UNIVERSITY OF PÉCS

Faculty of Health Sciences

HANDBOOK FOR HEALTH PROMOTION

AND PREVENTION OF CHRONIC
DISEASES FOR HEALTH
SCIENCE STUDENTS
Authors:
Imre Boncz
Tamás Barcsi
Julianna Boros
Tímea Csákvári
Antonio De Blasio
Krisztina Deutsch
Katalin Júlia Dinnyés
Zsuzsanna Füzesi
János Girán
Andrea Horváth-Sarródi
István Kiss
Kinga Lampek
Orsolya Máté
Zsuzsanna Nagy
Katalin Németh
Zsuzsanna Orsós
Henriette Pusztafalvi
József Vitrai

University of Pécs Faculty of Health Sciences, Institute of Physiotherapy and Sport Science
EFOP-3.4.3-16-2016-00005
2022.

European Social
Fund

INVESTING IN YOUR FUTURE

 © Authors – 2022
This book is EFOP-3.4.3-16-2016-00005 Modern university in the modern city: Value-centeredness,
openness and inclusive approach in a 21st century higher education model
made with the support of a tender.

ISBN:
Publisher: University of Pécs Faculty of Health Sciences

Pécs, 2022.
 TABLE OF CONTENTS
INTRODUCTION 6
BIONOTES 7
I. THE FUNDAMENTALS OF HEALTH PROMOTION
(TAMÁS BARCSI - JULIANNA KATALIN DINNYÉS - HENRIETTE PUSZTAFALVI) 11
I.1. Introduction 11
I.2. On some philosophical and ethical aspects of health and health promotion -
Ancient thinkers on the importance of physical and mental health 11
I.3. Christianity’s perception of the body and health, its changes due to the Renaissance
and the Reformation 12
I.4. The concept of health and its changes 13
I.5. The development and change of the health promotion concept 14
I.6. The process of institutionalization of education and health education 16
1.7. Child protection 20
I.8. The concept of value 24
I.9. Modernity and biopower: health in the service of efficiency 30
I.10. Health in a consumer (and mediatized) society 31
I.11. The most important moral limitation of health promotion 32
I.12. Summary 33
I.13. Bibliography 34
II. HEALTH BEHAVIOUR (KINGA LAMPEK, JULIANNA
BOROS, ZSUZSANNA FÜZESI) 37
II.1. Introduction 37
II.2. Conceptual background of health behaviour 37
II.3. Protective factors in health behaviour 41
II.4. Risk factors for health behaviour 44
II.5. Summary 48
II.6. Questions to think about in the field of health behaviour change -
Strength-based development in health behaviour (also) 51
II.7. Bibliography 53
III. THE APPROACH TO COMPLEX HEALTH DEVELOPMENT
(JÓZSEF VITRAI) 55
III.1. The complexity of health 55
III.2. Social embeddedness of health 58
III.3. Behavior change 63
III.4. Complex interventions 64
III.5. Evaluation of health promotion programs 70
III.6. Summary 74
III.7. Bibliography 75
IV. HEALTH EDUCATION (KRISZTINA DEUTSCH, HENRIETTE PUSZTAFALVI) 79
IV.1. Health literacy and education 79
IV.2. The fundamentals of group health education 80
IV.3. Models of individual health promotion 84
IV.4. Pedagogical methods of effective health education (planning and methods) (D.K) 89
IV.5. Bibliography 95
V. THE SETTING APPROACH IN HEALTH PROMOTION (ZSUZSANNA NAGY,
ANTONIO DE BLASIO, JÁNOS GIRÁN, ANDREA SARRÓDI HORVÁTH,
HENRIETTE PUSZTAFALVI) 98
V.1. Introduction 98
V.2. Early childhood scenes 98
V.3. TIE - Whole school health promotion concept (WSHPC) 105
V.4. Occupational health promotion 107
V.5. The program and the methods of WHO European Healthy Cities 114
V.6. Programs for active aging 116
V.7. Bibliography 122
VI. THE ROLE OF HEALTH POLICY AND THE HEALTH ECONOMY IN
HEALTH PROMOTION (IMRE BONCZ - TÍMEA CSÁKVÁRI) 125
VI.1. Introduction 125
VI.3. Cost-utility analysis (CUA) 128
VI.4. How is the health economics analysis of a health promotion intervention different? 130
VI.5. The relationship between health policy and health promotion 130
VI.6. Summary 131
VI.7. Bibliography 132
VII. COMMUNICATION (ORSOLYA MÁTÉ) 134
VII.1. Characteristics of health communication 134
VII.2. Possible causes of communication problems 135
VII.3. Insufficient communication training for health care providers 135
VII.4. Communication gaps in the interaction between healthcare providers and patients 136
VII.5. Consequences of communication disorders 136
VII.6. Effects on the patient 136
VII.7. Models of the relationship in health care 137
VII.8. Situations requiring special communication 138
VII.9. The role of health communication in prevention 138
VII.10. Screening 142
VII.11. Risk assessment 143
VII.12. Primary prevention advice 143
VII.13. Self-examination 144
VII.14. Adherence to lifestyle advice 144
VII.15. Referral for screening 145
VII.16. Communication in primary care 145
VII.17. Communication in specialist care 145
VII.18. The role of mass communication in maintaining health 146
VII.19. Mass communication in the event of a crisis 147
VII.20. Bibliography 149
VIII. PREVENTION OF MAJOR CHRONIC NON-INFECTIOUS AND INFECTIOUS DISEASES
(ISTVÁN KISS, ZSUZSANNA ORSÓS, KATALIN NÉMETH) 153
VIII.1. Introduction 153
VIII.2. The public health significance and main categories of cardiovascular diseases 153
VIII.3. A Risk factors for coronary artery disease, classification, effects, risk factor-specific
prevention 154
VIII.4. Epidemiology and prevention of cancers 167
VIII.5. Respiratory diseases 182
VIII.6. Gastrointestinal disorders 186
VIII.7. Infectious diseases and their prevention 190
VIII.8. Bibliography 202
IX. GLOSSARY 204
IX.1. Basic concepts 204
IX.2. Activities 209
IX.3. Organizations 211
IX.4. Persons 212
IX.4. Bibliography 215
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

INTRODUCTION
The Handbook for Health Promotion and Preven- retical framework, the authors also tried to high-
tion of Chronic Diseases for Health Science Stu- light good practices, thus making the chapter clear
dents was created with the aim of helping health and easy to process.
science students to complete their studies. The In the chapter entitled „The role of health policy
handbook was prepared by well-known special- and health economy in health development”, the
ists in health promotion and preventive medicine authors undertook to present an extremely impor-
in order to make the relevant knowledge of the tant area, because it is necessary for the students to
two major fields accessible to students of health have a basic concept of the health economy, since
sciences in a single volume in an easy-to-use man- they may have to plan during their future work,
ner. We marked it as an important goal, since we and then economic analysis is unavoidable. The
did not have a similar book at our disposal, to fill examples are excellent for understanding.
the volume with content taking into account Hun- Health communication helps students to find their
garian - and in some respect international - social way in the world of special communication, so
characteristics. Our other priority goal was to that it supports the cultivation of their future pro-
make it readable and easy to understand, so we fession at a high level.
used easy-to-understand language, figures and ta-
bles to aid comprehension. The last chapter, the prevention of the main chron-
ic non-communicable and infectious diseases, out-
The first chapter introduces the reader to the his- lines the classic primary, secondary and tertiary
tory and foundations of health promotion. Further- possibilities of health promotion from a biomedi-
more, it presents basic knowledge that provides cal point of view, focusing on the typical diseases
decisive knowledge for later chapters. Knowing of our time and their prevention.
our past is important, as our future is built on it, so
we can come to know the development of the field The didactic glossary compiled at the end of the
of health sciences in outline. book can maximally facilitate students’ learning,
The second chapter explores the knowledge of accurate understanding and finding of definitions,
health behavior, and invites the reader to review highlighting the basic concepts, activities and or-
his or her own health awareness, wondering in ganizations used at the present time. In the last
which area he or she could exercise stronger con- part, we summarized the brief bionotes and activi-
trol over his or her own health. ties of the key people who introduced the preven-
tive health approach in our country.
The chapter on the approach to complex health
development presents the current worldview as a
guideline for the following chapters.
The health education chapter explores and guides
the reader through the didactic and systematic
system of individual and group interventions. It
presents the methodological foundations and pos-
sibilities of health education, exploring modern
educational possibilities.
Scene-based programs are a prominent area of
health promotion that demonstrates practical im-
plementation. In addition to presenting the theo-

6
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

BIONOTES
Dr. Tamás Barcsi, PhD De Blasio Antonio
He is a philosopher, lawyer, associate professor at President of the Carpathian Basin Association of
the Faculty of State and Law of the University of the Healthy Cities Movement, he has more than 30
Pécs, head of the Department of Legal Philosophy years of experience in planning and implementing
and Social Theory. He also teaches at the PTE Fa- local, national and international health promotion
culty of Arts and Health Sciences. He also works projects, as well as in developing local strategy
as a secretary of the Philosophical Working Com- documents. He has advised the World Health Or-
mittee of the Hungarian Academy of Sciences. He ganization on a number of occasions on health po-
researches moral and social philosophical topics. licy, health strategy, health communication, and
His most recent monographs: Exodus as Rebellion environmental health issues. Areas of research:
(2012), The Philosophy of Human Dignity (2013), health promotion in the local decision-making sy-
Three Philosophical Questions about Man (2016). stem, application of the health impact assessment
Major areas of education: Philosophy, ethics, bioe- method, health communication. Educational acti-
thics. For many years, he taught subjects related to vity: health communication.
health promotion -- their humanities aspects -- in
addition to the aforementioned (e.g. Mental recre- Krisztina Deutsch, PhD
ation, Media and health promotion) at the the Fa- She has been working at the Faculty of Health Sci-
culty of Health Sciences. ences of the University of Pécs since 2001 as a
senior lecturer, and since 2021 she has been the
Dr. Imre Boncz, PhD head of the Department of Health Pedagogy and
He is a medical doctor with a degree in econo- Emergency Foundation. She defended her docto-
mics, university professor and institute director of ral dissertation in the field of education in 2013:
the Health Insurance Institute, deputy dean at the “Principles and practice. Perceptions of health,
Faculty of Health Sciences of Pécs University. He health education and mental health in the light
is the strategic vice president at the Clinical Center of primary school health education programs and
of Pécs University. interviews with teachers ”. In her undergraduate
and master’s programs, she teaches health scien-
Julianna Boros, PhD ces and education, and her research is interdiscip-
She works as a sociologist, epidemiologist, and linary: it examines the relationships between sense
researcher at the Institute of Population Sciences of coherence, health behavior and health status,
of the CSO. She participated in the design, con- and the mental health of pupils, students, teachers
duct and analysis of the results of several ques- and health professionals.
tionnaire-based population health surveys (Natio-
nal Population Health Survey (OLEF) 2000 and Katalin Júlianna Dinnyés,
2003, World Health Survey 2003 (WHO), Europe- She is a PhD student at the „Education and Soci-
an Public Health Survey (ELEF) 2009 and 2014, ety” Doctoral School of Education at the Univers-
2016 Microcensus - Health Test) Disability Sur- ity of Pécs in the sociology of education sub-prog-
vey, Cohort ‚18 Hungarian Birth Cohort Survey). ramme, and a teaching assistant at the Faculty of
She wrote her doctoral dissertation on the health Health Sciences and Social Education at the Uni-
behavior of the Hungarian population at the Doc- versity of Szeged. In addition to her doctoral studi-
toral School of Demography and Sociology of the es, she considers the interests of doctoral students
University of Pécs. She teaches medical sociology to be a matter of her heart, which is why she is the
in Hungarian and English languages at Semmel- first vice president of the Department of Psycho-
weis University of Budapest. logy and Educational Sciences of the National As-

7
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

sociation of Doctoral Students, and then the pre- topic is the mental health of medical students and
sident from 2021. Her research area is related to she also tries to help the students as life coaches in
the examination of health appearing in textbooks, the form of individual consultations.
as well as the examination of the relationship bet-
ween health promotion, health value and health Dr. István Kiss, PhD, DSc
status. As a member of the PTE research group, He is the head of the Institute of Medical Public
she examines university students’ attitudes towar- Health, University of Pécs, Faculty of General
ds people with disabilities. Medicine where he has been working since 1986.
He defended his PhD dissertation in 2000 and
Dr. Zsuzsanna Füzesi, PhD became a doctor of the Hungarian Academy of
She works as a doctor, sociologist, coach, and Sciences in 2014. He has been involved in public
university professor. She works at the Institute health education for medical and dental students
of Behavioral Sciences, Faculty of General Me- for more than 35 years, as well as teaching phar-
dicine, University of Pécs, and is the head of the macy and biotechnology students, and he has been
Department of Medical Education Development involved in a number of courses at the Faculty of
and Communication. She teaches medical socio- Health Sciences. He is the author of a number of
logy, sociology of health, and health behavior in textbooks and one of the editors of the textbook
undergraduate and graduate education to medical “Public Health Medicine” written for medical stu-
students, public health students, and PhD students dents but also used in specialist medical training.
at the Doctoral School of Demography and Socio- His main field of research is the epidemiology and
logy at UP. Many of her researches in recent de- prevention of chronic non-communicable disea-
cades are closely related to health behavior topics. ses. He is the professional leader of the YourLife
Occupational Health Development Program at the
János Girán, PhD University of Pécs.
He is a senior lecturer at the Institute of Medical
Public Health of the University of Pécs, an expert Kinga Lampek, PhD
of the Carpathian Basin Association of the Healthy She is an economist, sociologist, professor at the
Cities Movement and the Foundation for a Healthy Faculty of Health Sciences of the University of
City in Pécs. His professional activities have fo- Pécs, head of department. Her main research in-
cused on community health promotion and muni- terests are in the field of health sociology: resear-
cipal health planning for about two decades. Areas ch on the impact of social factors influencing the
of research: the study of scene-based health plan- health status of the adult population, analysis of
ning methods, the health effects of the urban en- the health status and quality of life of health pro-
vironment, and the social determinants of health. fessionals, and the role of aging societies in sup-
porting and inhibiting healthy aging. Her field of
Dr. Andrea Horváth-Sarródi, education is partly the sociology of health and
She is an assistant lecturer at the University of partly the knowledge of the life situation and qua-
Pécs, Faculty of Medicine, Institute of Public lity of life of disadvantaged and vulnerable groups
Health, where she has been working since 2007 through health surveys.
and as a coordinator of the Health Development
Program (YourLife @ MSc) for 3 years. She ob- Orsolya Máté, PhD habil
tained her professional degree in Pre-Medical and She graduated in 2000 and has been working at
Public Health in 2011. She has been able to parti- the Faculty of Health Sciences of the University
cipate in workplace health promotion projects at of Pécs since 2001 and is currently a Director of
many employers in the region, during which she Foreign Affairs and an Associate Professor. She
gave not only lectures but also trainings on com- obtained her PhD degree in 2013 at the Doctoral
munication and stress management. Her research School of the University of Pécs with the qualifi-

8
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

cation of “summa cum laude”, and was habilitated Zsuzsanna Orsós, PhD
in 2021. Her main research is in the field of health She is a senior lecturer at the Institute of Public
communication and the communication and pre- Health, Faculty of General Medicine, University
vention of public health programs. The number of of Pécs. She wrote her doctoral dissertation on al-
scientific publications of Dr. Orsolya Máté is 85. lele polymorphisms of genetic factors involved in
Of these, 19 were published in foreign languages, early carcinogenesis. She is the author of the chap-
the author of 2 monographs and 5 book chapters, ter “Epidemiology of Tumors” in the textbook
one of which was in Hungarian. As an instruc- Public Health Medicine published in 2013. She
tor, she teaches in 3 languages, gives lectures and delivers her knowledge and experience to medical
exercises in Hungarian, German and English. She students as part of the optional course “Tumor Pre-
works as a senior pedagogical expert at EMMI du- ventability”. Her professional interest focuses on
ring textbook registration procedures. health inequalities in disadvantaged communities,
particularly the risk factors that can be influenced
Tímea Molnárné Csákvári by chronic non-communicable diseases.
In 2013, she graduated from the Faculty of Health
Sciences of the University of Pécs as a health in- Henriette Pusztafalvi, PhD
surance specialist and in 2015 as a health mana- She is a teacher of pedagogy, since 2002 she has
gement expert. She is currently pursuing a PhD in been working at the Faculty of Health Sciences
research on innovative fundraising tools, in parti- of the University of Pécs as a senior lecturer and
cular the public health product tax in Hungary. associate professor at present. Her field of educa-
tion is pedagogy, health education and personality
Zsuzsanna Nagy development. She participated in the training of a
The head of the Foundation for a Healthy City in health teacher as a coordinator. Her main field of
Pécs, she has more than 20 years of experience research is the development and measurement of
in the development and implementation of health effective health prevention and education. In 2011,
promotion projects and programs in various fields she obtained a doctorate in the process of institu-
(settlement, school, workplace). Areas of resear- tionalization of health education. She has given a
ch: application of the method of municipal health number of scientific and educational presentations
planning and health impact assessment in the mu- on health prevention topics and considers research
nicipal decision-making system, operation of the on the factors that determine the quality of life and
WHO European Network of Healthy Cities. the study of educational methods in health educa-
tion to be an important activity.
Dr. Katalin Németh
In 2000, I obtained my general medical degree at József Vitrai, PhD
the Faculty of General Medicine of the University He is a biologist with a basic education but has long
of Pécs. After that, I worked at the Epidemiologi- been involved in research as an expert in biostatis-
cal Department of the ÁNTSZ in Baranya County. tics and epidemiology. He is one of the initiators
In 2005, I obtained a specialist degree in Preven- of the introduction of modern health surveys and
tive Medicine and Public Health. Since 2013, I health monitoring in Hungary, and he participated
have been working at the Institute of Medical Eth- in several health reports as an editor and author. In
nology of PTE ÁOK as an assistant lecturer. I am his doctoral dissertation, he summarized the results
writing my PHD thesis on the topic of infectious of his research in the field of health inequality. He
diseases. I regularly participate in the education of took an active part in the professional management
Hungarian and foreign students in the epidemio- and support of the health promotion offices. Prior
logy and prevention of infectious diseases. to his retirement in 2020, he worked as the Head
of the Public Health Department at EMMI. Sin-
ce 2016, he has been the editor-in-chief of Health

9
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Development magazine. Total number of publica-

tions account for 229, Independent citations 1055,
Hirsh Index 16.

10
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Chapter I.
I. THE FUNDAMENTALS OF HEALTH PROMOTION
(TAMÁS BARCSI - JULIANNA KATALIN DINNYÉS -
HENRIETTE PUSZTAFALVI)

I.1. Introduction I.2. On some philosophical and ethical aspects

According to the famous German philosopher, Ar- of health and health promotion - Ancient think-
thur Schopenhauer, nine-tenths of our happiness ers on the importance of physical and mental
depends on our health: “Through it, everything health
becomes a source of pleasure, without it, on the The great Greek and Roman philosophers general-
other hand, no external thing provides pleasure, ly emphasized the importance of physical health,
and even the subjective goods, the characteristics but they also pointed out that this alone is not
of the mind, mood, and temperament are greatly enough for a good life. For the Greeks, diet (diaité)
degraded and withered by the disease” [1]. On meant an art of living, the science of which was di-
the basis of sociological research on the value etetics, whose practitioners developed appropriate
of health [2], we can risk the statement that even strategies for taking care of the body, taking into
more people would approve of this idea today than account changing circumstances (dietetics covers
in the 19th century, since in today’s globalized physical exercises, food, drinks, dreams and sex-
world, people consider happiness and health to be ual relations). They saw the goal of practicing the
of outstanding value, even if they cannot say ex- lifestyle not in prolonging life at all costs, but in
actly what they mean by happiness and they per- ensuring a useful and happy life. Neglecting to
ceive health primarily as physical health. There is deal with the body can also affect the mind in a
obviously a correlation between the two values. negative way, but the effect of the soul on the body
Schopenhauer also talks about health in a narrow- is even more decisive, since moral fortitude is nec-
er, physical sense, and believes that a fit person is essary to follow the correct way of life [3] (more
cheerful, and cheerfulness has a great influence on about the way of life: Foucault , 2011: 104-114).
happiness. Physical well-being does indeed con- In Plato’s State , Socrates talks about the fact that
tribute to happiness, but the idea that nine-tenths in the ideal state, after the art of the Muses, young
of our happiness depends on our physical health people should be educated with physical training,
is questionable, since Schopenhauer exaggerates. and the importance of this remains even later: “We
Certainly, the philosopher also writes at length must educate them carefully in this, from child-
about other aspects of happiness in his work on hood throughout their lives”, at the same time he
the wisdom of life, and notes that health is not al- also adds: “I don’t think that the body, even if it
ways a guarantee of cheerfulness, sometimes even is healthy, would make the soul of good quality
a perfectly healthy person can be melancholic, and with its excellence, but it is the other way around:
he agrees with Aristotle that excellent, great-mind- the right soul makes it possible with its excel-
ed people are all melancholic [1]. In this chapter, lence for the body to be of the best quality” [4].
we approach health development from the histor- Thus a person with virtues also takes care of his
ical side and show what ideas and practical meas- body, but a healthy body alone does not guarantee
ures were formulated by our ancestors to maintain a healthy soul. Aristotle interprets virtue as striv-
health on the international and domestic level. ing for the middle, thus avoiding deficiency and

11
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

excess, and he cites the “self-evident” example of health. However, the Christian view regarded the
physical strength and health to prove that deficien- body primarily as the source of sins, so the Chris-
cy and excess are both poor: “the excessive and tian authors of the Middle Ages placed less em-
the incomplete physical exercise is both harmful to phasis on the effort to preserve physical health.
physical strength, just as food and drink, whether In the Renaissance era, the relationship with the
more or less than necessary, undermine health, and body begins to change: this is also reflected in the
if used in the right amount, they not only establish, fact that the great Renaissance painters and sculp-
but also increase and maintain” [5]. Like Plato, Ar- tors glorify the beauty of the human body in their
istotle also rejects - among other, undesirable ways works, for example Botticelli ‘s Birth of Venus or
of life - the pleasure-seeking life. Michelangelo ‘s David. The Renaissance writ-
Cicero also believes that nutrition and groom- er Agnolo Firenzuola wrote a treatise on female
ing should be for the preservation of health and beauty in 1541, the main topic of which is not the
strength, not for pleasure [6] . The Stoic think- examination of spiritual beauty and love, but the
ers also proclaimed the primacy of mental and capture of the physical characteristics of a “lady of
spiritual health. With Seneca, for example, we can perfect beauty” [9]. The Venetian nobleman Luigi
read the following: “I admit that we are instilled Cornaro’s treatise on the moderate life was pub-
with tenderness for our bodies... I do not deny that lished in the middle of the 16th century, in which
we should care, but I deny that we should serve. he described the beneficial effects of giving up cer-
Many others will be addicted, because those who tain meats and wines, but emphasized that the diet
are addicted to their body, fear it too much and re- was not only worth following because of its bene-
late everything to it” [7] (Ethical Letter XIV). “It ficial effects on health, but also because it helped to
was an old custom that survived until my age to overcome carnal passions [10] . In Protestantism,
add to the first words of a letter: ‘If you are healthy, health is seen specifically as a gift from God, the
everything is fine, I am healthy.’ But we correct- preservation of which is a moral duty [11]. Among
ly say: ‘If you philosophize, everything is fine.’ others, Cornaro influenced the English doctor
without it, the soul is sick. ... Therefore, first of George Cheyne, whose dietetics is also based on
all, take care of your mental health, then the other” religious and moral principles. In the first half of
[7] (Moral Letter XV). Roman thinking during the the 18th century in his published books Cheyne
imperial period placed great emphasis on encour- recommended a milk and vegetable diet, regular
aging people to take care of themselves: the goal exercise and sleep, avoiding alcohol, and of course
is to achieve the individual’s control over himself, he also mentioned the beneficial mental effects of
which is accompanied by serene joy. Self-knowl- the diet (for example, it eliminates gloom, see:
edge is essential for self-control, but so is the de- Turner , 1997: 56-61). Protestant authors consid-
velopment of an appropriate relationship with the er the preservation of health and an ascetic life-
body ( parallels can be discovered between medi- style essential because it ensures the condition of
cal thinking and philosophy, the concepts of “pa- hard work [10]. In his famous writing, the sociol-
thos” and “affectus” apply to both spiritual passion ogist Max Weber pointed out that the development
and physical illness [8]. of capitalism was facilitated by the importance of
work for the glory of God, perceived as a voca-
I.3. Christianity’s perception of the body and tion, as well as by the Protestant view emphasizing
health, its changes due to the Renaissance and the virtues of thrift and restrained consumption,
the Reformation according to which wealth is not objectionable
The aforementioned Greek and Roman thinkers if one has achieved it through hard work and he
placed mental and spiritual health before phys- lives in moderation, without ostentatiousness [12].
ical health, and believed that a virtuous person Kierkegaard, the 19th-century Lutheran Danish
can relate to the body in an appropriate way, but philosopher, distinguished between the “aesthet-
they also emphasized the importance of physical ic” and “ethical” approaches to life: while the per-

12
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

son living the “aesthetic” life wants to enjoy life, na in 1874, adopted a resolution on the establish-
the person living the “ethical” life is aware of his ment of a permanent international epidemiologi-
own life task and fulfills. There are different ways cal committee. Then in 1903, Paris held the 11th
to realize the “aesthetic” view of life. There are International Health Conference. A convention on
people, for example, whose life revolves around a the protection against cholera, plague and yellow
single thing, they find the meaning of their life in fever was adopted. Due to the ongoing pandemics,
this, however, they do not control this thing. This in Rome 1907, the delegates of 12 states founded
thing can be health or beauty (or indeed wealth, and created the first international health organiza-
authority, talent) , however, since these are transi- tion, the International Office of Public Health,
tory, sooner or later - in the case of a life built on whose tasks included the following:
health and beauty, obviously when diseases appear – continuously inform public about the epide-
or when the beauty of the individual wears out - miological and health situation in the world,
this outlook on life leads to unhappiness, and as – coordinate the fight against epidemics,
Kierkegaard writes: if a person has lived the “aes- – organize international exchanges of experi-
thetic” life at an appropriate level, they reach men- ence.
tal despair, so they see the futility of their outlook
on life. This existential crisis also represents an In 1919, the International Public Health Of-
opportunity: one is forced to make a choice. If you fice was integrated into the League of Nations
discard your previous outlook on life based solely in response to the worsening health situation,
on the enjoyment of life and choose yourself, in its such as the great influenza epidemic known as
eternal validity, you can move into the “ethical” the Spanish flu, which claimed nearly 15 million
life. Those who live “ethically” also like to enjoy lives. Furthermore, they were tasked with the fight
life, know the magic of the moment, but are not at against the main epidemic diseases, such as chol-
the mercy of their moods, moments, desires [13]. era, plague, yellow fever, smallpox, and typhus at
the international level, in the period between the
I.4. The concept of health and its changes two world wars. Furthermore, the monitoring of
In the 19th century, thanks to the development of the implementation of the international convention
science and technology, there was already a world- on the treatment of venereal diseases of seafarers
wide demand for the creation of a new system of and the international standardization of anti-diph-
public administration organizations, with public theria serum were a major task. Perhaps the most
health also a part of it. This is due to the fact that significant task was the organization and control
before the establishment of the WHO, which cur- of the fight against drug abuse. Finally, on July 22,
rently functions as the coordinating authority for 1946, the World Health Organization (WHO) was
international public health, there were already in- established at the international health conference
ternational initiatives that were created to combat convened by the UN Secretary General in New
epidemics or other diseases. York, where its charter was adopted.

The International Health Conference held in It officially began its operations as a specialized
Paris in 1851, where the international coopera- institution of the United Nations on April 7, 1948
tion aimed primarily at preventing the spread of - this day has since become World Health Day .
epidemic diseases: cholera, plague and yellow fe- The headquarters of the WHO is Geneva (Swit-
ver. Only 5 of the 12 countries present ratified this zerland), and it currently has 194 member states.
agreement. The governing body of the WHO is the General
Two more similar conferences were held, one in Assembly consisting of member states, which
1859 in Paris and 1866 in Constantinople, where meets every year. The General Assembly elects a
no results were achieved either. 24-member Executive Council, whose decisions
The International Health Conference, held Vien- and policies are implemented. The General As-

13
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

sembly prepares an annual work program, direc- ment of medicine, the average health status of the
tives and recommendations for the governments population, and social patterns.
of the member countries. It consists of Regional Quality of life is also an important indicator of an
Committees. The Regional Committees, consist- individual’s health, as defined by the World Health
ing of representatives of each geographical region, Organization as follows: “Quality of life is the indi-
meet once a year. Our country has been a mem- vidual’s perception of his or her position in life, as
ber of the WHO since the establishment of the or- influenced by the culture and value systems of his
ganization. Since 1954, the cooperation has been or her living space, as well as his or her own goals,
close and continuous. We have been participating expectations, patterns and relationships. Broadly
in the Healthy Cities project since 1986, the aim interpreted concept, which in a complicated way
of which is to place health on the agenda of city includes the individual’s physical health, psycho-
decision-makers and to promote the development logical state, degree of independence, social rela-
of comprehensive local strategies to ensure health tionships, personal faith, and the relationship to
and sustainable development. the essential phenomena of the environment.” A
permanently impaired state of health can be tragic
World Health Organization (WHO), founded in for the indiavidual in many ways, as effects (e.g.
1948, defined health as follows: “Health is a state pain) arise not only from the disease itself, but as
of complete physical, mental and social well-being a result of the disease, the individual may become
and not merely the absence of disease or infirmity” hindered from working and his or her social envi-
[14]. ronment may also change. They may have difficul-
ties, for example, in establishing and maintaining
We can interpret and define the concept of health social relationships. The disease is therefore not
through its dimensions, which are as follows: only a burden for the individual and society due
biological health : the proper functioning of our to the decrease in physical function, but also neg-
body atively affects the “sense of competence” in other
mental health : a sign of our personal worldview, areas of life, which significantly reduces the sub-
principles of behavior and peace of mind and peace jective quality of life and may result in further de-
with ourselves terioration of the health status [15].
mental health : the ability to think clearly and con-
sistently I.5. The development and change of the health
emotional health : the ability to recognize feelings promotion concept
and express them appropriately In 1974, Canada’s Minister of Health and Welfare,
social health : the health of developing relation- Marc Lalonde, published a publication entitled “A
ships with others New Perspective on the Health of Canadians”. The
most important point of the publication was that
Based on the realistic formulation, however, it improving the environment (structural approach)
should also be seen that health can never be de- and human behavior (lifestyle approach) would
fined objectively, because the social image of result in a significant reduction in morbidity and
health is always subjective, i.e. it develops accord- premature death. As a result of the report, the Ca-
ing to the current expectations of a given society. nadian government shifted its focus from disease
With realistic simplicity, we can say that based on treatment to disease prevention and, ultimately,
the general state of health of the population and health promotion. The Lalonde report reflected the
the development of medicine, a picture of health beliefs of many who considered the medical ap-
(which varies by age group) is formed, and healthy proach to health too narrow-minded. One should
is someone whose health is no worse than the so- not separate the body from the soul, the disease
cial expectation created in this way. The health from the patient, and the person from the environ-
picture is basically determined by the develop- ment, the society in which he or she lives. While

14
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

the roots of the medical model focused on a causal mendations on public policy supporting health:
approach to scientific explanations, they ignored 2nd International Health Promotion Conference.
the more complex social issues that the individual Furthermore, the Sundsvalli statement on the
had to deal with. The new guidelines of the La- health-supporting environment: They agreed at
londe report and the even more recent aspirations the 3rd International Health Promotion Confer-
were really publicized only nine years later, in the ence. The Jakarta Declaration was held under the
1986 Ottawa Charter. The literature unanimously title of the Health Care in the 21st century. Then,
considers this document to be the most decisive in the 5th Global Health Development Conference in
terms of the approach to health promotion, since Mexico City in 2000 envisioned the elimination of
it was here that the WHO officially announced inequality. The aim of the 6th international confer-
the Health Promotion Program for the first time. ence was to examine the extent to which globaliza-
Regarding the issue of social factors, the charter tion affects health promotion activities. In the final
created the social model of health - Holistic health document of the 7th international conference on
concept. The model draws attention to the fact health promotion, organized in Nairobi in 2009, it
that there is a strong correlation between the lo- was emphasized that, despite the evidence on the
cation on the social ladder and the rate of death effectiveness of health promotion and the previous
and disease occurrence. According to this, the rela- international declarations, the broad realization of
tionship between social and economic conditions, the goals of health promotion is still to be seen.
physical environment and individual lifestyle is Shortcomings were identified in three areas, such
inseparable. as the implementation of evidence, the consider-
The Ottawa Charter created the basic principles of ation of social determinants of health in political
health promotion that are still valid today and its decisions, and the movement of health systems
five areas: in the direction of health promotion. That is why
1. Policy supporting health. Health promotion it is important for governments to take responsi-
goes beyond the scope of health care, there- bility for public health, the conditions for which
fore the coordinated and conscious contribu- are intersectoral cooperation, the involvement of
tion of all organizations of the state is nec- the population, and the building of partnerships.
essary. The promotion of social justice and equal oppor-
2. An environment that supports health. Here tunities, and the social and economic health that
it warns about the effects of life, work and underpins this, should be treated as a priority
rest. Work and rest should become a source [16,17,18,19,20].
of health.
3. Strengthening community actions. Commu- In 2013, the 8th international health promotion
nities should have the opportunity to influ- conference was organized around the “ Health in
ence their own destiny all policies “ approach. Its main feature was the
4. Development of individual skills. If society validation of health aspects at all levels of poli-
is educated and cultured, it can influence its cy-making, i.e. it wanted to expand the impact of
own health. decisions on the health care system. In 2016, at the
5. Rethinking the direction of patient care. The 9th international health development conference
task of the health sector must shift in the di- in Shanghai, The Shanghai Declaration stated that
rection of health promotion, in addition to health and well-being are essential for achieving
providing institutional and curative care. sustainable development goals. For this, it desig-
nates 3 main areas of action: the first is proper gov-
Several significant and turning-point conferences ernance, i.e. political decision-making for health.
took place later on, which determined the guide- Within the framework of this, it recommends,
lines for international health development. Such among other things, the tightening of taxation and
was the case, for example, of the Adelaide recom- legal regulation of unhealthy products, as well as

15
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

the introduction of general health insurance. The to live and be healthy, in order to learn and keep
second is the implementation of local actions with it, it is his main duty to teach the right behavior.”
the involvement of cities and communities. Final- István Mátyus Kibédi, a doctor from Kolozsvár-
ly, through the development of health literacy, the Cluj, explains in detail how an individual should
main goal would be to empower the population, maintain his health in his book Dietetics (Old
i.e. to increase their decision-making capacity [16, and New Dietetics), presenting methods aimed
21]. at maintaining a healthy lifestyle. In his first pub-
We can see that the world conferences determine lished two-volume work, he expands and explains
the main directions, but the implementation of these preventive areas in detail in one volume
each goal is decided in the local governmental and each, based on several years of experience. For
professional policy. example, in the 4th volume where physical exer-
cise is detailed, he presents the different forms of
I.6. The process of institutionalization of educa- exercise and explains exactly what physical work/
tion and health education exercise he recommends separately for men and
Similar to other European states, the concept of women according to their age. This more than
preserving and maintaining health in Hungary was 400-page work, with its meticulousness and detail,
part of the way of life of educated people and the draws attention to the fact that the population of
activities of doctors, as evidenced by early written the time was also inclined to a comfortable life-
records. style and that people could prevent many diseases
János Csere Apáczai defines health in his Hun- with conscious and regular exercise [22].
garian Encyclopaedia, as follows: “Health is the The process of institutionalization of health pro-
internal state of a person, with which, being well motion and health education took place almost si-
in his organs, he carries out his actions well”, says multaneously in the world. We can wonder how
Apáczai, then he reflects on the important factors this process, which can also be interpreted as early
that determine a healthy life in this world. These globalization, could have developed despite the
are: “air, food, drink, sleep and care, movement fact that the exchange and sharing of information
and standing, released and retained, the emotions was much more difficult and slower. The 18th and
of the mind, as well as clothing, house and bed”. 19th centuries provided space for the rapid ex-
He repeatedly mentions the importance of staying change of information, as the magazine revolu-
healthy and the need for human well-being for tion took place, the publication of technical books
everyone. Apáczai’s Encyclopaedia created a space was becoming more and more organized, and they
for the description and interpretation of health-re- were not only published in the nations’ own lan-
lated knowledge and skills in Hungarian, because guages, but appeared in world languages within a
it created Hungarian versions of many previously year or two, so that the new knowledge or even
unknown or Latin terms and concepts. He places the new concept or innovation should be known
the relationship between health and illness in the internationally. In addition to the information
context of the individual and the family, in which channels of trade journals, world conferences were
he highlights their role in everyday life situations. organized almost every year, where recognized ex-
Pax Corporis, Ferenc Pápai Páris openly accepted perts of the profession represented their nation as
the advisory and educational role of the doctor and state delegates. This was the case, for example, at
re-arranged it among the doctor’s duties alongside the 1st School Health Congress, which was held
the almighty healing role. The 18th and 19th cen- in Nuremberg in 1904, with the participation of
turies were the era of the rise of Hungarian health nearly 1,400 people. Hungary sent eighteen lead-
education. Among the great figures of the time, we ing specialists.
can mention János Zsoldos, who in his work enti- Of course, institutional education also strove to
tled “ Diateetics or Rules for Maintaining Health pass on modern knowledge. Elementary school
and Preventing Disease “ writes: “whoever wants became available to an ever-wider range of people,

16
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

and even later with the introduction of compulso- areas of health education in English schools, sex-
ry education (1868 law on public schools). Even ual education and the concept of character devel-
though there was no longer any question that these opment closely related to it. Health education for
important knowledge for everyday life became children was already part of the state curriculum
available to everyone. published in 1870. In 1908, the School Medical
For the first time in the Ratio Educationis (1777) Service was established. In 1927, the state Educa-
we can read the knowledge of health, since there tion Committee also included health education in
the preservation of the students’ health was an im- the curriculum of elementary schools, and in 1928
portant factor in school education. Analyzing its it published the Handbook of Health Science,
meaning, however, the document only deals with which went through 6 editions. Teachers used this
maintaining the physical health of the individual. guidebook as a bible for health education, with
At the same time, it highlights the importance of which they were able to achieve effective physi-
seeing a doctor, which they wanted to make aware cal and mental health maintenance. In the first 3
of during the education. The design and name of editions, the topics of physical health activities,
the space for free movement - playground - also physical fitness, cleanliness, good food and prepa-
proves this. ration for motherhood and child care dominated.
The introduction of hygiene was particularly sig- The discussion of the alcohol problem and in-
nificant in teacher training, as children could large- fectious diseases belonged to the chapter dealing
ly rely on themselves and had no other help while with threats to physical health. The author men-
raising children. Thus, starting from the 1840s, tions the conservative way of thinking appearing
hygiene was included as an independent subject in the book as a significant problem, which was
among the subjects of the Hungarian Teacher mainly a problem in sex education, since the book
Training Colleges (boys and girls), and later in promotes sexual innocence and turns a blind eye
nursery training schools and the nanny training to the spreading movement of free ideas in real-
(now known as the Kindergarten Training School). ity. This contradiction has been present in public
The first textbook that was proven to be used for health concepts since the 1940s.
the subject was written by Jakab Zimmermann, It has been possible to teach health sciences in
entitled Health and Emergency Medicine. This Hungarian schools since 1885, when the school
modern textbook was certainly used until the 1879 physician and health science teacher training was
edition published under the title of Schermann introduced at the medical universities (Budapest
Adolf: Body and Health, because no other similar and Kolozsvár-Cluj) under the leadership and
work was available in Hungarian [23, 24]. management of József Fodor. In addition to József
Fodor, we can find Mór Kármán, who taught ped-
I.6.1. The introduction of health science as a agogy, among the invited instructors, as well as
school subject and the role of József Fodor in Gyula Dollinger and István Csapodi. Later, from
the school hygiene movement the academic year of 1895, Gusztáv Rigler also
There have already been many examples of the participated in the organization of the course and
emergence and introduction of health education as in the teaching work. “It can be considered a sign
a school subject in the world. In France, it was the of the times that - as our newspaper was informed
first in the world to be introduced together with - 105 people applied for admission to the course
the institution of the School Doctor between 1833 ,” József Fodor recalled about the school medical
and 37. Another significant example is the English course in the Public Health Guide . “The VKM
medical school institution, which has also devel- issued regulation No. 48.381 of 1885 on the train-
oped a specific organizational form, yet we can ing and employment of secondary school doctors
draw parallels with the Hungarian concepts in its and health teachers, according to which 20 people
ideology and practice. From Jane Pilcher’s (2007) could be hired at the medical universities in Hun-
study, we can get an idea of one of the important gary every year from September 15 to December

17
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

15. The course was free of charge, but the exam the unfortunate sudden death of József Fodor, the
cost 9 frts, the price of the certificate 1 frts. In ad- negotiations were suspended.
dition to the exemption from the course, exami-
nees pay 50 frt. Their salary was 200 frt (400 K) School medicine came into effect on February
in the case of state full secondary school teachers, 17, 1906, No. 14,532 was extended to elemen-
100 frt (200 K) for non-full teachers, where health tary schools by decree, which had the following
science was not required to be taught. title: “On the employment of school doctors in
It was the duty of the health teachers to check the public elementary public schools “. The duties of
health status of the school and the students, the the school doctors, which so many emphasized,
students’ apartments, and to present the health sci- only covered preventive activities. According to
ence. The person was a member of the secondary the 1906 regulation, children entering elementary
school teaching board and had a vote in health schools had to undergo a screening test in the same
matters. Health science had to be taught in the 7th areas as in the case of secondary school students.
or 8th grade of all secondary schools (gymnasium Central measures were also taken against the ideo-
or real) as an extraordinary subject throughout the logical system of spreading health knowledge, the
year, for 2 hours a week.” best example of which is the introduction of the
unified teacher training curriculum in 1902, which
The curriculum of the course covered school eliminated health science as a regular subject in
health and the part of health science to be taught state teacher training schools. The determined and
in secondary schools, according to § 11 of the reg- sober principals made up for the central loss and
ulations. The qualification examination consisted left health science as an extraordinary subject in
of practical and oral parts. In the practical exam, quite a few institutes in the fourth year. However,
either a lecture experiment had to be presented or the duties of the school doctor remained in second-
a school health examination had to be carried out, ary teacher training schools as well (qualification
which lasted at least a quarter of an hour. In the was obtained in today’s high school education sys-
oral exam, the candidate proved his knowledge tem).
of school health and his teaching ability. The title
obtained at the end of the qualification was “qual- Decree No. 40.036 of 1907 expanded the duty of
ified secondary school health teacher”, and if the care of school doctors, as their task became to ex-
students were employed, they could bear the name amine all the students of their school, not only the
“secondary school doctor and health teacher”. Un- examination of newly enrolled children and the
fortunately, the problems with the training system examination of students with poor health. The ex-
grew over the years, so the managers decided to amination had to be done right at the beginning of
renew the training [25]. the academic year, and during the academic year,
the healing activity also entered the list of tasks,
The proposals made during the ministerial discus- as the healing of inpatient and outpatient students
sions affected the following areas: the expansion also came under their authority.
of pedagogical knowledge should be aimed at all With the introduction of higher, regular, full-time
fields, not only at secondary school age, and it was schooling for girls and the acquisition of the legiti-
also necessary to acquire knowledge of pedagogi- macy of girls’ high schools, the provision of school
cal methodology, “because doctors are not capable medical duties was expanded to a new area. First,
of teaching”, wrote the self-critic Juba in relation doctors were given a place in upper schools, and
to doctors in his comment. then, with continuous expansion, in other types
The most important proposal, which Fodor him- of schools as well. According to the ministry’s
self put forward, was that school doctors should idea, they wanted to employ female school doc-
be employed in all types of schools, even in the tors in girls’ schools, but getting this accepted was
ministry, in all matters requiring expertise. Due to not an easy task either. Among the girls’ schools,

