designed to minimize exposure to risk factors implicated in the causation of disease and ill health. Of particular concern to the COR is the impact of socio-economic and physical environmental conditions on health, and the effect of inequalities, such as poverty and unemployment, and access to preventative or curative health facilities.

1.3. The recognition of the many contributory factors to poor health is also welcome. The COR believes that successful public health initiatives demand a framework which enables a holistic view of the various policy initiatives within the overall action programme to be taken, and of which health promotion, education and training is just one part.

1.4. The COR stresses that action in the field of health promotion is most effective only if those members of the Community which the action programme is designed to target, live and work in an environment which enables them to exercise informed healthy choices and pursue healthy lifestyles once information, training and education have been imparted to them.

2. Health promotion: concepts, objectives and scope

2.1. Concepts and Objectives of Health Promotion

2.1.1. The COR accepts that the health of an individual can be characterized by endogenous, behavioural and environmental factors, but does not agree that, in all circumstances, individuals have the opportunity to exercise full control over certain behavioural factors. Those subject to poverty, poor housing, or those in care, for example, may not be able to access or afford improved nutrition or physical exercise.

2.1.2. Persuading the individual to adopt a responsible lifestyle and behaviour is, in respect of certain population groups, not solely dependent on the provision of skills and knowledge to live a healthy life, but also on a socio-economic and physical environment conducive to good health. The Community has a role in encouraging the delivery of both.

2.1.3. The COR accepts and supports the assertion that the primary focus of health promotion must be health, rather than disease, while recognizing in some circumstances that health promotion is complementary to other, more specific, Community public health action.

2.1.4. COR supports also the overall aims of health promotion in the European Union both at Community and Member State level, but stresses the need to coordinate the action programme on public health with other Community action programmes. As an example, the objective of providing individuals with the information and knowledge necessary to take action against accidents and injuries must be supported by an appropriate framework of health and safety, and consumer protection legislation.

2.1.5. The extent to which modern life is sedentary and the decision by many people to do the minimum amount of walking is another example. It is fully recognized by most individuals that the lack of adequate physical exercise is a determinant of certain diseases and ill-health conditions, yet planning and transportation policy in many areas militates against exercise. In many regions, employment, shopping, leisure and education are conveniently accessible only by car. The extent to which the car or public transport is preferred to walking or cycling is also dependent on wider factors such as the safety of the built environment and social issues such as crime. While the COR would support activities to promote more exercise, it is again the case that there is a need for an appropriate infrastructure to ensure that less sedentary patterns of life are a viable alternative.

2.2. Scope of health promotion: health determinants

2.2.1. The COR is pleased that the Commission recognizes that the state of health of a community depends to a certain extent on the prevailing physical environment and socio-economic conditions. Of particular interest to the COR is the extent to which these vary from region to region. The COR supports the recognition of housing and urban planning, quality and level of education, employment and working conditions as social and environmental conditions of decisive importance for health. The COR believes also, however, that the quality of the environment plays a significant part in determining good health. Clean water, effective sewerage, the absence of vermin, clean air and appropriate collection and disposal of waste are also vitally important.

3. Overview of trends and actions at Community level

3.1. The health promotion approach

3.1.1. The COR supports the shift from single issue health promotion approaches towards a multi-issue approach. The COR agrees also with the broadening of the approach so that improvement in health is regarded as an important element in determining quality of life. It is important to recognize, however, that, in targeting action, a single issue approach may be most appropriate when dealing with those most disadvantaged or vulnerable groups within the Community or the most significant health scourges. Until those priorities have been dealt with, many of the more general health promotion messages may be inappropriate.

3.1.2. The adoption of the WHO's Health for All programme by many Member States is recognized as a key component of many health policies. The COR supports the attention being given currently by WHO to the holistic approach to health with its recognition of the importance of the link between health and the environment. The COR feels that there is much more work to be done in the field of environmental health, although there is much to be learned already from the Healthy Cities Programme and its experience of single and multi-issue approaches. The COR would support an improved network of expertise and research within the Community on which future health promotion programmes can be based.

