European Journal of Public Health, Vol. 15, No.
1, 68
European Journal of Public Health, Vol. 15, No. 1, q European Public Health Association 2005; all rights reserved
Doi: 10.1093/eurpub/cki100
...........................................................................................
Commentary
...........................................................................................
Health promotion in hospitalsa strategy to
improve quality in health care
Oliver Groene, Svend Juul Jorgensen*
Keywords: health promotion, quality, standards, health promoting hospitals, reorientation of health
services
...........................................................................................
The international network of health
promoting hospitals
The(HPH)
International Network of Health Promoting Hospitals
was initiated more than 10 years ago with the aim to
reorient health care institutions to integrate health promotion
and education, disease prevention and rehabilitation services in
the curative care.1 An increasing number of chronic patients,
requiring continuous support, and hospital staff frequently
being exposed to physical and emotional strains pushed in this
direction.
Health promotion is defined in the Ottawa Charter as the
process of enabling people to increase control over, and
improve, their health.2 Health in this context not only refers
to the objective view of the absence of disease but also to
implying a subjective and holistic view, adding mental resources
and social well-being to physical health. Health promotion is
understood to embrace health education, disease prevention
and rehabilitation services, but stresses that information,
education and advice only lead to sustained behavioural change
if supported by prevailing norms, rules and cultures. Health
promotion interventions in organizations therefore have to
address these underlying causes.
Public health relevance
There is large scope and public health motivation for offering
health promotion strategies in health care settings.
Hospitals consume between 40% and 70% of the national
health care expenditure and typically employ about 1% to 3% of
the working population.3 These working places are character-
ized by certain physical, chemical, biological and psychosocial
risk factors. Paradoxically, in hospitalsorganizations that aim
to restore healththe acknowledgement of factors that
endanger the health of their staff is poorly developed.
Hospitals can also have a lasting impact on influencing the
behaviour of patients and relatives, who are more responsive to
health advice in situations of experienced ill-health.4,5 Given the
increasing prevalence of chronic disease in Europe and
throughout the world and low compliance with treatment,
therapeutic education is becoming a major issue.6 Most hospital
treatments do not cure but rather aim at improving the quality
* Oliver Groene1, Svend Juul Jorgensen2
1 Technical Officer, WHO European Office for Integrated Health Care
Services, Barcelona, Spain
2 Consultant, WHO European Office for Integrated Health Care
Services, Barcelona, Spain
Correspondence: Oliver Groene, Marc Aureli 22-36, 08006 Barcelona,
Spain, tel: +34 93 241 82 70, fax: +34 93 241 82 71,
e-mail: ogr@es.euro.who.int
of life of patients. To maintain this quality, patients and relatives
have to be prepared and educated more intensively for
discharge.
Hospitals produce high amounts of waste and hazardous
Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 29, 2016
substances. Introducing health promotion strategies to hospitals
can help to reduce the pollution of the environment and
cooperation with other institutions and professionals can help
to achieve the highest possible coordination of care. Further-
more, as research and teaching institutions, hospitals produce,
accumulate and disseminate a lot of knowledge and can have an
impact on the local health structures and influence professional
practice elsewhere.
Assessment of activities in the
international network
In order to draw attention to the issue of health promotion,
hospitals in the International Network commit themselves to
becoming a smoke-free hospital and to run three specific
projects/activities addressing health issues of staff, patients, the
community, or improving organizational routines with a
possible impact on health. A database was established to
register projects and activities, providing information on key
indicators of the hospital and the health promotion activities
(table 1):
Table 1: Five most frequent activities related to patients, staff,
organizational and community issues.
The projects have a strong patient and staff orientation but
mostly do not address the underlying structural or cultural
problems. A further review indicated that most health
promoting activities are still limited to a specific project or
within the responsibility of a single staff member, rather than
being implemented organization-wide.7
Further developing health promotion
in hospitals
While initially many health promotion activities were driven by
the conviction of individuals that hospitals could do more for
the health of the people, evidence now supports the effectiveness
of health promotion activities in hospitals. In addition, greater
impact on the health of individuals and groups will be
accomplished by health promotion activities being integrated
in quality improvement programmes.
Expanding the evidence-base for health promotion
interventions
The evidence base for health promotion is a main factor for
HPH, since the lack of evidence, coupled with prevailing cost
 Health promotion in hospitalsa strategy to improve quality in health care 7

