Health Education Research, Vol. 14, No. 2, 151-154,
April 1999
© 1999 Oxford University Press
Editorial |
Health and the Celtic Tiger: progress of health promotion in modern Ireland
Department of Health Promotion Clinical Sciences Institute National University of Ireland Galway Republic of Ireland
If socio-economic factors do indeed determine our health status then the challenges facing modern Ireland are remarkable. In recent years the Republic of Ireland has seen unprecedented economic growth, in considerable measure due to our membership of the European Union (EU). In the space of a quarter of a century Ireland has moved from being a country with a strong agriculture tradition and recurrent problems of enforced emigration and unemployment to being among the most economically competitive countries in Europe. There has been considerable growth in the size and infrastructure of the principal cities, most particularly Dublin, major development in the service industries, and the overall economic indicators were satisfactory enough for us to join the European Monetary Union (EMU) initiative.
There have also been major social and cultural changes. These are various and not necessarily in any way related but include the decline in viable rural farming, particularly smaller-sized holdings, the contracting of average family size and hence informal carer support for older people, and the entry of women into the workforce in much larger numbers. Traditionally a religious country, in more recent years attendance at religious services has begun to decline, particularly among the younger urban-dwellers. There are signs of development in cultural creativity in virtually every town and city, with a growth in tourism, music, theatre and the film industry. The political troubles in Northern Ireland, perhaps the saddest hindrance to development on the island as a whole, have also at last diminished thanks to the peace process brokered by the two governments of the UK and Ireland with the help of the US.
What is the relevance of these diverse developments for health promotion? Socio-economic changes on this scale might be expected to translate into both positive and negative impacts on health and well-being in the population. To date how have these changes been reflected in our health indicators and how well do we measure them? In simple demographic terms, though there is evidence of the greying population as is seen in other European countries, we still have the relatively youngest population in Europe (Kelleher, 1993
). However, life expectancy for both Irish men and women is amongst the lowest in the EU. Rates of cardiovascular disease have begun to decline but we are still at the top of the EU league table for this disease, as are rates of colon cancer, particularly among women (WHO, 1998).
What do we know about health and lifestyle attitudes and behaviours in Ireland? Up to now, surprisingly little. There are indirect signs of considerable changes. Taking diet and nutrition as an example, surveillance data show falls in consumption of butter, increased purchases of fruit and vegetables, and huge shifts away from traditional retail outlets towards supermarkets (Kelleher and Friel, 1996). These changes might be expected to translate into changes in food consumption and nutrition status. At a more subtle individual level there may be changes in attitudes to how we define our health, as exemplified by a qualitative study on the views of older people about all aspects of their health (MacFarlane, 1998) or indeed the concepts of school-going children about different kinds of health care systems (Murphy and Kelleher, 1995).
No comprehensive quantitative national surveys of health behaviours were ever undertaken in Ireland. This year we report on two such surveys for the first time. The SLAN survey on lifestyles, attitudes and nutrition of a random nationally representative sample of Irish adults over 18 years of age comprised 6539 participants. A comprehensive 257 item questionnaire was devised based on a review of similar instruments in the literature. The survey covered a range of aspects of general health and well-being, traditional lifestyle behaviours including smoking, alcohol consumption and drug misuse, and a very detailed section on diet. The HBSC (health behaviours in school-going children) survey followed the strictly defined international protocol and had 8497 participants in 187 nationally representative schools. The first report (Kelleher et al., 1999) focuses on whether we have attained the pre-set targets for risk reduction set in the National strategy document Shaping A Healthier Future published in 1994. There were interesting findings throughout the data, particularly in relation to both smoking and alcohol. Although the national target was to achieve a rate of 20% smokers in all those 15 years and over by the year 2000, this is far exceeded by a present overall population rate of 31%. For the first time we have detailed socio-demographic information showing that only women over 55 years and men of the same age in social classes 1 and 2 are at the target level. Rates among girls and women in social class 5 and 6 reach 40%. In common with developed countries everywhere we have an escalating problem among young people, particularly women, and a continuing sharp socio-economic class gradient. It is therefore clear that targets should be re-formulated to reduce these demographic variations. Smoking interventions require a major re-think; in particular, health education initiatives will need to be more focused and perhaps geared towards issues around the environmental impact of smoking or debate about the potential for social exploitation on the part of the tobacco industry (Kelleher and Sixsmith, 1999). Alcohol patterns too have changed. We once had relatively high rates of teetotallers thanks to the pioneer abstinence movement of Victorian times. Only those over 55 years of age continue to show this kind of pattern. Less than 10% of adults are teetotaller and less than 5% of young adults. Among young people there are high rates of alcohol experimentation and reported misuse.
What strategies for health promotion and health education are in place? Health education has been prominent in Ireland since the mid-1970s when the Health Education Bureau was established. This was replaced in 1990 with a Health Promotion Unit within the Department of Health itself. Metcalfe (Metcalfe, 1997) documented the changes in health promotion practice over this time period and the perceptions of key providers about these changes. The emphasis traditionally was on topical issues such as heart disease and related risk factors, and many campaigns were run centrally by national agencies with a predominant focus on media campaigns and general community education. Over the last decade there have been major developments at an organizational level in the health sector, closest in model to the those of the UK, with the establishment of both departments of Public Health and of Health Promotion, and moves within each board to set up a range of health promotion and education initiatives in the four key settings of community, school, workplace and hospital. This affords an opportunity for more concerted, coordinated initiatives at regional and local levels with closer collaboration on community and one-to-one initiatives. From a point of very little information and research, much is now available. The demonstration cardiovascular prevention project in Kilkenny (Shelley et al., 1995) produced findings similar to other such interventions in that rates of traditional risk factors declined in both intervention and reference county but there were some differences between the two areas; rates of rise of obesity were less steep in Kilkenny and there was some evidence that there was better penetration of the programme across social classes. More importantly perhaps the project facilitated the development of materials for use in primary care and school settings, and provided a basis for the development of more holistic community development type interventions in the future.
