Health Promotion Outcomes Research Articles

Are Medicare wellness visits improving outcomes?

As the largest and unhealthiest population in American history enrolls as Medicare beneficiaries, it is vital for primary care providers to understand how to maximize Medicare wellness provisions. The Baby Boomer population has been documented to have the highest chronic disease prevalence related to preventable lifestyle behaviors. Perpetual unhealthy lifestyle behaviors associated with chronic disease prevalence are detrimental to life quality and the American Medicare resource structure. Since 2011, the Affordable Care Act provisions have included free wellness visits designed to prevent disease for Medicare beneficiaries, who continue to grossly underuse these services. This systematic review was conducted to evaluate the quality, level, and strength of evidence regarding Medicare wellness service efficacy on related health outcomes. The methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for selection of 21 research-based articles included in the analysis. Results from the 21 eligible studies revealed low research quality and vigor; therefore, lacking causality and generalizability of medicare wellness visit (MWV) efficacy on health promotion outcomes. The evidence is focused on how MWVs are affecting preventive care utilization instead of patient health outcomes. In the interest of reducing chronic disease prevalence and the economic burden on our health care system, it is important to understand how these services affect health promotion outcomes. The results of this systematic literature review substantiate the need for primary care providers to study MWV efficacy on health promotion outcomes for the Medicare population.

A life satisfaction approach to valuing the impact of health behaviours on subjective well-being

BackgroundIncreasingly, decision-makers are interested in understanding the returns on investments in programs and policies that promote health and prevent chronic diseases. While the costs of these programs are more easily quantified, many of the outcomes they aspire to achieve are intangible and lack obvious market values. The subjective well-being (SWB) method was developed to value a wide range of non-market goods, including health outcomes directly in monetary terms. This paper presents an application of the SWB approach to estimate the monetary value of health-promoting behaviours as the intermediate outcomes of health promotion and chronic disease prevention programs and policies.MethodsLife satisfaction (LS) was used as a proxy of individuals’ SWB. Based on the combined Canadian Community Health Survey 2009–10 data, we modeled LS as a function of income and healthy behaviours, controlling for the socio-demographic factors associated with LS at the individual level using ordinary least squares regression. Equivalent effects of income and healthy behaviours on LS derived from the models allowed us to estimate the trade-off between income and healthy behaviours.ResultsWe found that income and healthy behaviours were positively associated with LS. The values of increased physical activity, an additional daily serving of fruits/vegetables, and not smoking are respectively $631, $115 and $563 per week. These represent the amounts of additional weekly income required to maintain an individual at their level of LS in the absence of each of these behaviours.ConclusionsThe SWB method holds promise as a method to monetize the value of a range of non-market goods, including healthy behaviours for which market values do not exist. The SWB method can be applied efficiently and cost-effectively using readily available survey data.

Implementation of a Shared Medical Appointment as a Holistic Approach to CHF Management.

Congestive heart failure is a costly chronic disease within the United States. The purpose of this study was to examine the effect of a holistic shared medical appointment (SMA) approach to congestive heart failure. Findings suggest the SMA approach improves depression, quality of life (QOL), and health-promoting behaviors. This study implemented congestive heart failure self-management education in primary care using a holistic multidisciplinary approach with SMA to provide evidence-based interventions to improve depression, QOL, and health promotion outcomes. Patients participating in the holistic multidisciplinary SMA experienced improvement in depression, QOL, and health promotion behaviors. A comparison of the means between preintervention and postintervention showed an overall reduction in systolic blood pressure, weight, depression scores, QOL scores, and several indicators of health promotion lifestyle.