18
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

the commercial schools were the latest to employ center. The school medical course was suspended
a school doctor, but even then only occasionally, in the first half of the 1920s.
although the teaching of organized health science
would have been important. This did not happen The decree published under the title 1926/13.618
everywhere, as the school doctor’s fees were paid VKM School Doctors Qualification realized the
only in public schools, and in other maintained in- long-awaited requirement of the weight of peda-
stitutions the leaders still had to reimburse the fee gogical knowledge and practice in the training of
of the doctor who was compulsorily employed. school doctors. By extending the work of school
medicine to public elementary schools, it became
According to the VKM decree 3798 of 1916 in essential to acquire knowledge of educational the-
state public schools (general schools), the educa- ory, methodology and psychology. The training
tion was started, in which the following subject thus consisted of several parts: the school medi-
contents were designated in the fourth grade: “first cine course (theoretical and practical) and the the-
aid: injuries and their care, hemostasis, broken ory of pedagogy (pedagogy, methodology, other
bones, sprains, bandaging, fainting, euthanasia, ar- school educational activities) and practice. The
tificial respiration, danger of suffocation, poison- practice was conducted strictly under the guidance
ings; drunkenness; convulsions; stroke; epilepsy; of qualified and experienced health science teach-
sunstroke; freezing; lightning strike; patient trans- ers and required actual attendance. In addition to
port” (which presented the work of rescue associ- the school doctor, the director of the school also
ations). participated in the sample teaching, which also
meant obtaining the qualification.
The defeat of the war had an effect on the schools,
and thus also on the work of school doctors. And The place and time of the pedagogical practice
after the Trinanon Treaty, the country’s territori- was approved by the minister for the candidates.
al loss also caused a serious shortage in educa- The time and topic of the model teaching were
tional institutions. Rethinking and rebuilding the subject to the minister’s approval. The filling of
school network imposed a great task on the coun- the positions was also within the competence of
try’s leadership. The relocation of the universities the ministry.
(Kolozsvár-Cluj to Szeged and Pozsony-Brati-
slava to Pécs) created a new situation in medical The decree issued in 1933 provided for the new
education and further education. The opening of regulation of the course, which restored regular
the university in Debrecen also opened up a new and planned uniform training. According to the
space in the training of doctors and in the territori- VKM decree .No. 12,663 of 1933, training once
al delimitation of medical health education work. again provided a uniform school medicine and
The medical school courses were assigned to a health teacher qualification. Once again, the uni-
newly established institution, the Central Board versities could organize the courses under their
of Continuing Medical Education, but only from own authority. The course lasted two months and
the point of view of organization and announce- could be offered twice a year, in October-Novem-
ment. Applications for courses had to be submit- ber and in the spring, March-April. The textbook
ted on an official form. The order of the courses version of the lectures of the school medicine
had been regulated and the order and timetable of course, published in 1933 under the title Health of
the trainings had been published in advance. They the School Age, was used to systematize and uni-
continued to leave it up to the universities to con- fy the training. The book fully covered the course
duct and hold the courses. The construction of the material. Among the authors we can find the most
medical hostel, where colleagues from the coun- outstanding representatives of the profession,
tryside could stay for free during the course, great- such as Gyula Darányi, Kálmán Perjéssy, Sándor
ly helped the further trainings with the Budapest Imre, Pál Ranschburg, Mihály Horváth, Zsigmond

19
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Gerlóczy, Gusztáv Bárczy, József Melly, György these effects prevailed, but the intervention also
Gortvay, among others, of course, without claim- became urgent due to the statistics showing lower
ing to be complete. As Gyula Darányi wrote in his and lower birth rates. At the same time, the num-
foreword. It is possible to create a summary vol- ber of orphaned or semi-orphaned children, which
ume that has never been published since the school also appeared as a consequence of the war, was
medical institution was introduced. The book also also increasing, and this called these movements
served as a support for the students of later courses to life. The activities of organizations providing
[25]. assistance and generous support were no longer
School medical training survived until the end sufficient, but the organization of state interven-
of the Second World War, and so did the system tion was necessary. The patroness of the “Nation-
itself. After the nationalization of schools - from al Association for the Protection of Mothers and
1948, however, health education merged into ed- Babies” was the Royal Princess Stefania. Elemér
ucation for community life at school and into the Lónyay’s enthusiastic and inspiring words at the
pioneer movement. School medicine is still part opening ceremony of the first “Mothers’ Home”
of the work of public education institutions, but it sum up the spirit of the age well: “If only my be-
is implemented with significant alterations in the loved compatriots would accept my word, and let
constantly changing system. School doctors now the flame of enthusiasm not only flare, but insti-
only carry out medical work (status examination, tutes serving our goals should be established and
administration of mandatory vaccinations, treat- function in this country!”
ment of acute ailments), while school health vis-
itors who previously performed the task of school In 1901 (Article VIII of 1901) the law provided for
nurses teach health education (I note that it is not the state protection of children found and officially
necessary to obtain a teacher’s qualification) and declared abandoned. In the category of “abandoned
assist in conducting screening tests. In the 2000s, children”, it classified all those children under the
independent health teacher training started again in age of 15 with no property who have no relatives
university courses, but their school placement was who were obliged and able to support and educate
not guaranteed (it was incidental to teach health them, and whose education was not adequately
in schools) [26]. Currently, the school nurses have provided for by relatives, benefactors, charitable
taken over the education of health experts, along institutes or associations. The law ordered the es-
with teachers specializing in biology and physical tablishment of state children ‘s shelters. The first
education. state children’s shelter was opened to its purpose
on May 15, 1902. Orphanages were built in all
1.7. Child protection major settlements, which affected nearly 50,000
I.7.1. Child protection: Mother and baby pro- children every year [27]. In the past, children were
tection and the role of the Green Cross move- cared for either by the Charitable Women’s Asso-
ment in health promotion ciations or orders maintained by the church. Sim-
Child protection (social care) in our country was ilarly, in Pécs the Orphanage was maintained by
fulfilled by the appearance of an increasing num- the Merciful Order (together with an orphanage,
ber of civil organizations and associations at the which was unique in the country) [28].
beginning of the 20th century. On the one hand,
the establishment of the institutions was due to the I.7.2. Rockefeller Fundation and public health
initiatives of the supportive and sensitive nobility, The appearance of the Rockefeller Foundation in
and on the other hand, strong anti-discriminatory Hungary dates back to 1920. They already asked
movements that were strengthening in other parts the American institution here, the Budapest office
of the world had an impact on the social measures of the American Relief Administration of the Eu-
created for the upbringing of poor and low-sta- ropean Children’s Fund, for advice on who they
tus children or orphans. In our country, not only should contact. In the end, Emil Grosz, an ophthal-

20
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

mology professor was chosen. After the Second tion was founded in Hungary in 1915, whose task
World War, the Foundation attempted to continue, was to protect needy mothers and babies with ad-
but with little success. vice and assistance. With its establishment, it em-
braced the protection of mothers and babies and
Regarding the fields of expertise, healthcare and the provision and care of orphaned children, and
medicine have always been at the center of the has continuously expanded its network throughout
Foundation’s activities in Hungary. At the time the country. In addition to care, the goal was to
of the start, they mainly helped to replace the in- reduce infant mortality, which required qualified
complete equipment of the laboratories and the prevention specialists. The task of the Institution
missing volumes of journals in the libraries of the was to protect unborn children, to study and teach
clinics. As a first step, the scheme of the Founda- prevention of hygienic and social harms affecting
tion’s activities carried out a survey in all target- pregnant women and mothers, as well as babies
ed areas. The first study was prepared by the later and the organization of courses for professionals
deputy president Selskar Gunn under the title Pub- such as midwives, doctors, pediatric nurses, med-
lic Health in Hungary in 1926. The approximately ical students, etc.
100-page booklet contains relevant statistics, the
most important diseases, the main institutions, The development of the national network of the
a description of the Hungarian organization of Stefania Association began in 1916 in the cities of
healthcare, even the medical museum, partly based Szeged, Arad, Debrecen, Újpest, Kolozsvár-Cluj-
on printed materials, partly based on the domestic Napoca, Paks and Salgótarján, and then also in
orientation, interviews and discussions. Minister Temesvár-Timisoara, where the institution opened
Kunó Klebelsberg and the person in charge of sci- the following year, and the range of institutes and
entific affairs, Professor Zoltán Magyary, showed homes continued to expand year by year through-
themselves to be willing partners. According to the out the country [31].
Gunn study, the sanitary condition of the country The association announced the following program;
was not satisfactory. The consequence of this was - the mother cannot be worse off because she
that the largest-scale facility built with the support gives birth to a new life and raises it;
of the Rockefeller Foundation, which then also - the mother and her fetus must be protected
served as their headquarters here, became the Na- from the dangers of the delivery process;
tional Institute of Public Health, opened in 1927. - be allowed to breastfeed;
Its first director, Johann Béla, was also considered - mothers must be informed about issues of
their resident here. One of the main permanent education;
items of their Hungarian budget was the main- - society must recognize the loss resulting
tenance and development of the institute; from from infant mortality.
1936, they also supported a research topic: the
study of influenza. Between 1925 and 1940, the Vilmos Taufer, an obstetrician, supported the
institute received a total of 370,000 dollars in sup- movement from its inception, and the term, health
port. Another conclusion of the Gunn study was visitor, comes from him.
that the number and level of training of nurses was Another task of the association was the profession-
inadequate. From 1927, the Foundation provided al training of nurses/midwives, and later of Green
ever-increasing assistance to the nursing educa- Cross midwives, which at first was only carried
tion in Budapest and the later started in Debrecen, out by the National Hungarian Center for Mater-
which was initially initiated and carried out by the nal and Infant Protection, based in Budapest. This
Stefánia Association [29, 30]. work was also supported by the Capital/Budapest.
Here, 30 people could be trained on a course each
I.7.3 The Stefania Association year, but the number of participants in professional
Following foreign examples, the Stefania Associa- training turned out to be small.

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

I.7.4 Green Cross Movement the help of the Green Cross siblings. The press
The Green Cross Movement, started in 1927, un- helped to spread awareness of the Green Cross’s
der the leadership of State Secretary Johann Béla. work through its propaganda activities, so for ex-
It gave a new impetus to the activities and training ample, the article “The Green Cross teaches the
of nurses. With the establishment of model dis- village women how to cook” was published in the
tricts and the continuous increase in tasks, many journal of the American Hungarian People’s Word
more qualified professionals were needed, so the under the title “How to cook”. Almost every week,
training of the Green Cross Women’s Guards al- the paper reported on the work of the Green Cross.
ready started in Debrecen. This was later joined by At the same time, the Green Cross Movement
Szeged, Kassa and Kolozsvár-Cluj-Napoca, where made a much bigger change, in order to highlight
professional training could begin after the estab- only the work of the health visitors, as it brought
lishment of the institutes. Later on, the state took healthy drinking water to the people living in the
over this task and created state training courses in village and brought about a change in the quality
a unified system. of life for the residents living in the village by or-
ganizing and building electrification. The reorgan-
But let’s see what the duties and activities of the ization, organization, and nationalization of health
health visitors were. The health visitor, or health care significantly changed health care in several
nurse in a broader sense, is the employee in the
protection of the mother and infant: maternal and
infant nurse, or employed in pulmonary care insti-
tutions: pulmonary nurse, or working in the school
health service: school nurse; but in a narrower
sense however, we refer to nurses working with-
in the Green Cross Health Protection Service as
“health visitors”.

The public calls them “green cross health visitor”

or “green cross sibling” known by its name [30].
Health visitors were trained by the director of the
H. Royal National Institute of Public Health He
also employed and assigned them to one of the
health protection services. He also transferred
them and dismissed them. The Institute allocated
their salaries, which were covered by the budget
of the Ministry of the Interior [29].

Child protection activities were considered one of

the most important sectors of work for the future of
the nation, but let’s see what changes the new legal
reform has brought, what new health science pro-
fessions were being created and what actions had
appeared in the lives of villagers and city dwellers.
In terms of campaigns, the Green Cross Milk
Campaign, the Green Cross Sugar Campaign, the
Green Cross Children’s Meals, and the advertising Fig. 1. Green Cross health visitor
of regular and occasional campaigns were signif- Source: [30] Johann Béla (1939) Healing the
icant. They helped these poorest settlements with Hungarian village, Budapest

22
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Figure 2 , Mother and Baby Home, People waiting for counseling

Source: [31] Tolnai Világlapja, 1936, 01, 454-460
The wonderful operation of the Green Cross is blessed

Figure 3, Mother and Baby Home, Baby’s examination by a Green Cross doctor
Source: [31] Tolnai Világlapja, 1936, 01, 454-460
The wonderful operation of the Green Cross is blessed

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

areas, and this also formed the basis of our organ- I.8. The concept of value
ization today. The chapter aims to introduce the topic of health as
Such was, for example, the organization of patient a value, starting with the historical aspect, several
transportation and rescue (building an ambulance definitions of the concept of value, an overview
service in the country). Public health was com- of value changes, the tools of value research and
pletely transformed with the nationalization of the presentation of health awareness that reflects
the organization, such as the recruitment of Chief health as a means and target value.
Medical Officers and doctors into the state system, No consensus has been reached regarding the con-
i.e. they had to decide whether to run a private cept of value [33], and its connection to different
practice or become full-time state officer doctors/ scientific fields also makes the definition difficult
doctors in a fixed promotion system. In the same (e.g. health science, education science, psycholo-
way, the organization of nurses and public health gy, marketing, entrepreneurship, economics, soci-
visits and district medicine and the construction of ology, philosophy). The terminology of value was
the medical system and health centers, all 1936: a topic of discussion in many sciences, only in the
IX. Article of law, and the 1936: XXIII. article of field of social science, i.e. sociology-psycholo-
law supplemented by decrees 100/1936. BM § 22 gy-anthropology, the concept of value is uniform.
of the decree and 1030/1936. BM. decree created One of the most commonly used value definitions
a completely new system. The fact that they came among marketing specialists can be linked to Mil-
under the Ministry of the Interior instead of the ton Rokeach’s 1973 definition, which interpreted
VKM, and the Chief Medical Officer took over it as a list of 36 elements and created a tool suit-
many tasks from the Education Inspector brought able for measuring values, which is still used by
a significant change to the life of the kindergartens. researchers today. According to Hofmeister-Tóth
However, we must note that this operation accord- (2017), values are “standards, criteria for our be-
ing to district funds helped to modernize the do- havior and attitudes, which allow us to criticize
mestic healthcare system, reduced child mortality others and ourselves. Values are culturally deter-
and improved the fight against infectious diseases. mined and we learn them through socialization”
While in 1920 18.7% of 100 babies died, by 1940 [34]. According to Kluckhohn (1951), “value is a
the mortality had dropped to only 11.7%. Help was concept of desirable things, which can be explicit
provided to mothers raising babies with the soap or implicit, specific to an individual or a group,
and trousseau allowance. In the village, 42.7% of and which influences the choice between certain
mothers used prenatal care, while 73.3% used in- available modes, means and ends” [35]. Kluck-
fant care in 1941. 756 health protection districts of hohn’s (1954) specialist literature suggests that it
this size had already been established in the coun- means the satisfaction and blocking of values and
try [30, 31]. needs, as well as the elicitation of new needs and
the linking of Maslow’s pyramid based on physio-
The transformation of kindergartens into a health logical needs and values. Based on Super ‘s (1995)
organization did not last, because it was returned to interpretation, values arise from needs. According
the system of educational supervision and the defi- to Roberts and Robins (2000), value is the moti-
nition of early childhood in the health system did vational system of human personality. According
not work. Similarly, when looking at the system to Hankiss (1977), value means from a subjective
of the nursery school institution, it now considers point of view what a system considers important
the administration of care for children between the for its own development and objectively means the
ages of 0-3 as belonging to the social sector, but at factors necessary for existence and operation [36].
the same time, it also includes early childhood ed- In Andorka ‘s (2006) formulation, value refers to
ucation in the teacher training system. The current the cultural principles that express what the giv-
health prevention activity can be found in detail in en society considers important, desirable, or good
the chapter presenting the scene-based theory. [37]. Based on other literature, values organize and

24
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

divide our past, present and future, “orient, regu- own values, so the respondent has to think about
late the use of our physical and mental energies, his own personal motivations. The figure below re-
limit and express our social affiliation and social fers to the study by Hofmeister-Tóth (2017), which
self” [38]. vividly depicts the process from Value “health”:
value to product.
The asset-goal chain model is a hierarchical
knowledge structure that includes value groups and Hofmeister-Tóth (2017), values are not elements
product characteristics. The essence of the princi- born with us, but the products of socialization, the
ple is that “the meaning of a concept depends on formation of which is determined by the social
the meaning of one or more other concepts to the environment, family, education, and belonging to
extent that they are connected to each other in the social class. Changes in values can be caused by
association network” [34]. The asset-goal chain the life cycle, generation, education and the envi-
model is illustrated by Hofmeister-Tóth (2017) ronment itself. In order for a value change to take
with the following example: “low-cholesterol place, it is necessary to create new values, reeval-
margarine - healthy diet - no deposits on the blood uate the value hierarchy and abandon old values.
vessel walls - value = living health-consciously”. The elements interact with each other. The au-
Asset represents the activity or object, while goals thors, Hofmeister-Tóth-Simányi, can be associat-
refer to values. For example, the activity of running ed with a comprehensive study of value changes,
or yoga represents the means, while goals represent according to which a shift in emphasis can be ob-
the end state, which manifests itself in happiness, served in relation to values directed at the individ-
safety, or performance. The elements of the as- ual and other people. Politeness, helpfulness, and
set-goal model connect values and behavior, which responsible values were of decreasing importance
are intended to describe the consumption process. in the examined period between 1992-2005, while
Based on Hofmeister-Tóth’s (2017) approach, the health, happiness, and inner harmony were more
asset-goal chain uses a ladder technique in value popular and came to the fore based on the order
research, the essence of which is to reveal with the of importance. While politeness, helpfulness and
help of an in-depth interview how it is possible to responsible values were aimed at the environment,
reconcile the properties of the products with their health and happiness referred to the physical and

I. Figure 4: Value “health”: from value to product

( Source: Hofmeister-Tóth , 2017)[34]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

emotional state of the individual. Family, security, logical dimensions. They appear as a lack of needs
and true friendship appeared in each group of the and are interesting from a psychological point of
population specifically based on their investiga- view because they can never be satisfied. To put it
tion. The authors state that the individual and his simply, a person motivated by lack is at the mercy
or her narrow environment came to the fore, while of his or her own lack and these motivate him or
the importance of the group and society was de- her to take actions that seek to eliminate the lack.
valued. “This phenomenon reflects on the mech- Inglehart’s assumption also confirms this point of
anisms of the market economy, as opposed to the view, according to which people value those that
former socialist solidarity. It is in line with the new are scarce.
living conditions that the focus shifts to the impor-
tance of goal values as opposed to asset values”. According to Keller (2008), the statement of
In the 1990s in our country, the value of assets for Rokeach and Schwart belongs to the group of val-
a lifestyle based on traditions, which formed the ues and motivations, but he considers it important
moral basis of society, played a significant role. Af- to mention that Charles Morris is associated with
ter the change of regime, social control decreased, the concept of perceived (desired) values, as well as
so compliance with others was pushed into the the formulation of (operative) instrumental values
background, therefore, it is much more necessary that prevail as guiding principles in people’s lives.
to be innovative in finding ways and appropriate A test often used in value research, the Rokeach
solutions. The environment changes rapidly, i.e. Value Survey (RVS), actually represents a classifi-
the tendency to develop is essential [34]. cation system of values. To understand human ac-
tion, Rokeach distinguishes between the concepts
The dominant value hierarchies in society, “influ- of values and attitudes. According to Rokeach, an
ence, shape or even determine the views of gener- attitude is a summation of persistent behaviors in
ations through school” [39]. When we think about relation to an object, while a value is a persistent
values, things and cultural elements that determine belief that refers to individually and socially de-
the important elements of our lives may come to sirable behaviors and end states. Basically, it dis-
mind. The common characteristics of the values tinguishes between target value and asset value, to
formulated by Schwartz (2012) can be read in which it assigns independent values. “Instrumental
Pavluska ‘s (2015) study, according to which the values are the means of achieving the target val-
values: ues, that the desirable modes of behavior are asset
1. a belief that becomes saturated with emotion values”[2]. Rokeach’s 18-18 target value and asset
when activated, value can be seen in the table below.
2. are part of desirable goals that stimulate ac-
tion, Rokeach’s value system is used in sociological,
3. they go beyond the given action and situa- marketing research and psychological studies.
tion, The other significant psychological value theory
4. function as criteria, and model can be linked to the name of psycholo-
5. they guide action and attitudes. gist Schwartz. Ten basic values were defined by
Schwartz, which are based on three universal re-
As Keller (2008) summarizes in his work, the quirements [2]:
value perception associated with the names of 1. the needs of individuals as biological organ-
Maslow and Inglehart is classified as the value isms,
perception of values and needs [33]. According 2. requisites of coordinated social interactions,
to Maslow’s view, human needs are arranged on 3. survival and welfare needs of groups.
top of each other like a pyramid system, so human
behavior is based on biological foundations, and The values are located along two bipolar dimen-
then moves from there towards social and psycho- sions: openness to change - preservation, reten-

26
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

I.1. table: Target value and asset value list

A./ Target values B./ Asset values

1. a world of peace 1. courage
2. inner harmony 2. ambition
3. happiness 3. obedience
4. wisdom 4. imagination
5. family security 5. self-control
6. equality 6. responsibility
7. a sense of accomplishment 7. capatibility
8. national security 8. intellect
9. true friendfship 9. cheerfulness
10. mature love 10. logic
11. an exciting life 11. forgiveness
12. a comfortable life, material well being 12. independence
13. self-respect 13. honesty
14. pleasure 14. helpfulness
15. freedom 15. broad-mindedness
16. social recognition 16. love
17. social recognition 17. cleanliness
18. salvation 18. politeness

(Source:[2] Rokeach , 1973 In: Pavluska, 2015, 4)

tion, and then self-realization - altruism. Values “people’s faith (values, culture) plays a key role in
are related to each other, opposite or compatible. economic development, the rise and fulfillment of
In terms of values and motivation, the name and democracy, gender equality and effective govern-
work of Rokeach and Schwartz are outstanding. ance” [2].
International value research began in the middle
of the 20th century, which has grown into the most I.8.1. The emergence of value as a concept in so-
important field of foreign and domestic sociology. ciety
In the 1980s, objections to the tests intensified, Based on early lifestyle research, health as a value
despite this, Inglehart’s international research se- already appeared in the consciousness of primitive
ries (World Values Survey, WVS) started at that human communities [40]. The importance of the
time. One of the most significant results of this harmony appearing in the relationship between
large research series is the so-called cultural map. body-soul-man-community was also known, and
The map became popular because it proved that then the organic worldview was replaced by the

27
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

holistic view, the complex conceptual understand- with which, according to the literature, he actually
ing of human health, but the description of this is popularized prevention. According to Kéri (2007),
only the result of the last century. The develop- specialist literature related to the concept and pres-
ment of the image of health has undergone many ervation of health began to proliferate in Hungary
changes in recent times. As the statement that a in the 18th century. In medicine, this was a very
person is largely responsible for the development significant period, since it was then that an out-
of his or her own health, was believed in the world standing amount of specialized literature not only
of the Greek polis, it is still valid today. It reflects on the concept of health, but also on the topic of
the individual’s health awareness [40,41]. Individ- childcare was born in our country [40]. As a result
ual responsibility plays an important role in health of rising education levels, the demand for quality
awareness, as it means responsible action taken for food, lifestyle and responsible healthy child rear-
the sake of one’s physical-spiritual and relational ing has increased. Health as a value has appeared
balance and to achieve well-being [41]. everywhere throughout history.
Health as a value can be explained by the factors
that we do in order to be able to maintain or restore I.8.2. Examining health as a value
our state of health, or to reach the appropriate state, Health as a value can be explained by the factors
thus connecting the topics of health as a value and that we do in order to be able to maintain or re-
health awareness [2]. store our state of health, or to reach the appropri-
We can see many parallels on the value of health in ate state. This is how health as a value and health
the history of the topic. The teachings of the Hip- awareness is connected.
pocratic school (Greek medical theories) mostly According to Varga et al.’s [41] (2008) OTKA ten-
emphasized health preservation and disease pre- der report, there is a strong relationship between
vention instead of cure [40]. In the Christian per- the importance of health value and health aware-
spective, the issue of health is a gift from God, ness as a complex variable. Based on Harris and
since the main teacher for them is Christ, who is Guten’s (1979) model, eight main variables belong
a physician and teacher, and the guide to health to health awareness: conscious nutrition, personal
preservation, and the collection of life rules is the hygiene, regular health self-examination, avoiding
Holy Scriptures themselves. The Bible contains substance abuse, balanced mental life, rest hy-
many health and illness-related tasks (physical giene, use of screening tests, physical activity [42].
health, personal hygiene, treatment of diseases,
tasks related to infectious diseases, rules for clean- The model of health awareness was supplemented
ing, instructions for food). According to their with sufficient sleep and liquid consumption [42]
view, health is completeness, which can only be (in the research of Freyer et al., 2019.) According
achieved with firm faith, since peace and harmony to Szakály et al. (2014), the majority of the Hun-
of the soul are necessary, because without these garian population has the knowledge they could
the physical body cannot function well. According use to preserve their own health, nevertheless, they
to the Bible, the soul is more important than the do not act. This is confirmed by the fact that, based
body, because it does not need to be taken care of. on the study, 48% of the respondents do not even
Purification of the soul can be achieved by stretch- plan to change their lifestyle for the sake of their
ing the body. We include the English philosopher own health. That is why it is an important mes-
John Locke among modern thinkers, who in his sage for us that, paying attention to the needs and
17th-century work entitled “Some Thoughts on circumstances, education for a more health-con-
Education” formulated pedagogical principles, scious lifestyle should be supported and preferred
touching on the concept of health and the possi- - for all age groups.
bilities of preserving the health of the body. Ac- In another study, Pavluska (2015) created the
cording to his opinion, reaching a healthy state can health portfolio, which represents a checklist “that
best be achieved without a doctor and medicine, can be used to evaluate the realization of health

28
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

as a value and to examine health behavior” [2]. “The process of becoming a consumer in Hunga-
Health as a value in general refers to those factors ry”. The study analyzed the importance and reali-
and actions that appear as instrumental values in zation of the values. According to the respondents,
achieving, maintaining and restoring health. In- health comes first, followed by family, security,
strumental values are ways of behaving that serve happiness and honesty. The youngest age group
to achieve the target value. In the government doc- indicated the zest for life first, followed by health.
uments currently in force, health as a value is of The young age group considers frugality the least
prime importance. The Basic Law clearly states important, while the oldest age group values suc-
that everyone has the right to physical and men- cess instead of modesty. The results are presented
tal health. The law interprets that this basic value in the summary figure below.
can be achieved with the right environment, health
care, sports, food, drinking water and the proper Based on a representative study conducted in
operation of public health. The National Coopera- Hungary, there is a difference between the impor-
tion Program includes health in addition to work, tance of values and their implementation. Based
home, family, and order. The government’s com- on the answers, health is important, as it is in the
mitment is confirmed by the “Healthy Hungary first place, but in terms of implementation, it is
2014-2020” and the currently valid “Healthy Hun- already much lower, falling to the 14th place. In
gary 2021-2027” programs. the ranking of personal values, health - which is
closely linked to material values (fitness, physical
In 2006, the health value was investigated in Hun- strength, etc.) - ranks high. By researching health
gary within the framework of the project entitled behavior, we can get an answer about the value of

Figure 2: The importance of personal values and their achievement among the entire population
(Source: [2] Hofmeister-Tóth – Neulinger, 2009 In: Pavluska, 2015)

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

health, since health as a value is manifested in ac- Volume I of his work on the history of sexuality,
tion. Michel Foucault asserts that the sexual “strategy”
of the 19th-century bourgeoisie was not charac-
The elements that serve as asset values in achiev- terized by asceticism and the devaluation of the
ing, maintaining and improving a suitable state body, but, on the contrary, by the appreciation of
of health can be summarized in a health value the body. The aim of the citizens was to preserve
portfolio. The elements of the health value port- their health, increase their physical strength, create
folio are divided into larger categories: lifestyle and raise healthy offspring, and the means of this
(health-conscious nutrition, sports and exercise, were taking care of the body, controlling the body
mental health, quality free time, etc.), prevention and sexual life [45]. Foucault explains the general-
(screening tests, conscious consumer behavior, ization of control and supervision over health and
awareness, use of vaccinations, etc.) and treat- life in general by the fact that decisive changes
ment/ the category of recovery (cooperation with in power took place in Western Europe from the
primary care and specialist care, treatments, etc.) 17th century. In previous centuries, the sovereign’s
can be separated. privilege was the right over life and death, which
is symbolized by the broadsword: power is primar-
Health as an asset value. The field of health val- ily a taxing forum, an expropriation mechanism,
ue includes the examination of those activities and the ruler can even take the life of his subject if he
behaviors in which the health value appears. This breaks his laws. From the 17th century onwards,
includes the field of health behavior, i.e. the ex- the emphasis was less and less on confiscation, it
amination of health awareness. Health as an asset became only one element of power, the purpose of
value is manifested in the health status of young which was less submission, and more the efficient
people (physical activity, alcohol consumption, organization of life, power became, as it were, the
smoking, sexual behavior, nutritional behavior, guardian of life, became biopower ( the power over
drugs and other illicit substances, abuses) [2]. death was a supplement to this power , the bloody
Health behavior “Personal attributions such as modern wars were no longer started in the name
beliefs/convictions, expectations/guessings, mo- of the ruler, but in the name of the community as
tives, values , perceptions and other cognitive a whole, referring to the preservation of the life of
elements; personality traits, including emotional the people, the “race”, and the certainty of its sur-
and emotional states and individual characteris- vival, [45]. Two types of appearance of biopower
tics; and certain behavioral patterns, activities and can be distinguished. (1) Anatomy-politics of the
habits related to the maintenance, restoration and human body. Its subject is the human body under-
development of health.” [43, 44]. stood as a machine, and it strives to create supervi-
As we can see from the above, health as a value is sory systems in which people function as obedient
of interest for research and investigations, howev- and useful bodies (school, barracks, workshop,
er, without a thorough knowledge and interpreta- factory, hospital, prison), various regulations play
tion of the concepts of health awareness and health a decisive role here.
behavior, we cannot start a well-founded research. (2) The biopolitics of the population (its develop-
Therefore, we consider the overview analysis of ment can be dated to the middle of the 18th centu-
the above chapter to be decisive and important in ry): “this pole already focuses on the body, which
relation to the interpretation of health. is permeated through and through by the mechan-
ics of living matter, and which is the scene of bio-
I.9. Modernity and biopower: health in the ser- logical processes: that is, on population reproduc-
vice of efficiency tion, birth and death rate, health, lifespan, and all
In the 19th century, religious and moral aspects the conditions that contribute to the development
are still present in discourses about health, but of these factors” [45], Foucault also dedicates a
efficiency becomes the most important aspect. In separate book to the first form, in which he talks

30
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

about the microphysics of power when analyzing with beautiful and healthy-looking people (main-
surveillance systems [46]. ly slender women), advertisements and magazines
Health policies are also related to these two forms. featuring movie stars suggest that a beautiful body
At this time, the preservation and especially the is a condition for enjoying life. With the change
development of health is less important in most in clothing habits clothes show more and more of
supervisory institutions - except for example the the body, and it does not matter what the body is
better schools - the point is that the individual is like, because instead of character, people increas-
able to perform his task properly: when the diets ingly see an attractive personality as the guarantee
are compiled, the counting of calories begins, the of success (in private life, social life, at work), and
research into what minimum diet is required for this also includes an attractive appearance, pri-
maximum energy production [47]. In 19th-century marily in women, but more and more also in men.
factories, the situation was often particularly poor Women (and men) who are receptive to the val-
from a health point of view. The improvement of ues of the consumer world constantly check their
the situation of urban factory workers living and bodies and lifestyles to see if they correspond to
working in unhealthy conditions, as well as the the “ideal” body and lifestyle seen in advertising
treatment of health-damaging factors in cities in images and magazine photos of Hollywood mov-
general, required biopolitical interventions (within ie stars [48]. All of this is only apparently a big
the form of biopower called by Foucault the bi- change compared to the “restraint” of the Victori-
opolitics of the population). Turner basically trac- an period: as mentioned, the bourgeoisie was also
es the recognition of the need for central public very concerned with health in the 19th century in
health provisions in Western states to three factors: order to increase the efficiency of the body, effi-
infectious diseases spreading among the urban ciency is still important, but precisely because of
poor and urban filth threatened the health of the psychoanalysis, sexual liberation” is seen as nec-
upper classes as well; the housing and care of the essary to ensure a healthy, efficient body [45], and
sick poor meant serious tax burdens for the rich; even more emphasis is placed on body mainte-
finally, at the beginning of modern mass warfare, it nance, as physical beauty is valued. Of course, the
became obvious that young people from the work- “mania” of body maintenance is spreading more
ing class were in many cases unfit to be soldiers, and more among the lower classes as a result of
due to their poor health [47]. advertisements, magazines, films, and then tele-
vision. Supervisory institutions and the biopoli-
I.10. Health in a consumer (and mediatized) so- tics of the population are also influenced by the
ciety aforementioned social trends. In the second half
Between the two world wars, a consumer culture of the twentieth century, masses of people in wel-
emerged in the West (first in the USA, then in Great fare societies are already waiting to be freed from
Britain), and modern advertisements aimed first at the constraints of school or work and enjoy life in
the middle class and then at ever wider masses ap- the afternoon and on their days off, which mostly
peared, with the help of which companies tried to means consumption (not only consumption of ma-
create new needs and desires, and which instead terial goods, but also consumption of experienc-
of the values of hard work, duty, and frugality, the es). The individual does not even realize that by
values of enjoying life and seizing the moment consuming and maintaining the body in order to
were slandered. Many unhealthy products are also achieve the current ideal of beauty (diet, fitness,
presented in advertisements (just think of tobacco solarium, etc.), he or she is also fulfilling social
advertisements, after World War I, smoking also expectations, adapting to what is expected, exer-
started to spread among women), but the emphasis cising self-control if he or she likes (and treating
on health as an important value has been present himself in such a way as if it were a commodity, a
in consumer culture from the very beginning, in consumer product, see about this: [48]. In relation
connection with beauty. Products are advertised to the biopolitics of the population, highlighting

31
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

only one aspect: those health education campaigns ior, the issue of health preservation is important to
that highlight the effects of a healthy lifestyle on many people only to the extent that it is in the ser-
beauty and good appearance will be the most ef- vice of improving their external appearance, what
fective [48]. is outside of this is neglected (e.g. participation in
Today, in the period of globalized (digital) capi- screening tests, etc.). Of course, there are people
talism, people are confronted with an incredible who do not put their beauty before their health and
amount of still and moving images depicting ideal want to do everything to protect their health, but
bodies on Internet social portals (Facebook, Ins- they can easily become a follower of some pseu-
tagram, etc.) and video sharing platforms (You- do-expert or some unscientific method without the
Tube, TikTok, etc.). We live in the age of the cult help of a specialist, relying only on information
of beauty and health, which has many problem- found on the Internet. That is why it may hap-
atic features, for example what Kierkegaard al- pen that the effort to preserve health also leads to
ready described, that a life built on one of these health destruction. Fortunately, initiatives to mit-
values - or even both - may sooner or later end up igate the negative effects of the media are on the
in a crisis, but even if someone avoids the crisis, rise: we can find advertisements that do not feature
the one who does not work on developing him- models with exceptional physical attributes, but
self lives an “empty” and meaningless life. It is women with more ordinary physiques, rating sys-
also a problem that many people try to be or stay tems for websites dealing with health issues have
beautiful at the expense of their health (which of been developed (see: Ködmön , 2018) [50], but
course was also present in previous centuries, we the entertaining and educational health campaigns
can also read in the already mentioned Firenzuola can also be mentioned. However, during the COV-
that there are women who overdo the powdering, ID-19 pandemic, we witnessed the fact that despite
not thinking about the fact that it wears off pre- the fact that information helping to protect health
maturely and their skin ages, [9]; or think of the reached the masses, representatives of virus-deny-
corset, which was popular even at the beginning of ing and virus-skeptic and anti-vaccination views
the 20th century), this seems quite a contradiction were able to cause great damage by using social
in the age of “healthism”. The background to this media. In our mediatized world, health promotion
is the completion of the already mentioned phe- specialists must not only help those who know lit-
nomenon typical of consumer societies, that suc- tle about health protection due to their poor social
cess is associated with a young or at least youthful situation and poverty (one of the manifestations of
body that conforms to the current ideal of beauty which is information poverty), but also those who
manipulated by business interests, and failure is are lost in the flow of health-related information.
associated with a body shape that does not con-
form to the “prescribed”. It can be frustrating for I.11. The most important moral limitation of
people with a body shape different from the “ide- health promotion
al” that they have to face the sight of (apparently) During health promotion work, whether it is indi-
perfect bodies in commercials, Hollywood films, vidual counseling, group work or planning a media
series, images and videos uploaded to social me- campaign, the principle of respect for human dig-
dia sites who knows how many times a day. The nity must always be taken into account. The most
desire to conform to the beauty cult can also result quoted formulation of the principle is attributed to
in serious health damage, young girls often devel- the philosopher of the Enlightenment, Immanuel
op anorexia or bulimia (of course, the beauty cult Kant: “ Act in such a way that you always need
has an increasingly strong effect on men as well, humanity, both in your own person and in some-
body image disorders can also develop in men, e.g. one else’s, as an end, never as a mere means” [51].
muscle dysmorphia is typical in their case, see for We can give another formulation of the principle
example: Túry – Pászthy , 2008 [49] ). But even of respect for human dignity - different from the
if there is no question of health-damaging behav- one described by Kant, but which assumes that

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

man is an end in himself. Thus, for example, we ful life. Numerous psychological researches have
can grasp the principle as follows: the human per- supported what was already formulated by an-
son has self-worth as a result of his existence , and cient Greek and Roman thinkers: mental-spiritual
consequently it is in his fundamental interest that health, or with another terminology: a meaningful
the “sanctity” of his life, the widest possible free- life also has a positive effect on our physical health
dom, and his unique personality are respected on (see [55,56]. Professionals who interpret physical
an equal basis with other persons (for the interpre- health in connection with mental and spiritual
tation of this, see: Barcsi, 2013) [52]. Therefore, it health and help people to lead a better, more com-
is important that the health promotion profession- plete life carry out work of great importance.
als sees the people they come into contact with as a
goal and not as a means, and respects the sanctity,
freedom, and personality of other people’s lives.
Media campaigns that entertain and educate have a .
raison d’être, since more attention is paid to them
than to dry social advertisements that only present
the facts (dangers, statistical data). However, it is
important that campaigns do not violate the princi-
ple of respect for human dignity. This kind of thing
happens sometimes, even if it is obviously not on
purpose. For example, they presented a social ad-
vertisement about the harmful effects of smoking,
which stigmatized smokers and made them hate. A
young woman with a pushcart appeared in one of
the advertisements made to prevent drunk driving.
Disabled people took action against the advertise-
ment because they saw that it portrayed their dis-
ability as worse than death (for more on this and
other examples, see: Császi , 2004 [53]).
Just like doctors and nurses, health promoters also
have to take into account additional important
(bio)ethical principles. According to the principle
of “Do no harm!”, the health promoter must al-
ways act with the greatest possible care to mini-
mize the possibility of potential dangers associat-
ed with his activity. The realization of charity is
also a fundamental goal, since the health promoter
must improve the health of all those with whom
he or she deals. The principle of justice primarily
means the prohibition of discrimination between
people, which also follows from respect for human
dignity (more on bioethical principles [54]).