4. The Community approach

4.1. The COR stresses that Community action must take account of the principle of subsidiarity and the requirement of proportionality. The COR notes and supports the principle objectives for Community action as being:

(i) to prevent premature death;

(ii)

to increase life expectancy;

(iii)

to promote the quality of life;

(iv)

to promote the general well being of the population.

4.2. The COR believes, however, that the Commission should set itself targets by which its actions to secure these objectives can be measured. An assessment of the contribution of health promotion to these programme areas is essential to ensure that future action is appropriate, efficient and cost effective.

4.3. The COR believes also that, in attempting to promote coordination of policies and programmes among Member States, due weight should be given to regional issues and the role and contribution of regional and local authorities. Cooperation is essential at national, regional and local levels to achieve the most from the proposed action programme.

5. Community action programme on health promotion (1995-1999)

5.1. The COR would support a contribution from the Commission to improve knowledge of the mechanisms involved in the design of health messages. Evaluation of health information measures by promoting exchanges of expertise, information and experience is also broadly supported. The COR believes, however, that an important element of the programme will be an evaluation of the way in which the message is delivered and the mechanism which is used to deliver it. There could be a case for regional and local differences to reflect local circumstances and the Commission should accordingly encourage regional initiatives within a Community framework.

5.2. The COR supports the objectives of Community actions in respect of health information and health education and also those measures aimed at improving the expertise and knowledge of health professionals. It is important to recognize, however, that many professions are involved in the promotion of health, health education or, more generally, public health. The way in which collaboration between all of them can be successfully established needs further consideration.

5.3. This recognition is important when developing specific prevention and health promotion activities and when considering health promotion structures and strategies. No single national or regional body can be responsible in isolation for health promotion and it is important that all participants are fully represented, and the intersectoral dimension of health promotion fully recognized, when networks are established.

5.4. The COR welcomes, therefore, the proposed interdepartmental consultation procedure, prior to Commission decisions, to ensure that health considerations are taken into account in other Community policies.

5.5. The COR also welcomes the fostering of cooperation with third countries, some of which have close links with the regions of the Community and which, in public health terms, have a great deal in common.

6. Consultation and participation

6.1. The establishment of an Advisory Committee to be chaired by the Commission is to be welcomed. The COR urges, however, that membership of the Committee be extended to include representatives of local and regional authorities and non-governmental organizations, to fully recognize the regional implications of Community policy.

7. Evaluation and reports

7.1. Evaluation and reporting are essential elements of the Community action programme and are supported by the COR.

8. European Parliament and Council Decision

8.1. Article 1

The COR offers its full support to the Community action programme on health promotion, information, education and training and recognizes it to be a priority area of the Commission's Communication on public health

8.2. Article 2

The COR believes that, having regard to the budget the Commission has identified and the breadth of activities that the programme embraces, the action programme might benefit from being more focused and specific to ensure an appropriate level of achievement and cost effective use of resources.

8.3. Article 4

The COR stresses the importance of ensuring consistency and complementarity between Community actions and other relevant Community programmes.

8.4. Article 5

The COR urges the Commission to recognize the importance of regional and local interests on the proposed Advisory Committee.

8.5. Article 6

The COR stresses the importance of cooperation with third countries and with the World Health Organization.

8.6. Article 7

The COR welcomes the recognition by the Commission of the importance of regularly published information and the proposal to report to the COR with a mid-term report.

9. Annex - Community Action Programme

9.1. Health Information

It is not clear to the COR what is meant by support for a European Infrastructure for information but believes that the exchange of information should not be limited to details of information campaigns.

9.2. Health Education

The COR recognizes that school health education is not well established in all Member States but is concerned that proposals exceed the Commission's current powers. The COR is particularly anxious that there is a full understanding of the differences between health promotion and health education and notes that in many places the terms are interchanged inappropriately. The COR believes, for example, that, within the workplace, health promotion is preferable to general health education. The workplace is an area where action by individuals determines also the health, safety and welfare of others. The COR would be pleased to see further clarification and amplification of the support that is intended for health education and health education projects.

9.3. Vocational Training in Public Health and Health Promotion

The COR believes that there may be significant variation among Member States in the format and role of schools of public health and, as a result, the proposal for exchanges may be over ambitious at this stage.