Table 1 Projects related to patients, staff, organization and community (HPH database)

Projects Issue addressed Frequency

Patient-oriented (314 overall) Patient satisfaction 127

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Psychosocial aspects 84
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Nutrition 75
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Diabetes 62
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Tobacco 59
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Staff-oriented (270 overall) Staff satisfaction 106
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Interprofessional communication 79
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Working environment 74
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Psychosocial stress 65
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Other 60
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Organization-oriented (174 overall) Quality management 94
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Culture change 66
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Hospital as a workplace 51

Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 29, 2016

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Building a learning organization 51
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Hospital hygiene organization 36
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Community-oriented (172 overall) Health information 59
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Communication hospital-community 57
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Nutrition 43
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Tobacco 42
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Other 37

pressures in almost any health care system, tends to make health
promotion programmes an easy choice for budget cuts.8
Evidence for health promotion was the focus of the Inter-
national Conference on Health Promoting Hospitals in 2001
and the identification of present evidence and the creation of
evidence where it is absent is now one of the main targets for the
international network.
Health promotion in hospitals includes interventions
directed at structures and processes, as well as interventions
directed at individuals (patients and staff). The quantitative
approach is relevant in the evaluation of many interventions.
The value of specific interventions such as induced tobacco
cessation or alcohol abstinence prior to planned surgery is
unquestionably documented in randomized controlled trials.9,10
Also more complex interventions as rehabilitation programmes
are documented by the quantitative approach.11,12 A prospec-
tive controlled trial proving the effects of an overall hospital
programme for health promotion, a quality management plan
or an accreditation program, however, is not feasible. Processes
and structures in a programme must be assessed by a
qualitative approach and this leaves room for interpretation of
the results and a subjective or political judgment.13 A further
development of assessment tools is important for HPH in the
enforcement of the evidence base.
Standards for health promotion in hospitals
The dominant approach to quality assessment of health care
organizations is based on the definition of standards for the
activities. Several organizations have developed standards
mainly directed at hospitals but also some for the primary
health care sector. Analysis of the standards reveals that they
are relevant in focus and cover hospital services sufficiently
except the issue of health promotion and patient edu-
cation.14,15
This problem was taken up in the European HPH Network
and a working group was established in May 2001 to develop a
set of standards for health promotion in hospitals.
The International Society for Quality in Health Care has
developed guidelines for quality standards described in the
ALPHA programme.16 The working group decided to follow
these guidelines in order to develop a set of standards to fill out
the gap in the existing standards. However no decision was
made about the assessment of the compliance to the standards
by the hospitals in the International Network of Health
Promoting Hospitals.
The five core standards describe the responsibility of
the management to set a framework for health promotion
and the demands on the organization and the staff in order to
meet the patients needs for health promotion.17 This implies
the identification of patients needs, patient education and
advice (in order to empower the patient to correct risk factors),
programmes for interventions and rehabilitation, cooperation
with other sectors in health care to ensure continuity of care,
and a special focus on facilitating a healthy workplace.
The standards were pilot-tested in 36 hospitals in nine countries
and in their revised form presented at the 11th International
Conference on Health Promoting Hospitals in May 2003.18 The
pilot test demonstrated that the standards were assessed by health
professionals to be applicable and relevant, but compliance with
standards was very low. Future work has been carried out in
developing indicators, and a self-assessment tool for standards in
health promotion in order the strengthen the systematic planning,
implementation of evaluation of health promotion in hospitals.19
Outlook
Despite little legislative support in many member countries the
number of hospitals and countries joining the International
8 European Journal of Public Health Vol. 15, No. 1, 68

Table 2 Development of International Network of Health Promoting Hospitals

Year Developmental stage Number of Number of Number of

countries networks hospitals

1989 1996 Project Health & Hospital, 1 NA 1

Hospital Rudolphsstiftung, Vienna
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
1993 1997 European Pilot Project of HPH 11 NA 20
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
1998 Development of national and regional networks 14 19 210
under the umbrella of the International
Network of Health Promoting Hospitals
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
1999 16 29 280
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2000 19 29 508
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2001 22 29 540
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2002 22 32 627
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
2003 24 34 693