I.12. Summary
As a conclusion, health is very important, but it
does not guarantee our happiness by itself, our
behavior aimed at preserving and improving our
health must be part of the pursuit of a meaning-

33
Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

I. 13. Bibliography Péter, Tatár György, Gondolat, Budapest,

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dapest leumi lapszám
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története III. Törődés önmagunk- Fourth International Conference on
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tor, Máriabesnyő-Gödöllő. 25 July 1997. http://www.who.int/health-
10. Turner, Bryan S. (1997): Az étrendről promotion/conferences/previous/jakarta/
folyó diskurzus. In: Mike Featherstone – declaration/en/
Mike Hepworth – Bryan S. Turner: A test. 20. Kishegyi J, Makara P. (szerk): Az
Társadalmi fejlődés, kulturális teória. egészségfejlesztés alapelvei. Az egészség-
Ford. Erdei Pálma, Jószöveg Műhely Ki- fejlesztés alapvető nemzetközi dokumen-
adó, Budapest, 54-69. tumai. Egészségfejlesztési módszertani
11. Magyar L. A. (2011): Egészség és prot- füzetek. Országos Egészségfejlesztési In-
estantizmus https://elitmed.hu/ilam/ tézet, 2004. pp. 35-36. http://regi.oefi.hu/
gondolat/egeszseg-es-protestantizmus modszertan1.pdf
[2021.08.20.] 21. Shanghai Declaration on promoting
12. Weber, M. (1982): A protestáns etika és health in the 2030 Agenda for Sustainable
a kapitalizmus szelleme. In: Max Weber: Development. The 9th Global Conference
A protestáns etika és a kapitalizmus sze- on Health Promotion, Shanghai, China,
lleme. Vallásszociológiai írások. Ford. 21-24 November 2016. http://www.who.
Gelléri András, Józsa Péter, Somlai int/healthpromotion/con-ferences/9gchp/

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shanghai-declaration.pdf?ua=1 sadalmi pozíció. MTA Szociológiai

22. Mátyus I. Kibédi: Ó és Új Diaetetica Kutatóintézet. [2020.11.23.] https://
I-VI kötet (Pozsony, 1787-1793) w w w. y u m p u . c o m / h u / d o c u m e n t /
23. Zsoldos J. (1814) Diaetetika vagy Az read/17989966/ertekrend-es-tarsadal-
Egészséget fenntartó, és a Betegségtől mi-pozicio-mta-szociologiai-kuta-
tartóztató Rendszabások, Györben, özv- tointezet
egy Streibig Józsefné betüivel 34. Hofmeister-Tóth Á. (2017). A fogyasz-
24. Tigyi Zné Pusztafalvi H.,(2011) tói magatartás alapjai. Akadémiai Kiadó.
Egészségtan tanítása a Tanítóképzőkben, https://doi.org/10.1556/9789630598897.
a 19. században használt tankönyvek al- https://mersz.hu/hivatkozas/
apján, In: Pinczésné, Palásthy Ildikó (sze- dj241afma_18_p1#dj241afma_18_
rk.) A református tanítóképzés múltja, p1[2020.11.23.]
jelene, jövője , Debrecen, Kölcsey Ferenc 35. Kluckhohn, Clyde. K. M. (1951): Val-
Református Tanítóképző Főiskola ues and value orientations in the theory of
25. Tigyiné Pusztafalvi H., (2013) Az action. In. Parsons T. – Sils, E. (szerk.),
egészségnevelés intézményesülésének Toward a general theory ofaction. Cam-
története, EDUCATIO 22 : 2 pp. 224- bridge, MA: Harvard University Press,
234. , 11 p. 388-433.
26. Pusztafalvi H. (2017) Egészségtanta- 36. Hankiss E. (1977): Érték és társada-
nár képzés a Pécsi Tudományegyetem lom. Tanulmányok az értékszociológia
Egészségtudományi Karán, In: Ku- világából, Budapest, Magvető Kiadó
rucz, Rózsa (szerk.) A pedagógusképzés 37. Andorka R. (2006): Bevezetés a szoci-
évszázadai a Kárpát-medencében, Pécs, ológiába. 2. jav., bőv. kiadás. Osiris Ki-
PTE Kultúratudományi, Pedagógusképző adó, Budapest
és Vidékfejlesztési Kar 38. Kamarás I. (2010): Érték, értékelés
27. Johann B. (1941) Az egészségügyi és és értékrend (szociológiai és szo-
szociális gyermekvédelmünk bírálata, ciálpszichológiai szempontból), http://
Budapest www.metaelmelet.hu/pdfek/tanulman-
28. Pusztafalvi H,(2007) Az óvodákról yok/ertek_ertekeles.pdf
szóló fejezetek, In: Pásztor, Andrea (sze- 39. Meleg, Cs. (2015). Nevelésszocioló-
rk.) Régi pécsi iskolák albuma, 1868- giai problémakörök és nézőpontok. In
1948 Pécs, Baranya Megyei Múzeumok Varga, A. (Eds). nevelésszociológia
Igazgatósága, alapjai, Pécs, HU: Pécsi Tudomány-
29. A Zöldkeresztes védőnők munkája, Mag- egyetem Bölcsészettudományi Kar
yar Rendőr, 1938 (5. évfolyam, 1-24. Neveléstudományi Intézet Romológia és
szám)1938-05-01 / 9. szám Nevelésszociológia Tanszék, Wlislocki
30. Johann B, (1939) Gyógyul a magyar Henrik Szakkollégium. http://mek.oszk.
falu, Budapest, A Magyar Kir. Országos hu/14500/14566/14566.pdf
Közegészségügyi Intézet közleményei. 7. 40. Kéri, K. (2007): Az egészség
Sz kultúrtörténeti megközelítése (az ókortól
31. Kalichné Dr. Simon M. (2015), A a 18. századig). In: Egészségpszichológia
védőnői hivatás története, Medicina Ki- a gyakorlatban. II. rész, II. fejezet. Sze-
adó, Budapest rk.: Kállai J., Varga J-, Oláh A.; Medicina
32. A csodálatos Zöldkereszt áldásos Könyvkiadó, Budapest, 2007, 37-50. o.
működése (1936) Tolnai Világlapja, 01, 41. Varga K. (2003) Értékek fénykörében,
454-460 40 év értékkutatás és jelen országos
33. Keller, T. (2008). Értékrend és tár- értékvizsgálat, Akadémia Kiadó, Buda-

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pest cikk/2004_04_tel/01_az_egeszsegneve-
42. Freyer T., Horváth D., Nagy Á. les_reprezentacioja [2021.08.20.]
(2019) Fogalomtisztázó törekvések az 54. Kovács J. (1999): A modern orvosi etika
egészségtudatosság vizsgálatához. alapjai. Bevezetés a bioetikába. Medici-
43. Nagy, L., Barabás, K. (2011). Az na, Budapest
egészségműveltség és egészségmaga- 55. Ryff, C. D. – Singer, B. H. – Dien-
tartás diagnosztikus mérésének le- berg Love, G. (2004): Positive health:
hetőségei. http://pedagogus.edia.hu/ connecting well-being with biology. In:
sites/default/files/public/2_6/Nagyne_ Philosophical transactions of the Royal
Barabas_2011.pdf Society of London: Biological sciences,
44. Giddens, A. (2003): Szociológia. Osiris 359(1449), 1383-1394.
Kiadó, Budapest 56. Seligman, M. 2011: Flourish – élj boldo-
45. Foucault, M. (2014): A szexualitás gan! A boldogság és a jól-lét radikálisan
története I. A tudás akarása. Ford. Ádám új értelmezése. Ford. Bozai Á. Akadémi-
Péter. Atlantisz, Budapest. ai Kiadó, Budapest In the above chapter,
46. Foucault, M. (1990): Felügyelet és bün- Tamás Barcsi noted the sections marked
tetés. Ford. Fázsy Anikó és Csűrös Klára. with numbers 1, 2, 3, 9, 10, 11, 12.
Gondolat, Budapest.
47. Turner, Bryan S. (1997): Az étrendről
folyó diskurzus. In: Mike Featherstone –
Mike Hepworth – Bryan S. Turner: A test.
Társadalmi fejlődés, kulturális teória.
Ford. Erdei Pálma, Jószöveg Műhely Ki-
adó, Budapest, 54-69.
48. Featherstone, M. (1997): A test a fogy-
asztói kultúrában. In: Mike Featherstone
– Mike Hepworth – Bryan S. Turner:
A test. Társadalmi fejlődés, kulturális
teória. Ford. Erdei P., Jószöveg Műhely
Kiadó, Budapest, 70-107.
49. Túry F. – Pászthy B. szerk. (2008):
Evészavarok és testképzavarok. Pro Die
Kiadó, Budapest.
50. Ködmön J. (2018) Egészségügyi in-
formáció az interneten. Orvosi Hetilap,
159 (22). 855-862.
51. Kant, I. (1991): Az erkölcsök metafiziká-
jának alapvetése. Ford. Berényi Gá-
bor. In: Immanuel Kant: Az erkölcsök
metafizikájának alapvetése, A gyakorlati
ész kritikája, Az erkölcsök metafizikája,
Gondolat, Budapest, 13-101.
52. Barcsi T. (2013): Az emberi méltóság
filozófiája. Typotex, Budapest.
53. Császi L. (2004): Az egészségnevelés
reprezentációja a médiában. Médiaku-
tató. 5 évf./4. https://mediakutato.hu/

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Chapter II.
HEALTH BEHAVIOUR
(KINGA LAMPEK, JULIANNA BOROS,
ZSUZSANNA FÜZESI)

II.1. Introduction more or less similar way. One of the key differenc-
In the twentieth century, especially since the es in these definitions is how responsibilities are
1950s, a significant proportion of health problems shared between the individual, the community, and
in developed countries have been caused by chron- society as a whole, while we also find differences
ic, non-communicable diseases, in the context of in the resources and motivations to build and sus-
which a number of studies have confirmed the im- tain activities for human health.
portant role of lifestyle factors. However, the life- In our study, we use the definition of Harris and
style is not based on separate individual decisions, Guten, often quoted, that health behaviours are the
but also summarizes the characteristics of the so- totality of individual behaviours and attitudes that
cial position, the specifics of the given community are intended to maintain, promote, or restore an in-
and the personality factors of the individual [1]. dividual’s health status, regardless of whether the
behaviours are actually effective or beneficial to
It is also known that maintaining good health is a the state of health [2].
factor that significantly affects our quality of life.
Changes in our health status can change the activi- Observing our daily lives, we can also see that the
ties and habits of our daily lives to varying degrees majority of people believe that they can signifi-
in the long or short term, but they can also affect our cantly influence the development of their health
social relationships. Many disciplines, especially and take an active role in increasing the length
the behavioural sciences, have been researching of life spent in health. Some learn and follow it
for decades how people respond to their health or from an early age to learn health-promoting hab-
illnesses, what, how and why they do, what they its, while others are only led by a serious illness
want to do to maintain or improve a positive situ- to develop and maintain habits. Research has also
ation, or use defence mechanisms. The main goal shown that, although to varying degrees from so-
of the research is to understand human behaviour, ciety to society, some people act regularly, routine-
the motivations behind it, the individual, commu- ly, others occasionally or ideologically to protect
nity and social factors and opportunities that influ- their health, on a fairly wide range of activities.
ence the behaviour. The chapter contains a concise Often the various socio-demographic factors in-
summary of these researches, focusing on the data fluencing the behaviour - the individual’s gender,
and processes characteristic of the health and risk age, education, labor market position or financial
behaviour of the Hungarian population. and income situation - also have a significant im-
pact on the chosen behaviour.
II.2. Conceptual background of health be- Kasl and Cobb [3] distinguish three types of health
haviour behaviours: preventive behaviours, disease be-
II.2.1. The concept of health behaviour haviours, and patient role behaviours. Preventive
The concept of health behaviour has been defined health behaviour includes all activities aimed at
by many researchers since the 20th century in a preventing an individual who considers himself or

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

herself to suffer from illnesses or health problems and “hormone hunger” (eg endorphins, adrenaline,
(such actions as regular physical activity, avoiding etc.) also triggering the exercise to be repeated.
smoking, eating healthy). Illness behaviour, on the Like any exaggerated habit has its setback, e.g. if
other hand, refers to the activities of individuals we demonize our diet (anorexia, bulimia) or be-
who feel sick, with the aim of accurately defining come addicted to exercise.
the disease and seeking a therapy. Patient role be-
haviour is also related to clients, but its goal is to re- Health behaviours are often approached as individ-
cover from the disease - this includes, for example, ual-level behaviours, but, especially in the social
participation in various treatments, willingness to sciences, health behaviours can also be measured
work with doctors and health professionals. These and analyzed at the level of groups or populations
behaviours are referred to by the authors of this [4; 5; 6].
study as “problem-focused” because they respond
to a potentially occurring or existing problem in Activities of health behaviour can be preventive in
the future, also seeking a solution to it. nature, which can lead to the preservation and, in
many cases, development of health, and can also
Health behaviours can be interpreted as health-re- be hazardous behaviours that pose a risk to health
lated and behaviours targeting health [3]. The for- in the short or long term [7]. Preventive health be-
mer is usually not consciously aimed at health, haviours are characterized by awareness, including
but it also has an effect on health as an unintended the development and maintenance of healthy eat-
consequence. For example, if someone only walks ing habits, regular physical activity, moderate al-
to work for half an hour a day because he or she cohol consumption, avoidance of pollution, habits
does not own a car, exercise can still have the same related to accident prevention, and the prevention
benefits to their health as walking, because they or timely detection of diseases. Behaviours that
know that regular exercise can reduce the chances have a detrimental effect on health, such as regular
of developing a number of illnesses. Actions are smoking, excessive alcohol consumption, physi-
another behaviour, especially consciously seeking cal inactivity, eating habits that result in obesity,
pleasures, also, as we call it, “hedonist-focused”. risky, unsafe sexual behaviour, and inappropriate
The term hedonistic is not used in the meaning of stress management, are called risk or risk-seeking
the search for exaggerated pleasures, but in the behaviours.
sense that it seeks the main driving force of human However, preventive and risk-seeking behaviours
behaviour in pleasures and also appears in many can often only be sharply distinguished in one
philosophical, religious trends, cultures, and sub- model. Some sports are specifically risky augmen-
cultures. In all cases, in addition to experiencing tative activities: think of skiing, snowboarding, or
pleasures, they are specifically designed to help any athletic sport that carries the risk of injury, it is
maintain or improve health. not even necessary to practice extreme branches.
Medical interventions, whether for preventive pur-
The two approaches (problem-focused and hedo- poses, can also pose a risk to an individual’s health
nistic) are not mutually exclusive, they are fortu- (eg, due to infections and other iatrogenic harms).
nately related. Just think of nutrition, which, in ad- A series of examples can be continued, but they do
dition to energy supplementation and the intake of not call into question the importance of preventive
the necessary nutrients, is also enjoyable, especial- health behaviours. Undoubtedly, a trip can also
ly if it also serves our needs for social activity. The carry risks (from colds to tick bites to more serious
“problem-focused” approach can also turn into a accidents), yet we think that sitting on the couch
“hedonist”: e.g. when exercise, doing sports is not for years carries much greater health challenges.
only used to prevent future illnesses or to maintain
or improve the current ones, but when integrated Behaviours that have a positive effect on health
into the nerve pathways, it becomes a habit pattern can be characterized along two other dimensions:

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

the dimension of simple, easy-to-perform or com- sonal, behavioural, and environmental factors. He
plex behaviours that may involve more effort and found that the personal factor refers to how much
inconvenience, and the dimension of the required an individual believes in his or her ability to follow
frequency of a given behaviour. For example, tak- a particular behaviour; the behavioural factor is
ing a daily vitamin or possibly taking part in rou- the response that an individual receives when per-
tine screening may be less of a burden. Activities forming an action; and the environmental factor
that require more effort include exercising regular- shows the effect of the social or physical environ-
ly, reducing- quitting smoking, or changing eating ment on the ability of an individual to successful-
habits. In terms of frequency, we can talk about ly perform an action. The three factors constantly
health protection activities that require one-time or interact. In observational learning, a person looks
occasional repetition, as well as actions that need not only at how another person is performing an
to be performed frequently or continuously. action, but also at what confirmation he or she is
receiving in the process [9]. Social cognitive the-
II.2.2. Health behaviour theories ory is a value- and expectation-based approach: in
A number of theories and models have been de- relation to health behaviour, value means avoiding
veloped in relation to health behaviour, of which disease or maintaining or improving health, while
three main model types are presented: health belief expectation refers to the fact that a particular be-
theory [8], social cognitive theory [9], and planned haviour or action can prevent a disease or improve
action theory [10]. health [11].

Development of the “Health Belief Model” (HBM) The “Theory of Planned Behaviour (TRA)” is
by Rosenstock and Hochbaum, who in the 1950s based on Theory of Reasoned Behaviour (TRB),
investigated what could be the socio-psychologi- according to which attitude is defined by the in-
cal reason why people had not participated in TB tention to behave and the idea and belief in
screening even if it was a curable disease. The health-related activities and outcomes. The theo-
study did not require any special energy invest- ry of planned action adds to this that health be-
ment because residents did not have to travel much haviour is not only an individual endeavor but
because of the use of screening buses. According also a good practice for regulating behaviour, and
to the HBM model, people are willing to take ac- draws attention to the important role of beliefs that
tion about their health if they perceive them to be are precursors to intention and actual behaviour.
prone to an illness that is expected to have serious The theory assumes a causal chain between be-
consequences or if there is a possible behaviour or havioural – normative – and control beliefs, as
action that can reduce their predisposition to the well as behavioural intentions and behaviours
illness or severity of the condition. In addition, it realized through attitudes, subjective norms, and
can increase activity if there are benefits to the ac- perceived control. The version of the theory of
tion or if the costs and difficulties of the action do intentional action further developed by Montano
not outweigh the benefits [11]. and Kasprzyk is the integrated behaviour model,
in which intention plays a key role in the devel-
“Social Cognitive Theory” (SCT) is based on Mill- opment of behaviour, but four other factors also
er and Dollard’s theory of social learning. Bandura directly affect behaviour: behavioural knowledge
further developed this by incorporating elements and skills, habits, environmental constraints (or
of observational learning and reinforcement to their absence) and that the behaviour is important
try to find an explanation for how people devel- to the individual. Behavioural intent is influenced
op and follow certain patterns of behaviour. For by three factors, attitude (both experiential and
this purpose, he developed a three-factor model instrumental), perceived norms, and the personal
that shows how the observation of an observed component — perceived control and self-efficacy
behaviour is influenced by the interaction of per- [11].

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Finally, it is worth mentioning the model of Oke- is a matter of individual choice and personal re-
chukwu et al. [12], which examines how health sponsibility, and education to change health beliefs
behaviour can be changed in a social context. The and actions is a key societal element of change in-
model assumes that although health behaviour is tervention [16]. All of this was conceived by the
an individual characteristic, interpersonal, family, transmission of information (and still is conceived
historical, social, political, and other factors out- by many today), despite the fact that information
side the individual influence its realization. Basic alone, while necessary, is not a sufficient condition
socio-economic characteristics, such as gender, for triggering and sustaining desirable actions.
age, social class, ethnicity, mother tongue, place
of birth, act through the modification of several From the 1970s onwards, sociological approaches
factors. These, i.e. interpersonal factors (e.g. fi- to health emphasized the need to examine individ-
nancial circumstances, social ties, extent of net- ual behaviour in a social context, taking into ac-
work of friends, family roles, responsibilities), count the constraints on choice, the system of so-
organizational factors (e.g. workplace atmosphere, cial values and norms, and the system of inequality
social capital), residential factors (e.g. security of and power relations that shape social structure. It
the living environment, neighborhood relations, can be stated that health behaviour takes place at
transport options) ) and possible discrimination the individual level, but is shaped by the commu-
as a social factor that can both affect individual nity (meso) and social (macro) levels [14]. At the
characteristics. Individual (self-efficacy, attitudes, macro level of society we can classify e.g. labor
beliefs, knowledge, intentions) and social (social market conditions, the health care system, and be-
norms, social support, organizational environ- low the meso level we can think of the close inter-
ment) mediation mechanisms also contribute to all personal relationships in which people live their
this [13]. daily lives: families, friendships, workplaces, re-
ligious communities, and so on. Research shows
II.2.3. Investigation of social factors influencing that the development of health behaviours is sig-
health behaviour nificantly influenced by meso-levels - e.g. family
Health behaviours shape the health and well-be- socialization, peer relationships, the school and
ing of both individuals and members of society at work environment - but all of which are signifi-
large. So far, we have focused on individual be- cantly affected by macro-level inequalities - e.g.
haviour, but behaviours that affect health do not poverty rates, low educational attainment, unem-
operate in isolation, but always as part of a com- ployment, the emergence of health as a value and
plex, larger whole. their expression in behavioural norms. In the case
of meso-level, consider, for example, the eating
Scientific and political interest in the social deter- habits followed in the family, smoking caused by
minants of health has grown significantly in recent peer groups, and stress management methods in
decades. Researchers agree that the differences in the workplace. At the macro level, we can mention
the health status of the population are not primarily as an example that although members of Hungar-
determined by the characteristics of the health care ian society consider health to be a very important
system, but by the lifestyle that can be developed value, heavy alcohol consumption, which carries
in the given natural and social environment, the in- a significant risk, is a common and well-tolerat-
dividual socio-demographic factors (gender, age, ed behaviour, or smoking habits are very diffi-
education, labor market activity, financial, income cult to change in the Hungarian population. This
situation), as well as health - related knowledge, is despite the fact that Act XLII of 1999 and the
beliefs, habits, motivations [14; 15]. 2011 XLI. measures to protect non-smokers have
been formulated and regulated by law, e.g. ban-
In the first phase of research on health behaviours ning smoking in workplaces, means of transport,
and interventions, the approach was that education restricting access to those under 18 years of age.

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

However, according to the results of the European addition, although the health benefits of sus-
Population Health Surveys, there is unfortunately tained behaviour are most closely related to
no significant decrease in the prevalence of smok- consistent long-term performance, interrup-
ing in Hungary. tions or persistent relapses may be common
in these behaviours. It is therefore essential to
II.2.4. Interventions to change health behaviour develop continuous motivation and self-effica-
There are three important issues about interven- cy, emphasizing the supportive power of psy-
tions based on theories of health behaviour: what chological and physical resources, habits, and
can be the basis and motivation of the intervention, environmental and social impacts.
how can the change take place, and how can the
changed behaviour be sustained. To do this, we try II.3. Protective factors in health behaviour
to provide practical advice on how to implement After the theoretical summary, let’s look at some
change in health behaviours, which we can use to specific data on how the health behaviour of the
deal with ourselves and our clients: Hungarian population can be characterized. As
- One of the common problems with our at- already mentioned, there are basically two main
tempts to improve health behavioural interven- types of individual health behavioural and lifestyle
tions is that while determining what needs to factors: on the one hand, we can talk about protec-
change to change behaviour, there is a lack of tive factors, that enable us to maintain or improve
planning for concrete, even measurable, steps health, and on the other hand, risk behaviours that
to change these existing patterns of behaviour. are harmful to health are equally important.
- When changing health behaviours, we may
often find ourselves in a position to suggest Some of the protective factors are social factors
more behavioural interventions to improve such as social support (including the support-
overall health. This could be the case, for ive function of the family), social capital (trust),
example, if we want to change our smoking, or religion. In addition, a number of psychologi-
eating and physical activity habits at the same cal traits can also contribute to maintaining good
time. Research in this area has concluded that health, including optimism, life satisfaction, belief
interventions targeting a moderate number of in the meaning of life, self-efficacy, self-regulatory
recommendations have resulted in the greatest behaviour, and future orientation [17].
change. This has been explained by the fact
that interventions aimed at changing a single Another important factor is health conscious-
behaviour increase the power of intent for a ness, i.e. recognizing that we are responsible for
given behaviour and may be more effective our own health - without health consciousness,
if individuals are encouraged to prioritize this it would be impossible to change our established
behaviour change goal over other competing health behaviours.
goals. In this chapter, we now provide an insight into the
- In addition to the goals of changing health be- protective factors that are more closely linked to
haviours, it is worth placing more emphasis on lifestyle, highlighting the area of physical activity
maintaining the newly developed health be- and diet, and finally examine the proportion of the
haviours, as the improvement of health status is Hungarian population who use the preventive ser-
primarily related to longer-term interventions. vices of the health care system.
As a health promotion professional, there is a
need for a greater understanding of the factors Based on the data of the European Health Inter-
that determine the maintenance of health be- view Survey (ELEF) conducted in 2019 [6], it
haviours, as these are likely to differ in many seems that the majority of the Hungarian popula-
cases from the factors that characterize the tion is aware of their own responsibilities in this
initiation of a change in health behaviours. In area, as 26% think that they do much, and another

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

58% think that they can do quite a lot for their own Young people have different recommendations due
health. However, theoretical knowledge is often to their different physical characteristics: ideally,
not reflected in everyday life, as evidenced by data they should exercise at least one hour a day or ex-
on exercise and eating habits. ercise 4 times a week. According to the 2018 Hun-
garian data of an international survey conducted
II.3.1. Physical activity every four years on the health behaviour of school-
The right amount and quality of physical activi- age children [20], boys play sports more often than
ty has beneficial effects on the musculoskeletal girls in all three age groups (11, 13 and 15 years
system, the cardiovascular system, the respirato- old) participating in the survey, but compared to
ry system, and the endocrine system, thereby re- the previous survey (2014) differences between
ducing the risk of premature death, cardiovascular the sexes narrowed as the frequency decreased in
diseases, high blood pressure, colon cancer, and boys but there was no change in girls. II.1. Figure
diabetes [18]. In addition to physical well-being, 1 also shows that the proportion of people who ex-
exercise also plays a major role in maintaining ercise during the recommended period decreases
mental health, as it can help overcome stress, in- rapidly with age.
crease self-esteem, and overcome sleep difficul-
ties. II.3.2. Eating habits
Lifestyle factors that directly affect health include
The World Health Organization recommends that diet.
you take at least 150 minutes of physical activity a Eating habits are undergoing very frequent chang-
week to get the benefits of exercise. It is estimated es today: industrialization, urbanization, econom-
that about a third of European adults are physically ic development and the globalization of markets
inactive [19]. are accelerating the pace of change. Although the
standard of living and access to services has gen-
According to the data of ELEF2019, less than a erally increased, there are also setbacks to change:
quarter of the adult Hungarian population per- a reduction in physical activity and inadequate nu-
forms at least 150 minutes of leisure-time exercise trient intake can easily contribute to the develop-
per week, 27% of men and 21% of women. Age ment of certain chronic diseases. The energy-rich
has a significant effect on sports habits: 42% of diet rich in fat (especially saturated fatty acids)
men aged 15-34 exercise, 22% of those aged 35-64 and low in complex carbohydrates is a worldwide
do exercise and 17% of those aged 65 and over do problem, coupled with a decline in physical activ-
physical activity. The proportion of women doing ity and lower energy consumption.
sports is only 30%, even in the young, which drops There are many biological, cultural, lifestyle,
to 22% in the middle-aged and 11% in the elder- and economic reasons for the development of the
ly. A better financial situation clearly increases the “Western” diet. Most researchers agree that eco-
chances of someone exercising properly, as edu- nomic reasons include the transformation of the
cation does. In the latter case, A-level exam is the food system, behind which is the globalization of
dividing line: those up to 8 primary school years food production, transportation, and marketing
and those with a vocational certificate are both technologies. As a result, the level of food process-
less likely to move in their free time than those ing is shifting from fresh raw materials and prod-
with secondary graduation and higher education ucts to a high level of processing. The general ad-
graduates. In addition to leisure-time exercise, we vancement of ultra-processed foods (such as soft
cannot ignore the importance of being physically drinks, salty snacks, sweets, meat products, pack-
active in a significant proportion of our daily work. aged ready meals, instant soups) increases energy
According to the survey, 40% of people sit mostly, intake, carbohydrate, added sugar and saturated fat
11% stand still, 42% mostly walk, do easy exercise intake, but reduces the amount of fibre, vitamins
at work, and 7% do heavy physical work. and minerals important to the body. [21].

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

II.1. Figure: Proportion of those who exercise 60 minutes a day by gender and age group 2018 (%)
Source: HBSC [20]

Nutritional recommendations are changing, but II.3.3. Preventive medical consultations

there has long been a consensus that eating vege- Protective health behaviours also include using
tables and fruits is extremely important for health. health services for prevention. In Hungary, sev-
Regular daily consumption of vegetables and eral screening programs are coordinated by the
fruits significantly reduces the risk of mortality, government, of which breast and cervical cancer
especially in the case of cardiovascular diseases. screening stand out, which are of particular impor-
tance because cancer mortality is extremely high
According to the results of ELEF2019, more than in Hungary. Regular (at least every 3 years) par-
half of the adult population (61% of women and ticipation in cervical cancer screening is recom-
49% of men) ate fresh fruit at least once a day. mended for women aged 20-69 years. According
The frequency of consumption was highest in the to ELEF2019, 74% of women in this age group
oldest age group: three-quarters of those aged 65 participated in the study within 3 years, but this is
and over included fruit in their daily diet. Howev- a decrease from the previous survey (2014), when
er, only a third of young men and less than half of the proportion was still 79%. It should also be not-
young women were regular fruit consumers (Fig- ed that 39% of screenings took place in private
ure II.2). Consumption of fresh vegetables was care rather than in the public screening program.
slightly less popular than fruit, with 43% of men
and 49% of women consuming it on a daily basis. According to professional recommendations,
Consumption of fruit and vegetables can also be women between the ages of 45 and 60 are recom-
related to education: 52% of those who complete mended to have a breast x-ray every two years for
up to 8 classes eat fruit daily and 40% eat vegeta- early detection. Half of middle-aged women were
bles, and 58% and 48% of those with higher edu- in this type of study in the two years prior to the
cation, respectively. 2019 survey. Participation was also strongly cor-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

II.2. Figure: Frequency of fruit and vegetable consumption by sex and age group, 2019 (%)
Source: ELEF2019 [6]

related with education and income: a higher pro- we present the two most harmful habits affecting
portion of those in a better financial position and health: smoking and alcohol consumption.
those with a higher level of educational attainment
went for a mammography examination. II.4.1. Smoking
Screening is also recommended for the other sex: Among the risk behaviours, smoking causes the
it is recommended that men over the age of 50 greatest damage to health. Cancer, cardiovascular
be screened for prostate cancer each year. 28% and respiratory diseases are more common among
of those aged 65 and over appeared on screen- smokers, therefore, the WHO estimates that about
ing within a year, however, 39% had never been half of smokers die prematurely, on average 14
screened. The impact of education is still signifi- years earlier than their non-smokers counterparts.
cant in this case: while 7% of men with a primary In addition to worsening individual life prospects,
education took part in the screening in time, 12% smoking also increases the volume of health care
of those with a secondary education and 18% of expenditures, and lost working days due to illness
graduates - even the latter is a very low value. reduce economic indicators. The effects of smok-
ing have been well known for decades, not only
II.4. Risk factors for health behaviour among professionals but also among lay people,
In addition to protective factors, let’s also take a and even most smokers are aware of the risks. If
look at the risk factors that affect health. It is well we look at the world as a whole, we can see that
known that the Hungarian population is character- the proportion of smokers has started to decline
ized by rather unfavourable morbidity and mor- in the last 40 years, but in absolute terms, due to
tality data, and these are due, if not exclusively, the growing population, there are now about 1.3
to a significant extent to the unfavourable health billion smokers in the world, an increase of more
behavioural and lifestyle factors. In this chapter, than half a billion compared to 1980.

44
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

According to the latest Hungarian data, ie the income situation, we can see that the proportion of
results of ELEF2019, a quarter of the adult pop- those who light a day is twice as high among those
ulation smokes on a daily basis. Although this in the worst financial situation as among those in
frequency is still high, there has been a modest im- the highest income quintile (38% vs. 20%). We can
provement over the last two decades. The decline also observe geographical differences: the highest
is more common in men, especially in the young proportion of regular smokers is in Northern Hun-
and middle-aged. The decline in women in the gary and the Northern Great Plain (31% and 30%,
young age group seems to have stopped in recent respectively), while the lowest proportion is in
years, with 3 percentage points more women aged Budapest (17%). Occasional smokers, on the other
18-34 smoking in 2019 than five years earlier. In hand, tend to come from the more educated and
the oldest age group, a definite increase can be ob- those with higher incomes, although their propor-
served, so the difference between the two sexes in tion is negligible compared to regular smokers.
the age group 65 and older has essentially disap-
peared (Figure II.3). The habit of smoking often occurs before the onset
Overall, smoking affects a slightly higher propor- of adulthood, and the period between the ages of
tion of men than women: 29% of the former and 15 and 19 is critical in this respect, when young
23% of the latter are regular smokers. Education people are often addicted by the desire to become
is also associated with smoking: the proportion of independent and the pressure of peer groups. Bet-
regular smokers was four times higher (48% vs. tina Pikó provides four main explanations for the
12%) among men in up to 8 grades, and almost development of substance use in adolescence:
three times higher (31% vs. 11%) among women conflict resolution, social motivation, self-affirma-
than those with higher education. According to the tion, and boredom [22]. According to the Hungari-

II.3. Figure: Proportion of regular smokers by sex and age group 2000-2019 (%)
Source: ELEF 2019 [6]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

an data of the HBSC international survey in 2018, of women are heavy drinkers, ie they consume at
smoking shows a popular but declining trend least 14 drinks a week - in case of men - or 7 drinks
among adolescents: 25% of 15-year-old girls and a week – in case of women . The two non-alcohol-
21% of boys smoked in the 30 days before the sur- ic drinking patterns differ by age group: there is
vey - in 2014, 32% of girls and 28% of boys [23]. no significant difference in the proportion of heavy
drinkers among age groups, while older men have
II.4.2. Alcohol consumption a higher proportion of daily but moderate drinkers
In addition to smoking, alcohol is the other legal- and fewer occasional drinkers. The prevalence of
ly consumable drug that has been embedded in abstinence among women in the oldest age group
our culture for centuries. Excessive alcohol con- is outstanding: more than half of women aged 65
sumption plays a role in the development of about and over do not drink alcohol at all, according to
two hundred different diseases, the best known of their own admission (Figure II.4).
which are liver cirrhosis, stroke and cancer, but
can also be the cause of many accidents [24]. At Regarding alcohol consumption, differences can
the same time, moderate alcohol consumption has also be observed according to education and finan-
a preventive role against cardiovascular diseases, cial status. For both sexes, a lower level of edu-
according to some studies: those who drink alco- cation increases the chances of abstinence (59%
hol only occasionally are less likely to have cardio- of women with up to 8 grades and 23% of those
vascular disease than abstainers and heavy drink- with higher education, the same proportions for
ers. However, it should also be mentioned that the men: 32% vs. 9%). Similarly, those in the worst
positive role of moderate alcohol consumption in income quintile also abstain from drinking more
the literature is unclear, as abstinence can often be than those living in the best financial conditions.
mediated by disease.
As for young people, HBSC data show that half of
According to consumption data on pure alcohol per 15-year-olds (51%) drank alcohol in the 30 days
capita, alcohol consumption was highest in Hun- prior to the survey, and 20 percent of girls and 24
gary in the 1980s (16.9 litres in 1980), then began percent of boys got drank at least once during that
to decline after the change of regime, and has been time. But even those younger by two years were
more or less stagnant in the last 10 years. This got drunk at least once a month, both boys and
value was 10.8 litres / person. This value, which girls, and 23 percent of 13-year-old boys and 17
is at least above the EU average, places Hungary, percent of girls drank alcohol within a month.
Germany, Poland, Luxembourg, Portugal, Spain,
Romania or the United Kingdom among the coun- In many cases, smoking and alcohol consumption
tries with relatively high consumption, but there have a detrimental effect before someone is born:
are also more alcohol-consuming countries, such cigarettes and alcoholic beverages consumed
as France, Ireland, the Czech Republic or the Unit- during pregnancy can lead to fetal harm, lower
ed Kingdom, the Baltic states. birth weight or preterm birth, and the effects on
the unborn child can be affected by the effects on
According to ELEF 2019 self-reported data the uterus.
(which can be considered a strong underesti- With the help of the Cohort ‘18 Hungarian Birth
mate), the proportion of adults who drink alcohol Cohort Survey [25] we can get an impression of
daily is 6%, and one in five people drink alcohol the health behaviour of Hungarian pregnant wom-
at least once a week (but less than a day). At the en. The research is a longitudinal study of a rep-
same time, almost a third of the adult population resentative sample of children born in 2018, the
does not consume alcohol at all. If we take into first phase of which was enrolled among pregnant
account the quantities consumed, we can see that mothers before birth, in the seventh month of preg-
every tenth of men and just over one hundredth nancy.

46
 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

II.4. Figure: Alcohol consumption categories by sex and age group 2019 (%)
Source: ELEF 2019 [6]

The results show that more than half of pregnant worst financial status is almost five times higher
women (53%) smoked at some point in their lives, in terms of smoking: 45% of the poorest and only
the vast majority of them for more than a year, and 8% of the richest. Half of pregnant women under
more than a third (34%) even three months be- the age of 20 smoked during pregnancy, compared
fore pregnancy were smokers. This rate decreased to them the frequency is less than half in the 25-
somewhat during pregnancy, but was still high: 29 age group (21%), and this proportion continues
more than one-fifth (23%) of expectant mothers in to decline in the older age group. The differences
the first trimester of pregnancy and 16% from the are also significant according to the place of resi-
fourth month of pregnancy. A small proportion of dence: one in eight pregnant women living in the
smokers (3-4%) belonged to only occasional smok- capital smoked, while one in three people living in
ers, the rest smoked on a daily basis, although the small settlements with no more than 1,000 people
amount smoked per day decreased slightly during smoked. Three times more people smoked living
pregnancy. While 14% of mothers smoked more in cohabitation (34%) than married ones (11%)
than ten cigarettes a day just before pregnancy, and almost five times as many people without a
only 4% in the first three months of pregnancy and partner (51%).
2% from the fourth month onwards. A slightly different pattern can be observed for al-
cohol consumption. Contrary to the general rec-
Significant differences in smoking during preg- ommendation that alcohol should not be consumed
nancy can be observed across socio-economic at all during pregnancy, one-tenth of expectant
groups. Younger non-married pregnant women mothers drank some form of alcohol during the
living in smaller settlements, with lower educa- first three months of pregnancy and 8% in the post-
tion and in poor financial status smoked at a high- fourth month, more or less often.
er rate. For example, one in 23 graduates smoked
during pregnancy, while more than half (55%) Alcohol consumption during pregnancy affects
of up to 8 grades of primary school. Similarly, mothers with higher social status to a greater ex-
the difference between people in the best and the tent: more educated, metropolitan, older, better-off

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

II. Figure 5: Smoking before and during pregnancy (%)

Source: Cohort ‘18 Hungarian Birth Cohort Survey [25]

married women have consumed more alcohol, at nomic status) create motivation to choose and live
least according to their own statements, both be- a healthier lifestyle. But even there, it’s not always
fore and during pregnancy. a matter of course! What could be the reasons for
this ineffectiveness?
II.5. Summary
The current study is intended for future profes- One of the biggest shortcomings of the approach
sionals who will work in the field of health pro- to health behaviours and the interventions based
motion, either directly or indirectly, so that their on it is that they do not take into account the whole
attitudes and practices will have a major impact on personality during design and implementation.
the health behaviour of individuals and population According to the paradigm of the whole person-
groups. Our critical approach in the summary is ality [26], in addition to the physical (physical,
therefore not self-concerned, but its intentions are biological) dimension, the person has an intellec-
very inspiring to make the necessary changes. tual dimension (need for continuous development,
learning), an emotional dimension (need for social
We do not believe that it is an exaggeration to state connection, love affairs) and a transcendental di-
that the efforts and intervention attempts of the mension for most people – searching for the pur-
Hungarian public health in relation to health be- pose of life). Under 4L, Covey sums up our need
haviour and health promotion (health education) for this: Live, Learn, Love, Leave a Legacy. Inter-
cannot be considered to be clearly effective. Based ventions related to health behaviours, on the other
on the data, we seem to achieve results in groups hand, are still very strongly influenced by the con-
where knowledge (from higher education) and cept of health based on a medical approach, which
living conditions (from the appropriate socio-eco- works primarily with the physical dimension in

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

II.6. Figure: Frequency of alcohol consumption among pregnant women (%)

Source: Cohort ‘18 Hungarian Birth Cohort Study, Pregnant Research Phase.
CSO Population Research Institute, 2020 [25]

everyday healing practice. Although modern brain ships, seeking meaning in our existence, therefore,
research has made it clear in recent decades that it is also worth investing in health behaviours.
the human personality is very complex and that
staying healthy depends not only on our physical Compassion is very often lacking in health pro-
health, it is not yet available in practice (neither in motion, interventions that seek to influence health
health promotion nor in medicine). In other words, behaviour. That is, understanding active and emo-
although Descartes is dead for hundreds of years, tional attention and reflection in understanding the
his theory of the separation of body and soul, the situation of a given demographic and social group,
supremacy of rationality, is still alive. In addition, in shaping interventions for the individual / com-
we admire modern brain research, but we have not munity. We often recommend and consider mod-
yet been able to put its results into practice prop- els alone (even in the form of instructions) that we
erly. This can also be seen as significantly limiting would not choose, let alone an individual signifi-
our approach (our initial paradigms) and because cantly different from us in age, social status (e.g., a
of this, our actions remain limited, as a result of disadvantaged young person in adolescence). Nor
which we get nowhere else but where we started. It is it credible to just ban something but not recom-
is easy to see that if we build on the same (faulty) mend it, or even to look for another opportunity
paradigm, we use the same (outdated) methods, it to live a full - or at least better - life in accordance
is not surprising that we get the same results (fail- with the client’s capabilities and intentions. No
ures). The paradigm of the whole personality - as one chooses an ascetic life, a renunciation of plea-
opposed to and taking into account the restrictive sures and happiness, in the hope of a result with
physical / biological interpretation - deeply be- an uncertain outcome, possibly detectable in its ef-
lieves in continually reflecting on ourselves (eg fects decades from now. We don’t either! Lack of
through self-improvement), caring for our relation- compassion with the most disadvantaged individu-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

als and groups is debatable not only professionally what makes something good (or to leave it). That
but also morally, especially if it involves accusing is, it looks at what isn’t working, instead of fo-
the victim. cusing on what makes something work. Positive
psychology [28], although not hundreds of years
Professionals working in this field are expect- old, has been present in the sciences for decades;
ed learning agility, flexible and rapid adaptation, therefore, it is time to start using its proven results
adaptability, and to respect the autonomy of in- in shaping health behaviour. In other words, “the
dividuals and communities. This is not a laissez problem is” [29] - borrowed from a song of the
faire approach and practice. Instead, managed / Hungarian band “Belga” and the frequently used
controlled autonomy is preferred, i.e. a framework Hungarian vernacular, we should instead adopt the
provided by science and proven good practice, and “# that is good” [30] approach. Reactive language
within that, to encourage individuals / communi- use induces restrictive actions (“what to do”) and
ties to act freely in order to choose and act accord- does not help to motivate, while proactive lan-
ing to their opportunities, attitudes and personal guage use (“ I decided to do this” ) energizes and
development. It is based on a deep respect for both gives us a sense of control over our lives and ac-
the individual and the community, recognizing that tions in health behaviour is.
they are adults who are expected to make indepen-
dent decisions in almost every area of their lives. What constitutes preventive behaviour and what
That is why, in health promotion, they cannot be carries risks is very often defined by professionals
persuaded to follow our advice blindly without and decision-makers (politicians). For example,
consideration. the consumption of consumer culture to create and
maintain identities is rarely questioned, as their
There is still room for improvement in terms of role as GDP generators has been described as so-
credibility for professionals. This credibility is cially useful. For example, boosting sales of cars
given by honesty, and goodwill (i.e., together with and digitization-related products, increasing the
character), appropriate abilities, and proven effec- distribution of preserved foods and clothing, and
tiveness (i.e., together with competence). [27]. In even the constant compulsion to work and perform
many cases, only character, i.e. honesty and good- work against good health decisions. A good citizen
will, can be demonstrated, but professional skills works a lot and consumes a lot because it spins the
and effectiveness are no longer. However, these economy. That is, he or she puts in a lot of it and
make the models recommended by experts for uses it a lot, often sacrificing his or her own health.
the target groups acceptable and followable. The It is also long overdue to question this approach,
question is whether we have a sufficient number and perhaps a pandemic in European countries
of professionals who have a modern approach to since the beginning of 2020 could accelerate this
the VUCA world, responding flexibly and success- process.
fully to the very rapidly changing circumstances The basis for planning and interventions for health
in the 21st century? The term VUCA means Vol- behaviour, as in other areas, is the so-called 4C:
atile, Uncertain, Complex, Ambiguous, meaning critical thinking, creativity, collaboration, com-
a fast-changing, uncertain, complex world that is munication. Without them, there is no efficiency
difficult to understand. Although the concept has that reaches new generations as well in the 21st
been on the market for a few years, the pandemic century.
has made it extremely clear that other skills, para- Health promotion is very often modeled on health
digms and cultures than ever before are needed in care and unfortunately carries the same organiza-
an environment that can change so rapidly. tional culture. That is, it does not respond to needs,
it basically targets only the individual, even if you
Health promotion, the practice of health behaviour, call the interventions community. In addition,
still places more emphasis on prohibitions than on it treats the person or target group intermittent-

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

ly from their own environment, and “diagnosis” • If you step on this one, what else will it af-
and “decision-making therapy” (from school to fect? (Think of any dimension of your ev-
workplace) take place over the head of the client / eryday life, your work, your relationships!)
community. It often takes over specific health care • How often should you do this activity of
tasks (e.g. screens students and employees with- your choice? (daily, several times a week,
in the framework of health promotion). A serious daily, etc.)
problem is that, like health care, it is deeply under- • If you imagine your activity on a scale,
funded and, due to ineffective interventions, waste where 0 means you have not done anything
of scarce resources can be felt. about it yet, and 10 means you have already
done everything, where are you now?
The inconsistency of health-related behaviours, • How did you get to where you are now? For
recommended courses of action, messages at the example, if you are now at 3, how did you
societal level is not used in the commitment to achieve that? Think about what factors, ac-
healthy choices. If the cooking of 50 liters of 80% tions, and possibly individuals and groups
brandy per person per year in Hungary is a legiti- you have gotten here with!
mate activity (corresponding to 100 liters of 40%), • And what can help you get from your current
it is difficult to fit into the alcohol consumption value (e.g., 3) to the next level (e.g., 4).
advertised as moderate by health promotion pro-
fessionals. How many strengths do you have that have already
helped you get here? Do not forget to remember
In health promotion, too, it is often the case that these! (And be proud of them!)
we focus not on our sphere of influence, but rath- • If it is only 0 on the imagined scale, what has
er on our sphere of interest. There are actions in held you back so far from moving forward?
the sphere of influence that we can take and take • If you examine these difficulties, arguments,
responsibility for. We have no control over the ac- obstacles separately, how would you rate
tivities that belong to our sphere of interest, so the them? Insurmountable obstacles or some-
question of action and responsibility does not arise thing else?
either. The decision is in our hands. • What can you do to move from 0 onwards
on the imaginary scale to the desired goal,
II.6. Questions to think about in the field of despite the difficulties and obstacles?
health behaviour change - Strength-based de- • Has there ever been one in your life where
velopment in health behaviour (also) you really wanted something, and although
We recommend that you do the following self-di- there were obstacles, difficulties, you over-
rected exercise for yourself. Remember, you do came them and did it? Remembering who/
not have to meet anyone and any expectations, so what helped you with this?
you can afford to answer your questions honestly.
You may not find them right away, no problem: If you have found such strengths (helpers), you
think about them, come back to your answers later, may be able to build on them now! What do you
and modify them. The time you spend exploring think? Count them, write them down!
yourself and your strengths is the most valuable Wherever you are on the scale, now imagine that
thing you can give yourself! you have managed to move forward or start. You
• What would be the only thing you would do may only be able to do a few things, but you are
to improve your health a lot and / or presum- already moving on. Even today, tomorrow, weeks
ably keep it for a long time? are slowly passing and still…
• Why is this activity the most important of • What else do you think will happen in your
your health care activities right now in your life if you can keep that?
current life situation? • What will you experience for yourself?