9.4. Specific Prevention and Health Promotion Measures

The COR feels that the resources available to the Commission might be better utilized if support was offered for specific and targeted health promotion activities rather than the broad range being proposed. Targeting might relate, for example, to specific disadvantaged groups. The COR does believe, however, that the development of robust health promotion programmes will be assisted by more and better research work to evaluate the effectiveness of health promotion.

9.5. Health Promotion Strategies and Structures

The COR would welcome further details of activities to encourage and support cooperation between Member States.

Done at Brussels, 16 November 1994.

The Chairman

of the Committee of the Regions

Jacques BLANC

APPENDIX

Supplementary Opinion of the Committee of the Regions

On 26 July 1994 the Committee of the Regions, acting under Article 9(1) of the Rules of Procedure, decided to draw up a Supplementary Opinion on the above-mentioned proposal.

The Commission on Education and Training, which was responsible for preparing the Committee's work on the subject, adopted the following Supplementary Opinion on 24 October 1994. The Rapporteur was Mr O'Neachtain.

This Supplemenary Opinion was enclosed with the Opinion of the Committee of the Regions (CdR 246/94) adopted at its 5th plenary session (meeting of 16 November 1994).

1. Health education

The COR agrees with the Commission in its Communication that health education is the cornerstone of health promotion policy. It stresses that in view of the fact that many illnesses, and deaths are related to lifestyles and behaviour, these can be preventable and that education and training systems have a key role to play in teaching positive healthy attitudes.

1.1. It underlines that health education, as distinguished from other health promotion actions, implies a dynamic process of learning, involving interactive feedback between the learner and educator. The COR maintains that health education forms an integral part of any health promotion strategy and supports the Community action programme's coordinated framework for the actions proposed.

1.2. The COR stresses the importance of teaching positive attitudes to school children, starting at primary school level, since this would have a beneficial influence on their future behaviour patterns. It supports the promotion of health education in school curricula yet stresses the importance of an interdisciplinary approach to health education. In this light, the COR in particular supports projects giving support for the European Network of Health Promoting Schools in cooperation with the WHO and the Council of Europe.

1.3. Whilst recognizing that children should be a priority target group for health education, the COR maintains that health education should not stop with the classroom. In order for there to be effective health promotion an adapted process of continuous education should be available to all citizens, at all ages, whether in their workplace or their local communities. Measures should therefore encourage active participation of the whole Community in acquiring necessary knowledge to lead a healthy life and prevent disease, accidents and injuries; the attainment of a high level of health protection being an objective of the Maastricht Treaty.

1.4. The COR supports the Commission's health promotion approach in health education based on the principle 'prevention is better than cure' yet points out that in order to address problems at their source a more in depth analysis is required, especially of the determining factors for unhealthy risk-taking behaviour. It is important therefore to be able to distinguish the cause of such behaviour from the symptoms and to recognize that health promotion measures will be ineffective if these causes are not properly tackled.

1.5. The COR calls on the Commission to explicitly refer to unemployment and social exclusion as important determinant factors for unhealthy lifestyles and maintains that education and training measures in health promotion should go hand in hand with policies aiming to improve social and economic conditions, in particular increased health service provision.

1.6. In this light special attention should be given to the provision of health education to disadvantaged population groups and particular deprived territorial areas (depressed inner-city or peripheral areas, rural areas) which have particular difficulties in promoting health education.

1.7. The COR maintains that the Commission's proposals for health education objectives should specifically refer to mental health. Any effective Community health education strategy cannot overlook this area which is particularly relevant given that suicide is now one of the major causes of mortality in the EU.

1.8. Psychological determinant factors such as stress, boredom and alienation (which can also be related to unemployment) should also be considered here. Factors such as these, point towards the need for establishing a citizens' Europe which attaches importance to the quality of life as well as the standard of living.

1.9. The COR stresses the importance of conveying positive, clear and scientifically justifiable messages in health education. It should therefore focus on the benefits of healthy lifestyles, balanced nutrition, preventative measures such as vaccination, sport and leisure activities, safe sexual behaviour and avoidance of smoking, drug and alcohol abuse as well as avoidance of dangerous driving. It stresses the value of visits to hospitals and health institutions as well as effective audiovisual material, demonstration projects. These bring the citizen closer to the issues of public health promotion and raise awareness of the importance of risk-taking behaviour avoidance.