Successful Aging in Individuals From Less Advantaged, Marginalized, and Stigmatized Backgrounds

Health and well-being in later life are heavily influenced by behaviors across the life course, which in turn are influenced by a variety of wider contextual, social, economic, and organizational factors. There is considerable potential for inequalities in health-promoting behaviors and health outcomes, arising from poverty, social, and environmental factors. This suggests that individuals from disadvantaged backgrounds and circumstances may have more exposure to (chronic) stressors, coupled with reduced access to resources, and increased susceptibility to risk factors for ill-health and mental disorders in later life. This drastically decreases the likelihood for successful aging in individuals from less advantaged backgrounds. Nevertheless, despite these adverse circumstances, some high-risk, disadvantaged individuals have been shown to achieve and maintain good health and well-being into later life. This scientific update provides an overview of recently published research with samples that, against expectations, demonstrate successful aging. Favorable personality traits, cognitive strategies, and a high-level of intrinsic motivation, paired with a supportive social environment, have been found to build a prosperous basis for successful aging and positive health outcomes in later life for individuals living in aversive environmental circumstances. For clinical psychologists, the movement towards the investigation of underlying mechanisms of successful aging from a psychological perspective, particularly in disadvantaged individuals, may be a critical step towards understanding the vast heterogeneity in aging. Successful aging is possible in disadvantaged individuals. Psychological and social resilience resources may compensate for the impact of disadvantage. The application of multi-level resilience models can aid future research on successful aging. Successful aging is possible in disadvantaged individuals. Psychological and social resilience resources may compensate for the impact of disadvantage. The application of multi-level resilience models can aid future research on successful aging.

The role of Māori community gardens in health promotion: a land-based community development response by Tangata Whenua, people of their land.

For Māori in Aotearoa New Zealand, land is not only an economic foundation but an anchor for tribal identity and a spiritual base. The forced alienation of Māori land since the 1800s, due to colonisation, has distanced communities from a direct relationship with their lands. There is little published research on Māori community gardens (māra) and their potential to reconnect Māori with ancestral lands. This study explores the motivations for developing māra and examines the role of māra in Māori health promotion. The paper describes findings from kaupapa Māori research that involved interviews with seven leaders of māra initiatives. Our findings suggest that the development of māra is motivated by a desire to empower Māori collectives towards a vision of vital communities thriving as Māori. Māra provide a rich site for community development grounded in a cultural connection to ancestral land. The utilization of ancestral lands enables groups to draw on a deep sense of shared identity that is rooted in those lands and fosters an intergenerational orientation. Māra offer activity linked with ancestral knowledge, customary practices and tribal connection. They provide opportunities to practice Māori language and cultural processes in functional everyday ways, and thereby strengthen a sense of commitment to protect cultural heritage as a resource for community life. Importantly, hands-on collective activity with shared decision-making, which is characteristic of māra, fosters social cohesion and collective efficacy. Overall our findings indicate that māra are land-centred community development initiatives that fit within the parameters of Māori health promotion and have much potential to contribute to achievement of Māori health promotion outcomes.

Testing the Role of Narrative and Gain-Loss Framing in Messages to Promote Sleep Hygiene among High School Students

Insufficient sleep is common during high school and associated with adverse developmental and health outcomes. School-based health promotion efforts hold promise for improving student sleep health. This study examines two message strategies, short personal narratives and gain versus loss message framing, in shaping intentions to get healthy sleep and intentions to talk about the information received. We also examine the mediating roles of transportation and positive emotions (happy, content) and negative emotions (fear, anger). We utilize a 2 (narrative vs. non-narrative) by 2 (gain vs. loss framing) between-subjects, randomized experimental design, to test the effect of print messages on these outcomes among a sample of high school students (N = 378). Exposure to the narrative message was directly associated with greater talk intentions but not sleep intentions. Message framing was not directly associated with sleep intentions or talk intentions. Mediation analyses revealed that exposure to the narrative was indirectly associated with sleep intentions and talk intentions via transportation, and indirectly with talk intentions via both participant-reported happiness and fear. Exposure to gain-framed messages was indirectly associated with talk intentions via positive emotion. These findings extend and complicate our understanding of the roles of narrative and equivalence framing in shaping key health promotion outcomes.