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

• What will others see in you?

• And what will you think of yourself?

One last scale question. And now how committed

are you on a scale of 0 to 10?
Remember: you have a lot of strengths, as do your
clients, your patients. We develop these and leave
our weaknesses!

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

II.7. Bibliography Francisco: Jossey-Bass.

1. Pikó, B. (2002). Egészségszociológia. 12. Okechukwu, C. Davison, K., & Em-
Budapest: Új Mandátum. mons, K. (2014). Changing health behav-
2. Harris, D. M., Guten, S. (1979). iors in a social context. In Berkman, L. F.,
Health-protective behaviour: An explor- Kawachi, I., Glymour, M. M. (Eds.), So-
atory study. Journal of Health and Social cial Epidemiology. Second edition. (pp.
Behavior, 20(1), 17–29. 365-395). New York: Oxford University
3. Glanz, K., Maddock, J. (2002). Behavior, Press.
Health-Related.Encyclopedia of Public 13. Boros J. (2019). A felnőtt magyar
HealthEncyclopedia.com. https://www. népesség egészségmagatartása PhD
encyclopedia.com/medicine/psychology/ disszertáció http://szociologia.btk.pte.
psychology-and-psychiatry/ health-be- hu/sites/default/files/Doktori_Iskola/
havior Letöltés: 2021. április 17. egeszsegmagatartas_doktori_ertekezes_
4. Európai Lakossági Egészségfelmérés bj_pte.pdf Letöltés: 2021. április 10.
2009. 14. Short, S. E. Mollborn, S. (2015). So-
http://www.ksh.hu/docs/hun/xftp/ido- cial Determinants and Health Behaviors:
szaki/elef/elef_2009_osszefoglalo.pdf Conceptual Frames and Empirical Ad-
Letöltés: 2021. 04.10. vances. Current Opinion Psychology, 5,
5. Európai Lakossági Egészségfelmérés 78–84. doi10.1016/j.copsyc.2015.05.002
2014. 15. Vitrai, J. (2015). Mennyire változtatható
https://www.ksh.hu/elef/archiv/2014/ jogszabályokkal az egészségmagatartás?
kiadvanyok.html Letöltés: 2021. 04.10. Mitől függ és hogyan változtatható az
6. Európai Lakossági Egészségfelmérés egészségmagatartás? Egészségtudomány,
2019. 3, 57-70.
https://www.ksh.hu/docs/hun/xftp/ido- 16. Cockerham, W. C. (2005). Health life-
szaki/elef/te_2019/index.html Letöltés: style theory and the convergence of agen-
2021. 04.10. cy and structure. Journal of Health Social
7. Matarazzo, J. D. (1980). Behavioral Behavior, 46(1), 51–67.
health and behavioral medicine: Frontiers h t t p s : / / d o i .
for a new health psychology. American org/10.1177/002214650504600105
Psychologist, 35(9), 807-817. 17. Pikó, B. (2010). Védőfaktorok nyomában
8. Becker M. H. ed. (1974). The Health Be- – Pozitív fordulat a magatartáskutatások-
lief Model and Personal Health Behavior. ban? In Pikó, B. (szerk). Védőfaktorok ny-
Thorofare, NJ: Slack omában. A káros szenvedélyek megelőzése
9. Bandura, A. (1989). Social cognitive és egészségfejlesztés serdülőkorban.
theory. In R. Vasta (Ed.), Annals of child (pp.11-21). Budapest: L’Harmattan.
development. Vol. 6. Six theories of child 18. U.S. Department of Health and Human
development (pp. 1-60). Greenwich, CT: Services (2008). Physical Activity Guide-
JAI Press. lines Advisory Committee Report, 2008.
10. Ajzen, I. (1991). The theory of planned Washington DC.
behavior Organizational Behavior 19. European Commission, Directorate-Gen-
and Human Decision Processes 50(2), eral for Education and Culture (2014).
179-211. https://doi.org/10.1016/0749- Sport and physical activity report. Special
5978(91)90020-T Eurobarometer 412. Brussels
11. Glanz, K., Rimer, B. K., Vishwanath, 20. Health Behaviour in School-aged Chil-
K. (2015). Health Behavior -Theory, dren, HBSC (2018). http://www.hbsc.
Research and Practice. 5th edition. San org/ Letöltés: 2021. április 20.

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21. Steele, E. M., Popkin, B. M., Swinburn, művészet találkozása: egy modell - egy
B., & Monteiro, C. A. (2017). The share zeneszám. In I. Farkas Ferenc Nemz-
of ultra-processed foods and the over- etközi Tudományos Konferencia Kötet
all nutritional quality of diets in the US: (pp. 343-361). Pécs: PTE KTK.
evidence from a nationally representa- 30. Szilágyi, J. (2020). #azaajó… blog a
tive cross-sectional study. Popul Health LinkedIn-en
Metr., 15(1), 1-11. doi: 10.1186/s12963-
017-0119-3.
22. Piko, B. F., Varga, S., & Wills, T. A.
(2015). A Study of Motives for To-
bacco and Alcohol Use Among High
School Students in Hungary. J Commu-
nity Health. 40(4), 744-749. doi:10.1007/
s10900-015-9993-4
23. Inchley, J., Currie, D., Budisavljevic, S.,
Torsheim, T., Jåstad, A., Cosma, A., ...
& Samdal, O. (2020). Spotlight on ado-
lescent health and well-being: Findings
from the 2017/2018 Health Behaviour in
School-Aged Children (HBSC) survey in
Europe and Canada. WHO Regional Of-
fice for Europe: Copenhagen, Denmark.
24. Committee on Health and Behavior Re-
search Practice And Policy, Board On
Neuroscience And Behavioral Health
(2001).: Health And Behavior: The In-
terplay Of Biological, Behavioral, And
Societal Influences http://www.nap.edu/
html/health_behavior Letöltés: 2021.
április 17.
25. Veroszta, Zs., Boros, J., Kapitány,
B., Kopcsó, K., Leitheiser, F., Szabó,
L., & Spéder, Zs. (2020). Várandósság
Magyarországon. Kohorsz ’18 Magyar
Születési Kohorszvizsgálat. Kutatási
Jelentések 103. KSH Népességtudományi
Kutatóintézet, Budapest.
26. Covey, S. R. (2004). The 8th Habit: From
Effectiveness to Greatness. Free Press.
27. Covey, S. M. R., Merrill, R. R. (2011).
A bizalom sebessége. Budapest: HVG
Könyvek
28. Seligman, M. E. P. (2008). Autentikus
életöröm – A teljes élet titka. Győr: Lau-
rus.
29. Titkos, Cs. (2019). Az a baj. Szinkro-
nicitás, avagy a szervezetfejlesztés és a

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Chapter III.
THE APPROACH TO COMPLEX
HEALTH DEVELOPMENT
(JÓZSEF VITRAI)

Health is about being able to do what we want un- This simplistic approach ignored a number of fac-
der the given the circumstances. After all, it does tors already well known at the time. As a justifica-
not matter what we know, what skills and experi- tion, we quote Joseph Fodor, also known interna-
ence we have, if our physical and mental health at tionally as the “first apostle of our public health,” :
the given moment limits the usability of our oth- “ There are many factors that affect a person’s life
er abilities. Our health affects how much knowl- and health. The most important of these are: 1. nu-
edge we absorb, what jobs and resources we can trition, 2. housing, 3. occupation, 4. body care, 5.
acquire, and what living conditions we create for infectious diseases, and 6. accidental danger. “[1]
ourselves through them. Ultimately, our health af- Expanding Plato’s view, based on the observa-
fects the career we run in our lives. There is no tions and research of the modern age, the so-called
doubt that health is the key to our prosperity, one lifestyle model approach emerged. According to
of our greatest values. which our health depends fundamentally on what
we eat, how much we move, how we sleep, and
III.1. The complexity of health how much stress we experience, and if we expe-
To improve health and reduce health inequalities, rience any problems with our health, we ask for
we must first clarify what factors affect our health. help. The combination of this and the biomedical
Perceptions of influencing factors are often sum- model is the so-called causal chain model, accord-
marized in health models. ing to which we have a detrimental factor in our
lifestyle that causes biological changes in our bod-
III.1.1. Development of health models ies that lead to disease.
Even the ancient Greeks were aware that health
is affected by the physical environment (Hippo- The individual-centered health models mentioned
crates), the occupation of a person (Socrates), or above are based on two worldview beliefs, such
the way of life (Plato). Medieval scientists have as individualism and reductionism. According to
identified tiny particles, infectious substances, or the previous, the individual is internally defined
even bad air that get into the body as the cause and the population is equal to the sum of the in-
of disease. Althoughbacteria had already been dis- dividuals, the population ratio of the diseases cor-
covered in the 17th century, yet it took two hun- responds to the sum of the individual events. The
dred years for Pasteur to show that the bacteria second assumes that the properties of the parts de-
could cause disease. Understanding the diseases termine the whole, and therefore it is sufficient to
that could be traced back to microbes and clarify- examine the parts to understand the whole.
ing the role of DNA led to the biomedical health
model. According to this view, when the balance Arguments have been gathering since the 19th
of biological processes in our body is disturbed, a century that political conditions such as the qual-
disease occurs. Restoring balance through medical ity of democracy and governance or the social se-
intervention, such as medication, restores health. curity system strongly determine the health of the

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

population. In response to these factors, at the end characteristics of influencing factors [4]. The first
of the last century, Dahlgren and Whitehead is that environmental influences are about to be in-
created the notable “onion peel” model, shown in corporated into individuals, that is, they become
Figure 1. It was designed to identify the levels of biological properties. An example of this is that
interventions to reduce health inequalities [2]. It the offspring of a starving generation due to eco-
should be emphasized that displaying social and nomic crises digest food differently. Second, she
community relationships also means acknowledg- explained that influencing factors have varying de-
ing the importance of psychological factors. For grees of impact at multiple societal levels as well
this reason, the model can also be interpreted as a as over time and space. Her third argument is that
bio-psycho-social model. the interactions between individuals ’exposure to
environmental impacts and their resilience to in-
An approach that incorporates both individual and herited diseases accumulate over individual and
environmental factors was further developed by historical time. More simply, people living in dis-
experts from the World Health Organization in the advantaged conditions tend to be in poorer health.
first decade of the 21st century [3]. In Figure 2 , In the longer term, apart from the consequences
the number and thickness of the arrows represent- of adaptation, this will be inherited. Fourth, and
ing the effects indicate that, according to experts, this is perhaps the most unusual finding: science
health is largely determined by socio-economic is socially defined. In other words, what we know
factors. about the definition of health today is determined
by the current (and past) socio-political conditions.
Krieger on the causes of inequalities in the health For example, what, how they research, and how
of different social groups drew attention to four the results are explained are influenced “through”

III. Figure 1: Onion peel model of the main determinants of health

Source : own editing [2]

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure 2: Model summarizing the effects of social determinants of health

Source: own editing [3]

the values and expectations of the given society. duced from the properties of each component. 1All
A good example of this is previous studies on the living things can be considered a complex system
characteristics of human “species” (such as eugen- of biochemical processes and, as such, “create”
ics, the development of “species” or Nazi species life as a new property. The communities of living
theory) and current scientific research on races things (formicary, swarm, flock, etc.) can be con-
(e.g. research on Roma-specific biological differ- sidered as a complex system, too.
ences). Csizmadia summarized Krieger’s ecoso-
cial theory in Hungarian [5]. The most important feature of complex systems
is that modifying an external effect or the opera-
III.1.2 Complex health model tion of an element can often cause unpredictable
Among the previous and other models not detailed changes throughout the system. A class of complex
here, Bircher’s health model based on a systems adaptive systems can adapt to changes in the exter-
approach, created in 2005, stands out, which is de- nal environment — that’s what evolving life does.
scribed in more detail in Hungarian by Csizmadia The uptake of systems science knowledge and
[6]. According to the model, health is a product methods is progressing slowly in most disciplines,
of a complex system that includes the individual, yet the approach has emerged in public health for
not a property of the individual. To understand the quite a few years and some of its tools are being
health model, it is absolutely necessary to have a applied [7].
systems science approach, to know the peculiari-
ties of complex systems. Complex systems are a Let us assume that the amount of own resources
collection of many interconnected, multi-level el- available to meet the needs and requirements es-
ements that have new properties that cannot be de- 1
Considering a cell as a complex system, it can be seen that life , the new
property of the cell as a complex system, its “product”, cannot be connec-
ted to the individual constituents, it cannot be interpreted without the cell.

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

sential to an individual’s life is, on the one hand, II.2.1 Culture of Health
the amount of the inherited and, on the other hand, Many people tend to identify culture with classical
the amount acquired during the career up to that music, fiction, or the fine arts. However, according
point. The balance of resources needed to meet to the definition of the United Nations Scientific
the needs and demands of a given time determines and Cultural Organization (UNESCO), culture is
where the state of health is between perfect (100%) much more than that: “the different intellectual,
and death (0%), as shown in Figure 3. material, intellectual and emotional characteristics
If one’s own resources are not sufficient to meet of society or a group of society, which, in addi-
the needs and demands, we can speak of deterio- tion to art and literature, includes lifestyles, ways
rating health and illness (areas marked in red in the of living together, values, traditions and beliefs.”
figure.) Both the needs and demands interact with Culture in an extended sense actually encompasses
the individual’s environment, together with the everything that man himself has created, and this
complex system outlined in FIG 4 . Therefore, it is most vividly illustrated by the Rocher’s Iceberg
is important to emphasize that health is to be inter- model in Figure 5 [9].
preted in the interaction of the individual with the
environment, in other words, a change in health It includes the physical world around us, such as
can only be hoped for by an intervention affecting the settlement structure that determines local trans-
the individual and the environment, i.e. the whole portation, which affects how much we walk, but
system. includes newspapers, goods, sculptures, and other
works of art, that is, virtually all “above water”
III.2. Social embeddedness of health created by human activity , that is, an observable
The determinant role of social factors is re-emerg- „thing.” Another great area of culture is the level
ing in health theories. This is not surprising, since of “hidden things,” which includes, for example ,
human is not only a biological being but also a so- the written and unwritten rules, values, customs,
cial actor. The social embeddedness and definition traditions, myths, and expectations of the behavior
of health can be better understood on the basis of of individuals in a given communityAs we grow
the following. up, we incorporate these into our personalities, as

III. Figure 3: Change in health status from birth to death in Bircher ‘s health model
Source: own editing [8]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure 4.: Health as a “product” of a complex system

Source: own editing [8]

III. Figure 5: Iceberg model of culture

Source: own editing [9]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

well as our preconceptions, tastes or assumptions nomic factors that determine the patient’s living
about the world, to shape our lifestyles and thus conditions.
our health, so that we can meet the challenges of
our lives as successfully as possible.” III.2.2 Health inequalities
Social inequalities are traced back by many to the
In summary, the components of culture determine spread of agriculture about 10,000 years ago, when
our self-image, our worldview, the framework in private property appeared against the community.
which we make our decisions, the actions we take The formation of the power relations ensuring the
to act in our family, our communities, our work- protection and enrichment of private property and
place, our social environment. Based on this, it is the culture supporting it resulted in the formation
obvious that we bring our actions only partly out and perpetuation of inequalities between social
of our free will, since on the one hand our will de- groups.
pends on our socialization, and on the other hand
we are forced to take into account the possibilities As we have seen above, the health of individuals
of the circumstances. This is why interventions and communities, in addition to the natural envi-
aimed only at individual responsibility and behav- ronment, is strongly influenced by the man-made,
ior are doomed to failure [10]. artificial environment, the culture as broadly un-
derstood. Differences in the health of different so-
The part of culture that deals with health and cial groups are denoted by several terms: inequal-
the factors that affect it is often called culture of ities , disparities , inequities , injustices . Health
health. An example is the role of food and meals inequalities are the differences in health caused
in culture. In 2014, the Mediterranean diet was in- by factors that can be modified to the best of our
cluded in the UNESCO Representative List of the knowledge.
Intangible Cultural Heritage of Humanity. Accord-
ing to Barbara Nagy [11], the list (in a complex Education is a social dimension often used to illus-
way) characterizes diet as skills, knowledge, and trate health inequalities. For example, Hungarian
traditions that include crops, harvesting, fishing, men with tertiary education could expect to live
animal husbandry, processing, cooking, and espe- more than 11 years longer in 2017 than those who
cially sharing and consuming food as a whole. The did not complete 8 grades of primary school3 [14].
Mediterranean diet is also characterized by hospi- According to the European Health Interview Sur-
tality, the importance of neighborhood, intercul- vey 2019 4, the data presented in Figure 7 also con-
tural dialogue and creativity, and respect for diver- vincingly illustrate the inequalities in the health of
sity, which makes it clear that eating is never just social groups.
about nutrition. The World Health Organization’s
Regional Office for Europe [12] illustrates the ex- The figure shows that the proportion of those who
tent to which the social embeddedness of diseases consider their health to be very good or good and
relative to medical activity has an impact on the those without restrictions in their daily activities is
care of diabetics, as shown in Figure 6 . increasing in parallel with their education. Severe
disability due to a health problem shows a 7-fold
Recognition of the key role of socio-economic fac- difference between the lowest and the highest ed-
tors in the treatment of diseases has prompted a ucated persons!
group of upstream doctors2 to extend their activi-
ties beyond traditional medicine [13]. It has been
proved that the development and persistence of the The development of health inequalities is ex-
treated disease is partly caused by the socio-eco- 3
https://ec.europa.eu/eurostat/databrowser/view/demo_mlexpecedu/

2 default/table?lang=en
https://www.ted.com/talks/rishi_manchanda_what_makes_us_get_sick_
4
look_upstream https://www.ksh.hu/docs/eng/xftp/idoszaki/elef/te_2019/index.html

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure 6: “Halving rule” in the treatment of diabetes

Source: own editing [12]

III. Figure 7: Health inequalities in Hungary in 2019

Source: own editing [15]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

plained by the different effects of factors influenc- 7. Make sure you have wealthy parents.
ing health on social groups. Since these factors, as 8. Don’t live in damp, low-quality housing,
we have seen in the health models, are complex next to a busy road or near a polluting fac-
determinants, identifying the causes of inequali- tory.
ties for a particular group is a complex task and 9. Be sure to own a car if you have to rely on
tackling them is a major challenge. Yet if we read neglected public transportation.
the 10 good pieces of advice given by the Brit-
ish Chief Medical Officer [16] to maintain good
health, the task seems simple: in a small border settlement shows a high inci-
dence of hypertension and diabetes with a frequen-
However, if we read the advice of [17], we can see cy well above the national average. Experts who
that reducing inequalities is not an easy task: have thoroughly analyzed the situation conclude
The following example illustrates the difficulty of that smoking and alcohol consumption, as well
reducing inequalities. A comprehensive screening as lack of exercise, are the main causes of illness.
study After a thorough analysis of the situation, experts
conclude that smoking and alcohol consumption,
Advices linked to the stress of unemployment, and physical
1. Don’t smoke. If you can, stop. If you can’t, inactivity are the main causes of the diseases. Un-
cut down. employment is the result of the geographical loca-
2. Follow a balanced diet with plenty of fruit tion of the municipality, the low level of education
and vegetables. of the population and the inertia caused by a lack
3. Keep physically active. of prospects.The causes can be further explored,
4. Manage stress by, for example, talking things the effects of various factors can be dispersed, but
through and making time to relax. it can be seen from the above that a number of in-
5. If you drink alcohol, do so in moderation. terrelated socio-economic characteristics play a
6. Cover up in the sun, and protect children role in the development of diseases. If they want to
from sunburn. improve the health of the residents, it is obviously
7. Practice safer sex. not enough to prescribe medication, because in ad-
8. Take up cancer screening opportunities. dition to not being triggered due to lack of money,
9. Be safe on the roads: follow the Highway the causes of the disease will continue to work.
Code. It is often found that due to the causes of causes
10. Learn the First Aid ABC : airways, breath- given in the example, or the fundamental social
ing, circulation.” causes (“money, knowledge, prestige, and benefi-
cial social relationships” by Link and Phelan [18])
1. Don’t be poor. If you can, stop. If you can’t, many interventions to reduce inequality — most
try not to be poor for long. often improving access to health-promoting prod-
2. Live near good supermarkets and affordable ucts or services can even have the opposite effect.
fresh produce stores. Csizmadia summarizes the findings of Link and
3. Live in a safe leafy neighborhood with parks Phelan as follows: “… an intervention to reduce
and green space nearby. health inequalities that presupposes the activity
4. Work in a rewarding and respected job with and / or compliance of disadvantaged groups -
good compensation, benefits and control which in fact requires adequate skills, motivation
over your work. and a supportive environment - remains ineffec-
5. If you work, don’t lose your job or get laid tive, or it may even lead to an increase in inequali-
off. ties instead of the expected health gains. … In con-
6. Take family vacations and all the benefits trast, interventions that are affordable and easy to
you are entitled to. use in practice, relying primarily on regulation and

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure 8: Inequalities in access to social resources

Source: own editing [20]

not directly influencing an individual’s health be- III.3.1 Theories of behavioral psychology, COMB
havior, will make it possible to reduce inequalities. model
” [19]. Thus, the fastening of the seat belt requires, Since the emergence of societies, they have been
the iodination of table salt does not require activity consciously seeking to change human behavior
to achieve health gains, so the former can increase for both economic and political reasons. It is not
while the latter reduces inequality. surprising, then, that hundreds of theories on this
have emerged over time [21]. Urban summarized
Improving access to a variety of products, servic- the main explanatory models of health behavior,
es and resources is a common means of reducing such as health beliefs, defense motivation, the the-
inequalities. But, as Figure 8 shows, depending on ory of planned action, or the transteoretic model
the implementation, whether it achieves its pur- of behavior change in Hungarian [22]. A group of
pose and proves to be effective compared to the renowned experts in theoretical and applied psy-
expenditure. chology undertook to review and summarize the
many, mostly linear models in the early 2000s.
III.3. Behavior change Based on the results of their work, the COM-B
Our behavior determines our health in two ways: model of the behavioral system was born, and the
on the one hand, our behavior exposes us to the “wheel of behavior change” model of the interven-
harmful (eg tobacco smoke) or supportive (eg tions that have been proven to change behavior.
friendly conversation) effects of the environment, [23]. According to the COM-B model, Capabili-
and on the other hand, our behavior can modify our ty, Opportunity, and Motivation together influence
harmful (eg environmental protection) or helping Behavior in such a way that it has an effect on the
(eg NGO formation) effects of the environment. influencing factors on the one hand and they also
Behavior change is therefore essential for health interact. According to the COM-B model based
promotion intervention. on professional consensus, which summarizes 19
psychological theories, in order to do something,

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

we need at the same time the knowledge and skills healthy eating and reduce obesity. An example is
necessary to implement it, enough motivation to the modification of the food selection at checkouts,
carry out the action and the conditions to carry it which offers health-promoting products (ready-to-
out, i.e. to both the physical and social environ- eat, canned fresh fruits) instead of risky products
ment that supports our behavior [24]. (e.g. sweets, salted crackers) [27]. An example of
this is health promotion for children, which often
For example, in order to follow a healthy diet, we uses game-based knowledge enhancement and
need to know the principles of healthy eating, be motivation, for example through points-based re-
able to prepare healthy food (skills), want to eat wards or competition.6
healthy (motivation), and have access to the neces-
sary food, cooking facilities and a family-friendly III.4. Complex interventions
environment that supports our determination (en- The communities of living beings, such as human
vironment). groups and societies, are also complex systems:
the development and behavior of the individuals
The “wheel of behavior change” model can be living in them are determined by others and the
studied in Figure 9. where the two outer rings habitat environment.
of which contain proven effective interventions
and policies that can be used to change behavior. III.4.1 Complex social problems
Again, some interventions and policies focus on Rittel and Webber [29] formulated nearly 50
the environment that influences behavior — out- years ago why it is devilishly difficult to solve
side the individual —! community problems. The topic of wicked prob-
lems has again come into focus in recent years due
III.3.2 Behavioral understanding: “nudging” to social problems such as inequalities that persist
and “insight” or have worsened despite efforts to address them.
“Nudging,” that is a magic word, a gentle urge to The reasons for the failures are easy to understand
influence behavioral economics, political theory, if we briefly review the thoughts of the two schol-
and the behavioral sciences to influence behavior ars illustrated in Figure 10 and summarized in the
and decision-making with positive affirmation and box below in 10 points.
implicit references. For example, if you are pre-
sented with a choice in an online store, the default I. It is difficult to define the wicked problem.
option is usually in the best interests of the store. Social problems — as opposed to tamed
This encourages us to choose the one that suits problems — are intertwined, interacting
them instead. At the same time, it is in the public many times over, so causes and solutions
interest that the English regulations on organ dona- are inseparable. The higher rates of obesity
tion, which, in the absence of a prior denial of the among the disadvantaged are not only due to
donation, consider the use of the deceased’s organ the unaffordability of fresh fruit and vegeta-
to be consent. In 2013, the Behavioral Insight Team bles, but also, for example, they are not sold
of Behavioral Psychologists5, which supported the nearby (there is no demand for them) or their
English government, experimentally demonstrated eating habits (tradition of consuming ener-
that a statement about organ donation should be gy-rich foods) do not make them desirable.
about refusal and not about authorization [25]. The To understand the problem and, of course,
group made a number of other recommendations to choose a solution that promises results,
for behavioral health risks, which were summa- therefore, a systems approach is essential.
rized in Hungarian [26]. II. There is no definitive solution to the wick-
Several options have been tested for the use of be- ed problem. Because the problems of com-
havioral psychology in interventions to promote
6
http://www.okosdoboz.hu/hu-hu/Exercises/Index?-
5
Free Hungarian translation: Behavioral Group; https://www.bi.team/ classes=1,2,3,4&topic=830

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure 9: The “wheel of behavior change” model

Source: [24]

III. Figure 10: Characteristics of the wicked problems of societies

Source: own editing [30]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

munities are related to many others, it is not wicked problems. Based on our knowledge
possible to solve all of them at once, finding expanding with the evaluation of the experi-
a final solution for all of them at the same ence gained, the list of available solutions is
time. Targeted obesity, for example, can be constantly expanding. Today, good practice
gradually reduced through interventions on is found to be less effective, such as one-to-
income, education, food trade and produc- one counseling, while an intervention that
tion, and we are learning more and more still seems extreme today, such as the indi-
about the causes that interact with each oth- cation of energy content in the menus in ad-
er. But there is no point where we can no dition to food, will be disseminated later..
longer expand our knowledge, when we can VII. Each wicked problem is unique. Local char-
say we already know all about obesity acteristics make both problems and solu-
III. The solution is not objectively right or tions unique, so there are no pre-fabricated,
wrong, but is good or bad according to those ubiquitous solutions. There are many tried
involved. As a result of the nature of social and tested tools to increase the consump-
problems, there is not a single scientific as- tion of health-promoting foods, such as food
pect that can be used to state whether a solu- stamps, tax breaks, prescribed supplies,
tion is clearly right or wrong. Depending on community gardens, kitchen kitchens, etc.,
their own values and needs, some groups in but what combination can be effective in a
the community may say that the proposed given municipality must be decided there,
solution is good, while other groups with taking into account local specificities. It is
different interests may find the same solution possible that cooking competitions could be
bad. Restricting the marketing of high-sugar the trigger to change things there.
soft drinks is detrimental to traders, but just VIII. Each diabolical problem is a symptom of
as beneficial to the overweight population. another. Since the causes of a given prob-
IV. The wicked problems never go away. They lem are themselves diabolical problems, one
just transform. This is because the attempts solution does not solve the other. It can also
to solve them create new ones. Taxation of be said that the problem to be solved is a
high-sugar soft drinks, for example, has led cause, a symptom of the underlying cause.
to an increase in the consumption of “zero For example, consuming few fresh vegeta-
sugar” or “light” beverages, in which sweet- bles and fruits in a disadvantaged settlement
eners pose an unknown health risk today. is a symptom of poverty, ignorance, supply,
The situation is similar with e-cigarettes, and so on. If poverty is targeted, it is a symp-
which replace traditional smoking. tom of illiteracy, lack of jobs, and so on.
V. There is no trial option. Whatever we do to IX. There are several explanations and solutions
solve the problem, it goes “sharp”, it can to a wicked problem. Each of the stakehold-
even improve or worsen the situation. In fact, ers interprets the problem based on their own
it changes! For example, a nutrition survey knowledge and experience and sees a solu-
can expand knowledge: it can draw the re- tion accordingly. Because there is no easy-
spondent’s attention to previously unknown to-adopt solution (see statements VI and VII)
new concepts such as high-fiber bread or and there is no opportunity to try (V), only
saturated fatty acids. And newly acquired several evaluations and solutions remain.
knowledge can cause a change in consump- Easy access to foods that pose a health risk
tion patterns. For example, an American an- is seen by some as the most important issue
ti-drug campaign among young people had to address, and therefore the “thinning out”
an unexpected negative impact because try- of fast food restaurants around schools. Oth-
ing became more common afterwards ers blame traditional eating habits, so they
VI. There is no complete list of tools for solving see improving school meals as a way to curb

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

obesity. The selection of interventions that III.4.2 Partnership, participation

lead to results can be led by a joint decision Due to the complexity of communities, each indi-
of the stakeholders through consultations. vidual in a community plays a role in influencing
X. The expert has no right to be mistaken. the behavior of others to varying degrees. When
Everyone involved in solving communi- analyzing the community relations and effects, it
ty problems needs to be aware that what- should be remembered that 90% of the iceberg of
ever solution they support affects the lives the culture is “under water”, i.e. it is difficult or
of members of the community. The views impossible to observe. In addition to the system
of the expert supporting the solution to the of relations between the members, the network of
problem are as “valid” as those of the lay connections influencing the behavior of the com-
people (III.), especially if the expert advis- munity, it should be taken into account that the
ing is not a member of the community. Shar- members of the communities judge the problems
ing responsibilities also makes participation and the possibilities of implementation differently,
essential in solving community problems. as Figure 11 also illustrates. Different aspects are
influenced by individual knowledge, experience,
Complex health problems such as solving obe- skills, interests, willingness to act, and resources
sity requires a complex approach that takes into willing to sacrifice for a common goal.
account the interrelationships of the influencing
factors: this is the only reason why interventions Community decisions based on a variety of ap-
targeted the individual alone prove to be unsuc- proaches to problems and solutions can ensure
cessful. that the majority agrees with them and partici-

III. Figure 11: From the same object, but from different point of view, different conclusions can be drawn
Source: own editing [31]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

pates in their implementation. Such stakeholder the fact that SUS became a Somerville Municipal-
7
-based decisions, in addition to being more likely ity program by 2012 and has continued ever since
to succeed, increase community trust, coherence, a [41].
sense of belonging, enrich the community’s social
capital through community value creation. Due to
the large number of people involved in a problem, “People think being overweight is an abnormal
they are often represented by a coalition of part- individual reaction to a normal environment. This
ners 8 [32]. is not true at all! This is a normal reaction to an
abnormal environment. ” said. Seidell, a profes-
III.4.3 Complex health promotion programs sor at the Free University of Amsterdam, is cited
The literature treats the fact that health promotion by Kaposvári [42]. Launched in 2013, the Amster-
programs that address one or a few factors cannot dam Healthy Weight Program, like SUS, is a city
achieve lasting results [33,34]. It is less well known government program to reduce childhood obesity
that more complex, multi-attack interventions are [43]. The interventions listed in the text box in the
not always successful. Following the model of the program have been launched, and between 2012
French EPODE program launched in 2004,9 [35] and 2015, the proportion of overweight or obese
support for the South Australian version of the children fell from 21% to 18.5%, although the
Hungarian COME - Child Health Program [36] latest data show that by 2019 it has not changed12
was discontinued 10 [37] by the government be- [44].
cause the program did not reduce obesity in lower
grade school children [38]. It can be assumed that III.4.4 Community health planning and imple-
it was difficult to mobilize all stakeholders and in- mentation
volve them in joint action. As a result of the above, only a health promotion
intervention that involves all stakeholders in the
Complex, whole-of-community or whole sytems planning and implementation process can achieve
health promotion programs based on partner- lasting success. The process of community health
ship and participation is the so called, “Shape Up planning can provide a suitable framework for
Somerville!” (SUS) [39]. The reason for the initi- the implementation of a wide range of activities
ative was revealed that in Somerville, near Bos- to improve the health of the community (behav-
ton, 46% of 1st and 3rd graders were overweight ior change, creating an environment conducive
or at risk (2003) 11 [40]. Recognizing that children to a healthy lifestyle), reconciling the interests of
are limited in changing food and physical activ- different actors and thus involving as many com-
ity opportunities, researchers at Tufts University munity resources as possible [45]. Community
have partnered with the municipality to launch a planning and action supported by experts pro-
community-level, intersectoral initiative. The im- vide stakeholders with the opportunity to identify
plemented intersectoral program is described in problems affecting their health, identify the caus-
Figure 12. Already in the first two years, SUS re- es, select appropriate solutions, and acquire the
sulted in a statistically significant decrease in the knowledge and skills needed to implement them
body mass index of elementary school students. and evaluate their activities [46]. Consistent appli-
The sustainability of the intervention is ensured by cation of the principle of participation ensures that
7
We consider anyone to be affected by the problem or benefiting from it, or different life situations, interests and experiences
who is or may be involved in solving the problem. Taking smoking as an
example, the family members, friends and employees of the smoker who in the community do not compete with each other,
“enjoy” the smoke are involved, as well as the legislator, the public health
professional, but also the companies that produce and distribute tobacco but that their diversity is an advantage.
products.
8
https://www.euro.who.int/en/health-topics/Health-systems/pub-
lic-health-services/coalition-of-partners
9
https://mdosz.hu/gyere-program-diosgyor/
10
https://indaily.com.au/news/local/2016/12/21/sas-35m-childhood-anti-
obesity-program-to-be-abandoned/
11
https://www.somervillema.gov/departments/health-and-human-services/ 12
https://www.amsterdam.nl/sociaaldomein/blijven-wij-gezond/amster-
shape-somerville dam-healthy/

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure12: “Shape Up Somerville!” sectoral participants in the program

Source: own editing [39]

Prevention creating a healthier selection of shelves near

• screening for infant obesity the checkout; placing traffic lights on food
• counseling for mothers planning a child • Prohibition of sponsorship of unhealthy food
• counseling for pregnant mothers on healthy and drink at sporting events
eating • Prohibition of advertising of unhealthy food
• breastfeeding support and beverages on municipal properties
• additional support for teenage and disadvan-
taged mothers Health care
• creating a healthy school environment • appointment of nurses
• increase the safety of cycle paths • planning care procedures
• ensuring that children are busy after school • providing care for overweight and obese
• support for sports club membership fees for children
low-income families • communication to better understand behav-
• Appointment of a Community Health Am- ior
bassador
• cooperation with supermarkets and food ser- Support activities
vice providers: change menus, reduce por- • a fact-based approach
tions; improving the adequate supply of food; • monitoring of interventions ,use of novel

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

digital devices that media campaigns have not had an impact on

• use of innovative digital devices reducing use and have had a weak impact on the
• introduction of digital health cash use of illicit substances. Concerns about possible
• examining factors and interventions that in- side effects are a cause for concern, as experience
fluence healthy sleep has shown that young people are more willing to
try drugs after media campaigns. ” [49]. Involving
The planning, action and evaluation cycle begins professionals to reduce risks is essential in both
with identifying community health issues and as- the design and implementation of health promo-
sessing the needs and requirements of those in- tion programs.
volved. Based on the needs and requirements, the
community identifies and then ranks the issues to Careful evaluation is needed in many ways to as-
be addressed. Taking into account local possibili- sess the effectiveness and applicability of health
ties, keeping in mind the criteria of feasibility, ef- promotion programs. In addition to analyzing the
ficiency and effectiveness, the community decides impact of an intervention, evaluators should ex-
what interventions it wants to implement. The amine the implementation process, the resources
community evaluates the implementation process used, the participants in the implementation in ad-
and effectiveness from time to time and modifies dition to the target group, and the possible exter-
the planned activities as needed based on experi- nal conditions and reasons for the changes in order
ence. Community planning and action, supported to classify a health promotion activity as effective
by experts and modified based on the evaluation and recommended as good practice. Implementa-
of experience gained during implementation, is in tion science dealing with the implementation of
fact a participatory action research 13[47,48]. programs and interventions14 [50] distinguishes
between two major groups of evaluation frame-
III.5. Evaluation of health promotion programs works, as described in Figure 13. One group is
Most of the effective health promotion interven- more characterized by an experiment-based ap-
tions reported in the literature do not prove suc- proach, while the other is characterized by a theo-
cessful later, repeated elsewhere. Was not only the ry-based approach.
methodological description detailed enough in the
original publications? Did they slip over important In the experimental approach, the statistical meth-
but seemingly insignificant details? What factors odology provides a framework for the evaluator to
determine whether an intervention will be success- draw conclusions from this. In most cases, how-
ful? What aspects need to be taken into account in ever, the constraints of a statistical methodology
order to be able to implement an intervention that cannot be applied to reality, for example, a school
has been used successfully elsewhere in the past? health promotion program cannot be conducted
as a double-blind study, therefore, this evaluation
When evaluating health promotion programs, it is framework is ill-suited to analyzing the effective-
important to emphasize that while they are clearly ness of complex health promotion interventions.
well-intentioned, they may not be effective, mean- The framework of the evaluation based on the the-
ing that they may be a waste of scarce resourc- ory is formed by the theoretical models, which also
es and may even cause harm. A good example of include the previous experiences, thus they are
the latter is communication campaigns to prevent more in line with the reality than the experimental
drug use: “ A joint analysis of the research shows ones. For this reason, the results of the evaluation
13
Participatory action research aims to promote social change that increases
can be better utilized in practice, and researchers
local democracy and reduces inequalities; takes into account local speci-
ficities, often targeting the needs of a particular group; a repetitive cycle of
14
Implementation science is the study of methods to facilitate the introduc-
research, action and evaluation; and often seeks to “liberate” participants tion and integration of evidence-based practices, interventions, and policies
so that they are more aware of their situation so that they can take action. in routine health care and public health. This science seeks to systematically
bridge the gap between knowledge and action, theory and practice, by iden-
https://www.participatorymethods.org/glossary/participatory-action tifying barriers that slow or stop the application of best health interventions
and evidence-based practices. https://impsciuw.org/implementation-sci-
ence/learn/implementation-science-overview/

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III. Figure 13: Evaluation frameworks

Source: own editing [50]

can further refine the applied theoretical model. from them before launching an intervention that is
In the following, we present some of the evalu- planned to be taken over.
ation procedures that are best suited for complex When planning, it is expedient to examine, for ex-
health promotion interventions. ample, what is to be adhered to from the interven-
tion to be taken over and what is worth adapting to
III.5.1 Evaluation for implementation the local conditions (Elements of Intervention I). It
It is worth considering first the system of evalu- is also important to consider what kind of support
ation criteria developed by implementation sci- (External Environment II ) can be expected to im-
ence theories related to health services [51]. The plement the intervention, what kind of impeding
application of the criteria system when adapting and helping forces can act. As the organizational
an intervention provides an opportunity to exam- culture and mode of operation in the implement-
ine which factors may play a key role and which ing community (III. Internal environment) is a key
are worth monitoring and evaluating in order to factor, so it is essential to prepare the community
achieve success. The criteria were developed on satisfactorily in many ways. Composition of the
the basis of the theoretical model set out in Fig community and commitment of its members (IV.
.14. According to the model, the implementation Individuals) form critical elements of successful
of an intervention 15 is influenced by 4 factors in implementation, and should be addressed during
addition to the characteristics of the intervention: the preparation period. Finally, in order to imple-
the external and internal environment, the charac- ment the intervention as smoothly as possible (Pro-
teristics of the implementing individuals, and the cess V), it is worth assessing in advance who can
process of implementation. be expected to volunteer as a “front-runner” when
an unexpected difficulty arises. The system of cri-
A community can identify critical elements and teria can also help in the preparation of the moni-
develop solutions to problems that can be deduced toring of the intervention, as it is worth choosing
15
The left side of the figure also shows graphically that the intervention a process or result indicator for the factors consid-
does not suit the local conditions, while the right side shows a matching
intervention.

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III. Figure14: Theoretical model of the implementation of the intervention

(Source: own editing [51] afterDamschroder et al., 2009)

ered important for the given intervention, then col- The theoretical model “ Context and Implemen-
lecting its values during the implementation and tation of Complex Interventions ” developed for
finally analyzing it. this purpose [52, 53] highlights the importance of
understanding and taking into account the circum-
III.5.2 Evaluation of complex interventions stances and conditions of implementation when
It proposes a much more complex approach to the planning and evaluating the implementation of
design and successful implementation of complex complex interventions.
interventions and programs than the system of cri-
teria described above. To achieve their goals, com- The model helps to understand the multi-level sys-
munities do not, in fact, implement a “package tem of factors influencing the results, and helps to
of interventions” consisting of several elements . determine which elements of the implementation
Complex interventions consist of several elements and which factors and conditions of the environ-
that can operate independently or interact in a pro- ment played a critical role in the development of
gram. When evaluating complex interventions, it the results. The knowledge gained in this way also
is often difficult to separate the effects of different contributes to the mapping of how a complex in-
interventions and to determine the role played by tervention or “good practice” could be implement-
the circumstances of their implementation. Wheth- ed on a different level, in the settings for health.
er an intervention can really bring about change
requires a joint assessment of the circumstances, III.5.3 Realistic evaluation
the conditions and the process of implementation. The starting point of the realistic school of philos-

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III. Figure 15: Elements of the theoretical model

“Context and implementation of complex interventions”
Source: [53]

ophy is that both the material and social worlds are underlying the intervention is “refined” based on
“real” and both can have real effects, so both need experience. The initial theory is based on previous
to be considered in order to understand what caus- research, experience, and the assumptions of the
es change. In the realistic evaluation introduced designers of the intervention. In fact, at design, all
by Pawson and Tilley are looking for answers three elements, the mechanism, the outcome, and
to questions not for the “does it work? ” But“ the circumstances (conditions) are considered to
What works, for whom, what changes, how much, be known, and monitoring, i.e., data and informa-
under what circumstances and how? ” [54 ,55]. To tion collection, is designed accordingly.
answer 16the complex question, the realistic evalu-
ator identifies the Mechanism that created the Out- Realistic evaluation explains the change brought
come and how it was influenced by the specific about by the intervention to those participants (in-
Context (CMO). cluding implementers and target groups) (or not)
Such an evaluation begins with a theory and ends a situation under specified circumstances and un-
with a theory, because in the evaluation the theory der the influence of external factors (including
16
Better Evaluation: Realist Evaluation. https://www.betterevaluation.org/ the intervention itself) act and change (or not) a
en/approach/realist_evaluation

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

situation. Participants and interventions are seen only be achieved through a number of coordinated
as embedded in a social reality that influences the actions.
implementation of the intervention and how those
respond to it (or not). Third, behavior change is seen as a key element
in improving health, because behavior change can
In the first stage of the analysis, in accordance with reduce exposure to health risks or increase the re-
the initial theory, it is examined whether the data to silience of an individual or community, and behav-
be collected are related to the intervention imple- ior can change the environment to be health-pro-
mented and to the circumstances, the mechanism, moting. As people ’s behavior is determined by a
the results and the groups of participants. They broadly understood culture, they see the role of
then determine the conditions under which each individual decisions as limited in terms of health.
mechanism operates (or not). Conditions may re- This also underscores the importance of systemic,
late to certain groups of participants, some imple- ie community, intervention.
mentation processes, or organizational, socio-eco-
nomic, cultural and political circumstances. In the Fourth, in complex health promotion programs,
final phase of the analysis, it is determined which the identification of problems, the identification
CMO finding provides the most reliable and ap- of appropriate solutions, and implementation are
propriate explanation for the pattern of observed achieved with the active participation of those in-
results. The resulting CMO finding is then com- volved in health problems. The task of the health
pared to the baseline theory, which is modified (or promotion specialists is to promote the establish-
not) in light of the evaluation, and this will be the ment of partnerships representing the stakeholders
baseline theory for the next intervention. (Com- and to prepare them for the implementation of the
pare the planning-action evaluation cycle of par- programs. The creation of a physical and social en-
ticipatory action research mentioned in section 4.4 vironment conducive to health and the spread of a
Community health planning!) healthy lifestyle within the community is a long,
recurring process of planning-action-evaluation,
III.6. Summary in which the expert support of the participants is
The basis of a complex approach to health pro- essential throughout.
motion is the recognition of the complexity of
health. Therefore, the task of improving health is
approached from several directions with a systems
approach, using the knowledge of several disci-
plines.