Network of Health Promoting Hospitals has increased steadily 7 Johnson A, Baum F. Health promoting hospitals: a typology of different

Downloaded from http://eurpub.oxfordjournals.org/ by guest on April 29, 2016

over time (table 2).
The network was build on philosophical principles and values
without guidelines or concrete programmes for the implemen-
tation of activities in member hospitals and there is still a lack of
information on the scope and quality of health promotion
activities being carried out in these hospitals. Also there is no
information available on the motivation for hospitals joining
the network.
Health promotion has to prove that it is worth the
investment and so far we have little knowledge that a HPH
is better than a non-HPH. However, only limited resources
have been used to strengthen health promotion, so there is
no reason to believe that it had a detrimental effect on
hospital activities by reallocating resources from the core
functions of the hospital.
To obtain more information on the content and quality of
health promotion activities in member hospitals, and to further
anchor health promotion in hospital services and health care
reform there is strong need for standards and the development
of assessment tools for health promotion.
References
1 World Health Organization, European Office for Integrated Health Care
Services (http://www.euro.who.int/healthpromohosp) [accessed 1 August 2003].
2 World Health Organization (WHO). Ottawa Charter for Health Promotion.
Geneva: WHO, 1986.
3 McKee M, Healy J, editors. Hospitals in a changing Europe. Oxford: Open
University Press, 2001.
4 Ogden J. Health psychology: a textbook. Oxford: Open University Press, 1996.
5 Florin D, Basham S. Evaluation of health promotion in clinical settings. In:
Thorogood M, Coombes Y, editors. Evaluating health promotion. Practice and
methods. Oxford: Oxford University Press, 2000:140 50.
6 World Health Organization. Adherence to Long-Term Therapies. (http://
www.who.int/ncd/chronic_care/a_project) [accessed 10 October 2002].
organizational approaches to health promotion. Health Promotion Int 2001;
16(3):281 7.
8 Speller V, Learmonth A, Harrison D. The search for evidence of effective health
promotion. BMJ 1997;315:361 3.
9 Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative
smoking intervention on postoperative complications: a randomised clinical
trial. Lancet 2002;359:114 7.
10 Tonnesen H, Rosenberg J, Nielsen HJ, et al. Effect of preoperative abstinence
on poor postoperative outcome in alcohol misusers: randomised controlled
trial. BMJ 1999;318:1311 6.
11 Lacasse Y, Brosseau L, Milne S, Martin S, Wong E, Guyatt GH, Goldstein RS.
Pulmonary rehabilitation for chronic obstructive pulmonary disease.
Cochrane Database Syst Rev 2002;(3), CD003793.
12 Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-
based rehabilitation for coronary heart disease. Cochrane Database Syst Rev
2001;(1), CD001800.
13 Rada J, Tatima M, Howden-Chapman P. Evidence-based purchasing of health
promotion: methodology for reviewing evidence. Health Promotion Int 1999;
14:177 87.
14 Joint Commission International: Standards for Hospitals (1st edition).
Chicago, 2000.
15 Agence Nationale dAccreditation ed dEvalution en Sante (ANAES):
Accreditation Manual for Health Care Organizations. Paris, 1999.
16 The International Society for Quality in Health Care Inc.: International
Standards for Health Care Accreditation Bodies. Victoria, 2000.
17 World Health Organization. Standards for health promotion in hospitals.
Copenhagen: WHO Regional Office for Europe, 2003 (http://
www.euro.who.int/document/e82490.pdf).
18 Groene O, Jorgensen SJ, Engleholm AM, Moeller L, Garcier-Barbero M. Results
of a pilot test standards for health promotion in the European countries. Int J
Health Care Qual Assur (accepted for publication) 2005; 18 (4).
19 Groene O, Junl Jorgensen S, Garcia-Barbero M. Standards for Health
Promotion in Hospitals: Self-assessment Tool for Pilot Implementation. WHO
Regional office for Europe, Copenhagen, 2004 (http://www.euro.who.int/
document/E85054.pdf).