Health education initiatives in schools began in the late 1970s. While there has been no consistent policy in this field there have been lifeskills or personal development projects in several of the boards. An evaluation of the largest scale of these, the lifeskills programme in the North Western health board (Nic Gabhainn and Kelleher, 1995), demonstrated that the programme promoted more responsible behaviour in relation to alcohol but had no impact on smoking rates. There was also a more marked effect for girls compared with boys. This has highlighted an emerging problem for health education, i.e. the lack of participation by men generally and this will have to be addressed. We cannot turn the clock back but we can promote sensible drinking and this at least we know we have achieved with schools health education programmes. Policy has now moved towards the health promoting schools project and this too seems to be developing well, though again there are signs that demographic factors are highly influential and need to be taken account of in the future policy developments (Nic Gabhainn and Kelleher, 1997). A new policy initiative on workplace health promotion was recently launched (Department of Health and Children, 1999). Given the relatively large proportion of public sector employees in Ireland, this will be an important first step. There is a clear commitment to work with health and safety authorities, to take as holistic and comprehensive an approach as possible, and given the particularity of the work situation special initiatives for small and medium enterprises are planned.
The new challenge facing Ireland is to avoid the emerging patterns of inequity that are almost inevitable, it appears, in situations of rapid urban development. The emerging new economic prosperity is not necessarily equitable and may well create the kinds of situations of extreme disadvantage that have plagued affluent countries for years. In all our evaluation, observational and review data over the last decade we have seen in every setting evidence of socio-demographic variation in attitudes, behaviour and outcome (Kelleher, 1998) which are confirmed now by the findings from the National Health and Lifestyle surveys. We still have the opportunity to develop the kind of infrastructure that will promote and maintain rural life, decentralize services, and improve public transport and housing in urban areas. Our health and education services are still predominantly funded through public taxation and must be seen to have contributed positively to the existing social developments seen in Ireland in recent years, coined as the prevailing term Celtic Tiger (Sweeney, 1998). Keeping that Celtic Tiger healthy and well will require political vision and investment. Let us hope Irish politicians are listening.
References
Department of Health and Children (1994) Shaping a Healthier Future. A Strategy for Effective Health Care in the 1990s. Government Publications Office, Dublin.
Department of Health and Children (1999) Health Promotion in the Workplace—Healthy Bodies, Healthy Work. Government Publications Office, Dublin.
Kelleher, C. (1993) Measures to Promote Health and Autonomy for Older People: A Position Paper. National Council for the Elderly, Dublin, publ. no. 26.
Kelleher C. and Friel, S. (1996) Nutrition surveillance in Ireland. Proceedings of the Nutrition Society, 55, 689–697.[Web of Science][Medline]
Kelleher, C. (1998) Evaluating health promotion in four key settings. In Davies, J. K. and MacDonald, G. (eds), Quality, Evidence and Effectiveness in Health Promotion. Striving for Certainties. Routledge, London, pp. 47–67.
Kelleher, C., Friel, S. and Nic Gabhainn, S. (1999) Health and Lifestyle in Ireland: Report of the SLAN and HBSC Surveys, in press.
Kelleher, C. and Sixsmith, J. (1999) The riddle of the Sphynx: why do women smoke? Position paper for British Heart Foundation symposium, London 1998. In Kelleher, C. C. and Edmondson, R. (eds), Health Promotion; Multi-disciplinary or a New Discipline? Irish Academic Press, Dublin, in press.
Metcalfe, O. (1997) The development of health education and health promotion in Ireland 1970–1997. Dissertation in part requirement of Master of Arts degree in Health Promotion. National University of Ireland, Galway.
Murphy, A. and Kelleher, C. (1995) Contemporary heath practices in the Burren. Irish Journal of Psychology, 16, 38–51.
MacFarlane, A. (1998) Medical Pluralism in Ireland 1930s–1990s. Dissertation in requirement of degree of Doctor of Philosophy degree, National University of Ireland, Galway.
Nic Gabhainn, S. and Kelleher, C. (1995) Lifeskills for Health Promotion. The Evaluation of the North Western Health Board's Health Education Programmes. Centre for Health Promotion Studies, Galway and the North Western Health Board, Letterkenny.
Nic Gabhainn, S. and Kelleher, C. (1998) The Irish Network of Health Promoting Schools. A collaborative report. In Irish Network of Health Promoting Schools, Progress Report 1993–1996. Departments of Education and of Health and Children, Dublin.
Shelley, E., Daly, L., Collins, C., Christie, M., Conroy, R., Gibney, M., Hickey, N., Kelleher, C., Kilcoyne, D., Lee, P., Mulcahy, R., Murray, P., O'Dwyer, T., Radic, A. and Graham, I. (1995) Cardiovascular risk factor changes in the Kilkenny Health Project. A community health promotion programme. European Heart Journal, 16, 752–760.
Sweeney P (1998). The Celtic Tiger: Ireland's economic miracle explained. Oak Tree Press, Dublin, pp. 1–17.
World Health Organization (1998) Health for All Database. Copenhagen, Denmark.
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