First, health is seen as the product of a complex

system that includes the individual or community.
Consequently, going beyond the biomedical ap-
proach, it interprets health in its context, that is,
with its environment and antecedents. Thus, it is
understood that it expects results only from a wide
variety of interventions aimed at the entire system
that includes the individual or the community.

Second, it also perceives the natural and artificial

environment, which largely determines health, as
a system, and therefore argues that transforming
the environment into a health-promoting one can

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

III.7. Bibliography 13. Manchanda, R. (n.d.). What makes us

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kutatás a népegészségügy területén - át- 19. Csizmadia, P. (2017). Az egyenlő-
tekintő közlemény. Egészségfejlesztés, tlenségek alapvető társadalmi okai
57(4), 3-11. és az elmélet alkalmazási lehetőségei
8. Bircher, J. (2005). Towards a Dynamic az egészségügyi szakpolitikákban.
Definition of Health and Disease Medi- Egészségfejlesztés, 58(2), 17-19.
cine Health Care and Philosophy 8:335- 20. Pacific Northwest University (n.d.). Eq-
341. uity vs. Equality Defined. https://www.
9. Rocher, G. (1969). Introduction à la soci- pnwu.edu/about/office-of-diversity-eq-
ologie générale. (3 tome) Montréal, Hur- uity-and-inclusion/dei-education/gen-
tubise HMH. der-equity/ (Elérve: 2022. 05. 03.)
10. Baum, F. & Fisher M. (2014). Why be- 21. Rimer, B. & Glanz, K. (2005). Theory at
havioural health promotion endures de- a Glance. A Guide For Health Promotion
spite its failure to reduce health inequi- Practice (2nd Edition). National Institutes
ties. Sociol Health Illn, 36: 213-225. of Health, U.S. Department of Health and
11. Nagy, B. (2017). Hogyan befolyásol- Human Services.
ja a kultúra az egészséget? II. rész: 22. Urbán, R. (2017). Az egészség pszicholó-
Táplálkozás, kultúra és egészség. giai alapjai. ELTE Eötvös Kiadó, Buda-
Egészségfejlesztés 2017;58(2):42-46. pest.
12. World Health Organization Regional 23. Michie, S., Van Stralen, M. M. & West,
Office for Europe. (2017). Culture mat- R. (2011). The behaviour change wheel:
ters: using a cultural contexts of health A new method for characterising and de-
approach to enhance policy-making. Co- signing behaviour change interventions;
penhagen. Implementation Science. 6.42.

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24. Vitrai, J. & Kimmel, Zs. (2015). Men- A whole systems approach for tackling
nyire változtatható jogszabályokkal az child obesity in cities, European Jour-
egészségmagatartás? Mitől függ és hog- nal of Public Health, Volume 30, Issue
yan változtatható az egészségmagatartás? Supplement_5, September, ckaa165.516,
I. rész. Egészségtudomány, 59(3):57-70. 10.1093/eurpub/ckaa165.516
25. Behavioural Insight Team (n.d.). https:// 34. Waterlander, W. E., Luna Pinzon, A., Ver-
www.bi.team/ (Elérve: 2022. 05. 03.) hoeff, A., den Hertog, K., Altenburg, T.,
26. Taller, Á. & Csizmadia, P. (2016). Dijkstra, C., Halberstadt, J., Hermans,
Viselkedésértés – A magatartástudomány R., Renders, C., Seidell, J., Singh, A.,
eredményeinek hasznosítása a szakpoliti- Anselma, M., Busch, V., Emke, H., van
ka alkotásban. Egészségfejlesztés, 57(2), den Eynde, E., van Houtum, L., Nusselder,
55-61. W. J., Overman, M., van de Vlasakker,
27. Devosa, I. (2020). Cikkismertetés: S., Vrijkotte, T., … Stronks, K. (2020).
Segít-e, ha a pénztáraknál kínált ropog- A System Dynamics and Participatory
tatnivalókat egészségesebbre cserélik? Action Research Approach to Promote
Egészségfejlesztés, 61(3):20-20. Healthy Living and a Healthy Weight
28. Okosdoboz. (n.d.). http://www.okos- among 10-14-Year-Old Adolescents in
doboz.hu/hu-hu/Exercises/Index?- Amsterdam: The LIKE Programme. In-
classes=1,2,3,4&topic=830 (Elérve: ternational Journal of Environmental Re-
2022. 05. 03.) search and Public Health, 17(14), 4928.
29. Rittel, H. W. J. & Webber, M. M. (1973): https://doi.org/10.3390/ijerph17144928
Dilemmas in a General Theory of Plan- 35. Borys, J. M., Le Bodo, Y., Jebb, S. A.,
ning. Policy Sciences, 4, 155-169. Seidell, J. C., Summerbell, C., Richard,
30. Maqsood, T., Finegan, A. D., & Walker, D., De Henauw, S., Moreno, L. A., Ro-
D. H. T. (2003) A soft approach to solv- mon, M., Visscher, T. L., Raffin, S., Swin-
ing hard problems in construction project burn, B., & EEN Study Group (2012).
management. In Second International EPODE approach for childhood obesity
Conference on Construction in the 21st prevention: methods, progress and inter-
Century (CITC-II), Sustainability and In- national development. Obesity reviews :
novation in Management and Technolo- an official journal of the International As-
gy, 10−12 December 2003, Hong Kong. sociation for the Study of Obesity, 13(4),
http://eprints.qut.edu.au/27439/ (Elérve: 299–315. https://doi.org/10.1111/j.1467-
2022. 05. 03.) 789X.2011.00950.x.
31. Martinez, N. D. (2020). Allometric 36. Magyar Dietetikusok Országos
Trophic Networks From Individuals to Szövetsége. (n.d.). GYERE® Program
Socio-Ecosystems: Consumer–Resource -Diósgyőr. https://mdosz.hu/gyere-pro-
Theory of the Ecological Elephant in gram-diosgyor/ (Elérve: 2022. 05. 03.)
the Room. Frontiers in Ecology and 37. InDaily. (2016.12.21.) SA’s $35m child-
Evolution. 27 May 2020. https://doi. hood anti-obesity program to be aban-
org/10.3389/fevo.2020.00092 doned. https://indaily.com.au/news/
32. WHO Regional Office for Europe. (n.d.). local/2016/12/21/sas-35m-childhood-
Coalition of Partners. https://www.euro. anti-obesity-program-to-be-abandoned/
who.int/en/health-topics/Health-systems/ (Elérve: 2022. 05. 03.)
public-health-services/coalition-of-part- 38. Bell, L., Ullah, S., Leslie, E., Magarey,
ners (Elérve: 2022. 05. 03.) A., Olds, T., Ratcliffe, J., Chen, G., Mill-
33. Den Hertog, K. & Busch, V. (2020). The er, M., Jones, M., & Cobiac, L. (2019).
Amsterdam Healthy Weight Approach: Changes in weight status, quality of life

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and behaviours of South Australian pri- néhány összefüggése. Egészségfejlesztés.

mary school children: results from the 60(3):16-19.
Obesity Prevention and Lifestyle (OPAL) 46. Anselma, M., Altenburg, T. M., Emke,
community intervention program. BMC H., van Nassau, F., Jurg, M., Ruiter,
public health, 19(1), 1338. https://doi. R., Jurkowski, J. M., & Chinapaw, M.
org/10.1186/s12889-019-7710-4 (2019). Co-designing obesity prevention
39. City of Somerville (n.d.). About Office of interventions together with children: in-
Food Access and Healthy Communities. tervention mapping meets youth-led par-
https://www.somervillema.gov/ofahc ticipatory action research. The interna-
(Elérve: 2022. 05. 03.) tional journal of behavioral nutrition and
40. Economos, C. D., Hyatt, R. R., Goldberg, physical activity, 16(1), 130. https://doi.
J. P., Must, A., Naumova, E. N., Collins, J. org/10.1186/s12966-019-0891-5
J., & Nelson, M. E. (2007). A community 47. Institutes of Development Studies. (n.d.).
intervention reduces BMI z-score in chil- Participatory Action Research. https://
dren: Shape Up Somerville first year re- www.participatorymethods.org/glossa-
sults. Obesity (Silver Spring, Md.), 15(5), ry/participatory-action-research (Elérve:
1325–1336. https://doi.org/10.1038/ 2022. 05. 03.)
oby.2007.155 48. Málovics, Gy. (2019). Tudás létrehozása
41. Appel, J. M., Fullerton, K., Hennessy, társadalmi hatással karöltve: a részvételi
E., Korn, A. R., Tovar, A., Allender, S., akciókutatás (RAK) megközelítése. Mag-
Hovmand, P. S., Kasman, M., Swinburn, yar Tudomány 2019/8.
B. A., Hammond, R. A., & Economos, 49. European Monitoring Centre for Drugs
C. D. (2019). Design and methods of and Drug Addiction. (2013.05.). Can
Shape Up Under 5: Integration of sys- mass media campaigns prevent young
tems science and community-engaged re- people from using drugs? (Perspectives
search to prevent early childhood obesi- on drugs). http://www.emcdda.europa.
ty. PloS one, 14(8), e0220169. https://doi. eu/publications/pods/mass-media-cam-
org/10.1371/journal.pone.0220169 paigns (Elérve: 2022. 05. 03.)
42. Kaposvári, Cs. (2018). Az Amszterdami 50. University of Washington. (n.d.). What is
Egészséges Testsúly Program. Egészség- Implementation Science? https://impsci-
fejlesztés folyóirat, 59(4), 38-43. uw.org/implementation-science/learn/im-
43. Hawkes, C., Russell, S., Isaacs, A., Rut- plementation-science-overview/ (Elérve:
ter, H. & Viner, R. (2017). What can be 2022. 05. 03.)
learned from the Amsterdam Healthy 51. Damschroder, L.J., Aron, D.C., Keith,
Weight programme to inform the policy R.E., Kirsh S.R., Alexander J.A., Lowery
response to obesity in England? Universi- J.C. (2009): Fostering implementation
ty College London, National Institute for of health services research findings into
Health Research Obesity Policy Research practice: a consolidated framework for
Unit, Rapid response briefing paper. advancing implementation science. Im-
44. Council and Health Department of Amster- plementation Science, 4,50.
dam. (n.d.). Amsterdam Healthy Weight 52. Pfadenhauer, L.M., Gerhardus, A., Mozy-
Programme. https://www.amsterdam.nl/ gemba, K., Lysdahl K.,B., Booth A., Hof-
sociaaldomein/aanpak-gezond-gewicht/ mann B., Wahlster P., Polus S., Burns J.,
amsterdam-healthy-weight-programme/ Brereton L.,Rehfuess E. (2017): Making
(Elérve: 2022. 05. 03.) sense of complexity in context and imple-
45. Girán, J. (2019). Az egészséget támogató mentation: the Context and Implementa-
közpolitika és az egészségtervezés tion of Complex Interventions (CICI)

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framework. Implementation Sci 12, 21.

53. Kaposvári, Cs., Járomi, É. & Vitrai, J.
(2018). A komplexitás értelmezése a kon-
textusban és a megvalósításban: a kom-
plex beavatkozások kontextusának és
megvalósításának (CICI) keretrendsze-
re – cikkismertetés. Egészségfejlesztés.
59(1):56-60.
54. Better Evaluation. (n.d.). Realist Evalu-
ation. https://www.betterevaluation.org/
en/approach/realist_evaluation (Elérve:
2022. 05. 03.)
55. Pawson, R. & Tilley, N. (1997). Realistic
Evaluation. London: Sage.

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Chapter IV.
HEALTH EDUCATION
(KRISZTINA DEUTSCH,
HENRIETTE PUSZTAFALVI)

IV.1. Health literacy and education tween functional health literacy and demograph-
The term health literacy appeared in public health ic and socioeconomic variables. A 2007 study of
and health care in the 1970s. A study that reviewed British adults using the TOFHLA (Test of Func-
the health literacy literature identified no less than tional Health Literacy in Adults) [4] found that
17 different definitions, one of the most frequent- people with lower levels of education, men and
ly cited being the WHO definition that health lit- those on low incomes were more likely to fall into
eracy is “people’s cognitive and social skills that the category of limited health literacy.
determine an individual’s motivation and ability On average, 47.6% of people in Europe have in-
to access, understand and use information that adequate health literacy. Regarding the Hungarian
promotes and maintains good health [1]. What study, the researchers obtained even worse results
we see as the success of treatment, as well as the in 2016, examining a representative Hungarian
success of preventive interventions, is determined sample in which 20% of the participants reported
by whether the patient / client / individual under- insufficient and 32% problematic health literacy.
stands and uses medical information properly, and It should be noted that a more complex measure
this is greatly influenced by so-called “health lit- of health literacy is a measure of health aware-
eracy”. According to the most common definition ness; presumably, outcomes may be influenced by
of health literacy, “... the ability to access, inter- a person’s self-esteem, judgment of health-related
pret and understand basic health information and problem-solving skills, and even the patriarchal
services and the competence to use these informa- structure of a country’s health system.
tion and services to improve health” [2]. The 1998
WHO definition places particular emphasis on the Health literacy is a personal resource that enables
individual motivation to seek information and the the individual to make decisions in the areas of
cognitive and social skills behind it. Schulz and health services, prevention, and health promotion
Nakamoto’s [3] model breaks down health litera- in everyday life [5]. Thus, low health literacy is
cy into three components: declarative knowledge associated with the following factors: poor health,
(objective knowledge about health and its preser- high mortality rates, higher hospital stays, inade-
vation); procedural knowledge (the ability to ap- quate adherence to medical instructions, less ef-
ply subject knowledge in health-related situations fective communication with health professionals,
- including the operation of basic skills called lower participation in prevention activities, poorer
functional in other divisions, such as speaking, nu- health behaviors; and higher health expenditures
meracy, writing and reading) and judgment (effec- [4,6,7].
tive assessment of new information and situations
based on subject knowledge). In their study summarizing the review of health
literacy, Sørensen et al [8] reviewed health literacy
Research on health literacy in both the America and created the integrated model because previous
and Europe has highlighted significant links be- models were considered static that did not take

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

into account the process of health literacy. The ference in Shanghai identifies opportunities for
integrated model includes access, understanding, action on health promotion in micro- (local small
and information transfer. The model developed in group), meso- (wider community) and macro-lev-
this way is based on the fact that “health literacy el (population and / or governmental) structures,
is related to education and contributes to making focusing on professionals, settings and actors out-
people’s knowledge, motivation and competence side patient care [11]. This chapter deals with the
suitable for accessing, understanding, evaluating micro-level, i.e. the fundamentals of local small
and applying health information in the formula- group health education. The wording of Lászlóné
tion of opinions and decisions in the field of health Nagy and Katalin Barabás is the starting point in
care, prevention and health promotion, in order to the definition of health education, according to
maintain or improve the quality of life throughout which health education is “a set of consciously
our lives “ [8]. created learning opportunities using various forms
of communication that expand health-related
In order for health literacy to have a positive impact knowledge, and life skills to promote individual
on health throughout life [4], the promotion and and community health” [12].
development of health literacy in childhood and
adolescence is becoming increasingly important in IV.2.1. Target groups for health education
public health efforts. ([9]. In addition to measuring Group (small group) health education programs
health behavior and health status, health literacy are most often linked to the natural arenas of life:
is playing an increasingly important role, which schools, settlements, workplaces, and most of-
can provide guidance not only on the direction of ten focus on vulnerable groups identified by the
deficiencies in adults, but also on improving the WHO. The WHO places children, pregnant wom-
health literacy of adolescents and young people. en and the elderly at the center of health promo-
The Hungarian adaptation developed for young tion [13,14] and, in addition to them, decides at
people is available as HELMA-H [10]. the level of the society which other special groups
are considered to be of priority - see Chapter II for
An adapted questionnaire measuring the health details. Chapter III deals with vulnerable groups.
literacy of adolescents (HELMA-H) can play an If we want to systematically review the potential
important role before the planning of intervention target groups of health education and accept that
programs, which will enable health professionals health promotion needs may arise for other target
to identify gaps and adequately define interven- groups beyond the vulnerable groups, then the
tions and, accordingly, to develop the knowledge breakdown by age provides a possible framework
and skills of individuals. for the review. According to this, the target groups
of health education can be:
IV.2. The fundamentals of group health educa- - early childhood groups (0-6 years old, nurs-
tion ery and kindergarten),
First, we wish to define health education that is the - group of primary school children (6-10 years
focus of our chapter. Health promotion involves old, lower primary school children)
economic, regulatory, policy, public health, com- - groups of adolescents (upper primary school
munity and health prevention activities to improve and secondary school students and groups
the health of society. Health education is an inte- of adolescents associated with the place of
gral part of modern health promotion, aiming to residence or dormitory),
develop health-changing behaviors or change risk - groups of young adults (which may be relat-
behaviors in a process led by a professional but at ed to the educational / higher education in-
the same time based on the responsibility of the stitution, place of residence, place of work,
individual. life situation, e.g. pregnancy, childbearing),
The outcome document of the WHO World Con- - groups of mature adults (may be related to

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III. Figure 1: Onion peel model of the main determinants of health

Source : own editing [2]

place of residence, work, life situation, e.g. and expectations of the group? Are there
unemployment, raising children, involve- specific risk factors? e.g. disadvantaged
ment in chronic illness, disability), children, Roma people living in segregation,
- groups of the ageing and the elderly (may be special dangers / difficulties related to the
related to a place of residence, a residential workplace or settlement, a program that can
institution, a living situation, e.g. a lonely only be held in the evening, etc.
pensioner living with a certain illness). • In the following, we review the forms of the
groups and the characteristics of their op-
When designing your target group in planning a eration from a psychological point of view,
group health education program, it is worth an- without claiming completeness.
swering the following questions.
• In what community arena does the group ap- IV.2.2. Psychological characteristics of group or-
pear and how does it relate to our job and ganization and functioning
professional activity? In a socio-psychological sense, a group means
• Along what socio-demographic character- people who are in constant interaction with each
istics can the group be described? (gender, other and who are characterized by a common
age, education, social status, employment). goal, joint activity, cohesion, and group structure.
• What health promotion needs does the group Groups can be organized according to their size,
have? (health status, health and risk behav- the way they are organized and their function. Psy-
iors, chronic illness, mental crisis, abuse, chology defines a small group of 3 to 20 people,
etc.) It is worth presenting the need, the assuming that the members interact, have a per-
vulnerability at the group level, but also in sonal relationship, and are able to work together
a broader social context. In the case of the based on mutual trust and support. Above this we
latter, it is expedient to determine the public are talking about a large group of up to 50 people,
health severity of the problem and the possi- while over 50 people we are talking about a crowd.
bilities for prevention. The members also know each other in the large
• What are the special circumstances, needs group, but there is no direct connection between

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

them in all cases, thus they are necessarily divid- conflict, which is usually a struggle for posi-
ed into subgroups. This necessarily characterizes tions and roles. In the case of the health ed-
larger classroom communities as well. [15]. The ucation group, the group leader is measured,
practice of small group health education is also and discussions about the working method
characterized by a group size of around 15 - 17 may develop, but all this is important for the
people in order to facilitate efficient and reflective maturity of the group.
group processes [16]. 3. Stage-building phase: norms are consolidat-
ed along group-specific values and rules of
On the basis of group organization we can talk conduct. It is therefore necessary to lay down
about formal and informal groups, in which the the statutes at the beginning of the program,
formal groups are brought together by a common which should be discussed by the group in a
goal, while the informal group is organized on the democratic spirit, because consensus-based
basis of sympathy or common interest and is held rules are the best. It is especially important
together by the joy of emotional attachment. [15] to lay down confidentiality as the norm. But
Based on this, the health education group is un- duration (arrival, departure, breaks), eating
doubtedly a formal group, as it is organized along and drinking, other aspects of behavior and
a specific goal and task. However, due to previ- rules of communication are also import-
ous or emerging emotional relationships between ant. The group should discuss the expected
group members and the positive climate, the group tasks, the way and time of the evaluation in
continues to live as an informal group. There are advance.
examples, specific cases, that a pregnant group in a 4. Operation: the group focuses on the tasks to
health education program preparing for childbirth be performed with maximum efficiency.
and parental role continue to function as an infor- 5. Termination: the group completes its task,
mal group following the program and postpartum. disintegrates. We have to describe the time
All groups, including health education groups, go schedule of the program at the beginning
through five phases of group development. As a of the program, including the date of com-
group leader, we can recognize that the group goes pletion, the way of closing the program, to
through three developmental stages until the actu- which we also refer during the program.
al task-focused operation, and the group must be Thus, we create an opportunity for person-
prepared for termination. The phases of develop- al preparation for separation, which already
ment are as follows: [17] has a serious raison d’être in the case of a
1. Formation: This is when the group members longer-term program (several months, all
get to know each other, and the opportuni- year).
ties provided for a multifaceted introduction
help them to become a community. Here, The theory of group dynamics associated with
the institutional expectations and the cor- Kurt Lewin’s name serves to describe the relation-
responding performance are also shown. In ship between the individual and the group, and
terms of health education, this means pay- its significance lies in the fact that its knowledge
ing attention to the simple human gestures and proper application can generate more effec-
of welcoming group members (Where to tive group functioning. According to Bagdy and
put a coat, umbrella, pram; Where to find a Telkes, group dynamics are based on the fact that
toilet) To reduce the initial stress of arrival human coexistence always creates a kind of extra
and integration, efforts should be made to tension in those present [18]. During group dy-
apply methods and games that clarify initial namics, members interact, communicate and co-
feelings and expectations and support both operate with each other, as a result of which both
stress reduction and mutual acquaintance. the group and the person participating in the group
2. Storm: Most groups go through a phase of change [19]. Group dynamics include group cohe-

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sion, the roles that develop in the group, and the The third phenomenon of group dynamics is lead-
influence of leadership styles on the functioning ership style. In the health education group, the
of the group. leader works between the current situation and
task, and between the autocratic and democratic
Cohesion refers to the cohesion of the group, leadership style. Basically, both the supportive
and strengthening cohesion in the small group in empathic atmosphere and the free assumption of
health education is also an important task because opinions and skills, as well as the development
it results in a positive atmosphere, more effective of skills and abilities, are served by the methods
collaboration, better performance, and greater sat- of democratic leadership. However, there may be
isfaction [20]. tasks (such as teaching a form of movement or
According to György Csepeli, the individual be- relaxation technique) or situations that require a
havior in the group can be aimed at completing the quick decision when the group is waiting for clear
task, building the group, or even solving a prob- guidance - leadership, in which case autocratic,
lem. The functioning of the group is facilitated by i.e. leadership, will be needed. However, success-
constructive roles, while destructive roles hinder ful group leadership also depends on a number of
it, but the conflicts they cause can also have a driv- other factors, such as the personality and dominant
ing effect [21]. leadership style of the leader [22].

Constructive or task roles: IV.2.3. Some aspects of working with groups in

• Initiator: introduces changes, innovations, health education
sets goals. The following factors are favorable conditions for
• Information seeker: asks, asks for opinions group health education.
and information. • A supportive learning atmosphere in which
• Information provider: gives information, ex- new concepts and practices can be discussed
presses opinions. helps you to think and develop new things in
• Ruler: Creator and controller of group stan- a fearless way.
dards. • Direct feedback and reinforcement in a small
• Generalizer: summarizes, clarifies certain is- group is a strong motivating factor.
sues in front of the group. • The small group promotes active participa-
• Obedient: passive audience. tion in the learning process, giving persons
the opportunity to compare new ideas with
Destructive roles: other perceptions. Motivation increases
• Stuttering, quiz, omniscient, news bell. greatly when the participant feels the need
for change and accepts the learning situa-
Relationship roles for the survival of the group: tion. The small-group method is particularly
• Consistent. effective in reducing resistance to change by
• Gatekeeper: helps keep communication exploring alternatives.
channels open. • Experimental learning and a variety of meth-
• Encouraging: friendly, praise, accept others. ods provide a very realistic learning situa-
• Compromiser: willing to compromise. tion. Instead of the group leader is ready to
• Diagnostic: analyzes the emotional process- communicate the information, participants
es in the group that hinder the performance experience and learn from the experiences
of the task. of the exercises.
• Tension reliever: resolves negative emotions Dealing with problems and difficulties in the group
with a joke Health professionals often find group leader-
ship daunting and feel incapable of coping with
it. Progress is in acknowledging and addressing

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these fears and developing strategies in the event nally, we present in detail the transteoretic behav-
of problems. It can be helpful to initially lead a ior change model of Prochaska and DiClemente.
group in pairs and create a script and also prepare
for backup tasks. IV.3.1. Models of behavior change
IV.3.1.1. COM-B model
If too few people show up in the program, you According to the modern interpretation, this is the
need to rethink your preparation, advertising, and COM-B model for the purpose of behavior change,
marketing activities. For the sake of planning, which can help to design effective public health
the pre-application method and contacting and interventions, and for the operation of which the
informing about the program through several in- “wheel of behavior change” model provides an in-
fo-communication channels will help. terpretive framework. This is detailed in Chapter
2, it is important to note that we currently use this
Behavioral problems and group conflicts also model in the context of behavior change.
present difficulties for the group leader. The lack
of active participation and comment, but also the IV.3.1.2. HAPA model
problem of those who talk too much and comment The HAPA (Health Action Process Approach)
on everything, can be prevented by the circular model was developed by Ralf Schwarzer and his
question used as a method, pair and cooperative research team, which can be interpreted as a so-
group methods, interactive tasks and other struc- cial - cognitive process model of health behav-
tured methods. Conflict in the group should be ior. Its distinct advantage is that it incorporates
handled with assertive communication and, if pos- an improved version of models related to previ-
sible, a problem-solving strategy instead of look- ous health behaviors. Research shows that it can
ing for those responsible. be used effectively to change many health behav-
iors, whether short-term or long-term. The model
If someone is completely withdrawn, we can also proved to be effective in terms of exercise, healthy
address them directly, naming the person and in- eating, hygienic hand washing habits, and thera-
viting them to comment. If all this does not help, peutic adherence, among others. [23,24]
talk to him or her about the problem in person.
“Most socio-cognitive models are designed to ex-
IV.3. Models of individual health promotion plain and predict the development of behavioral
One of the major challenges for public health intent, but both ordinary experience and research
is to reduce the morbidity and mortality of life- suggest that developed intent does not always lead
style-related diseases by preventing changes in the to actual behavior. The model therefore - in or-
behavior of people at risk, preventing premature der to bridge the intention-behavior gap, it distin-
death and increasing life expectancy. The task of guishes between the motivational stage before the
individual health education is to use behavioral formation of intention, which (similarly to previ-
sciences to offer models that can effectively sup- ous models) resulting in the formation of inten-
port the process of behavior change, from motiva- tion, and the post-formation voluntary (volition-
tion through appropriate strategies. The theoretical al) stage, which leads to actual health behavior.
framework for this is mostly offered by psycholo- Compared to previous classical models, the HAPA
gy and pedagogy. In this chapter, we first under- model for integration places a strong emphasis
take to present some scientifically based models on post-intentional factors, such as planning for
for facilitating behavior change, and then review action and overcoming obstacles, as well as the
individual health education in a client-profession- sense of self-regulatory processes and personal ef-
al relationship, identifying the range of competent fectiveness that contribute to sustaining action. ”
professionals, the frequent needs for change, and [25]. This model was based on Bandura’s theory
the characteristics of a supportive relationship. Fi- of social learning, according to which the explo-

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ration and change of behavior can be explained by adapted to the current stage of change [27].
the same cognitive mechanisms, such as vicari- In the following, we review the phases of behavior
ous, symbolic, and self-regulating processes. Sim- change as interpreted by the model. The IV. Fig-
plified, the vicarizing mechanism means that we ure3 helps to understand the process.
learn from observing the behavior of others and
no longer have to try everything on our own skin 1. The pre-contemplation stage
using social experience. Symbolism is a mental The individual is not yet aware of the need for
process that allows us to work out the best solution change, i.e., either does not yet see it or intention-
to a problem on a cognitive level and not try out ally corrects the problem. He employs a whole
possible alternatives through action. Self-regula- host of self-defense mechanisms to avoid having
tion allows you to control your own behavior, in- to face the need for change and is therefore not
cluding dealing with environmental conditions and motivated to begin the process. In many cases, he
behavioral consequences. The central category of or she is confident that his or her problems will be
Bandura’s concept, and the HAPA model based on resolved by changing his or her environment, such
it, is self-efficacy, which is one of the main com- as his or her spouse, child, boss.
ponents of self-regulation. Based on self-efficacy, At this stage, professionals can help their client to
we believe in our abilities, which are necessary for enter the reflection phase by raising awareness of
the desired behavior, including emotional and cog- the problem and overcoming it. With the method
nitive processes, motivation, and personal control of attention and practice, maladaptive interven-
over the behavior. Thus, overall, self-efficacy also tions can be transformed into positive behavior.
affects our goals, efforts, and resilience to obsta-
cles [26]. Thus, a sense of self-efficacy is the most 2. Stage of contemplation
important predictor of behavioral intent [23]. The client already has enough motivation to
change, and the goals need to be articulated for
IV.3.1.3. Prochaska and DiClemente model of themselves. If the goals are too vague, the client
transteoretic behavior change can ask him or herself or the professional ques-
Following the traditional health education char- tions to clarify for the client.
acteristic of the second half of the 20th century, The professional who appears in the role of facil-
i.e. the paradigm shift based on the decades of itator can apply the strategies that help to clarify
work of psychologists, the transteoretic behav- attitudes and values at this stage. These strategies
ior brought about a real revolution. Although the help you think critically about the value system
authors gained the primary experience in con- and beliefs. Accurate observation and analysis of
structing the model from observing the recovery the problem at this stage, whether our meals and
process in addicts, the concept eventually proved energy intake, our alcohol consumption, or just
effective in a number of other areas of behavior our outbursts of anger over a cycle of one or more
change. The model describes the process at which weeks, will also help. Functional analysis plays an
the client goes through the change of habits and important role in this phase, i.e., the observation
behaviors, whether on his or her own or with the of things that directly precede or follow problem-
help of therapy, and consolidates the change. This atic behavior, so that events when a person loses
scientific approach assumes that the client knows control can shed light on it. At the contemplation
what stage he or she is at when it comes to the stage, we need to encourage our client to create
problem to be overcome, and the key to success is a self-inventory. The questions are about behavior
to apply well-timed coping skills. This is because on the one hand and change on the other: It is ad-
a person is doomed to change if he or she is not visable to gather all the arguments and counter-ar-
yet prepared for it, or if he or she is working on a guments about change for ourselves and our envi-
task that he or she has already achieved or exceed- ronment so that our decision is well-founded. The
ed. The challenge, task or coping must always be following methods used by a professional can help

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

IV. Figure 2. (Health Action Process Approach, HAPA; Schwarzer, 2011, p. 601) [25]

IV. Figure 3: Stages of change in health-related behaviors

(Source: Based of Prochaska, JO, Norcross, JC, DiClemente model of transteoretic behavior
change, author editing)

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to clarify the problem and increase self-awareness: • The preparation of the family, co-workers
• Ranking, categorization: Suitable for clari- and other important persons (the formulation
fying values. E.g. What does it mean to you of our intentions and requests), the prepara-
to be healthy? tion of the material environment in the apart-
• Value scale: This technique helps people to ment and at the workplace.
understand and define their own position • Inventory of helping persons and groups, the
within a given topic. ways in which you can expect help from a
professional.
3. The stage of the resolution and determination
After considering the arguments and counter-argu- 4. Stage of action
ments, the client makes a decision to change his / The process of change in which you are already
her unhealthy behavior. He/she makes his or her committed begins. According to the client’s plans,
decision public and asks his or her environment he/she is active, replacing risk behavior with other
for help. activities, controlling his/her behavior, living with
the supportive relationships, and trying to over-
Determination support strategies come daily difficulties. This phase usually lasts for
Step One: Create an accepting atmosphere in months.
which the client can become open. We express
unconditional acceptance, honesty, empathy with 5. Stage of maintenance
both our non-verbal and verbal communication. • At this stage, people struggle to sustain
Step Two: Help explore deeper needs and the prob- change and use different coping strategies to
lem with open and clarifying questions and active do. The change process has been going on
listening. for at least 6 months. Initiating and main-
Step Three: We help the client identify opportuni- taining the change also requires a serious ef-
ties, set realistic goals. fort from the client, in support of which the
“How would you feel if…” health professional uses and recommends
If things turned out the way you want them to, the following methods to the client.
what would be different than they are now?”(22) • Self-monitoring: means detailed and accu-
Step Four: We help the client to choose between rate observation of the behavior the client
the possible alternatives and ways of change, but wants to change, even following the change
it is very important that he / she chooses, as he / in the form of a diary. This method helps
she will only be committed to the implementation people analyze their own patterns of behav-
along his/her own decision. The choice involves ior, develop self-control, and define a base-
considering the pros and cons, considering the line against which to track progress.
possible consequences of following each alterna- • Sacrifices, Benefits, and Rewards: Behav-
tive, and choosing the best alternative. ioral change, sacrifices, must be consciously
Step Five: This is when the client prepares for the prepared for, which is offset by clearly de-
action we support, but also plays a key role in de- fined benefits, rewards, and perseverance.
veloping the action plan. The benefits can be short-term and long-
term, as well as indirect (e.g., the pregnant
The action plan includes: woman should live healthy to keep her child
• The way of the change in behavior, and in healthy).
some cases the extent of the change. • Assessing objectives and progress: realistic
• The starting date of the change, in some cas- goals are needed, and if the set progress is
es the time planned for the change. not achieved, the reasons for it must be ex-
• Preparing for behavior change, spiritual plored. Recognition of the effort is also im-
preparation, rethinking coping strategies. portant, even the smallest results should be

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rewarded and praised. ucation activities of a competent professional can

• Develop coping strategies: Change can only facilitate, i.e., promote and support, a change in
be sustained if appropriate coping strategies client behavior.
are in place to address feelings of deprivation
and stress. These include self-help groups, Concerning physical health: reduction of over-
stress-relieving methods, relaxation, devel- weight and obesity, change of eating habits, in-
oping the ability to say no, and so on [22]. troduction / increase / change of physical activity,
change of hygiene habits, prevention of accidents /
6. Stage of relapse falls, special needs related to pregnancy (physical
The client cannot sustain the change, he/she re- activity, nutrition, sexual hygiene, sexual life), sex
turns to his/her previous behavior and habit. This prevention of communicable diseases (STDs), pre-
is a common phenomenon, as a number of factors vention of osteoporosis, elimination of chemical
(e.g., overestimation of tripping, withdrawal social hazards, etc.
effects, extreme challenges and stressful situations, For mental health: development of emotional intel-
suffering, etc.) can hinder the process of change. ligence, development of coping strategies, devel-
However, suffering (including anxiety, loneliness, opment of communication - conflict management,
emotional problems, and depression) is the most development of self - knowledge - self - esteem,
common cause, appearing in 60-70% of relapses development of time management, need for crisis
in both addicted and people with eating disorder. management, support for social need, etc.
The authors observe that smokers are usually able Concerning mental and physical health: cessation
to cope with quitting after three relapses. If this of smoking, recognition of alcoholism / drug ad-
happens, the task of the specialist is to analyze diction / behavioral addiction, delegation to treat-
with the client the causes of the relapse, the short- ment / sobriety organizations.
comings of the preparation. Learning from these However, it is important to note that in the treat-
experiences they can prepare them for a change in ment of addicts and in supporting their social re-
behavior again, thus the stage of contemplation or integration, only smoking educators (physicians),
preparation can begin again. addictologists and psychiatrists and psychologists,
as well as the institutions they support (e.g. drug
7. Exit stage rehabilitation homes) and anonymous self-help
People have recorded a change in behavior, the groups (e.g. AA groups) are competent helpers.
new, already changed behavior is natural (they eat
according to a new nutritional model, have incor- IV.3.2.2 Professionals in individual health edu-
porated regular exercise into their lives, quit smok- cation
ing, etc.). It no longer requires effort to sustain the In the case of a health promotion professional, the
change, as it no longer requires sacrifices, the ben- kind of personal health-related need he or she can
efits are clear, and the client’s self-knowledge is respond to is mostly determined by the profession-
enriched and self-esteem is strengthened [27]. alism, field of work and professional competence
arising from the qualification.
IV.3.2 Needs involved in individual health edu- - Health professionals in primary care and
cation, characteristics of professionals and the specialist care: general practitioners and spe-
professional-client relationship cialists, dentists, nurses, nurses, dieticians,
physiotherapists, midwives, dental hygien-
IV.3.2.1 The most common needs in individual ists, etc.
health education - Health developers, mental health profession-
The following is an overview of personal health-re- als, psychologists.
lated needs that may require a change in behavior - Recreation professionals, trainers, physical
from preschool to old age, in which the health ed- educators.

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- Educators (health teachers) and pastors: as needed?

health educators, their role in supporting 6. Evaluation: What do we evaluate and how
mental health in their own area of work and (subject and method of evaluation)?
care is a key factor.
Richard Windsor in his work, Planning and Evalu-
IV.3.2.3 Characteristics of the client-specialist re- ation, also confirms aspects of our design, empha-
lationship sizing that the health promotion and disease pre-
In individual health education, the relationship is vention program plan should include the program
based on the acceptance of the professional, en- structure, process, content, methods, tools, and
suring the independence of the client, and a part- participating professionals. It also highlights the
ner approach. The essence of acceptance is that relationship between goals and evaluation [28].
the professional, being aware of his/her own and However, already when setting goals, we need to
his client’s value system, knowledge and attitudes, take into account the fact that “knowledge about
the differences, does not consider himself/herself health, no matter how extensive, does not guaran-
more valuable along these factors, he/she does tee a healthy lifestyle. … It should also be borne in
not judge the client. The professional can help mind that a particular form of behavior that affects
increase the client’s control over health by ensur- health does not exist in isolation, but as part of a
ing independence by encouraging the client’s own lifestyle in which different behavioral, social and
decisions, attempts, and ideas. The partnership is individual factors interact in a complex way ” [12:
characterized by openness and mutual trust, where 488]. The goals can be directed to the development
the professional builds on the client’s expression, of knowledge, skills and abilities in the spirit of
knowledge, and experience, and also acknowledg- education, i.e. personality development in general,
es that he or she has learned from him or her [22]. as well as to the change of attitudes and behavior
[29, 30]. Accordingly, the goals of group health
IV.4. Pedagogical methods of effective health education can be:
education (planning and methods) (D.K) • Transfer of knowledge, expansion and re-
As group health education is also a real education- finement of knowledge.
al process, we basically apply the concept of peda- • Shaping the attitudes of clients towards need.
gogical planning, which begins with the definition • Developing the skills and abilities of the cli-
of goals and tasks that reflect needs. We first out- ents related to the need.
line the design aspects and steps, and then we will • Changing the behavior and habits of clients
detail them later. related to need.

1. Characterization of the target group and In health education, it is important to plan the ac-
definition of the need and problem: Who is tivities and tasks precisely in order to achieve the
the program for? What deficiencies, needs, goals, because this is the only way to achieve ef-
and problems do we reflect on? fectiveness.
2. Aim, task: What will be the aims and tasks What do we expect from all members of the group
of the group? to increase knowledge or change attitudes during
3. Themes: What topics does the program fo- the program? What do we want to achieve about
cus on and in what time planning? behavior change? Can we be satisfied if the change
4. Methods: In what ways are the themes de- in behavior or habits starts in 1-2 members of the
veloped by the goals implemented, along group? Or are we expecting much more than that?
what specific tasks? Do we consider it an outcome if a part of the par-
5. Resources, tools: What human and material ticipants becomes a consideration, or is the pro-
resources are needed for the implementa- gram effective only if a certain part of the group
tion, and what infrastructure background is has already entered the stage of action? If you

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think about it, these are absolutely realistic ques- In terms of methodology, however, there are al-
tions for a smoking cessation or weight loss pro- ready good practices in school health education
gram. Thus, health promotion thinks about the task that point in the direction of efficiency. Launched
to be performed in such a way that it formulates in 2015, Learn, Teach, Know! (TANTUdSZ) The
the final result to be achieved in the given time in- Youth Health Education Program supports the
terval. Accordingly, the task must be realistic and health behaviors of primary and secondary educa-
measurable, along with the challenge for the pro- tion students with the help of peer educators trained
fessional and the group [22]. by university students. Instead of teacher-centered
knowledge transfer, health education is carried
Going along the pedagogical thinking, we prepare out using innovative and interactive methods de-
topics in the knowledge of the goals and tasks, so veloped by small groups of students [37]. During
we organize certain elements of the coherent con- the program, a complete task bank, a collection
tent and topic of the program, and in the case of of recipes defined for each age group, was devel-
skills and competency development, the activities oped, which contains a complete description of
for practice in a logical system, chronology. The the tasks, including the purpose of the application
advantage of thematic planning is the possibility and the pedagogical methods included in the task
of thorough preparation in addition to seeing in the [33]. The “Complex school health education pro-
unit [31]. The planning of the topic offers an op- gram” based on the COM-B model in Balassag-
portunity to think about the content depths of each yarmat also builds on e-learning-type knowledge
topic, the possibilities of skills development, and materials and interactive small group sessions led
as a result the structure of the program is formed: by peer educators [16]. Regarding the first aid ed-
the number and duration of each health education ucation for kindergarten and school children, the
event / session, and finally the program. methodological basis of the practice-based pro-
gram developed by Bánfai et al., which activates
While the effectiveness of the program ultimately children to the maximum, is outstanding [38,39].
depends on its educational strategies, i.e. wheth-
er we can achieve the set goals with methods and The choice and application of methods requires
tools appropriate to the target group, research re- significant training from the health care profes-
lated to health education in addition, outdated sional. In the collection of the methods we rely on
methodological practices, problems of adaptabil- didactic sources [40,41], as well as on the literary
ity, evaluation and efficiency are highlighted [16]. sources of health development and health educa-
According to Feith et al.’s research among high tion [22,42,33].
school students, the majority of health promotion
programs are still conducted in inefficient frontal First, we review the methods used in the group to
education without the active and problem-solving get to know each other and to resolve tensions:
participation of students [32]. name games, icebreaking games, pair introduc-
Organizing the intervention for digital natives of tory games, association games based on pictures,
the Z and alpha generations is a methodological cards, poems, songs about group members, writing
challenge, as different methods and approach- a four-line poem about feelings and expectations.
es are needed than for the X and Y generations.
[33,34]. Somhegyi also draws attention to the fact In the following, we review the attunement to the
that online information resources and tasks, such topic, the orientation of the participants’ knowl-
as the Smart Box Portal (Smart Box Portal)( 35) edge and attitudes, and the methods that under-
with playful online tasks and animated films, can pin interactivity. It should be noted that several of
be exploited in school health education practices these methods can serve not only to tune in, but
for comprehensive school health promotion (TIE) also to process the topic.
[36].