Can Cross-Sector Partnerships Increase Breast Cancer Screening in Hard-to-Reach Migrant Populations?

Background and context: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+; targeting women aged 50-74. The program reduces breast cancer-related deaths by up to 28%. BSV aims to ensure equitable participation for all women in the target age; however there are large disparities in screening rates for different subpopulations. Emerging migrant women participate in breast screening at lower rates than the general population. These women face complex barriers including cultural factors, low health literacy, and access. BSV identified cross-sector partnerships, with local trusted organizations who engage with emerging migrant women, as an approach to tackle the multidimensional problems in screening inequalities. Aim: Through cross-sector partnerships BSV aims to bring together diverse skills, knowledge and resources for more effective health promotion outcomes, including: 1. Increasing awareness of breast screening in emerging migrant communities, 2. Providing a culturally safe environment for women to access breast screening. Strategy/Tactics: BSV partnered with organizations beyond the traditional health sector. One key partnership is with AMES Australia, who provide settlement services for refugees and migrants. The main approach of this model is two-way capacity building between organizations. BSV built the capacity of AMES to deliver BreastScreen's key messages, and promote screening to eligible women accessing their service. This included training for staff, resource development/sharing, and support. AMES built the capacity of BSV by providing insight into barriers for women they engage, and guidance adapting traditionally clinical environments ensuring cultural safety. To date BSV has undertaken screening initiatives with AMES in 2 Melbourne locations. Outcomes: - Migrant women are introduced to breast screening by a trusted organization - BSV's key messages are delivered in a culturally appropriate manner - Development of sustainable skills, structures and resources in both organizations - Utilization of AMES relationship with their clients to engage women who BSV may not reach -not on the Victorian Electoral Roll - 6 group bookings with specific languages groups - Familiar case worker and in person translator supporting group bookings - Engaging mainly first time screeners who may not have accessed a breast screen - Overcoming cultural, language, and health literacy barriers - Tailored appointments for groups and walk-ins. What was learned: A lack of tailored strategies to engage women in breast screening compounds barriers for migrant women. Cross-sector partnerships increase the efficiency of systems that impact health by making the best use of different but complementary resources. Collaborations, joint resourcing and planned action should be considered ongoing practice, particularly for disengaged populations, to address the many determinants of health that lie outside the reach of the health system.

Polyunsaturated fatty acids intake, omega-6/omega-3 ratio and mortality: Findings from two independent nationwide cohorts

Polyunsaturated fatty acids (PUFA) have been reported to exert pleiotropic protective effects against various chronic diseases. However, epidemiologic evidence linking specific PUFA intake to mortality has been limited and contradictory. We aim to assess the associations between specific dietary PUFA and mortality among adults in China and America, respectively. Participants from China Health and Nutrition Survey (CHNS, n=14,117) and National Health and Nutrition Examination Survey [NHANES (n=36,032)] were prospectively followed up through the year 2011. Cox regression models were used to investigate hypothesized associations. A total of 1007 and 4826 deaths accrued over a median of 14 and 9.1 years of follow-up in CHNS and NHANES, respectively. Dietary marine omega-3 PUFA was robustly associated with a reduced all-cause mortality [Hazard ratio (HR) comparing extreme categories: 0.74, 95% CI: 0.61-0.89; P<0.001 for trend] in CHNS. Nevertheless, this inverse relationship was not observed in NHANES. The overall mortality was positively associated with the intake of α-linolenic acid (ALA) (HR comparing extreme quartiles: 1.23, 95% CI: 1.01-1.50; P=0.054 for trend) in CHNS, whereas weak inverse associations of ALA (P=0.035 for trend) and LA (P=0.027 for trend) with all-cause mortality were found in NHANES. Increased dietary intake of arachidonic acid was consistently linked with reduced all-cause mortality both in NHANES and CHNS. Importantly, consuming PUFA at an omega-6/omega-3 ratio of 6-10 was associated with a lower risk of death in CHNS. Intakes of different specific PUFA show distinct associations with mortality and these relationships also vary between Chinese and US populations. These findings suggest maintaining an omega-6/omega-3 balance diet for overall health promotion outcomes (NCT03155659).