1.10. The COR maintains that health care professionals, in particular doctors and nurses, have an important role to play not only in treating ill health but in promoting good health and the COR calls for support to be given to pilot projects encouraging health professionals to actively contribute towards health education in schools and in the workplace.

1.11. It emphasizes that rhetorical presentations which convey prohibitive messages could amount to a covert form of scaremongering which could be counter productive and encourage challenging behaviour.

1.12. The COR calls for health education measures promoting health and safety awareness, accident and injury avoidance at the workplace and in the home, taking into consideration the particular needs of the elderly and the ageing population trend.

1.13. The COR, whilst acknowledging that an effective health promotion and education policy will present considerable savings in the overall cost of health systems, stresses that this should not imply a resulting reduction in health service spending.

2. Vocational training in public health and health promotion

2.1. The COR supports the review and assessment of existing structures and training schemes in public health, health promotion and education and the compilation of a European directory. It endorses the constitution of networks of Schools of Public Health, colleges, universities and training bodies with a view to developing a common core in training courses and exchanges of students and teaching staff between EU countries. It also stresses the importance of emphasizing an interdisciplinary approach by promoting public health modules within training courses.

2.2. It maintains that any promotion of cooperation between Member States on the content of training courses and training activities in the fields of public health must involve interregional cooperation between the relevant actors, in particular local and regional health and education authorities. They have a better understanding of the real problems of promoting health within their communities whose different cultures, socio-economic conditions and prevalent lifestyles call for different approaches. Moreover, they have direct contact with teachers, social workers and medical and paramedical professionals who are the key players in health education. Community action can support cooperation and networking which strengthens their role.

2.3. The COR stresses the importance of developing effective teaching aids and materials, in particular audiovisual material which can be put to the widest use throughout Member States. The dissemination of information on 'best practices' is particularly valuable for training purposes.

2.4. The COR supports the coordination of community action in health promotion training with the proposed Socrates and Leonardo Da Vinci programmes and the taking into account of experience acquired through the existing Community education and training programmes including Erasmus and Comett.

3. Interregional cooperation in health education and training in public health and health promotion

3.1. The COR calls for the setting up of cooperation networks encouraging exchange of information, experience and supporting pilot projects involving schools, parent associations, relevant training and health institutions, universities, non-governmental organizations (in particular the Association of Schools of Public Health in the European Region and European Public Health Association) medical centres, hospitals, social workers, social centres, businesses, sports and recreational centres as well as local and regional authorities who have a key role to play as catalysts and coordinators, bringing all partners involved closer together under an integrated community-based approachapter It stresses the importance of compiling a European Directory enabling all the principal actors involved in health education promotion at local and regional level throughout the EU, to be identified and thus linked through Community networks.

3.2. The COR calls for support to be given to highly innovative local or regional demonstration-type projects, involving citizens themselves in particular young people, within the planning, implementation and especially evaluation of the projects. These pilot projects could provide invaluable information on good practice to all the actors involved in public health education throughout the EU. Projects such as the one in the UK which enables doctors to prescribe a course of swimming as treatment at a local leisure centre or the project in Ireland within semi-state bodies which involves compulsory attendance of a course for workers abusing alcohol, illustrate the important contribution of local and regional authorities towards positive health promotion strategy.

3.3. The COR, maintaining that health scourges have no frontiers and that health promotion is a global issue, strongly supports cooperation with non-member countries and with international public health organizations, including the World Health Organization, as well as the association of EFTA countries and the countries from Central and Eastern Europe and calls for interregional cooperation to be strengthened with third countries in the area of health education and training in public health and health promotion.

3.4. It concludes by underlining that effective coordination of health promotion and health education actions as well as effective planning and evaluation of the actions require the involvement of local and regional authorities, in accordance with the principle of subsidiarity.

Brussels, 24 October 1994.

The Chairman

of the Committee of the Regions

Jacques BLANC