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Brainstorming: a technique used to get people to the age, the amount and depth of knowledge relat-
think creatively without judging their thoughts. ed to the processing of topics varies, of course, but
Ask a question to which quick, one-word answers the important features of the methods are interac-
can be given: E.g., “What comes to your mind tivity, cooperation, creativity, playfulness, and ex-
when I say love?” All answers will be written on perience-based learning.
the board without comments or remarks. We can
group the thoughts according to some guiding Flash groups: small groups of three or more peo-
principle. Encourage the more retreating persons. ple within a group who discuss an issue or process
E.g. “Other ideas?” “Does anyone else want to a task with each other in a relatively short time,
add?” Maybe address the person. “I’d be interest- as determined by the group leader. This task is al-
ed in your opinion too!” ways closely related to the facts previously stat-
ed. If we want to share their ideas with the whole
Circular questions: The members of the group group, it may be written on a wrapping paper in the
make a short comment in a circle, one after the form of a poster.
other, or give a more detailed explanation of the
question asked by the group leader, so that every- Structured learning: When approaching a task,
one has an equal opportunity to participate. There participants, pairs, or smaller groups of partici-
are three important rules for successful circle ques- pants (e.g., three) are given a set amount of time to
tions: no one should be interrupted until they have process a topic. After that, they discuss their own
finished speaking, no comment can be made until results and opinions with the other pairs or groups
the circle is over, and anyone can choose to be left and form a common position.
out of a circle. This opportunity should be brought
to the attention of the group leader before starting Snowballing: Team members are individually giv-
the round questions: “You can pass for each ques- en a task to complete within a specified time. Af-
tion!” Circular questions can be useful at the be- ter that, similarly to structured learning, they dis-
ginning and end of group sessions. The questions cuss their thoughts and results in pairs, and then
used as a concluding round can be especially use- the pairs connect with each other and finally, the
ful as feedback, as a short evaluation of the daily opinion of the group is formed. This will make the
program for the group. e.g. “What did you really “snowball” bigger and more interesting. The mo-
like about today’s session?” “How did you feel to- bilization of one’s own prior knowledge and expe-
day?” “What did you learn in today’s session, what rience, the respect of individual opinions, and the
did you filter from what happened there?” possibility of correction are made by the individu-
al based on the feedback of others.
Discussion, use of discussion materials:
The discussion can be started with a related vid- Cooperative group work: Based on the activities
eo, poster, flyer, newspaper article, internet news, of the participants (4-6 people) in small groups.
podcast, etc. that share opinions. In a divided In addition to the development of knowledge and
group, it is the task of the participants to repre- intellectual skills, it is of paramount importance in
sent each other on the opposite sides of the topic, the development of social skills and cooperation
to persuade each other with arguments, according skills. There are many forms of the cooperative
to the jointly developed rules of discussion. The method, and of course new ones can be developed.
method develops logical thinking skills, but also It can be used in all age groups, and due to its time
communication skills, listening to each other. requirements, the method of mosaic learning or
group research and countless other cooperative
In the following, we present methods that help to forms can be well integrated into health education.
transfer knowledge, process and discuss the topic,
and build consensus at some points. Depending on

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Research - exploration method: the acquisition of Within the framework of structured exercises, the
knowledge can take place individually or through practical tasks related to the knowledge and factu-
cooperative group work, either through experi- al material are practiced at the skill level in pairs
mentation, by collecting data from the Internet or or in groups of 3 people, e.g. first aid, baby care,
library sources, and by developing critical think- food preparation, etc. The method ensures the safe
ing. acquisition of various practical tasks in a relaxed
Observation: it can serve to support the knowledge atmosphere compared to independent practice,
expressed, but also to formulate independent con- without stress in the case of proper pairing and
clusions through perception. Awareness of obser- group formation.
vation is ensured by observational considerations.
The observation activity determined in time is fol- Creating a mind map in small groups is a visual
lowed by the discussion and evaluation of what is representation of a topic or problem, with little
seen. text and lots of graphics. It makes learning more
intense and productive, yet enjoyable. The object
Discussion: A popular and common method that of the mind map is always in the middle, in a cen-
can be used at any stage of the health education tral place. From this, the main topics related to the
process, where the professional guides the conver- subject are branched out with key concepts and the
sation with appropriate questions. Group members corresponding content with the help of diagrams,
can also ask each other, it makes them think - ac- pictures and colors. As the exact content of each
tivity. It can be a useful method for clarifying the mind map is understood only by its creator, group
basics, introducing it to new knowledge, but it can cohesion is also supported by joint work, common
also serve as a summary. “coding”.

Lecture is a method for conveying knowledge, Other interactive tasks can be: making interviews,
for explaining a topic in a logical, detailed way. making posters, writing poems, making songs,
Its time frame ranges from 15-20 minutes to 1.5-2 making short films, online tasks, quiz games e.g.
hours, depending on the age of the participants. It Kahoot with Mentimeter.
usually combines elements of narration, explana-
tion, and illustration. It consists of an introduction, Questionnaire, test: it can be used as a method to
an explanation, and a summary, and the greatest start and end a group session. If used as a start-
difficulty is maintaining attention. In health educa- ing method, it can provide information about the
tion, it is important to consider in which age group group’s knowledge, opinion and attitude in relation
and in which topic we apply it, because it is inter- to the given topic or question. If used as a closing
preted as the least effective method. method, we can get feedback on the knowledge we
have acquired. If we use a test or a questionnaire as
During the demonstration, we present objects, a method of starting and closing a program, we can
phenomena and processes in order for the par- find out where the group started and where they
ticipants to perceive, observe and analyze them. got in terms of knowledge and attitudes. In such
During health education, we can directly illustrate, cases, it is important to use the same test and ques-
for example, movement, cooking techniques, and tionnaire at the beginning and end of the program.
relaxation techniques. But with the help of in- If participants compare their opening and closing
fo-communication tools, we are able to illustrate questionnaires themselves, it can be used to draw
almost anything, from physiological processes to personal conclusions regarding their own develop-
life situations to life-saving interventions. ment.
The following are methods for applying, organiz-
ing, and recording knowledge. According to the concept of gamification, the ef-
ficiency of prevention activities and interventions

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

can also be increased by installing game elements. way to reach a consensus on the definition of the
Games can be board games, verbal quizzes, online problem. After that, they try to develop the best
quizzes, e.g. Kahoot, but even crossword puzzles. solution strategy by considering the given options
The motivational power of games is huge for chil- and alternatives. The method helps to mobilize
dren, but even for adults, the method is motivat- prior knowledge and experience, open and critical
ingly busy, which is why they are experiencing a thinking.
renaissance in educational programs today. The
VoltEgySzer prevention mobile application devel- Role play: It usually means taking on the role of
oped by Kapitány –Fövény et al. proved to be ef- a person in a given situation and playing out how
fective in terms of the knowledge transferred and that character would act, what he or she would say
the frequency of substance use [43]. In the Pre- in that situation. The method develops empathy
vention Escape Room developed in recent years, skills, especially if we play the given situation by
the 45-minute gaming experience is followed by a changing roles, so we can examine the same situ-
nearly 30-minute small group discussion, where it ation and problem from different points of view,
is possible to deepen the information and process hiding in the skin of each character.
the gained experience [44]. An online version of
all of this helps preventive sessions in an exciting Situation practice, simulation: A method of pro-
way. cessing alternatives for solving a given situation. It
develops problem solving, open and critical think-
Project method: a common method used at school ing. After describing the basic situation, the small
level as well as in adult health promotion, based groups / pairs play the situation, showing a possi-
on the interest of the group or community, the ble solution to the problem. It is extremely import-
joint planning and implementation activities of the ant to discuss alternative solutions. Although there
group and the professionals. It always focuses on a is a game here as well, the goal and the way of re-
practical problem that the group tackles in a com- alization are different from the role-playing game.
plex way: e.g. processed in historical, technical,
economic, biological, public health contexts. It is IV.4.1. Resources, tools
always a joint product and evaluation that closes In the planning of the educational strategy, in ad-
the work, where the acquired and systematized dition to the methods, the material and info-com-
knowledge is almost a by-product of the program. munication tools and infrastructural background
As a final group of methods, methods for devel- necessary for their implementation must also be
oping communication and social skills, problem planned. Think of nutrition, sports, or first aid pro-
solving, critical thinking, and responsible deci- grams with special background needs. The design
sion-making are presented. of the methods in this way must therefore take into
account the institution, school, workplace, com-
We process a case that has occurred or is fiction- munity house, health center, club, etc. that provid-
al during the application of the case analysis. The ed the location of the health education program.
difficulties of the characters, the doubts, the deci- In the case of professionals representing the hu-
sion-making process and situation, the factors that man resources of the programs, well-thought-out
facilitate and hinder the solution, such as the fac- planning, organization and joint preparation are
tors influencing health, health beliefs, etc., can be also required. However, a number of studies in
presented by a lifelike story. It can also be a start- the young population show that the skilled pro-
ing point for opinion formation and discussion. fessional is not the most effective health educator.
“Prevention can only be effective if there is a psy-
In the problem-solving method, after the members chological‘ meeting ’between the preventers and
of the group receive information about a given is- the host party, the prevented. National surveys and
sue or situation, they first discuss in a structured efficiency studies supported our experience. A sig-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

nificant proportion, (60 percent) of young people case of shorter and less locally resourced munic-
turn to their peers with their problems, and only ipal, school and workplace health education pro-
then to their parents, teachers, professionals. In the grams, an evaluation reflecting the goals and tasks
case of peer-to-peer programs, the effectiveness of must also be carried out. Therefore, the objectives
the program in “reaching” young people far ex- and tasks must be considered first when planning
ceeds that of traditional educational programs. The the evaluation, as they are the subject of the evalu-
mediators of the program find their way to their ation of the health education program, and the val-
peers more effectively due to the similarity of their id evaluation methods must be designed accord-
life situation, problem vision and communication ingly. Particular care should be taken to ensure that
style. ” [45]. Thus, especially in school health pro- knowledge, attitudes and health behaviors are as-
motion, effective group health education by peer sessed before and after the program using the same
educators may be one of the ways forward, which measurement tools.
has been initiated in Hungary for several decades. The subject of the evaluation is therefore what our
Nowadays, however, there are also contemporary objective was. For example:
education programs that focus on many aspects of • expanding knowledge about the effects of
lifestyle and develop health awareness in a com- alcohol,
plex way, such as the TANTUdSZ program and the • development of first aid skills, abilities,
Complex School Health Education Program in the • changes in contraceptive attitudes and sexu-
light of the COM-B model. [46,37,16] al behavior,
• development of stress management meth-
IV.4.2. Assessment in health education ods, coping strategies,
A common lesson from international and domestic • changes in exercise, smoking and eating
literature is that in many cases the evaluation of habits.
the effectiveness of health promotion / health edu-
cation programs is lacking or does not meet the cri- The method of evaluation meets the criterion of
teria of scientific, objective measurement [47,48]. validity if it is capable of adequately measuring the
This is even more a shortcoming in Hungary, but subject of the evaluation. Assessment methods in
the TANTUdSZ program, which has already been health education programs can be: circular ques-
mentioned several times in the chapter, appears as tion, interview, questionnaire, test, self-reflection,
a positive example in this field as well, in which situation practice, practical presentation, prepara-
the efficiency analysis is carried out in all cases. tion of a behavior inventory. While knowledge can
“Based on this, knowledge, health behaviors and be measured with a test and a questionnaire, the
attitudes of the target population will be surveyed Likert-scale questionnaire and self-reflection can
using a quantitative method (self-developed ques- be used to measure attitude, and the behavioral in-
tionnaires) before the intervention and immediate- ventory is more suitable for measuring change in
ly after the health promotion program. Depending behavior in the case of interviews, self-reflection
on the health promotion topic, we try to include and follow-up.
other methods suitable for valid measurements in
addition to the questionnaire survey ” [37]. The in-
ternational literature also emphasizes that evalua-
tion should be an integral part of health promotion
planning in line with objectives, but also makes
evaluation recommendations, including the use
of group pre- and post-tests and non-randomized
controlled trials [28].
The lesson of the proposals is that an adequate as-
sessment of the objectives must be sought. In the

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

IV.5. Bibliography dülők egészségműveltségét mérő kérdőív

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ségmagatartás? Mitől függ és hogyan nak. https://regi.tankonyvtar.hu/hu/tar-
változtatható az egészségmagatartás? II. talom/tamop425/2011_0001_520_pszi-
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7. Varsányi P., Vitrai J(2016): Az Egész- 16. Eörsi D., Herczeg V., Árva D., Tere-
ségjelentés 2015 – Információk a hazai bessy A. (2020): Komplex iskolai egész-
egészségveszteségek csökkentéséhez ségnevelő program a COM-B modell tük-
című tanulmány bemutatása. Egészség- rében. Egészségfejlesztés, 61, 1. szám.
ügyi Gazdasági Szemle. 54, 1-2. szám. 36-47.
15-25.. 17. D. R. Forsyth (2006): Introduction to
8. Sorensen et. al. Health Literacy and pub- Group Dynamics. http://elibrary.vssd-
lic Health: A systematic review and in- college.ac.in/web/data/books-com-sc/
tegration of definitions and models. BMC mcom-pre/GROUP%20DYNAMICS.pdf
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nal Office for Europe (WHO Europe) lyiségfejlesztő módszerek az iskolá-
(2013). Health Literacy. The Solid Fa- ban. Nemzeti Tankönyvkiadó, Budapest.
cts. https://apps.who.int/iris/bitstream/ 19. Estefánné Varga M, Hatvani A, Taskó
handle/10665/128703/e96854.pdf T (2001): Személyiség és szociálpszicho-
[2021.05.23.] lógia. Távoktatási jegyzet. EKF. Eger.
10. Horváth C., Csányi T., Révész L., Ser- 20. Smith, Eliot R. – Mackie, Diane M.

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(2004): Szociálpszichológia. Osiris Ki- nulásához. Nemzeti Tankönyvkiadó Rt.

adó. Budapest. Budapest.
21. Csepeli GY (2001): Szociálpszichológia. 32. Feith H. J. Melicher D. Máthé G. Gr-
https://regi.tankonyvtar.hu/hu/tartalom/ advohl E., Füzi Ri. Darvay, S. Hajdú,
tamop425/2011_0001_520_szocialpszi- Zs., Nagyné H. E., Soósné K. Zs., Bi-
chologia/ch08s03.html [2021. 05. 23.] hariné K. I., Földvári-Nagy Lné, Lenti
22. Ewless L., Simnett I. (2013): Egészség- K., Molnár, E., Szalainé T. T., Urbán
fejlesztés. Gyakorlati útmutató. Medicina V., Kassay A., Falus, A. (2016): Tapasz-
Könyvkiadó. Budapest. talatok és motiváltság: magyar középis-
23. Schwarzer, R., Luszcynska, A., Zie- kolások véleménye az egészségvédő prog-
gelmann, J.P., Scholz, U., Lippke, S. ramokról. Orvosi Hetilap, 157, 2. szám.
(2008). Socialcognitive predictors of 65-69.
physical exercise adherence: three lon- 33. Füzi R A – Nagyné H. E (2019): Előszó
gitudinal studies in rehabilitation. Health az Egészségprogram receptgyűjtemény
Psychology, 27, 1.szám. 54–63. használatához. In: Feith Helga Judit, Fa-
24. Schwarzer, R. (2011). Health behavi- lus András (szerk.) Egészségfejlesztés
or change. In H.S. Friedman (Ed.) The és nevelés. A kortársoktatás pedagógiai
Oxford handbook of health psychology módszertana elméletben és gyakorlat-
(591–611). Oxford: Oxford University ban. https://mersz.hu/egeszsegfejlesz-
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25. Teleki Sz, Tiringer I (2017): Az 34. Végh V ; Pusztafalvi H., (2020) Leen-
egészségmagatartás változásának szo- dő és gyakorló biológiatanárok egészség-
ciális-kognitív folyamatmodellje (HA- definícióinak összehasonlító elemzése,
PA-modell). Mentálhigiéné és Pszi- Egészségfejlesztés, 61: 1 pp. 6-18
choszomatika 18, 1.szám. 1–29. 35. Okosdoboz portál egészségfeladatai és
26. Bandura, A. (1977). Self- efficacy: videofilmjei (2018). http://www.okos-
toward a unifying theory of behavioural doboz.hu/gyakorlas/osszes-osztaly/
change. Psychological Review, 84, 2. egeszsegneveles/osszes-temakor http://
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27. Prochaska, J.O., Norcross, J.C., DiC- 36. Somhegyi A (2019): Teljes körű intézmé-
lemente, C.C. (2009): Valódi újrakezdés. nyi egészségfejlesztés: jogszabályi előírás
Hatlépcsős program ártalmas szokásaink minden köznevelési intézmény részére.
leküzdésére és életünk jobbá tételére. In: Feith H. J., Falus A. (szerk.) Egész-
28. R. Windsor (2015): Planning ségfejlesztés és nevelés. A kortársoktatás
an Evaluation. https://oxford- pedagógiai módszertana elméletben és
medicine.com/view/10.1093/ gyakorlatban. https://mersz.hu/egeszseg-
med/9780190235079.001.0001/med- fejlesztes-es-neveles [2021.03.25.]
9780190235079-chapter-2 [2021.04.25.] 37. Feith H. J. – Falus A. (2019): A TAN-
29. Nagy S. (1993) Az oktatás folyamata és TUdSZ Ifjúsági Egészségnevelési Prog-
módszerei. Volos Kiadó, Budapest. ram létrejötte, felépítése, programjai. In:
30. Báthory Z. (1997) Tanulók, iskolák, kü- Feith H. J., Falus A. (szerk.) Egészség-
lönbségek. Egy differenciális tanításel- fejlesztés és nevelés. A kortársoktatás
mélet vázlata. OKKER Kiadó, Budapest, pedagógiai módszertana elméletben és
pp 143-144. o. gyakorlatban. https://mersz.hu/egeszseg-
31. Kotschy B. (2003): Az iskolai oktató- fejlesztes-es-neveles [2021.03.25.]
munka tervezése. In: Falus Iván (szerk.): 38. Bánfai B., Bánfai-Csonka H., Betle-
Didaktika - Elméleti alapok a tanítás ta- hem J. (2019): Hogyan menthetnek

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életet gyermekeink? Az elsősegélynyú- és nevelés. A kortársoktatás pedagógiai

jtás oktatásának lehetőségei az is- módszertana elméletben és gyakorlat-
kolában. Új Pedagógiai Szemle. 2019, ban. https://mersz.hu/egeszsegfejlesz-
1-2. szám. https://folyoiratok.oh.gov.hu/ tes-es-neveles [2021.03.25.]
uj-pedagogiai-szemle/hogyan-menthet- 47. Lukács J. Á. és mtsai (2018) Kortárs
nek-eletet-gyermekeink [2021.04.25.] egészségfejlesztési programok gyerme-
39. Bánfai B., Bánfai-Csonka H., Musch kek és fiatalok körében a hazai és a nem-
J., Derzsi-Horváth M., Deutsch K., zetközi szakirodalom tükrében – Szisz-
Betlehem J. (2020): Iskolai elsőse- tematikus áttekintés. Egészségfejlesztés
gélynyújtás oktatás a pécsi tankerületi 59, 1. szám. 6–24.
központban – kihívások és lehetőségek. 48. J. Kemm (2015): Evaluation. In: John
Egészségfejlesztés. 61, 4. szám. 17-29. Kemm: Health Promotion: Ideology,
40. Falus I. (2003): Az oktatás stratégiái Discipline, and Specialism. https://
és módszerei. In: Falus Iván (szerk.): oxfordmedicine.com/view/10.1093/
Didaktika. Elméleti alapok a tanítás ta- med/9780198713999.001.0001/
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módszerek és oktatásszervezési módok.
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szakmódszertan.
42. Meleg Csilla (2001): EGÉSZ-SÉG. Lel-
ki egészségvédelem és iskolafejlesztés.
Pécsi Tudományegyetem. Pécs.
43. Kapitány-Fövény M. és mtsai (2018) Po-
tential of an Interactive Drug Prevention
Mobile Phone App (Once Upon a High):
Questionnaire Study Among Students.
JMIR Serious Games 6, 4. szám. 19.
44. Kapitány-Fövény M. –Gilbert A. –
Szedmák E. (2019): Játékelemek al-
kalmazása az egészségfejlesztés terü-
letén: egy prevenciós szabadulószoba
bemutatása. In: Feith H. J., Falus A.
(szerk.) Egészségfejlesztés és nevelés.
A kortársoktatás pedagógiai módszerta-
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[2021.03.25.]
45. Paksi B. és Demetrovics Zs. (2003) Az
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J., Falus A. (szerk.) Egészségfejlesztés

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Chapter V.
THE SETTING APPROACH IN
HEALTH PROMOTION
(ZSUZSANNA NAGY, ANTONIO DE BLASIO,
JÁNOS GIRÁN, ANDREA SARRÓDI HORVÁTH,
HENRIETTE PUSZTAFALVI)

V.1. Introduction (1986) at the end of the 20th century. This conven-
The Ottawa Charter [1] opened a new era and new tion sets out the basic conditions and sources of
approach to health promotion. The basic docu- health: peace, housing, education, food, income,
ment of health promotion defines the concept of a stable ecosystem, sustainable resources, social
health promotion, the preconditions of health, the justice and equality. The healthy upbringing of
scope of health promotion activities- emphasizing children can only be ensured by having the above
the role of public policy for health. The setting ap- factors in different settings. As specific community
proach set out in the WHO Health for All Strategy settings provide an excellent platform for effective
[2] is also reflected in the Ottawa Charter, which health promotion interventions, it is necessary to
states that health is created in the scenes of every- make the most of this.
day life, where people learn, live, play and love.
According to the WHO definition, setting is the The scene approach, as defined by the WHO, is
place or social environment in which people en- the place or social environment in which people
gage in everyday activities in which the interaction engage in everyday activities, in which the inter-
of environmental, organizational and personal fac- action of environmental, organizational and per-
tors affects health and well-being, such as schools, sonal factors affects health and well-being, such as
workplaces, hospitals, villages and cities [1]. schools, workplaces, hospitals, villages and cities.
The practical application of the scene-based ap- [3].
proach was first realized in 1987 with the launch of
the Healthy Cities program, initiated by the WHO The community scene program is a strategic plan
Regional office for Europe. The success of the and action program aimed at a specific living
healthy Cities program soon led to the launch of scene, e.g. improving the health of people in a mu-
several new setting programs in the 1990’s: Health nicipality, school, workplace or any other commu-
promoting Schools, Health promoting hospitals, nity by changing the factors that affect the qual-
and Health and prisons. The network aiming at ity of life. The community scene program, while
workplaces as a setting was initiated by the Euro- serving the solution of specific problems affecting
pean Union. the given settlement, school, workplace and other
community (through the physical, mental and so-
V.2. Early childhood scenes cial well-being of the people living, studying and
For the upbringing of a healthy generation, the cre- working there), also promotes the introduction of
ation of an everyday living space - a healthy envi- new social practices and their elaboration , there-
ronment (interpreted as an everyday living space) by giving self-confidence and an opportunity for
is a basic need, as enshrined in the Ottawa Charter action [3].

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Autonomously organized communities that are ac- good quality toys, books) full of development tools
tively involved in solving their own problems can (climbing surface, mirror), suitable for household
be treated as resources. to convey knowledge (cleaning, cooking, garden-
ing).
V.2.1. Safe Start Children’s Homes Program
The original goal of the Safe Start children’s homes The professional leader, the staff, and the profes-
is to promote the development of young children sional manager of the children’s house is able to
living in disadvantaged settlements with limited perform the tasks, ensuring the appropriate selec-
early childhood institutions and to strengthen pa- tion of local human resources who will be the em-
rental competencies. In addition, the provision of ployee of the children’s house - a helper who is
a prevention service to compensate for the healthy preferably a local resident.
development of children with socio-cultural disad- The leading tasks of the children’s home include
vantages, in particular disadvantaged or multiple keeping records of, among other things, children
disadvantaged children. It should be noted that the (attendance, etc.), individual development plans,
institution does not provide a complex nursery ser- condition assessment, referral to a specialist, and
vice. recording of other activities such as family visits,
The main goal in setting up the institution was to discussions, lectures on parenting, health knowl-
eradicate growing deep poverty, deprived areas, edge (family planning, childhood illnesses, healthy
segregates or parts of settlements and as many dis- eating, leading a healthy lifestyle, etc.). The insti-
advantaged, low-stimulus environments as possi- tution is open to children and parents at least 4
ble. The negative examples were compensating for hours a day. Regarding the content of the sessions,
and reducing the risk of “dropping out” of those liv- it can be the development of creative occupations
ing in “captivity” or traditions. It is a well-known (fine motor skills, eye-hand coordination), the de-
fact that more children are born in poor families velopment of large movements (sense of balance,
and that, due to the large number of children, the body scheme, movement development, etc.). - In
mother does not usually work, so the household is terms of the content of the sessions, there can be
poor. The main goal is to ensure the optimal devel- developmental intervention (fine motor skills, eye-
opment of the children and to make the mothers a hand coordination development) and development
conscious parent, to learn community building, to of large movements (sense of balance, body sche-
learn to work with the nurse, the doctor, the social ma, movement development, etc.).
worker, the family helper, the child welfare service In addition, activities that promote sa
and other staff at the center. fe bonding, such as rhyming, fairy tales, poems,
The target group is primarily children aged 0-3 slide shows, puppetry (vocabulary development,
and their parents, mainly mothers, from the time etc.) and musical sessions, where a sense of rhythm
they become pregnant. The institution provides is developed. It is also responsible for organizing
services. The maintainer can be the state itself, the community-building and educational programs
church and the foundation. aimed at parents, such as interactive lectures, gym-
nastics / zumba, cooking together, and volunteer
The institution, according to its principles, is ac- activities.
cessible to all, free of charge, and is open every The organization of human services is also a goal,
working day of the year. It collaborates with par- such as the use of a development teacher, a phys-
ents and facilitates interprofessional collaboration, iotherapist, a speech therapist, a psychologist, etc.
supports such as early development, family assis-
tance, etc. It is mandatory to have two community open pro-
The building, where the child and parents are as- grams per month (holidays, excursions, etc.), at
sisted, is warm, dry, non-smoking, clean, safe least one meeting per month with the kindergar-
(physically, emotionally), rich in stimulus (lots of ten, child welfare service, family facilitator and

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

participation in “safe start” training, professional Holding a community event can be part of the
workshops and visits to other children’s houses. opening hours on weekends and holidays. The clo-
sure of the Safe Start Children’s Home has also
The amendment to the NM Decree (Nmr.) From been regulated, based on which the Children’s
1 July 201815/1998 on the professional duties of Home can be closed five working days a year in or-
child welfare and child protection institutions and der to carry out the tasks specified in its work plan
persons providing personal care and the conditions and during the elimination of SSChH, also under
for their operation. (IV. 30.) contained a number vis maior.
of important changes for the Safe Start Children’s
homes [4]. A child aged 0–3 who visits the Safe Start Chil-
dren’s Home with his / her parent for at least forty
The target group of the events is specified by law, percent of the opening days of the given month
and one of the two community events must be spe- is a regular user of the service provided by the
cifically tailored to the needs of the families tak- Safe Start Children’s Home. At least half of the
ing advantage of them. Under The Child protec- children who regularly use the service provided
tion Law ( 38 / A. § (1), The Safe Start Children’s by the Children’s Home must be in receipt of a
Homes may also carry out activities that meet lo- regular child protection allowance, together with
cal needs and are duly justified. the fact that at least half of the children receiving
Within this, they can recommend the use of nurs- the regular child protection allowance must also
ing care, other health services and social and child be considered disadvantaged or cumulatively dis-
welfare services, help with the transfer of family advantaged.
planning knowledge, prevent endangered preg-
nancies and help pregnant mothers prepare for The number of children who regularly use the ser-
having a child. vice provided by the Safe Start Children’s Home
must reach five children on a monthly average.
The Safe Start Children’s Home promotes the A daily attendance sheet must be kept for the use
successful social integration of the child and the of the service provided by the Safe Start Children’s
family in cooperation with the Family and Child Home. The attendance form contains the child’s
Welfare Service and the Family and Child Welfare name, date of birth, and social security number
Center. The connection is also strengthened by the (TAJ number). The identification code of the ac-
provision that the family and child welfare service tivity performed and whether the child receives a
informs the parent about the content and conditions regular child protection allowance and whether he
of the services of the Safe Start Children’s Home or she is considered to be disadvantaged or cumu-
in its area of care in order to alleviate the harmful latively disadvantaged must be indicated. The at-
effects of educational problems and deficiencies in tendance sheet is signed by the child’s parent.
the family, and assists in using these services.
A person employed as a manager in the Safe Start
In the regulation of opening hours, a more flexi- Children’s Home must attend professional work-
ble operation that better meets local needs will be shops organized for Safe Start Children’s Home .
possible. The Safe Start Children’s Home must be A person employed in a managerial position must
open for an average of six hours per working day complete the Safe Start Basic Training within one
per month, with the exception that the Children’s year of starting employment in a managerial posi-
Home must be open between 8 a.m. -12 a.m. every tion.
working day. Opening hours beyond the mandato-
ry opening hours are determined by the person em- A person employed in a non-managerial position
ployed as a manager in the Safe Start Children’s at the Safe Start Children’s Home must have a
Home based on local needs. Nmr. Annex 2 II. Part ‘I. Basic care ”title 2.1. with

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one of the qualifications specified for the job of which is constantly monitored by the head of the
educating young children. nursery. The educator of young children is also
responsible for maintaining the health of children
At the Safe Start Children’s Home, the service is with his or her example and personal skills, and by
provided according to a methodology approved by his or her health behavior he or she influences the
the Minister. The Minister publishes the method- education of parents and their children.
ology on the website of the Ministry he/she leads
and on the Social Sector Portal, and ensures that it An important task of an early childhood educator
is constantly updated. The administrative tasks are is to ensure optimal conditions during the care and
performed by the Directorate General for Social education program. The program will achieve its
Opportunity (hereinafter: TEF) in the case of the goal if: young children become trained, acquire
Safe Start Children’s Home, and by the National health habits appropriate to their age, and their
Institute for Social Policy (hereinafter: NSZI) for movements become more and more harmonious;
other services [5]. they like to stay and work outdoors. The child
learns a healthy lifestyle with the guidance of par-
In 2013, 58 such institutions were established in ents and early childhood educators, by making the
the country, by 2020 the program was already rules internal. Imitation, the example of an adult,
operating in 172 settlements, where 2231 people plays an essential role in the acquisition of hygien-
aged 0-3 participated in classes and events based ic operations. An age-appropriate right rhythm of
on the data of the CSO. Institutions have a very life and a good agenda are essential for healthy
important role to play in catching up and providing physical and mental development.
child welfare services [6]. By organizing nutrition, body care, dressing, ex-
ercise, breathing, rest and sleep, and related activ-
V.2.2. Opportunities for health promotion during ities and developing habits based on them, we en-
nursery education sure that young children develop a proper rhythm
The nursery is part of the basic child welfare care of life [8].
providing day care and professional education for
children raised in the family. The nursery places V.2.2.1. Health care - epidemiology, providing
great emphasis on maintaining health as one of the cleanliness
basic tasks of nursery education. Health education The early childhood educator is obliged to appear
is related to caring, somatic, emotional, willful, in- for the Occupational Health and Fitness aptitude
tellectual and social education. The goal of nursery test before starting work. He/she must sign a medi-
education is to develop good health habits and a cal declaration stating that he/she has no concealed
healthy lifestyle [7]. illness and takes part in the examinations ordered
by the occupational health doctor, on the basis of
In the field of health care we can mark the follow- which his/her suitability can be assessed (Decree
ing tasks in the nurseries: the creation and pro- 33/1998 (VI.24.) NM). The head of the nursery is
vision of personal and material conditions, com- obliged to monitor this constantly. The employee
pliance with epidemiological regulations, health is obliged to report to the head of the nursery if
rules for nursery workers, compliance with envi- there is a change in his / her state of health that
ronmental hygiene rules (cleaning, handling dirty adversely affects his / her work (febrile illness of
clothes, inspecting children’s equipment, group unknown origin, skin disease causing diarrhea, di-
room furniture, toys, yard toys) [8]. arrhea and acute gastrointestinal complaints).

It is the task of the early childhood educator to cre- A record of age-related vaccinations should be
ate and control the personal and material condi- kept on the medical record for nursery care. The
tions that help the development of the young child, detailed tasks related to vaccinations are defined

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

in the methodological letter issued annually by the (agenda to help develop and maintain physical
National Epidemiological Center for the activities and mental harmony - including eating, washing,
of the given vaccination year. It is the responsibili- dressing, sleeping, housekeeping, rest, breathing,
ty of the GP to record and report vaccinations. The exercise); performing prevention and corrective
vaccinated person should also be provided with in- tasks with the involvement of a specialist if nec-
dividual documentation of the vaccinations. essary.

If an infectious disease occurs or is suspected in The health promotion tasks of an early childhood
the nursery, it shall be notified in accordance with educator primarily concern young children, they
Decree 63/1997. (XII. 21.) NM [9]. also have an impact on parents, but they also need
to pay attention to their self-education.
Nursery interior equipment and fixtures should be
easy to clean and disinfect. Clean with a damp, Parents have more options for health education,
disinfectant cloth. In the event of an outbreak, such as indirect education through children, and
clean up in accordance with applicable public direct ones such as family visits, parental arriv-
health regulations. Toys used in the nursery group al and departure times, reception hours, parental
should be washed with running warm water sev- meetings, open days. In addition, it is possible
eral times a day, if necessary. In other groups of to pass on knowledge through a message board,
children, children’s toys should be washed week- health week and exhibition, etc. to transfer up-to-
ly. It must be disinfected once a week and out of date knowledge in health education during the pro-
turn during an epidemic. Disinfected toys should gram.
be rinsed thoroughly several times with warm run-
ning water. Cleaning should be organized so as not In summary, nursery health education is the first
to disturb children. Only rooms where children are and most suitable setting for developing healthy
not allowed can be cleaned during opening hours. lifestyle habits, as the toddler is at the most recep-
Clean with the window open. The rooms should tive age stage. At this age, it is even easier for par-
be tidied up after a meal and food scraps should be ents to form and shape because we can teach them
removed. Clean the floor with a damp, disinfectant to properly meet the basic needs of their children.
cloth. We can say that a childcare professional has a great
responsibility, as it is one of her tasks to make the
Nursery education has three main tasks: right, healthy lifestyle and the right agenda a habit.
1. Helping with emotional development and
socialization V.1.3. Tasks of health promotion in kindergarten
2. Helping the development of cognitive pro- Visiting the next institutional scene of kindergar-
cesses ten is now mandatory for all Hungarian children
3. Health protection, the foundation of a over the age of three, up to the age of six. It is
healthy lifestyle important to note that we are dealing with an scene
for healthy lifestyle education that reinforces the
Of these, the protection of health and the establish- process started during nursery education or, in the
ment of a healthy lifestyle are paramount. Protect- case of children now entering, continues or ex-
ing health, establishing a healthy lifestyle, creat- pands the activity of family education.
ing a healthy and safe environment for harmonious
physical and mental development, supporting de- In any case, as one of the first elements of the pub-
velopment; meeting primary needs according to lic education system, it plays a key role in educat-
individual needs; health protection, health educa- ing children for a healthy lifestyle.
tion, adaptation to the environment and support for
the development of basic cultural hygiene habits

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

The health care of children is regulated by the call appear. The intentional attention that
Decree (No. 26/1997 NM) 2011 law, in addition underlies learning appears, and elementary
to the Public Education Act. Participation in pro- conceptual thinking is also emerging.) The
fessional, preventive screening, such as dental development of spatial perception, visual
screening or hearing and vision screening, should and acoustic differentiation, spatial aware-
be ensured during pre-school care. The kindergar- ness, spatial movement development, body
ten maintains a close relationship with the district pattern development is of significant im-
nurse (although this varies from place to place) for portance.
the benefit of children, as it has a role in passing on 3. By the end of preschool, children are also
and practicing modern health care to parents and socially mature for school. A socially ma-
kindergarten teachers in addition to organizing and ture child can adapt to more and more
conducting screening tests [10]. rules, be able to delay meeting his or her
needs. His/her sense of duty is developing,
The Basic Curriculum for Preschool Education and this is manifested in the understanding
(ONAP) prescribes competency-based health edu- of the task, the keeping of the task, and the
cation (2012) and identifies areas and related tasks more and more efficient performance of
that promote the healthy development of preschool the tasks. The development of your perse-
children. verance, pace of work, independence and
self-discipline ensures this activity [11].
There are three main areas of preschool education:
• shaping a healthy lifestyle, V.2.3.1. Education for a healthy lifestyle will take
• emotional, moral and value-oriented com- place in the following areas of education
munity education, Physical education
• implementation of mother tongue, intellec- In accordance with the principles, special at-
tual development and education tention is paid to the planning, organization and
provision of everyday physical education. Regu-
Healthy lifestyles cover areas such as body lar health-enhancing physical activity, movement
care, bathing, brushing teeth, eating, especially games and tasks adapted to the individual level of
high-sugar foods and beverages, reducing the con- development of children, and the means of devel-
sumption of foods high in salt and unsaturated fats, oping, shaping and developing psychomotor skills
and encouraging the consumption of vegetables and abilities. The regular use of exercise games,
and fruit and dairy products, and shaping habits activities and tasks has a positive effect on the de-
for dressing, rest, disease prevention, and health velopment of strength and endurance, especially
care. By the end of preschool, most children will among the conditioning skills, which influence the
be ready to go to school. To start school, they need load-bearing capacity and healthy development of
physical, mental and social maturity: the children’s body. Spontaneous, free-play move-
1. A physically healthy child is able to move ment activities are complemented by controlled
more harmoniously by the end of pre- movement activities. The kindergarten strives
school. He/she is able to intentionally con- to make extensive use of cooperative movement
trol his/her movement, behavior and satis- games that best develop children. Daily physical
faction of his/her physical needs. education (morning and afternoon) and self-direct-
2. A mentally healthy child is ready to go ed exercises in the open air, as well as physical
to school with an interest open to the end education once a week - a compulsory activity -
of preschool. His/her learning skills make where the child performs controlled movements,
you fit to start school. In addition to in- serve his/her physical development.
voluntary engraving and recall, as well as
direct recall, intentional engraving and re-

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Personal and environmental hygiene Mental and social education

The child comes to the kindergarten from the fam- Mental health protection includes the practice of
ily with personal hygiene habits, which does not a healthy agenda, the development of appropri-
necessarily correspond to the daily hygiene order ate behaviors, the management of emotions and
of the kindergarten, therefore it is very important moods, and the development of skills. The main
that it is introduced tactfully, we teach the right tasks include the activity of social integration,
rules and procedures. The main educational task helping to develop an accepting, tolerant attitude,
is to develop hand washing habits (use of towels, as these are all patterns of learned behavior and
combs, brushing teeth, handkerchiefs and the most record a lifelong process of adaptation in children.
intimate use of the toilet). They need to be careful Patterns of integration and social relationships are
and consistent in their design. the basis for personality development, so it is im-
portant to treat this sensitive period with the right
In the field of environmental hygiene, we primar- weight.
ily mean the preservation of the cleanliness of
the nursery, its beautification, the ventilation of Development of self-knowledge, personal skills,
playing rooms, and the provision of heating and social interactions
lighting. It includes keeping the equipment clean, The child acquires information about himself
cleaning the rooms, and constantly cleaning the through social relationships. It is important to
toys. It is important that the environment is not acquire basic knowledge during the years of pre-
only clean but aesthetically pleasing. school that will enable the child to adequately
meet his or her existing needs. He/she is aware of
Healthy eating accident prevention and meeting your basic health
It is a very important task to develop healthy eat- needs. It is considered natural that the kindergarten
ing habits (to ensure a calm, aesthetic environ- teacher is a role model for maintaining and educat-
ment) and to eat as colorful as possible, based on ing health.
the principles of the SMART PLATE developed
by the National Association of Hungarian Dieti- Natural medium for integrated education - tol-
tians, which includes the principles of healthy eat- erance learning
ing [12]. We consider it an additional task to come Enforcing the principle of integration is becoming
to know the different natural flavors with children an increasingly important task in pre-school edu-
(salt and sugar-free foods, natural vegetables and cation. It is important for kindergarten teachers to
fruits, water as the essential liquid) so that we can teach to accept otherness. The aim is to establish
reduce the intake of unnecessary and harmful sub- and complete co-education as widely as possible.
stances. Developed healthy eating and a weekly Only in this way can children get to know and
vegetable and fruit day make children aware of master, that is, accept their atypically developing
this. It is important to note that the so-called in- peers who are different from the majority society.
direct education of parents should also appear as
a goal. It is possible to increase the knowledge of Summary
parents during the parental meeting and during the Kindergarten education plays a decisive role in the
health days. Reforming public catering also serves development of the individual in several respects,
this purpose in order to reduce the unnecessary ie its later role, activity and relationship with its
burden on children by giving them sugary and peers are established here and provide deeply in-
salty foods. Of course, the promotion of natural grained experiences for the individual. The adap-
(tap water) forms of fluid intake is an additional tation to a healthy lifestyle will be decided here,
task of everyday life in kindergarten. but the social relationships will also play a key role
in the entire life.