職域ヘルスプロモーション（WHP）の変遷と成果:―有効で感謝される働き盛り世代の健康支援とヘルスリテラシーの向上を目指して

職域ヘルスプロモーション（WHP）の変遷と成果:―有効で感謝される働き盛り世代の健康支援とヘルスリテラシーの向上を目指して

Promoting physical activity in worksite settings: results of a German pilot study of the online intervention Healingo fit

BackgroundWorldwide, one third of the adult population is insufficiently physically active. This fact has led to a strong demand for public health initiatives. Given the mixed evidence on the effectiveness of worksite interventions promoting physical activity (PA), a pedometer-based and gamified intervention, Healingo Fit, was developed and evaluated over a period of six weeks.MethodsThe effectiveness of Healingo Fit was evaluated as part of a randomized controlled trial (RCT) with two measurement points involving employees of an automobile manufacturer. Direct health promotion outcomes were assessed using self-developed items on PA knowledge, the HAPA brief scales and the exercise self-efficacy scale. IPAQ short version was used to assess different forms of PA behavior. Intervention effects were identified using a two-way analysis of variance (ANOVA) with repeated measurements.ResultsA total of 144 participants took part in the study (intervention group = 80, control group = 64). The results of the ANOVA show significant interaction effects (group x time) for health promotion outcomes (knowledge, intention, and self-efficacy), with medium to high effect sizes. In the health behavior related outcomes, there were significant improvements, with large effect sizes for low levels of PA, but not for moderate and high PA. Walking time increased by 125 min/week in the intervention group, corresponding to a percentage increase of 30% compared to baseline.ConclusionsPedometer-based interventions using gamification elements can have positive effects not only on health promotion parameters but can also lead to an increase in PA behavior. The online format of Healingo Fit is suitable for reaching large numbers of people and achieving population effects.Trial registrationGerman Clinical Trials Register (DRKS): DRKS00006105, date of registration: 2017–03-24.

Long-term housing subsidies and SSI/SSDI income: Creating health-promoting contexts for families experiencing housing instability with disabilities

BackgroundThough disability and housing instability are discussed separately in public health literature, few studies address families at their intersection. As a result, little is known about families who experience both homelessness and disability, how many receive disability benefits like SSI and SSDI, or the influence of those benefits on health-promoting outcomes like housing stability and self-sufficiency. Moreover, no previous research compares the ability of different housing and service interventions to increase disability benefit access. ObjectiveWe examine relationships between disabilities and SSI/SSDI income reported when families enter emergency shelters and later health-promoting outcomes (housing stability and self-sufficiency) and how housing interventions affect SSI/SSDI receipt. MethodsFamilies in the (name removed) Study (N = 1857) were interviewed in emergency shelters, randomly offered of one of three housing interventions or usual care (i.e., no immediate referral to any intervention beyond shelter), and re-interviewed 20 months later. ResultsA third of families reported a disability at shelter entry. SSI/SSDI coverage of these families increased nearly 10% points over 20 months but never exceeded 40%. Disabilities predicted greater housing instability, food insecurity, and economic stress and less work and income. Among families reporting disabilities, SSI/SSDI receipt predicted fewer returns to emergency shelter, and more income despite less work. Offers of long-term housing subsidies increased SSI/SSDI receipt. ConclusionsMany families experiencing homelessness have disabilities; those receiving SSI/SSDI benefits have better housing and income outcomes. Providing families experiencing homelessness with long-term housing subsidies and SSI/SSDI could improve public health.