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V.3. TIE - Whole school health promotion con- Whole school health promotion concept includ-
cept (WSHPC) ingthe regular performance of the following four
Domestic health losses are mainly due to behav- basic health promotion tasks in the day-to-day run-
ioral risks, as evidenced by the poor values of ning of the school - with all students, the entire
Hungarian health behavior indicators in the EU. faculty and staff community, school health service
Therefore, significant improvement can only be professionals, parents and the school environment,
expected from changing the health behavior of with professional support and supervision:
the population, mostly by taking advantage of the
scene approach, in the field of community health • Implementing a healthy diet (preferably by
promotion, so it must be established in public ed- linking local production to local consump-
ucation, especially in schools [13]. School health tion);
promotion seems to be more promising than inter- • Daily physical education for all students
ventions in other settings, as intervention in com- to meet health promotion criteria and other
munity health promotion can also lead to contin- physical activities that complement it;
uous reinforcement if school educators act in an • Promoting the transformation of children
exemplary manner. into mature personalities, ie mental health,
through person-centered pedagogical meth-
According to Article [1] of the Basic Law of Hun- ods and the effective application of the arts
gary XX “Everyone has the right to physical and in personality development (singing, danc-
mental health”. The strategy entitled “Healthy ing, drawing, storytelling, folk games and
Hungary 2014-2020” adopted in 2015 defines the ritual games, crafts, etc.);
main public health goals and tasks in accordance • Promoting the acquisition of a wide range
with the Basic Law, one of the interventions is of health skills at a skill level, in other words
comprehensive institutional / school health devel- health education [15].
opment (hereinafter: TIE/ WSHPC). WSHPC is
a summary name for school activities that promote According to Somhegyi, comprehensive school
the preservation and improvement of health, the health promotion results in better health through
effective prevention of disease, health-conscious evidence in the following areas, according to evi-
behavior, and a health-based approach. The imple- dence from the relevant international and domestic
mentation of comprehensive health promotion for literature:
schools was supported by several projects between • improving learning outcomes;
2013 and 2015. School health promotion (educat- • reduction of early school leaving;
ing students in health) is effective when it is com- • promoting social inclusion and equal oppor-
prehensive. This means that all of the main health tunities;
risk factors are affected; is present continuously • primary prevention of smoking, alcohol con-
and regularly in the daily life of the school; all stu- sumption, drug use and other passions;
dents in the health promotion school participate; • crime prevention;
the entire school is involved; and involves parents • improving social relationships with peers,
and suitable NGOs working close to the school, as parents, teachers;
well as the social environment of the school [13]. • improving self-knowledge and self-confi-
According to the WHO 2020 strategic resolution, dence;
it prioritises intersectoral activity, meaning that • improvement of adaptability, stress manage-
schools need to develop healthy schools together ment, problem solving;
with health care, meaning that an educational en- • development of a mature, autonomous per-
vironment that supports health can help to improve sonality;
learning outcomes. A child with a better learning • primary prevention of chronic, non-commu-
performance is also in better health [14]. nicable diseases (mental illness, cardiovas-

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cular, musculoskeletal and cancer diseases, As we can see in the figure above, the so-called
diabetes); Comb-B system, the model of behavior change
• increase social capital [15]. describing behavior change was developed by
Michie et al. in 2011, synthesizing all the theories
Based on the above, we can say that the effective describing behavior change known at the time.
implementation of comprehensive school health The model includes three basic determinants, such
promotion is a public health, pedagogical and so- as psychological and physical ability (Capability),
cietal goal. Therefore, in March 2016, the Secre- social and physical environment (Opportunity) -
tary of State for Education and the Secretary of which in a broader sense means the environment
State for Health issued a WSHPC TIE Recommen- around the individual, and automatic and reflec-
dation for educators, gathering where to find help tive motivation (Behavior) that influence behavior.
for their daily WSHPC activities. This WSHPC [13].
recommendation was sent by the Office of Edu-
cation to the principals of all schools on 19 April The main direction and possible breaking point of
2016 and posted on the website www.kormany.hu, health promotion aimed at changing health behav-
since April 2018 it can also be read on the official ior is school health promotion in several respects.
website of the National Center for Public Health At school, the target group for health promotion is
(NNK). concentrated. In addition, children spend a signifi-

V. Figure 1: Behavior change model of the Comb-B system [13]

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cant portion of their time in school, away from the ness Test (NETFIT) to assess the fitness status of
environment that may mediate a negative pattern students during a specific measurement period in a
in the family. At this age, personality development given school year.
is not over yet, young people are still receptive to
change, to the acquisition of new thought patterns. There have been several forward-looking regu-
Another advantage is that in order to change the latory steps related to another health behavior -
health behavior of children, it is only necessary healthy eating. With the EMMI Decree 37/2014 on
to change the health culture and thus the behav- nutritional health standards and the EMMI Decree
ior of a relatively narrow group of highly qualified 20/2012 restricting the supply of goods in school
people (health promotion professionals, teachers). canteens, the legislators aimed to promote healthy
However, it is important to note that protecting the eating habits among schoolchildren.
health of children for out-of-school social actors
is more motivating for them than improving their The aim of the WSHPC is to improve the health
own health. behavior of school-age children, to maintain health
and to increase the number of healthy life years,
McIsaac and colleagues examined the multilevel ie to have independent living skills as adults, to
relationship between social actors and systems us- be prepared for the considered and desired fam-
ing an approach similar to the concept of impact ily planning. The child should be conceived and
networking in school health promotion. According raised in a similarly healthy environment, able to
to them, school health promotion should be seen handle the trials of life with love.
as a complex system in which schools themselves
operate as a complex system. The class communi- V.4. Occupational health promotion
ties formed by the students, the teaching staff, the V.4.1. The concept of occupational health promo-
parents are actors in this system. Their behavior is tion
shaped by different interests and intricate systems According to the Luxembourg Declaration,
of relationships. At the same time, the school, em- “Health promotion at work is a joint effort by em-
bedded in the system of local society, cooperates ployers, workers and society to improve the health
with quite a few socio-economic actors (eg local and well-being of workers. This can be achieved
government, public catering, non-governmental by:
organizations, etc.). In addition, schools are part -improvement and development of the workplace
of the national system of public education insti- organization and the working environment
tutions, which influences the operation and infra- - encouraging active participation
structure of schools through legal regulations, the - encouraging individual participation.[17] “
provision of resources and the training of profes-
sionals. Occupational health promotion uses and blends in-
formation from many disciplines at the same time.
In 2013, the Hungarian Student Sports Association Thus, in addition to health promotion, it also draws
launched a priority project called Strategic Mea- on the subjects of medicine (including occupation-
sures in Physical Education in Health Develop- al health, preventive medicine), human resource
ment (T.E.S.I.), which focused on the only element management, sociology, psychology, marketing,
of health development, physical activity. One of architecture and ergonomics.
the research and development tasks of the project
was to create a system for measuring and evalu- International organizations involved in workplace
ating health-focused fitness that can be operated health promotion:
uniformly in the Hungarian school system. In the - WHO (World Health Organization)
new physical fitness measurement system, physi- - NIOSH (National Institute for Occupational
cal educators use the National Unified Student Fit- Safety and Health) of the CDC

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V. Table 1: WSHPC concept in different countries [16]

TIE 4 basic activity TIE concept

SHE (Europe, 2011) WSCC (USA, 2014)
(Hungary, 2012) (Hungary, 2015)

1. Facilitating the acquisi-

1. Individual health skills 1- Knowledge transfer,
tion of health skills at skill 1. Health promotion
and competencies skills development
level
2. Comprehensive phy-
2. Everyday physical 2. physical education and sical activity (lifestyle,
2. Healthy School Policy
education physical activity health behavior within the
target area)
3. Promotion of healthy
3. Meal conditions and nutrition (lifestyle, health
3. Healthy nutrition
services behavior within the target
area)
4. Promoting the balan-
4. Health services (indi-
ced, mature personality
3. Health services 4. Health services vidual student support
development (ie mental
services)
health) of children
5. Counseling, spiritual 3. Individual mentoring
and social support function

4. School social 6. Social and emotional 5. School culture, positive

environment atmosphere atmosphere

6. Adequate physical
5. Physical environment 7. Physical environment
environment

8. Well-being of 7. Well-being of school

employees employees

8. Creating a suitable
9. Involvement of families
family environment

6. Community relations 9. Community

involvement

10. Community 10. Involvement of out-of-

involvement school communities

Source: SOLYMOSI J. B, (2016) Comprehensive school health development concept Health development,
LVII. No.1.

- EU-OSHA (European Agency for Safety and - The relevant Hungarian organization is the
Health at Work) - Hungary’s focal point be- EMEGY (Association for Healthier Work-
longs to the National Inspectorate for Safety places).
and Health at Work
- the ENWHP (European Network for Work-
place Health Promotion)

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V.4.2. Basic documents for occupational health V.3.4. Need and demand in the workplace
promotion When we begin to assess the needs and require-
Ottawa Charter ments of employees in a workplace, we need to
The 1986 conference’s revolutionary document on make an important distinction between the two:
health promotion already contained information
on the workplace: The necessity: in the case of a basic dissatisfac-
tion, it takes the form of a feeling of lack.
“(…) Work and rest must become a source of Need: to meet a specific need [20].
health for people. The way society organizes work
should contribute to a healthy society. Health pro- According to some, needs should be taken into ac-
motion results in living and working conditions count in the development of occupational health
that are safe, stimulating, rewarding and enjoyable (but these are often difficult to map, as many peo-
(…) ” [18]. ple find it difficult to become aware of or verbal-
ize - even when asked), but it is also worthwhile
ENWHP Statements to address the needs. If we pay attention to these
The basic agreements, common goals, visions and well-defined needs, both at the individual and
missions of the members of the European network group level, it will be easier to involve employees
are contained in these documents, which can form in the health promotion processes, as in this case a
the basis and starting points for work for healthy kind of trust may develop, a sense of understand-
workplaces (Luxembourg, Cardiff, Lisbon, Barce- ing in the workers.
lona, Edinburgh, Brussels Declaration).
Occupational health is intertwined with the theo-
V.3.3. Scene-based approach in the workplace retical foundations, subject matter and tasks of hu-
“The community scene is where the person is at man resource management at several points.
home, where the problem is at home, and where
the intervention should be delivered” [19]. The theory of Maslow’s needs hierarchy (Figure
The workplace is also a special arena because in- VII.2) is also widely used, and its original purpose
dividuals form a community here with the aim of was to motivate employees to increase productivi-
generating (profit), receive salary and other bene- ty. However, this logic can be reversed: if a work-
fits for their activities and work. For this reason, er’s basic needs at work are not met (eg meals,
the primary goal of the current employer is to max- fluid consumption, going to the bathroom, ade-
imize production. If the employer is convinced quate climate, clothing, etc. in case of temperature
that those measurements that are concted – aiming changes), it doesn’t have any sense to deal with
at workplace health promotion -, do not reduce or higher needs, energy and financial resources, they
even increase the productivity of the organization, will not be receptive to these opportunities.
it will only support or even initiate relevant pro-
cesses. It is easy to see that if management does V.4.5. What makes a workplace healthy?
not see a guarantee for this (whether in the short, According to the WHO definition of a healthy
medium or long term), the leadership has no point workplace:
in investing energy in these areas.
Today, it can be said that more and more employ- “A healthy workplace is one in which workers and
ers (including mammoth companies like IKEA or managers collaborate to use a continual improve-
Google) are recognizing the power of caring for ment process to protect and promote the health,
the health of their employees, and in Hungary we safety and well-being of all workers and the sus-
can see more and more good practices and exam- tainability of the workplace by considering the fol-
ples not only in the corporate sector but also in the lowing, based on identified needs:
public sector. - health and safety concerns in the physical

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

V. Figure 2: Maslow’s hierarchy of needs [21]

(Ildikó Soósné Göböly: Human Capital Management II. Károly Eszterházy College, 2014.)

work environment; Elements that make up the built environment in-

- health, safety and well-being concerns in the clude the building (s) that make up the workplace,
psychosocial work environment, including their style and ambiance, the color, material, con-
organization of work and workplace culture; dition, cleanliness, the layout of the rooms, and
- personal health resources in the workplace; how they are separated (eg doors or larger Amer-
and ican-style offices, where no more than space di-
- ways of participating in the community to viders are provided). In the case of the immediate
improve the health of workers, their families physical environment, mention should be made of
and other members of the community ”[22]. the furniture, lighting conditions (natural and ar-
tificial light), air-conditioning. Ergonomic aspects
V.4.6. The work environment have an extraordinary effect on the health of work-
The physical and social elements of the workplace ers and improperly selected or incorrectly adjusted
environment intertwine to form an organic whole furniture and equipment can also cause permanent
like physical and mental (mental) health. In orga- damage to health. This is true of any activity that
nizational culture, the origins of both environmen- the employee performs in a repetitive manner, and
tal dimensions can be found. includes activities that involve immobility for ex-
tended periods of time. Thus, it is necessary to op-
timize the work surface and tools not only for the

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work process, but also for the physical characteris- For special occupations, physical factors (eg vibra-
tics of the employee. They often forget e.g. about tion, extreme heat, solar and other radiation, dust,
left-handers who need devices and circumstances etc.), chemicals (carcinogenic, highly hazardous,
with a completely different structure. flammable, explosive, etc.), biological risk factors
(viruses, bacteria, fungi, pollen, etc.) may also oc-
Special mention should be made of the sedentary cur. Adherence to occupational health and safety
work and tasks with precautions in front of a moni- regulations, their consistent communication with
tor. (During the Covid-19 pandemic of 2019-2021, employees, and the setting an example by manag-
a lot of people went to home offices, which can ers are extremely important and essential for pro-
probably last for many years in many workplaces, tecting the health of employees.
so it is worth dealing with this separately. Improp-
erly adjusted / positioned chairs, tables, monitors, Occupational risk assessment and management is
keyboards can cause long-term damage such as spi- a complex task, which is a professional activity in
nal hernia, various joint complaints, the so-called occupational safety and health. It is also worth in-
“pushed neck” phenomenon, or RSI syndrome (re- volving the employee in the process, and obtaining
petitive strain injury). Needless to say, if they do, information from a number of sources.
they will not only cause the worker suffering and
irreversible damage, but will also significantly in- The parts of the social environment are the direct
crease the number of sick days, thereby reducing and indirect social relations, the workplace and
productivity. For this reason, it is no exaggeration also the organizational culture, psychosocial fac-
to say that it is specifically worthwhile for the em- tors, and (existing or missing) traditions.
ployer to pay attention to this area, resp. financial
outlay. It is important to note that the appropriate It should be mentioned that the workplace is also
material conditions are in vain if they are not the scene of tertiary socialization, so the social
and communication norms native to the workplace
set specifically for the worker’s physical charac- (both in terms of open and hidden content) are sig-
teristics and habits. To do this, a specialist in ergo- nificant in the long run. If we consider that new
nomics (occupational therapist), a physiotherapist entrants or even “transit” trainees may be inclined
or even a spine therapist can come in handy. to follow the standards experienced in their first
We should also mention the jobs that have a sol- job later in life, we can gain cross-generational ad-
id, built infrastructure, but a significant part of vantages or fix disadvantages for the future.
the employees / subcontractors do not spend time
in these places, because a significant part of the V.4.7. Health planning or health promotion plan?
work is done in “external” places. Construction, In the relevant Hungarian literature, individual
agriculture and certain services belong to this cat- and community-level planning processes are dis-
egory. In these cases, the place of work is given a tinguished. The former is usually defined as health
completely different interpretation. However, the planning and the latter as health promotion plan-
lack of a built environment is important for certain ning, but we cannot talk about a uniform and con-
basic human needs (e.g., washrooms, nutrition, ex- sistent nomenclature yet. However, the workplace
treme temperature conditions, additional aspects collective is also a set of individuals at the same
from physical labor, etc.). time, so planning processes are relevant at both
levels. This is because an occupational health pro-
Conditions involving health risks in the field of oc- motion program is inconceivable where individual
cupational health, which are mentioned here, can differences are not taken into account and there is
be clearly identified. no central intention to have or support personal-
ized support services (such as an individual health
plan).

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The classic steps of a health promotion plan (as - fringe benefits: recreation, sports facilities,
with other similar planning processes): screening, lifestyle consultation, provision
1. Description of status of therapy
2. Situational analysis - adequate sports infrastructure that can be
3. Strategic formulation and action planning used free of charge by workers
4. Execute programs - compliance with prescribed rest periods
5. Evaluation, feedback (results, impacts, mon- - establishment of a relaxation room
itoring) - identification of stress factors, development
6. (Restarting the health promotion cycle) of possible solutions with the involvement
of employees (this often involves the trans-
It is clear that health promotion planning practical- formation of work processes)
ly follows the principle of the public health cycle. - making communication processes more ef-
ficient
Another important step before developing an ac- - involvement of employees in decision-mak-
tion plan is to conduct a SWOT and stakeholder ing
analysis of the workplace. Only in this way, in
the possession of the revealed information, can V.4.8. A return on investment? Occupational
the process itself be tailored to the given work- health promotion in numbers.
place, resp. all its elements, the extent and pace In Hungary, in 2016, the Health Insurance Fund
of change, the main priorities. As with other com- paid out HUF 89 billion in sick pay. And while the
munities, it is true in the workplace that it is only number of sick pay days has declined over the past
worth measuring outcomes relative to the level of decade, the number of sick pay cases is growing
development of the community, meaning we can- year by year. VII. Figure 3 also shows that (ex-
not talk about an “absolute zero” level. The point cluding pregnancy and childbirth sickness bene-
is to start a conscious development process. fits) the first two places are tumors and diseases
of the circulatory system, which are known to be
Although Mihalic and colleagues have collected preventable diseases. Approximately 2/3 of cases
key impediments to implementation in other types in this group of diseases are caused by smoking
of health promotion programs, one of these is in- and malnutrition. Thus there is no question that the
sufficient organizational and managerial support. money, energy and attention invested in preven-
By definition, in the absence of this, we cannot tion is worthwhile for employers.
talk about comprehensive workplace health pro-
motion, at most sporadic, occasional programs and How to measure the effectiveness and efficiency
initiatives. of workplace health promotion?
Some specific examples of programs and mea- Effectiveness: the extent to which we achieve /
sures that can be implemented in the framework of achieve the desired / expected result.
occupational health promotion: Efficiency: how much resources - money, human
- action days, health days, sports days resources, time, etc. - we use to achieve the desired
- team building programs result.
- acquisition of ergonomic work equipment, Examples of indicators that can be used to mea-
checking the correct posture, practicing with sure effectiveness include:
an occupational therapist - number of sick days (decreasing)
- meal-related measures (lunch time, cultured - productivity and efficiency increase
dining options, microwave oven, restaurant, - fluctuation (decrease)
buffet, modification of their offer in a healthy - employee satisfaction increases
direction, financial support of the healthy - health behaviors and risk behaviors are
menu by the employer) changing favorably

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V. Figure 3: Number of sick days per case by disease group [23]

Looking at the process of a complex, long-term ROI (return on investment) is a term used in eco-
health promotion planning, additional outcome in- nomics to mean a proportionate return on invest-
dicators could include: ment. Understandably, employers want to know
- the appearance of health and well-being this number when different elements of occupa-
measures in the strategic documents of the tional health promotion come up. According to a
workplace meta-study [24], examining 47 workplace health
- the emergence of health and wellbeing (as a promotion programs, 46 of them saved money and
principle) in decision-making processes 41 more than the amount invested.
- appearance of health and wellbeing as a
value in the mission statement of the orga- Another study [25] found that the ROI of the stud-
nization / workplace / organizational units, ies examined was 138% on average, but this val-
mission ue depended on the quality of the study, and in
- integrating health and wellbeing aspects into some cases negative ROIs were found (meaning
the organizational culture that In some cases, the amount invested was not
reimbursed). All in all, it can be said that the pay-
back of workplace health promotion programs and

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methods depends on many factors, and further re- and communications professionals, IT profession-
search is needed in this regard. als, administrative staff and even students.
The program not only launched consultations un-
V.4.9. Good practices der the four pillars, but continues to support the
Google integration of health as a value into relevant pro-
In the case of Google, we now highlight some ele- cesses in major decisions, infrastructural and other
ments of the organizational culture, which also has changes.
a tremendous impact on the physical environment.
They also have a mission to coordinate the Facul-
It reveals a lot that the founders of Google grew ty’s ongoing research and info-communication on
up following the philosophical principle of Mon- lifestyle issues not only at the university level but
tessori pedagogy, which means questioning every- also among lay-minded audiences.
thing instead of “lining up” according to the rules.
This spirituality permeates the entire organization, V.5. The program and the methods of WHO
and so it is understandable why the following prin- European Healthy Cities
ciples are most important: an inspiring work envi- V.5.1. Setting programs in the activities of the
ronment, freedom, an ownership approach instead World Health Organization (WHO)
of an employee, satisfaction, play and fun. The Ottawa Charter [1] brought in a new era and
new approach to health promotion. The basic doc-
It would probably be an astonishing experience for ument of health promotion defines the concept of
socialized workers in the domestic public sector to health promotion, the preconditions of health, the
step into a Google “office” full of bean bags, color- scope of health promotion activities - emphasizing
ful slides and bicycles. A fun environment favors the role of public policy for health. The setting ap-
creativity and work can become a real source of proach to WHO’s Health for All Strategy [2] was
joy. The management of the company is done with also fulfilled in the Ottawa Charter, which states
the active involvement of the employees, the opin- that health is created in the settings of everyday
ion of the employees really matters and is import- life where people learn, live, play, and love.
ant, and experience has shown that the introduc-
tion of some small measures and changes reduces The concept of settings: The place or social en-
the frustration to an extraordinary extent [26]. vironment in which people engage in everyday
activities in which the interaction of environmen-
PTE MSc YourLife @ MSc program (higher tal, organizational, and personal factors influences
education institution as a special workplace) health and well-being, such as schools, workplac-
The initiative, launched by the Institute of Public es, hospitals, villages, and cities. (WHO, 1998)
Health, based on the principles of Health Promot-
ing Universities, was approved in January 2018 by The practical application of setting approach was
the then dean’s leadership. One of the basic theses first realized in 1987 with the launch of the Healthy
is that a substantial change in the health status of Cities program, initiated by the WHO Regional
the citizens of the Faculty can only be achieved if Office for Europe. The success of the Healthy Cit-
we treat students and staff as one community. ies program soon led to the launch of several new
setting programs in the 1990s: Health Promoting
Following lengthy consultations and the surveys, Schools, Health Promoting Hospitals, and Health
the program managers organized their activities and Prisons. The network aiming at workplaces as
and communication around four pillars (nutrition, a setting was initiated by the European Union.
exercise, mental health, smoking). The YourLife
team is a multidisciplinary team: not just doctors, V.5.2. Introduction of the Healthy Cities program
dieticians, physiotherapists, but also marketing In 1987, the WHO Regional Office for Europe de-

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cided to launch a demonstration project to involve Preparing health plans for cities and institutions
non-health sectors, municipalities and communi- Health impact assessment of local government
ties in health promotion. The program works ac- strategic documents
cording to the following principles: Health promotion programs in different settings
(school, workplace, neighborhood), for different
• Multisectorality - involving and bringing social groups (women, men, children and youth,
together non-health sectors to contribute to the elderly)
health promotion. Providing information, raising awareness – im-
• Commitment of urban decision-makers to proving health literacy
health - municipal decisions have a signif- Networking, cooperation to promote health – or-
icant impact on the factors that affect the ganization of conferences, professional forums
health of the population (e.g. environment,
housing, social factors). V.5.3. The role of settings and that of the local
• Partnership - Extensive collaboration with governments in health development
other organizations in the implementation of Settings of everyday life play an important role
the Healthy Cities program in shaping health – the decisions of local govern-
• Community Involvement - Involving com- ments, educational institutions, workplaces, and
munities in decision-making mechanisms the social and physical environment they influence
that shape their health all have an impact on the health of individuals.
• The principle of providing equal opportu- Setting approach not only provides an opportuni-
nities - not primarily treated as a separate ty to reach a specific group of the population in a
matter, but integrated into each program el- targeted way (e.g. children, youth, adults) with a
ement, applying a horizontal approach message, a knowledge transfer program, a health
• Providing sustainable development - not just promotion activity, a project, nevertheless it al-
by organizing isolated programs, but by ap- lows us to transform the setting itself in a way that
plying a system-wide approach promotes the development of the health of individ-
uals and communities that make up the setting, the
The Healthy Cities program started as a demo ability to make healthy choices, whether through
project with 6 European cities (including the city organizational change, organizational culture, or a
of Pécs), but after the first few years it had 35 change in the specific physical environment [29].
member cities, and in a short time it has grown
into a worldwide movement. Currently, more than Development and improvement of the health and
1,500 cities in the European Region are part of the well-being of the population is in the interest and
program as members of nearly 100 project cities responsibility of both the individual and the so-
and 30 national networks [27]. ciety. In addition to the individual’s abilities and
From the beginning, the WHO European Network way of life, health is influenced by a wide range
of Healthy Cities sets its objectives for five-year of social, economic and environmental factors
phases. In each phase, the member cities work [30], therefore health development, improving the
along specific themes and priorities. Phase VII be- health and well-being of the citizens needs inter-
gan in 2019. sectoral cooperation which can be achieved with
Hungary has been an active participant in the Eu- systematic planning. One of the tools in this com-
ropean network since the launch of the Healthy plex decision-making process is health planning.
Cities program. The Hungarian national network
is the Healthy Cities Association in the Carpathian Regarding local health planning tasks, local gov-
basin, which currently has 24 member cities with ernments have a key role to play, as their decisions
8 member cities across the border [28]. The main have a major impact on the health and well-being
areas of activity of the Association are: of the population. In this way, it is important for

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decision-makers to be aware of the effects of their A brief outline of the process of preparing a city
decisions on health and how they can positively health plan is provided in Section V. Table 2.
affect the health of the population and how they If you are planning to prepare a health plan it is
can reduce or eliminate factors that adversely af- inevitable that the health plan has its client who is
fect health. also responsible for its implementation, so a health
plan can only be prepared for the area within its
In many cases, the decisions of the local govern- own decision-making competence, which will be
ment are based on the medium- and long-term implemented.
concepts and programs of the settlement, so it is
especially important that the principles and val- It is important to note that the organization of com-
ues supporting health appear in these documents. munity health promotion programs is not health
The method of health impact assessment and city planning in itself. The health plan of a given com-
health plan helps to achieve this. munity (settlement, school, workplace, other orga-
nization) serves the purpose that the health promo-
V.5.4. Summary of the method of preparing a tion activities to be implemented should be based
health plan on the priorities set out in the health plan and the
The method of preparing a city health plan was needs of the stakeholders. Thus, the use of existing
developed jointly by the cities participating in the resources (material, human, etc.) can be done in a
WHO European Network of Healthy Cities and planned and more efficient way. The health plan is
WHO experts, based on their decades of work and not the same as the strategies for the operation and
experience, adapted by the Healthy Cities Associ- transformation of the health care system, which
ation in the Carpathian basin, and the Association are often mistakenly called health plans.
distributed this method among its member cities,
and collaborating organizations and professionals. A V. Table 3 presents some practical examples,
with the help of the “Health Development Plan
A city health plan is a strategic planning document 2019-2024 of the City of Pécs” [33], that the solu-
that sets out the city’s lines of action for health and tion of a problem area revealed on the basis of the
health promotion over a period of time [31]. The research of the situation survey, how it appears in
primary role of health plans is to provide cities or the health plan, illustrating the causal relationship
organizations with the means to build and main- between the health picture and the health plan.
tain strategic partnerships to protect health and to
create a common approach that can inform all sec- V.6. Programs for active aging
tors and stakeholders that: where health and qual- V.6.1. An aging society. The place of the elderly
ity of life can appear in their work. At the same in society.
time, they are aware of the impact of their activi- The aging of the population (increase in life ex-
ties on health, so the success of health planning is pectancy at birth, average age and the proportion
not only the content of the completed document, of the elderly) has been a headache and a challenge
but also the collaborations established during the for public health, population policy professionals
process and their future utilization for health. and politicians for decades. An even more seri-
A health plan can be prepared for a settlement or ous problem is the gap between life expectancy in
its different settings (workplaces, schools), or oth- health (without disability or chronic illness) and
er institutions can also have a health plan (e.g. hos- average life expectancy (years of ill-health). This
pitals, prisons). The principles of the health plans period places a serious financial and other burden
prepared in each area do not differ from each other, on society, families and the individual. Mentioned
they are the same as the method of the city health as a classic example, when a man in his 50s who
plan (adapted to the specifics of the given organi- is still in their active and productive years suffers
zation or institution). from stroke, become paralyzed and as a conse-

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V. Table 2: Outline of the process of preparing a municipal health plan

Establishment of a working group, professional
Preparation consultation, definition of working methods, and
schedule
Population-based survey
Analysis of local government strategic documents
using the method of health impact assessment
Developing health profile
Structured interviews with decision makers
Assessing the state of the city using the WHO
European Healthy Cities Indicator System
Evaluating the results of the health profile
Defining the principles, and priorities and goals
Developing health plan
Professional, political, and social consultation of
the draft health plan

Implementation on the basis of annual action plans,

Health plan implementation
with the allocation of the necessary resources
At the earliest after 3-5 years, with an update of the
Monitoring
health profile
(Source: own editing)

quence needs chronic care. He can still live for at the same time more actively) with a much more
many years as a result of modern treatments, but positive outlook on life. The experiences of the
he will not be able to work and he will be placed elderly can and should be exploited, both in the
in a chronic care facility or a family member will workplace and in family life.
take care of them, leaving them out of work - thus
increasing indirect costs. We must also mention the changing roles in old
Among the many aspects of aging, we must also age. With the fact that childbearing is postponed
mention the cultural background and embedded- to a later age in Hungary (many women give birth
ness of this topic. Unfortunately, not only in the to their first child after the age of 30), becoming
case of consumer goods, consumer societies do a grandparent is also delayed. What was formerly
not strive to preserve and respect obsolete goods, common in Hungary, such as the coexistence of
but unfortunately this is also the case for our senior multi-generational families, the division of tasks in
citizens. In our accelerated world, older workers the family (eg while the parents work, the grand-
(such as those about to retire) have a harder time parents take care of the children, the grandparents
keeping up with new technological and IT solu- also live with the family, their care is solved within
tions, their workloads are decreasing and their the family, in fact, everyday) is now less and less
reflex time is increasing, which in many cases found.
leads to job losses. Although policymakers try to Families have become atomized, and we know of
moderate these processes (e.g., incentives to hire more than one million single-person households in
a worker over the age of 55), but only shifting Hungary, the vast majority of whom is elderly.
paradigm in this area can bring about long-term
improvement. Think of societies where the elderly V.6.2. Healthy lifestyle in old age
are really respected (eg Japan) and where citizens The origins of many chronic diseases (causing
experience their own aging more peacefully (and death or destroying quality of life) can be attribut-

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V. Table 3: Causal relationship between the health picture and the health plan based on the
“Health Development Plan of the City of Pécs 2019-2024”

Research material Finding Proposed action

(Health profile) (Health profile) (Health plan)

Respondents were least satisfied

Further development of the cycle
with the size of the cycle path
Population-based survey path network and the community
network when assessing factors
cycle network is needed
related to everyday life

Health impact assessment of

local government strategic
documents has been ongoing
Based on the positive experi-
Health impact assessment of since 2011, which contributed
ence, it is important to analyze
local government strategic to the fact that all documents
the strategy documents in this
documents examined during the research
direction in the future as well
of the health profile included
the principles of public policy
supporting health
Sports programs for the over-30s
and the elderly;
Complex health education pro-
Respondents need more oppor- grams for children and youth;
Structured interviews with tunities supporting active life- Prevention and awareness
decision-makers style, adapted to the specifics of raising programs should also be
a given age group provided at city events;
Increase the knowledge related
to international health promotion
days

79% of the homeless have a

chronic illness that is one and a Developing an action program
Assessing the state of the city half times the average popula- to prevent the development of
using the WHO European tion; chronic diseases and reduce life-
Healthy Cities Indicator System The estimated number of home- style health risks for homeless
less people in Pécs is higher than people
the national average

(Source: own editing)

ed to risk behaviors and bad habits that have ac- habits, to leave bad habits at this age (neither). It
companied individuals entering old age throughout is worth noting, therefore, that the prevention of
their lives. It is not easy to develop new, healthier diseases that cause problems in old age must be-

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gin much earlier, in childhood and even in fetal sult from them, such as pathological fractures, sur-
age (e.g., caries prevention). Although they are im- gical complications, pneumonia, decubitus, sepsis,
portant, we don’t believe that programs aiming at etc.) can be significantly reduced by regular exer-
exclusively the elderly would achieve real results cise that develops a sense of balance, such as yoga,
at the level of the population or in the long run. tai chi , the dance. At this age, it is also important
to spare the joints, so swimming and walking are
much more recommended, as opposed to forms of
V. Table 4: Illustrates who is called elderly. movement that suddenly affect the joints (eg run-
ning, especially on a concrete surface). Basically,
WHO classification of life stages just like in childhood, the grassroots approach (=
love of play, experience and sports instead of re-
50 to 60 ys the age of deflection sults) would be desirable for the elderly.

60 to 75 ys the age of aging In connection with the development of osteopo-

rosis, it is important to mention that those who
75 – 90 ys old age regularly performed antigravity-type movements,
running and jumping in their childhood and ado-
90 – 100 ys very old age lescence, and their diet also contributed to an ide-
al maximum bone mass and density, have a lower
100 y < methuselah age risk of osteoporosis.

(Source: own editing) V.6.4. Nutrition

Losing a previously active everyday life can up-
A significant period of life is the period around set the balance of energy intake and use in many
retirement or when someone quits their job. This people. This can lead to overweight and obesity,
period involves the restructuring of everyday life, which can be a precursor to many chronic diseas-
so with some awareness, favorable habits and a es (diabetes, heart attack, stroke, joint disease),
healthy lifestyle can be developed. While this is which is a very serious challenge to get out of this
a natural change in the lives of many, it can also vicious circle at this age.
play a role for the employer, in recent years it can As in any other age, it is important to consume ad-
support (health) conscious planning for its pre-re- equate amounts of vegetables and fruits in old age,
tirement employees. not only to get fiber, but also to get important mi-
cronutrients into the body. This is not always easy,
V.6.3. Move especially when you consider that many people are
“(…) For motion is life, and life is motion. (…) forced to eat with or without a prosthesis due to
”(Ron Fletscher) the loss of their teeth. Loss of appetite, decreased
With regard to ‘active’ aging, many are likely to saliva production, decreased fluid intake and dehy-
be the first to associate with physical activity. And dration can be serious problems.
indeed, perhaps one of the most important ele-
ments of active aging is movement. Regular and V.6.5. Mental health
well-chosen physical activity not only helps main- As we age, we most often see a decline in cognitive
tain muscle strength and the musculoskeletal sys- abilities, which has a major impact on daily living,
tem, but also reduces the chances of developing self-sufficiency and social relationships. The most
mental illness such as depression and dementia. If common mental problems are dementia, depres-
one chooses group exercise, the additional benefit sion and we should also mention the increased risk
is to maintain social relationships. The risk of falls of suicide.
in old age (and the serious consequences that re- In the case of dementia and depression, it has al-

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ready been shown that the Mediterranean diet re- phones to help the elderly improve their daily
duces the incidence of these diseases [34], thus not lives, including fall monitors, medication dispens-
only the beneficial aspect of cardiovascular dis- ers, heart rate monitors and magnifiers [36].
ease should be considered.
We must also mention here the ever-evolving dis-
Games, the player development activities, play an tance diagnostic solutions that are slowly becom-
important role in the work related to the elderly. ing a reality today and can truly save lives, make
Many people try to maintain their memory with the efficiency of the traditional care system more
crossword puzzles, but cognitive abilities are also efficient and complementary [37].
positively affected by solving simple puzzles or
even math problems in a playful way for the el- V.6.7. Good practices
derly. Senior Dance of Joy
Senior dance (and even sitting dancing) [38] has
Hobby activities also play an important role. They been around in Western Europe for almost five de-
are both joyful activities and structure time as reg- cades, but has only recently become established in
ular and predictable parts of everyday life. Many Hungary. It is a gentle sport that requires neither
older people do gardening, which contributes to prior dance knowledge nor a dance partner. Its ef-
physical activity, outdoor time, hobbies and even fects on depression and anxiety have been shown
livelihoods. It requires planning, and means a goal to be beneficial, with improvements in self-suffi-
from year to year, and it is not a negligible consid- ciency, family and social roles [39].
eration that it also means a sense of usefulness at
this age (just as at an earlier age, daily work did Religious communities
this). It means a lot to those who practice religion a lot
Social relationships, within and outside the family, that they can meet other believers from time to time
have significant protective effects on the elderly. and attend various community events on a regular
Their close relationship not only with their chil- basis. These communities have a very strong sus-
dren but also with their grandchildren has a ben- taining power and, along with faith, being an im-
eficial effect on the mental health of the elderly, portant handhold, perhaps most for single seniors.
and it has been shown that this relationship has a
positive effect on the (mental) well-being of their Home help with signaling system and further
grandchildren [35]. measures in Zalaegerszeg
An example is the Elderly Care Concept devel-
V.6.6. Tools for active aging oped by the Zalaegerszeg (a Hungarian town) lo-
Many seniors live alone in their homes, and the cal government for 2020-23 (we believe that they
supplements, minor considerations that can either deservedly won the Elderly-Friendly Local Gov-
save their lives or protect them from falling, are ernment Award a few years ago) [40].
especially important to them. These include hand-
rails installed in appropriate places (next to stairs, Older people are seen as a value, they support the
bathroom), removal of thresholds, use of fixed employment and lifelong learning of older peo-
mats instead of treadmills, proper crutches, walk- ple, and they regularly organize awareness-raising
ing frames, other walking aids. By using them, the programs to bridge the gap between the genera-
elderly person can maintain their autonomy for a tions. The Concept not only deals with socially
long time, which can also be important for self-es- based benefits, but also provides services such as
teem. e.g. day care for the elderly with dementia, resp.
if an elderly person needs temporary accommoda-
Technological solutions for active aging tion. Social workers regularly visit elderly people
A number of applications are available on smart- in need in their own homes and help them with

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

whatever they need, even to buying medicines or

during the Covid-19 pandemic, even in shopping
or other things to deal with.

They are also constantly working to make the

environment safer, which is not only reflected in
the investment in transport, but also in the grow-
ing number of emergency call devices that can be
installed in their homes, thus prolong the time of
self-sufficiency to avoid these people getting into
nursing homes.

Providence Mount St. Vincent

An obvious solution to today’s demographic chal-
lenge is the idea implemented in Canada [41] that
preschool children attended as regular visitors a
nursing home with 400 residents. Playing together,
exercising, and eating have an extremely good ef-
fect on the mental health of program participants.

“Rent a grandma”
Instead of a babysitter, seniors who have a lot of
free time and are in good physical and mental con-
dition can be hired for childcare. It can be a service
that works well in a voluntary or paid version.

“Click on it, Granny!”

At the beginning of the 2010s, seniors who were
happy to learn the tricks of computer management
took part in courses organized in Hungary from
European Union funds.

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

V.7. Bibliography 13. Járomi É., Szilágyi K., Vitrai J.,(2016)

1. WHO (1986): Ottawa Charter for Health Egészséges életmóddal kapcsolatos ku-
Promotion. WHO Europe. https://www. tatások a hazai iskolákban, Egészségfe-
euro.who.int/en/publications/policy-doc- jlesztés, LVII. évfolyam, 1. szám,
uments/ottawa-charter-for-health-promo- 14. Shanghai Deklaratívon on promoting
tion,-1986 [2021.04.20 health in the 2030 Agenda for Sustainable
2. WHO (1981): Global strategy for health Development, 9th Global Conference on
for all by the year 2000. WHO, Gene- Health Promotion, Shanghai 2016 http://
va. https://www.who.int/publications/i/ www.who.int/healthpromotion/confer-
item/9241800038 [2021.04.20.] ences/9gchp/shanghai-declara-tion.pd-
3. Füzesi Zs., Tistyán L. (2004) Egészség- f?ua=1[2021.04.20.]
fejlesztés és közösségfejlesztés a színter- 15. Somhegyi A., (2019) Teljes körű intéz-
eken, Országos Egészségfejlesztési In- ményi egészségfejlesztés: jogszabályi
tézet, Budapest előírás minden köznevelési intézmény ré-
4. 40/2018. (XII. 4.) EMMI rendelet a szére in.: Feith H.-Falus A. szerk. Egész-
gyermekek esélynövelő szolgáltatásain- ségfejlesztés és nevelés, A kortársoktatás
ak szakmai feladatairól és működésük pedagógiai módszertana elméletben és
feltételeiről gyakorlatban
https://www.hbcs.hu/uploads/jogszabaly/2554/ 16. Solymosi J. B., Teljes körű iskolai
fajlok/EMMI_szakmai_iranymutatasa. egészségfejlesztési koncepció Egészség-
pdf fejlesztés, LVII. évfolyam, 2016. 1. szám,
5. A koragyermekkori fejlődés megalapozá- 17. www.enwhp.org [2021.04.20.]
sa, Kézikönyv a Biztos Kezdet program 18. Dr. Kishegyi J, Dr. Makara P. (Szerk.)
munkatársai számára, https://mek.oszk. (2004) Az egészségfejlesztés alapelvei
hu/18000/18001/18001.pdf (Az egészségfejlesztés alapvető nemz-
6. https://www.ksh.hu/stadat_files/szo/hu/ etközi dokumentumai) OEFI.
szo0010.html [2021.04.20.] 19. Simonyi I. (2004) Segédlet az iskolai
7. Péter A. (2012): Egészségfejlesztés a egészégnevelési, egészségfejlesztési pro-
bölcsődében. In: Darvay, S. (szerk.): Ta- gram elkészítéséhez. Oktatási Minisztéri-
nulmányok a gyermekkori egészségfe- um, Budapest
jlesztés témaköréből. Eötvös Loránd Tu- 20. Szigeti O., Szakály Z. (2009) Market-
dományegyetem, Budapest. 23-53 ing. Kaposvári Egyetem
8. Balogh, L., Barbainé, B. K., Rózsa, J., https://regi.tankonyvtar.hu/hu/tartalom/tam-
Szombathelyiné, dr. Ny. Á., Tolnayné, op425/0059_marketing_hu/ch01.html
F.M., Vokony, É. (2009) A bölcsődei ne- [2021.04.20.]
velés-gondozás szakmai szabályai (Mód- 21. Soósné G. I. (2014): Humántőke
szertani levél). Budapest. Szociálpolitikai menedzsment II., Eszterházy Károly
és Munkaügyi Intézet Főiskola, https://regi.tankonyvtar.hu/hu/
9. 33/1998. (VI.24.) NM rendelet) a munka- tartalom/tamop412A/2011-0021_14_hu-
köri, szakmai, illetve személyi higiénés mantoke_menedzsment_ii/533_szksgle-
alkalmasság orvosi vizsgálatáról és véle- thierarchiaelmlet.html [2021.04.17.]
ményezéséről 22. Dr M. Neira: Healthy workplaces: A
10. 2011. évi CXC. törvény a Köznevelésről model for action. 2018. WHO https://
11. 363/2012. (XII. 17.) Korm. rendelet az www.who.int/occupational_health/publi-
– Az óvodai nevelés országos alappro- cations/healthy_workplaces_model_ac-
gramja tion.pdf [2021.04.20.]
12. Okostányér https://www.okostanyer.hu/ 23. https://www.ksh.hu/docs/hun/xftp/ido-

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szaki/pdf/tappenz16.pdf [2021.04.17.] files/ev_indikator_lista.pdf [2021.04.20.]

24. O’Donnell M.P.: (2015) What is the 33. Pécs Megyei Jogú Város Egészségfejlesz-
ROI for workplace health promotion? It tési Terve 2019-2024 és mellékletei https://
really does depend, and that’s the point. gov.pecs.hu/file/index/221922?entity-
American journal of health promotion : Type=REG_30176&t=REG_EDIT_
AJHP 29:3 (v-viii) PUBLISH_12014&ouid=&pgid#
25. Baxter S., Sanderson K., Venn A.J., [2021.04.28.]
Blizzard C.L., Palmer A.J.:(2014) The 34. Masana M.F., Haro J.M., Mariolis A.,
relationship between return on invest- Piscopo S., Valacchi G., Bountziou-
ment and quality of study methodology ka V., Anastasiou F., Zeimbekis A., Ty-
in workplace health promotion programs, rovola D., Gotsis E., Metallinos G.,
American journal of health promotion : Polystipioti A., Tur J.-A., Matalas A.-
AJHP 28:6 (347-363) L., Lionis C., Polychronopoulos E.,
26. http://bespokeprinciples.com/ Sidossis L.S., Tyrovolas S., Panagiota-
rolunk/2017/12/06/google-ti- kos D.B(2018): Mediterranean diet and
tok-avagy-miert-google-vilag-leg- depression among older individuals: The
jobb-munkahelye/[2021.04.17.] multinational MEDIS study. Experimen-
27. WHO Európai Egészséges Városok tal Gerontology 110 (67-72)
Hálózat https://www.euro.who.int/en/ 35. Flouri E., Buchanan A., Tan J.-P.,
health-topics/environment-and-health/ Griggs J., Attar-Schwartz S.(2010):
urban-health/who-european-healthy-cit- Adverse life events, area socio-economic
ies-network [2021.04.20.] disadvantage, and adolescent psychopa-
28. Egészséges Városok Mozga- thology: The role of closeness to grandpar-
lom Kárpát-medencei Egyesülete ents
in moderating the effect of contextual
https://www.egeszsegesvarosok.hu/ stress, Stress 13:5 (402-412)
[2021.04.20.] 36. h t t p s : / / w w w. o r i g o . h u / t e c h b a -
29. Whitelaw, S., Baxendale, A., Bryce, zis/20200316-okostelefonos-appok-ido-
C., Machardy, L., Young, I., Witney, seknek.html Letöltés: [2021. 04. 18.]
E. (2001): ’Settings’ based health promo- 37. Pusztafalvi H., (2015)Aktív időskort
tion: a review. Health Promotion Inter- támogató közösségi kezdeményezések:
national, 16, 339-353. https://academic. Színterek szerepe az idősek egészség-
oup.com/heapro/article/16/4/339/656751 fejlesztésében, In: Lampek, K.; Rétsá-
[2021.04.28.] gi, E. (szerk.) Egészséges idősödés :
30. Wilkinson, R., Marmot, M. (2003): So- Az egészségfejlesztés lehetőségei idős
cial Determinants of Health: The Solid korban (PTE ETK) 167 p. pp. 155-167.
Facts. Second edition. WHO Regional https://www.etk.pte.hu/protected/Ok-
Office for Europe, Denmark tatasiAnyagok/%21Palyazati/sport2/
31. WHO Regional Office for Europe (2001): EgeszsegesIdosodesJ.pdf (8-62p. és 155-
A working tool on city health develop- 166p.) [2021.04.28.]
ment planning – Concept, process, struc- 38. www.szeniortanc.hu [2021.04.28.]
ture, and content. WHO Centre for Urban 39. Santos D.P.M.A., Queiroz A.C.C.M.,
Health, WHO Regional Office for Eu- Menezes R.L., Bachion M.M.:(2020)
rope, Copenhagen. Effectiveness of senior dance in the health
32. Egészséges Városok Mozgalom of adults and elderly people: An integra-
Kárpát-medencei Egyesülete: WHO Eu- tive literature review. Geriatric nursing
rópai Egészséges Városok indikátor-listá- (New York, N.Y.) 41:5 (589-599)
ja https://www.egeszsegesvarosok.hu/ 40. https://zalaegerszeg.hu/dokumen-

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tum/27027/Idosugyi_Koncep-
cio_20162019.pdf [2021.04.28.]
41. h t t p s : / / w w w. h u f f i n g t o n p o s t .
ca/2015/06/21/preschool-inside-nurs-
ing-_n_7630064.html 06/21/2015
02:10am EDT | Updated August 10, 2015,
[2021.04.28.]