The Challenge of the ‘Art and Science’ of Health Promotion

Health promotion has a key role to play in preventing disease and promoting healthy lifestyles. Health promotion work is part science and part art. The science emerges from research and theory and the art emerges from our professional intuition and experience. The goal is to apply the science to achieve the best health promotion outcomes. However, an application of the theory, models and even the evidence, does not guarantee a desired outcome. To achieve this is an art and something that is often missing in practice. An understanding of how best to apply the ‘art and science’ of health promotion requires an appreciation that it is not only about being scientifically right but also about being real. The challenge for health promoters is to understand how they can use their judgement to best apply the available science to deliver successful approaches.

Critical perspectives on health and wellbeing education in schools

Purpose This Special Issue aims to place the spotlight on educational research and its contribution to the field of school-based health and wellbeing promotion. The purpose is to bring together scholars from across the world to consider current developments in research on curricula, interventions, policies and practices concerning health and wellbeing promotion and related professional development of teachers. Design/methodology/approach The members of European Educational Research Association (EERA) Network Research on Health Education (Network 8) were invited to submit their conceptual or empirical work addressing processes and outcomes in school health and wellbeing promotion. Additionally, an open call for papers was published on the Health Education website and on EERA website. Following the double blind peer review process and editorial work by the guest editors and the editor in chief, six of the submissions that were accepted for publishing are selected to be published in this issue and the rest w...

From child to grown up in a medical world: developing an adolescent transition programme at a Norwegian University hospital.

Background Akershus University Hospital has since 2012 worked systematically towards improving the process of transfer for adolescents from the Department for Paediatric and Adolescent Medicine (DPAM) to adult services in our hospital. Objective To improve the transfer process of adolescents we aimed at moving from a more administrative focus on transfers to a transition programme. The aim was both short-term and long-term gains, namely quality improvement of the healthcare we are providing and valued health promotion outcomes. Methods A guided transition programme for adolescents was developed, piloted and introduced. It was developed in close collaboration with our youth council. An e-learning programme and a handbook for health care professionals were developed for implementation. Results Data from the pilot testing the transition programme show that the adolescent participants found the information material to be relevant. They reported that it was used actively by the health professionals in their consultations and that they found this to be helpful. It was crucial that the management acknowledged and took responsibility for the programme. We experienced that a shared understanding of the adolescent patient in both sending and receiving departments was crucial. Conclusion Adolescent medicine should include competence and professionalism. Health care personnel must possess knowledge, skills and attitude that enable good, health promoting encounters. Further evaluation of pre- and post-implementation clinical outcomes, of patient empowerment and of satisfaction among employees will need to follow for evaluation of the effectiveness of this transition programme.

Free radicals and antioxidant enzymes in older adults after regular senior elastic band exercising: an experimental randomized controlled pilot study.

The aim of this study was to pilot test the effects of regular senior elastic band exercises on the generation of free radicals and antioxidant enzyme activities in older adults. Long-term regular exercises have positive health promotion outcomes. On the contrary, high-intensity, high-speed and short-term exercises in older adults may increase free radicals and cause chronic disease and ageing effect. A prospective randomized controlled pilot study. Data were collected during 2012. Twenty-five older adults were recruited from a community care centre, southern Taiwan and were randomly assigned to either an experimental or control group. Twenty-two participants completed the study: experimental group (n=10) and control group (n=12). The experimental group performed 6-month senior elastic band exercises while the control group kept regular daily routines. Both groups received blood tests (thiobarbituric acid-reacting substances and glutathione peroxidase) 30minutes before the study began and 1hour after the final intervention treatment. At the end of the 6-month senior elastic band exercises, no statistically significant differences in thiobarbituric acid-reacting substances and glutathione peroxidase values between the experimental and control groups. No significant differences existed in both thiobarbituric acid-reacting substances and glutathione peroxidase values before and after the 6-month senior elastic band exercises either. Regular senior elastic band exercises did not increase the generation of free radicals and antioxidant enzyme activities. Senior elastic band exercises have the potential to be promoted among older adults in the community as an exercise option without adverse effects on free radicals and have potential for mitigating ageing and increasing disease control.

Television-based health promotion in general practice waiting rooms in London: a cross-sectional study evaluating patients\u2019 knowledge and intentions to access dental services

BackgroundThis study aimed to evaluate whether television-based dental health promotion initiatives in General Practice waiting rooms would increase patients’ knowledge of and intentions to seek dental services.MethodsThis cross-sectional survey of 2,345 patients attending 49 General Practices in Brent, northwest London, evaluated the ‘Life Channel’ – a series of six brief health promotion advertisements, including one dental health promotion advertisement, displayed over ten minutes on television in General Practice waiting rooms. Primary outcome measures were a self-reported gain in the knowledge to contact a National Health Service (NHS) and emergency dentist, and an intention to seek dental services, attributed to viewing the Life Channel.ResultsAmong the 1,088 patients who did not know how to contact an NHS dentist prior to the survey, and the 1,247 patients who did not know how to contact an emergency dentist prior to the survey, 48.0 % (95 % CI 45.0-51.0 %) and 35.1 % (95 % CI 32.4-37.8 %) attributed the Life Channel to educating them how to do so, respectively. Among the 1,605 patients who did not have any intention to contact a dentist prior to the survey, 15.2 % (95 % CI 13.4-17.0 %) attributed the Life Channel to creating such an intention. We report adjusted odds ratios on sociodemographic disparities in this evaluation.ConclusionsTelevision-based dental health promotion may significantly increase knowledge of and intention to seek dental services in this sample in London. Television-based dental health promotion may appeal more to certain population groups. More research is needed to identify longer term outcomes of television-based health promotion.

Health Promotion Outcomes of a Newly Developed Elastic Band Exercise Program for Older Adults in the Community: A Pilot Test.

Studies indicate that the incidence of disease, the mortality rate, and medical costs are significantly higher in people aged 65 years and over who do not engage in physical activities than in their peers who do engage in these activities. Therefore, promoting appropriate physical activity among older adults in the community is essential to delaying the health implications of aging. This pilot test was developed to assess the effectiveness of a newly developed Senior Elastic Band (SEB) exercise program on the health of older adults in community care stations. A quasiexperimental design was used. A convenience sample of 20 participants from a community care station was recruited. The SEB intervention included three phases (warm-up, aerobic motion, and static stretching) and was conducted three times per week, 40 minutes per session for 1 month. Twelve health indicators in three categories (functional fitness, self-perceived health status, and sleep quality) were examined before and immediately after 1 month of SEB exercises. Participants showed improved performance at the end of the 1-month study for the following indicators: lung capacity, cardiopulmonary fitness, upper and lower body flexibilities, upper limb muscle power, lower limb muscle endurance, and self-perceived physical health status (all ps < .05). No significant differences were identified for the other indicators. The SEB exercise program shows preliminary and promising effects on improving the health of older adults in a community care station. Healthcare professionals who work with older adults living in the community may consider the SEB exercise program as a health promotion modality to recommend and implement with this population. However, we recommend further testing the long-term effects of this program on a larger population.

Framework of behavioral indicators evaluating TB health promotion outcomes: a modified Delphi study of TB policymakers and health workers.

BackgroundAlthough TB health promotion directed at policy makers and healthcare workers (HCWs) is considered important to tuberculosis (TB) control, no indicators currently assess the impact of such promotional activities. This article is the second in a series of papers that seek to establish a framework of behavioral indicators for outcome evaluation of TB health promotion, using the Delphi method. In the first article, we sought to establish a framework of behavioral indicators for outcome evaluation of TB health promotion among TB suspects and patients. The objective of this second article is to present an indicator framework that can be used to assess behavioral outcomes of TB health promotion directed at policy makers and HCWs.MethodsA two-round, modified Delphi method was used to establish the indicators. Sixteen experts who were knowledgeable and experienced in the field of TB control were consulted in Delphi surveys. A questionnaire was developed following 4 steps, and involved ranking indicators on a five-point Likert scale. The consensus level was 70 %. Median, mode, and Coefficient of variation (CV) were used to describe expert responses. An authority coefficient (Cr) was used to assess the degree of each expert’s authority.ResultsConsensus was achieved following the two survey rounds and several iterations among the experts. For TB health-promotion activities directed at policymakers, the experts reached consensus on 2 domains (“Resource inputs” and “Policymaking and monitoring behaviors”), 4 subdomains (“Human resources” among others), and 13 indicators (“Human resources per 100,000 person” among others). For TB health-promotion activities directed at HCWs, the experts reached consensus on 5 domains (“Self-protective behaviors” among others), 6 sub-domains (“Preventing infection” among others), and 15 indicators (“Average hours of daily workplace disinfection by ultraviolet radiation” among others).ConclusionsThis study identified a conceptual framework of core behavioral indicators to evaluate TB health-promotion activities directed at policymakers and HCWs involved in TB control. Validation in other parts of the world could lead to global consensus on behavioral indicators to evaluate TB health promotion targeted at policymakers and HCWs.Electronic supplementary materialThe online version of this article (doi:10.1186/s40249-015-0087-4) contains supplementary material, which is available to authorized users.

Building Social Capital Through a Peer-Led Community Health Workshop: A Pilot with the Bhutanese Refugee Community.

Despite the high health and mental health care needs, resettled refugees often face cultural and linguistic challenges that hinder the access to appropriate and timely interventions and services. Additionally, such concepts as preventive health or mental health treatment are foreign to this population, which creates additional burdens to the refugee community that already have difficulty navigating a complex health care system in the U.S. To address multiple and complex gaps in health and mental health support for the refugee community, requested is an innovative approach that can convey culturally responsive and effective interventions for health promotion, such as peer-based health education. Few studies have been conducted on the effectiveness of peer-led community health interventions with refugee populations in the U.S. resettlement context. However, peer-led interventions have been shown to be effective when working with cultural minorities and interventions in an international context. Adopting a social capital framework, the current study conducted qualitative evaluation on the impact of a pilot peer-led community health workshop (CHW) in the Bhutanese refugee community. A hybrid thematic analysis of focus group discussion data revealed the improvement in health promotion outcomes and health practice, as well as perceived emotional health. The results also showed that the peer-led CHW provided a platform of community building and participation, while increasing a sense of community, sense of belonging and unity. The findings posit that a peer-led intervention model provides culturally responsive and effective tools for building social capital and promoting community health in the refugee community.

Identifying nurse practitioners' required case management competencies in health promotion practice in municipal public primary health care. A two-stage modified Delphi study.

The aims of this study were to identify and reach consensus among municipal primary health care participants on nurse practitioners' (NPs') required case management competencies in health promotion practices in eastern Finland. The NP's role as a case manager of patients with chronic conditions has been found to have positive outcomes in health promotion, such as reduced hospital lengths of stay and readmission rates. However, the challenging work of health promotion requires NPs to have multidimensional competencies in health promotion, including communication, advocacy, assessment, planning, consultation and implementation. A two-stage modified Delphi study. Round 1 semi-structured interviews were conducted among municipal primary health care participants (n = 42) in 11 health centres from April-July 2009, and the round 2 questionnaire survey was conducted in the same health centres in eastern Finland in January and March 2011. The questionnaire was answered by 64% of those surveyed (n = 56). Content analysis and descriptive statistics were used for data analysis. We identified a total of 18 required case management competencies for NPs' health promotion practices in municipal primary health care. In 17 of these competencies (such as knowledge, skills and ability to work independently in health promotion), a consensus was reached (51% or over). However, the need to be interested in municipal decision-making (44·6%) did not reach consensus. Consensus was clearly achieved for 17 competencies that NPs were required to have, and these indicated the knowledge or abilities of health promotion. Nevertheless, there was no agreement on the NPs' need to be interested in municipal decision-making. NPs need a variety of case management skills and abilities to realise health promotion in municipal primary health care and they need to be supported by primary health care leaders to develop health promotion activities.