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Chapter VI.
THE ROLE OF HEALTH POLICY AND THE
HEALTH ECONOMY IN HEALTH PROMOTION
(IMRE BONCZ - TÍMEA CSÁKVÁRI)

VI.1. Introduction In recent decades, critical appraisal of various

According to the World Health Organization health care services has become particularly im-
(WHO), health promotion is a process that enables portant. One of the major challenges for developed
members of a population to improve their own countries in the health sector today is no longer
health [1]. However, in addition to so-called indi- just to ensure the efficiency and effectiveness of
vidual responsibility-based health promotion, the care and services. Every year, a number of new,
health status of individuals can be maintained or advanced health technologies appear on the mar-
improved at the societal level through political de- ket, along which hitherto incurable diseases be-
cisions, reorganization of health care or communi- come curable, life expectancy and the number of
ty activities. According to Table 1, health promo- healthy life years in the population increase. (Med-
tion is now not only a means of preventing healthy ical technology is any device or procedure that is
individuals, but can also appear at several points in intended to improve / maintain a state of health, be
an individual’s life (possibly illness) depending on it a drug, medical device, surgical procedure, vac-
the severity of different health conditions. cine, screening program, etc.) The problem is that
the growing public demand for these advanced
technologies is difficult to meet and is often ex-

VI.Table 1: Strategies for health promotion in the population

Strategies for health promotion in the population
Patients
Patients
Healthy population Individuals at risk (diagnosed, identified
(showing symptoms)
disease)
Promoting a healthy Promoting a healthy Promoting a healthy Promoting a healthy
lifestyle lifestyle lifestyle lifestyle

Organization of
Primordial Prevention Treatment Treatment
Screening Programs
Reduction and
Disability prevention,
elimination of risk
rehabilitation Disability prevention, ,
Primary prevention factors
rehabilitation
Development of
Early detection
resilience

Source: own editing based on a figure by Kumar and Preetha [2]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

tremely costly. However, with the increase in life analysis. The results should facilitate the choice
expectancy at birth, the number and proportion of between each alternative, taking into account ex-
the elderly in the population is on the rise, thus the isting budgetary constraints [3].
proportion of chronic patients and the number of In the rest of this chapter, we briefly present the
years spent in chronic illness are rising, which also basics of health economics analysis. The individ-
increases health expenditure. However, it is impos- ual forms of analysis are also presented through
sible to increase the financial resources available practical examples, focusing on the examination
for this expenditure at a pace that meets the needs of a preventive health promotion program in each
of the population. This challenge has given birth to case, in accordance with the topic of the chapter.
the era of efficiency in health care as well as health Finally, we discuss how the results of such analyz-
economics as a new, interdisciplinary discipline. es can be communicated as effectively as possi-
It is a generally accepted view in economics that ble to society and decision-makers, and how and
resources are always scarce in relation to the de- in what fields they can be utilized through health
mands placed on their use. It is essential to know policy decisions.
whether programs supported by the health budget
are actually making the best use of the limited re- VI.2. Fundamentals of health economics anal-
sources available to them. This is the most impor- ysis
tant question to be answered by health-economic In recent decades, in addition to clinical efficacy

VI.Figure 1: Possible outcomes of cost-effectiveness analyzes (red areas: rejection, green areas:
inclusion) Source: own editing

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in health care, the study of cost-effectiveness has inclusion should be considered. In practice, the re-
become an increasingly important and unavoida- sults for Q1 are most often obtained, meaning that
ble factor. Whether a particular medicine, medical the new alternative has higher benefits but also
device or even procedure is allowed to appear on higher costs than the comparator.
the market or included in the social security-fund-
ed group depends on the coexistence of several Depending on what exactly we mean by health
factors [4]. When a new health technology emerg- gains, we distinguish the following health eco-
es on the health market, its safety (guarantee that nomics analyzes:
any side effects are rare and / or dwarfed with the • cost minimization analysis,
expected health gains) and efficacy (evidence that • cost-effectiveness analysis,
the technology is indeed capable of curing the dis- • cost-benefit analysis,
ease,) its cost implications need to be examined • cost-benefit analysis.
in detail. Is the new drug more expensive than the
currently used (comparator) alternative? If it is The essence of the four forms of analysis and its
more expensive, will it bring you so much more most important indicators are briefly presented be-
health gain over the comparator that it is worth low. In addition, for each type, we present a study
switching to? The so-called health economics in which a health economics analysis was per-
analyzes examine these issues. formed for a health promotion program.
A WHO work team outlined the essence of the
analysis as “a systematic examination of an initia- VI.2.1. Cost-minimization analysis (CMA)
tive and its effects to provide information to those This form of analysis compares at least two inter-
interested in using it” [5]. ventions with the same benefit in all cases. In that
Health economics analyzes can be incomplete case, the only question is, if both alternatives re-
and comprehensive. Incomplete analyzes examine sult in the same output, which one will cost less?
only one technology in some respects (e.g., dis- Its advantage is that it is the simplest to perform of
ease burden analysis, budgetary impact analysis). the four health economics analyzes, as we do not
Comprehensive analyzes are used to compare two measure the benefits, we only prove their equali-
or more health technology alternatives, a new one ty, and it is enough to examine only the difference
that is awaiting inclusion or funding, and one that between the costs. The disadvantage is that if the
is typically already authorized and widely used consistency of the outputs is not checked, the re-
(comparator) [6]. Here, basically, two factors are sult can be misleading.
compared: the health benefits of the technologies /
interventions studied, and the costs of using them. Example: In their study, Tzeng et al compared
The possible results of the comprehensive analyz- two vaccination programs in a cost minimization
es are presented in Section VI. Figure 1. analysis. Prior to 2005, members of the U.S. Army
To use the chart, you must first place the com- were also vaccinated against hepatitis A, hepatitis
parator technology at the origin of the coordinate B, chickenpox, measles, and rubella. The Acces-
axis, and then specify the location of the new tech- sion Screening and Immunization Program (ASIP)
nology on the chart, which can be one of the four was introduced in 2005, the essence of which was
“quadrants” (Q1, Q2, Q3, Q4). If the intervention to subject soldiers to serological testing before
is less effective and more expensive than the com- vaccination. The purpose of the test was to screen
parator, it falls into Q4. In this case, the decision individuals who were immune to the disease and
is simple, we prefer the comparator. It is similarly no longer need to be vaccinated. Nothing better
easy to decide for Q2, when the new technology is justifies the need for ASIP, as 43.37% of the sam-
not only more efficient but also cheaper with the ple tested was immune to hepatitis B and 63.3%
procedure used so far (dominant). In the case of a to measles and rubella combined! The effect was
new technology falling into quadrant Q1 or Q3, its therefore the same for both programs (complete

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protection against the listed infections) but their creased by 5.6% compared to the control group (+
cost was different due to their method. But what 12.6%), so the proportion of smokers in the study
costs less: to vaccinate everyone without a sero- population decreased by 7% as a result of the pro-
logical test, or to test everyone and vaccinate only gram within the population. It has also been found
those who are exposed to the infection? The au- that using the SI + program costs an LYG € 11,200
thors examined the extent to which the two pro- and a life expectancy in perfect health € 19,900
grams generated expenditure over a two-year peri- (ICER), making it more expensive but also more
od. Health costs due to vaccines, diagnostic tools, healthy. The study looked at students in the Neth-
and side effects were assessed. It was found that erlands, the Health Economics Analysis Directive
the “general” screening program cost $ 410,561 states in Netherlands that any new intervention
more than ASIP, which also used serological test- with a lifetime (adjusted for quality of life) of less
ing, so the latter was definitely worth using in the than € 20,000 is considered cost-effective [8].
long run [7].
VI.3. Cost-utility analysis (CUA)
VI.2.2. Cost-effectiveness analysis (CEA) Cost-benefit analyzes differ from cost-effective-
In the course of cost-effectiveness analyzes, in ad- ness analyzes in that health benefits are typically
dition to costs, health benefits are also assessed. expressed in terms of a quality-adjusted life years
The latter is usually shown by some natural indi- (QALY). This indicator expresses how many years
cator (e.g., number of seizures, blood sugar levels, of a perfect quality of life a given intervention re-
etc.), while the former is also expressed in mon- sults in a patient. This eliminates the disadvantag-
ey. The advantage is that it is able to compare in- es of cost-effectiveness analysis, as this indicator
terventions with different degrees of benefit; the can even be calculated for health technologies
disadvantage is that we can only examine those designed for different purposes (diseases). Thus,
with an output measured in the same dimension. the effects of a drug can even be compared with
Its main result is the incremental cost effectiveness a health promotion program as needed. Its main
ratio (ICER), which gives the unit cost of living result is the incremental cost utility ratio (ICUR),
when a new technology is adopted. which indicates how much an acquired QALY will
cost if the new technology is adopted.
Example: Vijgen et al examined the effectiveness Example: Hagberg et al aimed to investigate the
of an anti-smoking school program in a cost-ef- cost-effectiveness of a comprehensive nutrition
fectiveness analysis. They formed three groups: program among breastfeeding, overweight moth-
the first (SI group) took part in a timed but “nor- ers. Between 2007 and 2010, 68 women were
mal” anti-smoking program, the second received surveyed in two groups: the members of the case
other leaflets and listened to a 45-minute lecture group were the subjects of a 12-week lifestyle
once a week for five weeks (SI + group), and the change program to change their eating habits,
third was uneducated (control group). Regarding and a control group was formed. Subjects in the
that their program focused specifically on repress- case group initially underwent an hour-and-a-half
ing regular smoking, the output was the propor- consultation and underwent another one-hour fol-
tion of students who occasionally smoked. Based low-up examination at their home six weeks later.
on this, a model was used to calculate how many The control group received ‘general care’ during
years participation in the program would prolong the investigation period. The cost per capita in the
the life of the participants (life-year gained, LYG). case group was $ 583.8 per person, compared to $
The cost analysis took into account the production 281.3 per person in the control group. Quality-ad-
of the leaflets, the salaries of the lecturers and the justed life years were also calculated, resulting in a
possible health costs of later smoking. During the total excess of 0.184 QALYs in the case group over
one-year period of the survey, it was estimated that the four years after the program compared to the
the proportion of smokers in the SI + group in- control group (change in quality of life was meas-

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VI. Figure 2: The “emblem” of the Ottawa Charter (1986) on the arenas of health promotion
Source: own editing based on the figure [15] Su et al.

ured using EQ-5D-3L and SF-6D questionnaires). completely different programs in different sectors
Finally, it was found that the estimated cost per become comparable, in Hungary it is not recom-
ICAL (ICUR) ranged from $ 8,643 to $ 9,758, de- mended to use it in healthcare. The reason for this
pending on which quality of life questionnaire was - and the biggest disadvantage of this - is that in
calculated. If we know that the willingness to pay most cases it is difficult to quantify the health ben-
to finance a new, more expensive but more useful efits (LYG, QALY, number of avoidable deaths,
intervention in Sweden is $ 50,000 / QALY, the etc.) [10].
cost-effectiveness rate for this program is 87-93%
[9]. Example: In their study, Ichihasi et al examined an
occupational oral health program with a cost-ben-
VI.3.1. Cost-benefit analysis (CBA) efit analysis. The analysis compared three health
Cost-benefit analyzes allow for the widest compa- promotion programs: one in the first, 2-4 in the
rability of different technologies and interventions second, and 5-6 in the third, and a control group
by expressing both health gains and costs in mon- was established. The analysis was carried out from
etary terms. These studies have a clear set of crite- an employer perspective, so a comparison was
ria. If the monetary value of the benefits outweighs made between the costs incurred and avoided in
the costs, a positive decision must be made about the workplace, and it was also expressed which
the new technology. This is defined as either the program precedes or generates what expenditure
difference between the two values (net benefit, NB until the seventh year after its introduction. In de-
where benefit-cost> 0) or the quotient (benefit-cost termining the costs of the program, the following
ratio, BCR where benefit / cost> 1). The subject of were taken into account: the wages of the health
the study is considered to be profitable and useful care workers, the cost of the equipment used, and,
if this indicator is positive and as high as possible. as an indirect factor, the cost of the employee’s ab-
Although it is an indisputable advantage that even sence from work during the training / visit. The es-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

timated cost of dental care incurred during the sev- In the case of health promotion programs, the ex-
en years following the introduction of the program amination of the fulfillment of the third point and
was measured by benefit. The authors showed that its consideration by decision-makers is especially
the control group would incur $ 645.82 in dental important. An intervention can be positive in all
costs over seven years, with $ 719.84 in the first other ways, but if it is not accepted by the popula-
group, $ 522.14 in the second, and $ 528.65 in tion for some reason, it will not be effective either
the third. Based on these, the most effective oral [12]. For example, in the case of a special tax on
health program was the version in which work- unhealthy foods, it has been shown that if tax rev-
ers participated 2-4 times. The cost / benefit ratio enue is used specifically for health purposes, such
(BCR) here was 1.46, compared to the first (-2.45) as health promotion or screening programs, con-
and third (0.73) groups [11]. sumers will even accept a higher tax rate [13]. In a
survey by Brownell and Frieden, the tax on sugary
VI.4. How is the health economics analysis of a drinks received much more support from the pub-
health promotion intervention different? lic if they knew that the tax paid in this way would
The health economics analyzes described above help fight obesity.
are most commonly used to examine drugs, med-
ical aids, or medical devices. In 1995, the WHO VI.5. The relationship between health policy
set up a working group, in collaboration with three and health promotion
government agencies (Canada, the United States, If the effectiveness of a health promotion program
and the United Kingdom), with the goal of assist- is demonstrated through one of the above analyz-
ing decision-makers and practitioners in conduct- es, it is more likely to be achieved through pub-
ing health promotion analyzes. Although there has lic funding. After that, decision-makers can apply
been a growing interest in analyzes of preventive health promotion and health awareness measures
measures in recent years, there are still relatively in several fields. The WHO defines the following
few examples in the international literature com- levels through which interventions to address the
pared to health technologies [5]. A possible reason health status of society can be implemented (VI.
for this is that such assessments need to take into Figure 2).
account greater attention and compliance with oth-
er criteria. VI.5.1. Developing individual skills
In addition to cost-effectiveness, efficiency and This includes all activities by which individuals
safety, the effectiveness of a health-promoting in- can take control of their own health and acquire
tervention is also guaranteed by its applicability knowledge and skills (e.g. through education, ad-
(the joint fulfillment of the following three points), vertising) that consciously change their immediate
therefore it is worth examining these factors be- environment and lifestyle in the hope of a healthy
fore implementing it. life. This includes increasing the level of health
- Technical applicability. It specifies whether literacy, which has become increasingly important
sufficient resources (human resources, tools, in recent years and decades.
capacity) are available for implementation.
- Financial applicability. It shows whether VI.5.2. Support for community actions
the program is feasible depending on the Community health promotion relies on existing
amount of money available human and material resources in the community
- Social applicability. Does it indicate to increase the public’s “capacity” and willingness
whether the intervention is acceptable to to participate in health promotion processes. This
the target population, is there a tendency to requires full and ongoing access to information,
apply it widely among the population, thus health-related learning opportunities, and funding
guaranteeing its effectiveness? [3] Also re- support.
ferred to as the “capacity” of society. A good example of individual and community

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health promotion is a lifestyle change program system that contributes to achieving the longest
for children in the Mohawk community in Canada possible health. The reorganization of health ser-
(Kahnawake School’s Diabetes Prevention Pro- vices is primarily about the health sector focusing
ject, KSDPP). The beauty of the KSDPP is that more and more on health promotion and preven-
cultural specificities have been taken into account tion, not only on clinical and curative services.
in the organization of the project, thus increasing An example is the work of the Royal Australian
the willingness to participate. The program in- College of General Practitioners (RACGP). Em-
volved community-initiated local health care pro- phasizing preventive work, they have developed
viders as well as researchers to create a long-term, clinical guidelines for health professionals to help
sustainable program.In addition to the short-term them play a role in supporting smoking cessation.
goals (weight loss, increasing physical activity), This shift in emphasis in the workplace of Aus-
the prevalence of type 2 diabetes has also been re- tralian GPs means that health professionals are
duced [2]. focusing more on disease and disease prevention
measures [17].
VI.5.3. Creating a supportive environment
Living and working conditions have a significant VI.5.5. Public health policy
impact on health. Basically, both the work envi- Health policy efforts to prevent, promote and im-
ronment and leisure time should serve people’s prove the health of society can take many forms,
health. At this level of health promotion, the main including legislation (e.g. limiting salt consump-
goal is to create safe, stimulating, satisfying and tion in schools, introducing daily physical educa-
enjoyable living and working conditions. tion, benefits related to screening programs), fiscal
WHO has created a guide that focuses on mak- measures (e.g. special taxes on tobacco, alcohol,
ing the workplace healthier. They aim to provide high sugar beverages, etc.) and organizational
practical assistance to employers and employees changes (such as the creation of health promo-
in implementing a healthy workplace framework. tion offices). The key is based on the coordinated
According to this study, “a healthy workplace is operation of different sectors (health, income and
one where employees and managers work together social policy). Joint action will contribute to safer
to apply a process of continuous improvement for and healthier goods and services, healthier public
the health, safety and well-being of employees and services and a cleaner, healthier environment [18].
the sustainability of the workplace, taking into ac-
count the needs identified: VI.6. Summary
• health and safety concerns in the physical In summary, in addition to efficacy and safety, it
work environment; is important to demonstrate cost-effectiveness in
• health, safety and welfare concerns in the health promotion interventions. In this way, we
psychosocial work environment, including can be sure to select and finance the most prof-
work organization and workplace culture; itable alternative from the available framework.
• personal health resources in the workplace; In addition, it is a characteristic of primary pre-
and vention activities that the capacity of individuals
• ways to participate in the community to im- (willingness to participate, change, etc.) should be
prove the health of workers, their families taken into account in planning, so the introduction
and other members of the community ” [16]. of such projects and the proper communication
of results to participants and decision-makers are
VI.5.4. Reorganization of the health care system of paramount importance. Programs supporting
Responsibility for health promotion is shared health promotion and health education must be
between individuals, community groups, health implemented at the individual, community and na-
professionals, health care institutions, and gov- tional levels. Last but not least, a healthy society
ernments. They need to work together for a health will boost the economy, as its members can contin-

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ue to work, take less time off work, so that overall, VI.7. Bibliography
more resources are allocated to public tasks, in- 1. World Health Organization (1986). The
cluding health care, in the long run. Ottawa Charter for Health Promotion.
World Health Organization, Geneva,
Switzerland, 1-2.
2. Sanjiv Kumar – GS Preetha (2012).
Health Promotion: An Effective Tool for
Global Health. Indian Journal of Commu-
nity Medicine. 37, 1. szám, 5–12.
3. Ligia de Salazar – Suzanne Jackson
– Allan Shiell – Marylin Rice (2007).
Guide to economic evaluation in health
promotion. Pan American Health Organi-
zation, Washington D.C., 11-14.
4. Boncz I – Csákvári T – Ágoston I –
Endrei D. (2015). Új egészségügyi tech-
nológiák befogadása a társadalombiztosí-
tási támogatásba. In: Boncz Imre (szerk.):
Egészségpolitikai esettanulmányok. Me-
dicina, Budapest, 17-32.
5. World Health Organization European
Working Group on Health Promotion
Evaluation – World Health Organiza-
tion Regional Office for Europe (‎1998)‎.
Health promotion evaluation: recom-
mendations to policy-makers: report of
the WHO European Working Group on
Health Promotion Evaluation
6. Csákvári T – Ágoston I – Endrei D
(2015). Hatékonysági mutatók az egész-
ségügyben. In: Boncz Imre – Sebestyén
Andor (szerk.): Egészségbiztosítási isme-
retek. Medicina, Budapest, 77-85.
7. Jeff Tzeng – Christopher Jankosky –
Hayley Hughes (2012). Cost-minimiza-
tion analysis of the U.S. Army accession
screening and immunization program.
Military Medicine, 177, 12. szám, 1508-
1512.
8. SM Vijgen – PH van Baal – RT Hoog-
enveen – GA de Wit – TL Feenstra
(2008). Cost-effectiveness analyses of
health promotion programs: a case stu-
dy of smoking prevention and cessation
among Dutch students. Health Education
Research, 23, 2. szám, 310-318.
9. Lars A. Hagberg – Hilde K. Brekke –

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Fredrick Bertz – Anna Winkvist (2014). cal Education. https://www.pdhpe.net/

Cost-utility analysis of a randomized better-health-for-individuals/what-stra-
controlled weight loss trial among lac- tegies-help-to-promote-the-health-of-in-
tating overweight/obese women. BMC dividuals/the-ottawa-charter-as-an-
Public Health, 14: 38. effective-health-promotion-framework/
10. Az Emberi Erőforrások Minisztériuma reorienting-health-services/ [2021. 04.
szakmai irányelve az egészségügyi tech- 19.]
nológia értékelés módszertanáról és en- 18. Health promotion action means. Wor-
nek keretében költséghatékonysági elem- ld Health Organization. https://www.
zések készítéséről (2017). Egészségügyi who.int/teams/health-promotion/enhan-
Közlöny, 66, 3. szám. 821-843. ced-wellbeing/first-global-conference/
11. Ichihashi Toru – Muto Takashi – Shi- actions [2021. 04. 19.]
buya Koji (2007). Cost-benefit analysis
of a worksite oral-health promotion prog-
ram. Indurtial Health, 45, 1. szám, 32-36.
12. Hajdú J – Vajda R – Danku N – Boncz
I – Horváthné Kívés Zs (2016). Attitude
and Willingness To Participate on Scree-
ning of FirstDegree Relatives of Colorec-
tal Cancer Patients. Value in Health, 19,
7. szám, A619.
13. Chantal Julia – Caroline Méjean – Flo-
rence Vicari – Sandrine Péneau – Ser-
ge Hercberg (2015). Public perception
and characteristics related to acceptance
of the sugar-sweetened beverage taxation
launched in France in 2012. Public Health
Nutrition, 18, 14. szám, 2679–2688.
14. Kelly D. Brownell – Thomas R. Frie-
den (2009). Ounces of prevention – the
public policy case for taxes on sugared
beverages. New England Journal of Me-
dicine, 360, 1805–1808.
15. Yi-Erh Su – Marguerite Sendall – Ma-
rylou Fleming – John Lidstone (2013).
School Based Youth Health Nurses and a
true health promotion approach: The Ot-
tawa what?. Contemporary nurse, 44, 1.
szám, 32-44.
16. Joan Burton – World Health Organi-
zation (‎2010)‎. WHO healthy workplace
framework and model: background and
supporting literature and practices. World
Health Organization, Geneva, Switzer-
land, 2-123.
17. Reorienting health services. HSC Per-
sonal Development, Health and Physi-

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Chapter VII.
VII. COMMUNICATION
(ORSOLYA MÁTÉ)

VII.1. Characteristics of health communication health appointments, yet health communication is

In addition to examination, diagnosis, and treat- generally not a mandatory part of medical training
ment, health communication is one of the most [2]. Most healthcare workers try to acquire these
notable tools for recognizing and treating health skills in a self-educated way [7]. As communica-
problems [1] Listening to and understanding ver- tion is an interactive process, patients also need
bal complaints allows the caregiver to explain the some expertise to be able to participate in deci-
information received in the light of the patient’s sion-making [5].
mental and social characteristics, giving a more
complete picture of the origin of the complaints Models of health communication
[2]. Healthcare communication is the basis of The relationship between healthcare workers and
the caregiver-patient relationship. With the help patients worldwide has undergone significant
of communication, the caregiver and the patient changes since the 1960s [8]. This development
can establish a relationship that can help achieve is primarily facilitated by the personalities, expe-
therapeutic goals. However, using it in everyday rience and professionalism of the caregivers and
life is not always problem free: “The gap between the patient. Other determinants play a role in the
the physician and the patient is gradually widen- process, such as the current spirituality of the age,
ing first due to the rapid development of scientific the advancement of technology and the concomi-
knowledge and secondly, the diagnostic process tant expansion of material knowledge, the grow-
based on these principles, and thirdly, doctors are ing recognition of the right to self-determination,
less motivated to understand why the patient is ethical constraints, legal provisions and changed
asking them assistance ”[3]. Health communica- medical possibilities themselves [9]. Research on
tion is extremely affected by comprehension prob- health communication has had recurring findings.
lems thus the patient rarely leaves his or her doctor Many patients were dissatisfied with the way car-
satisfied [4]. Patients’ low satisfaction is not due egivers communicated with them and many car-
to feelings of professional incompetence, but is egivers complained that patients did not follow
often due to unsatisfactory health communication their advice and did not follow treatment instruc-
[2]. Studies have shown that patient satisfaction is tions [10]. One of the most influential models of
highly dependent on the quality of communication health communication was Ley’s cognitive model.
experienced during the diagnostic and therapeutic (VII. Figure 1)
procedures [5].
There are concrete benefits to good health commu- Patient satisfaction and cooperation are strongly
nication. Effective communication also influences related to the understanding of what is provided
the outcome of therapy, which can be measured by caregivers and the extent to which the informed
through the experiences of emotions, symptoms, person can recall the information understood. Pa-
and pain [6]. Overcoming difficulties in a health- tient satisfaction can be increased by raising the
care caregiver’s communication skills can be ad- level of understanding and exercising the retrieval
dressed through appropriate training. A doctor’s of understood information [11], although the satis-
practice typically involves more than 150,000 fied patient shows much greater cooperation.

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VII. Figure 1: Communication model of satisfaction and collaboration

(Ley et al, 1976)

The other important model in this field is hall- incredibly rapid development and expansion that
marked after Korsch [12]. After analyzing 800 greatly held back the motto of “the doctor, the
consultations conducted in children’s hospitals, he best medicine” [16]. The focus is no longer on the
concluded that patient satisfaction depends on the patient but on the disease as a challenge to over-
affective behavior of the caregiver. When empa- come. Von Uexküll, the founder of psychosomatic
thy, the patient’s acceptance of emotions is absent medicine, calls today’s technically advanced but
in communication, patient satisfaction is reduced. non-patient centered medicine as the silent treat-
While Ley focuses primarily on cognition, Korsch ment of disembodied souls and soulless bodies
builds on the determinants of successful communi- (stumme Medizine) [18]. Although patients ac-
cation on affectivity and social interactions. During knowledge and appreciate the importance of sci-
the encounter between the health care provider and entific methods in care, they are nevertheless more
the patient, two groups of patient needs can be dis- dissatisfied and critical of care than ever before
tinguished [6.]: the cognitive need for information [5]- it is thus the spread of the biomedical model,
(to know and understand) and the emotional need which has been undermined since the end of the
to feel “taken seriously” (to know and understand) twentieth century by the rise of the bio-psychoso-
[6]: In response, the provider also considers two cial model and holistic healing.
different patterns of behavior, that is instrumental
behavior and affective or socio-emotional behav- VII.3. Insufficient communication training for
ior. The first involves competencies such as asking health care providers
questions and giving information, while the sec- As a result of the spread of technology and sci-
ond provides answers to expressions of emotion, ence, medical and health science training is strong-
such as expressing empathy and interest [13,14]. ly science-based. In addition to processing a large
Disorders in health communication amount of scientific material, there is often not
Communication conflicts not only make the trans- enough time left to master the basics of commu-
fer of information more difficult, but also poten- nication and conversation management techniques
tially impossible [15]. [18]. Even possible knowledge of communication
theory has no opportunity to be incorporated into
VII.2. Possible causes of communication prob- practice, as students have relatively few opportu-
lems nities to come close to a patient. Although they
The depersonalization of healing have the material knowledge, due to the shortcom-
In the twentieth century, the medical diagnostic ings of communication training, they start their
technique and imaging procedures underwent an careers with very little practical experience in the

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psychological management of patients. The short- revealed to him or her. Although patients have the
comings of communication training are then soon right to information, they are still overly inhibit-
revealed [19]. In addition to a depressing sense of ed to ask back [1]. However, according to a study
responsibility, a compulsion to perform, and an published by Fallowfield [24], responding phy-
initial sense of professional insecurity, beginning sicians identified cultural and ethnic differences,
health professionals are even struggled that they generational problems, patient emotional respons-
have not had the opportunity to learn and practice es, and patient projections as the major causes of
how to communicate with patients. According to communication difficulties.
Herschbach (1991), 90% of physicians are touched
by “possible long-term suffering of patients’, “the VII.5. Consequences of communication disor-
crying patient” if “the patient does not realistical- ders
ly see his/her chances of recovery”. Difficulties in Impacts on caregivers
starting a career can lead a doctor to try to move Burn Out Syndrome
emotionally away from patients, raise a wall and Ramirez et al [25] describe that providing health
keep a distance, and try to keep communication care providers with the opportunity to develop
to a minimum [20]. The doctor defends himself their communication skills to meet their patients’
against mental burdens by avoiding communica- information and emotional needs more confidently
tion [1]. [11, 6] could reduce the psychological burden on
caregivers and their daily stress and would have a
VII.4. Communication gaps in the interaction much lower risk of burnout.
between healthcare providers and patients
Patients usually complain that their health pro- VII.6. Effects on the patient
fessionals communicate little with them, focus- Patient dissatisfaction can negatively affect con-
ing mainly on problems and information, are not sultation with a physician [27]. It can range from
friendly, smile little, do not greet them, hold hands, medical malpractice or the use of alternative ther-
and do not listen if they want to tell what they think apies.
about treating their illness [21]. The study showed Non compliance
when a patient starts talking or asks a question, the Of all the factors that may affect compliance, fac-
doctor usually interrupts him or her after 18 sec- tors attributable to deficiencies in health commu-
onds. According to Waitzkin [22], in a 20-minute nication predominate. Only in a caregiver-patient
physician-patient consultation, physicians spent relationship characterized by proper communica-
just over one minute per patient to inform them, al- tion can a caregiver achieve that his or her patient
though physicians considered this 60–70 seconds is so confident that he or she is willing to believe
to be 9 minutes. Tuckett [23] also describes in his that the therapy the caregiver is proposing will use
study that 36% of patients with whom their doctor and the patients behave accordingly [27]. Accord-
made a diagnosis and outlined the significance of ing to studies published by LEY [1] and LAZA-
the illness did not understand what the doctor had RE [21], 50% of patients do not take prescription
told them. Communication disorders may also be medications properly because they are not aware
due to the patient’s lack of understanding of the of their significance. Patients ’non-follow-up be-
terms used by the physician. According to a study havior plays a major role in the patient’s eventual
in Basel, where 88 patients were asked immediate- hospitalization, and this has negative effects on the
ly after detailed medical information if they under- economy.
stood the nature of their disease, only 55% were
fully aware of their disease, 29% understood about Initiation of malpractice lawsuits
what the doctor said, and 19% understood less and In the event of treatment failure, patients who were
14% of patients did not understand at all what the dissatisfied with their physician’s communication
doctor said and the nature of the illness was not are much more likely to launch a revenge cam-

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paign against the physician, which may take the patient has the inviolable right to make decisions
form of initiating malpractice lawsuits [5; 28] about matters affecting his or her own body, but it
is ethically correct for decisions to be made with
VII.7. Models of the relationship in health care the fullest medical advice available [30]. One of
There are basically three models in the literature, its benefits is that it helps build a caregiver-patient
each with a different caregiver-patient relation- relationship because the caregiver treats the pa-
ship and a different way of decision-making. From tient as a partner here. But there is a small group of
Schofild’s [29] research, we can also get an idea patients who do not want information about their
of which model information is preferred by pa- condition [31]. For these patients, this model of-
tients: He asked 2,000 incurable patients about the fers no alternative.
amount of information they wanted. Nearly 60%
of patients said they expected immediate and com- 3. Personalized communication
plete information from their doctors, 16% did not According to this model, the amount of informa-
want to be informed, and a quarter of patients vot- tion provided and the level of information is de-
ed in favor of gradual disclosure. termined by the needs of the patient. This process
presupposes a certain level of mutual trust and
1. The non-communicating (paternalistic) model communication, the development of which takes a
The oldest model, its roots originate from Hip- lot of time and work [32]. Decisions are made by
pocrates. The role of the father (patron) refers to the partners (caregiver and patient) together, so the
the doctor / health care provider, the patient is the caregiver’s expertise and the patient’s knowledge
child who owes him unconditional obedience. Ac- of his or her own needs and values prevail [32].
cording to the model, the caregiver, as an expert, Optimal communication is a time-consuming pro-
is best placed to decide what is in the patient’s best cess in which the provider constantly monitors the
interest. Based on his or her expertise, the patient patient’s need for and receptivity to new informa-
is able to choose the treatment that seems most tion, and also checks the degree of processing of
effective. Its temporary advantage, according to previously received messages [33]. “Although the
Donovan, is that the patient is not confronted with model of personalized communication takes time
the facts immediately and irrevocably. “Non-con- and skills - and the busy doctor may feel that he or
frontation” as an individual coping strategy may she does not have them - it is still the best model,
be temporarily important to the patient. as the underlying assumptions are supported by
Disadvantages include that the lack of honesty and data from the literature. Furthermore, in today’s
openness places a significant strain on the caregiv- consumer world, the emphasis here is on consen-
er- patient relationship and the patient may feel sus, so that the patient’s quality of life can be made
that he or she has lost control of his or her own the best ”[30]. Nevertheless, for a long time, the
life, on the one hand, and that the patient and their university did not teach the delivery of bad news
relatives do not have room to deal with problems that it is medical competence to decide how much
and losses on the other. The temporary relief for fact to confront a patient at once, and all of this
the caregiver lies in the fact that he or she does affects the quality of communication.
not have to communicate bad news to the patient,
which usually places a mental burden on caregiv- In the late 1990s, however, the previously pater-
ers [30]. nalistic approach was gradually replaced in An-
glo-Saxon countries by a different approach, per-
2. An all-encompassing model sonalized communication. 96-98% of patients with
The model is primarily based on the fact that the a life-threatening illness expect to be informed
patient has the right to all information about him about their illness [34]. Although the patient has
or her so that he or she can then make responsible the right to know about problems affecting his or
decisions about his or her treatment. However, the her health and life, it is not his or her duty to be

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informed about the nature of his or her illness. Labor Convention on the Rights of Persons with
This basically means that the patient has the right Disabilities and its Optional Protocol. The fact of
to decide how much they want to know. As the ag- disability in communication with people with dis-
ing of society, the health status of the population, abilities is often easy, but can be even more diffi-
the growing cost requirements of the health care cult barrier to overcome in everyday communica-
system, waiting lists and the shortage of doctors tion. However, it is essential to bridge it [37] as the
are serious challenges in Hungary as well. In most right to satisfactory communication also applies to
OECD countries, Advanced Practice Nurse (APN people with disabilities.
MSc) training and careers have been introduced to
address these issues. According to the definition The use of special communication methods and
of the International Council of Nurses (ICN), this tools can significantly improve the quality of life,
MSc nurse has specialized decision-making skills independent living and social inclusion of people
and a wide range of competencies in clinical prac- with disabilities, including in the field of com-
tice. The MSc nurse with extended competence is munication. Among the sources of frustration for
able to provide a service equivalent to a doctor in a people with disabilities, it is worth highlighting
number of areas, as well as to establish a direction- communication difficulties. An essential condi-
al diagnosis and develop a treatment plan in a reg- tion for the survival of every living being is to be
ulated manner (Enabling the extension of compe- able to communicate adequately with its environ-
tence EMMI Decree 18/2016 (VIII.5.) [35]. Given ment. If communication with the environment is
that a job development and regulatory framework hindered for any reason, the individual may be
for expanded MSc nursing training is expected in severely damaged as a result. In a non-accepting
the near future, nurses with extended competence environment, a person with a disability is expected
will soon be in positions where they will need to to communicate at a higher level than he or she can
communicate the diagnosis and share the treat- do with all his or her strength. Although it brings
ment plan similar to a physician’s competencies. out the maximum in himself or herself, the envi-
After all, as a first step in providing information ronment does not understand him or her; people
about the diagnosis, the caregiver should assess are dissatisfied with the person, and they give in-
how much the patient wants to know about his or numerable signs of their dissatisfaction, which can
her own condition and shape the conversation ac- be a raised eyebrow, a clenched mouth, a wave, or
cordingly [8]. even a depressing remark [38]. However, it is also
worth considering people with disabilities as a ho-
VII.8. Situations requiring special communica- mogeneous group, as the nature and types of disa-
tion bility strongly determine the characteristics of the
Communication with people with disabilities communication with them. In the following, we
Disability is a long-term physical, intellectual, will try to provide some important guidelines on
psychosocial or sensory impairment that, together the communication corner points that may affect
with a number of other barriers, can limit a per- the success of communication based on the nature
son’s full, effective and equal participation in so- of the injury or disability.
ciety. Disability is a changing concept; anyone can
become disabled at any time. Disability does not VII.9. The role of health communication in pre-
exclude health: it is not a disease but a condition vention
that results from the consequences of the interac- Properly implemented health communication is
tion between people with disabilities and attitudi- essential in disease prevention. Through com-
nal and environmental barriers. These barriers pre- munication, patient education, and counseling
vent a person with a disability from participating techniques in patient care, you can increase the
fully and effectively in society on an equal basis effectiveness of a caregiver in preventing and
with others [36]. Ministry of Social Affairs and recognizing health problems and illnesses early.

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VII. Table 1: List of terms recommended and avoided when communicating

with people with disabilities

Term to avoid Suggested term Meaning, Note

Sick, crippled injured, in need of help

injured, in need of help,

Sick, crippled
Disability
disabled, injured, blind, deaf as fhuman, person with visual, its extensive use makes the style
a noun hearing impairment difficult
the word lame means only in
slang: clumsy, dull, stupid.
Person with disability, person
Disabled, lame, crippled originally and fundamentally
with paralysis
impaired in movement (paresis,
plegia)

forced into a wheelchair Person with wheelchair

the blind interpret the sightless

sightless Visually impaired person as deprived of the world in
Hungarian
for the deaf, the word deaf
deaf Hearing impaired person means loss of hearing or stupid
in Hungarian
pointing To sign, sign language Use of sign language

Sign language Sign language Independent language

dwarf, dwarf growth person with achondroplasia

(Sérültek.hu, 2020)

Appropriate communication techniques, as seen in the further process of treatment according to a

in a number of examples in the literature in the common decision-making model. A wide range of
previous chapter, increase the satisfaction of both secondary prevention interventions require us to
caregivers and patients and, last but not least, im- use the right counseling and patient information
prove the health outlook. If you think about it, pri- techniques and to communicate effectively, as well
mary prevention is essentially a communication as the need to adhere to the potentially small ele-
task. Guides, patient information, and risk reduc- ments of lifestyle change. Complex and / or con-
tion for behavior change rely heavily on sophisti- troversial screening tests (eg PSA test) explicitly
cated counseling techniques. require the caregiver to be involved in informing
In the future, caregivers at all levels of prevention patients and co-deciding why the patient needs
must also be prepared to make effective use of pa- this screening test and whether he or she really
tient education techniques under the auspices of needs it. [39]. Invasive screening procedures (e.g.,
prevention and to come to terms with their patients cervical cancer screening) and physical examina-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VII. Table 2

The nature of the disability Proposed means of communication

Different skills and needs require different communication

even in the presence of an attendant, talk to the communication partner

Mentally handicapped
persons clear, concise wording of the instructions

Don’t be frustrated if you have to repeat yourself.

Don’t end his or her words or sentences instead.

Symptom Proposed means of communication

disturbance of reality
Be simple and purposeful
perception

difficulty concentrating Be short, repeat yourself.

Do not force the conversation, limit the

Stressful condition
information
poor judgment Don’t expect rational conversation
dominance of the inner
Gain the client’s attention first.
world
Recognize the restlessness, the cause, and
Restlessness
find a way out.
Pszichiátriai és mood swings Don’t take words to heart.
szenvedélybetegek
Stick to the justification of the original plan,
fluctuations in plans
the reasons can be reconsidered

To be interpreted as a symptom, do not

little empathy for others
classify the person

Retreat Start a conversation

belief in delusions Don’t argue.

Fear Stay calm

lack of security the client should feel the acceptance

low self-esteem Stay positive and respectful

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VII. Table 3

The nature of
Proposed means of communication
the disability
avoid shouting
verbal introduction
in the case of a group conversation, name the participant
to activate the attention by naming the addressee, offering assistance, only in specific situa-
tions, upon request
Blind and avoidance of terms that are related to vision (there, here) in guidance. Correct: to the right,
visually left, in front of, behind, etc. in relation to the blind or / visually impaired person, offering an
impaired arm, avoiding revolving doors, showing a handrail, giving attention on an escalator when
stepping on, specifying a waypoint in open terrain
providing information when an object is moved by the interlocutor

recommended: Arial 18 bold, optimal brightness, shape for printed text

direct your communication to the disabled person, ask him / her questions, feel free to use
words to see and watch
seeing position when contacting
visibility is important when reading from the mouth: illuminating the room, avoiding exces-
sive lip movement, covering the mouth
Deaf and hard written communication is preferred, it is important to reduce background noise
of hearing
avoid shouting, communicate with concise questions
even in the presence of a sign language interpreter, speak to the communication partner
distinguish between deaf and deaf-mute
avoid presuppositions, gain certainty about the possibility of understanding speech
shouting is not an option, it is not about deafness
patience, don’t take the speech, don’t pretend to understand if you don’t understand some-
People with thing
speech and
language in case of misunderstanding, ask him/her to say it in other words
disorders Accept it if, despite all your efforts, you still don’t understand what you want to say.
Never assume that someone with a speech impediment does not understand what you are
saying, although he/she may need some means of communication (a communication board,
a speech device).
aligning gazes is important, sitting position, eye level communication
even in the presence of an attendant, talk to the communication partner
shouting is not an option, it is not about deafness

People with avoid paternalistic gestures (head slapping or shrugging)

reduced mobility simplification is unnecessary

in the case of transport, there must be an empty route to the destination and there must be an
empty seat without a chair in the meeting and in the restaurant

push the wheelchair only on request, avoid leaning on the chair

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tions (e.g., pelvic, prostate, rectal, and testicular prevention-friendly outpatient setting, conveying
examinations) require explanations and empathic the message that health promotion and disease
responses to relieve the patient’s anxiety or dis- prevention are important priorities and topics for
comfort [40]. Finally, self-examination techniques discussion, e.g. within the community of practice.
for early detection (e.g., breast, testes, and skin)
require effective demonstration and educational Information tasks and prevention advice
skills. [41, 42] Tertiary prevention to reduce dis- Information and patient information tasks related
ease complications using only appropriate patient to prevention counseling can be divided into five
educational communication techniques can be re- categories:
ally effective. (1) Information leaflets for the detection of certain
End-of-life prevention (treatment of avoidable anomalies,
symptoms and suffering) is one of the most com- (2) Risk assessment through medical history and
plex tasks in health communication [43]. assessment of risk behavior; (3) primary preven-
Regarding prevention counseling, three main tion messages to patients to avoid risk, exposure,
categories of communication tasks can be distin- or disease;
guished: (1) information tasks and counseling, (4) Counseling to change unhealthy / risky behav-
(2) improving compliance with healthy lifestyle iors and / or introducing healthy behaviors,
recommendations, and (3) communicating with (5) Teaching patients about self-examination tech-
patients about screening and other procedures per- niques. In some areas, information on the use of
formed under the auspices of care. It is important special information or screening protocols, and the
to consider the social and organizational environ- use of behavioral and motivational information
ment in which these services operate because they techniques are important.
can have a positive or negative impact on preven-
tive care and patient openness. Systemic effects on VII.10. Screening
patient openness may include the patient’s cultural In the Anglo-Saxon countries, the use of so-called
and living conditions, personal values and barriers filter scales is extremely common, e.g. to screen
to accessing health care, physical and emotional for mental health problems (depression) or addic-
barriers, and general societal norms and expecta- tion problems (alcohol, drug smoking). The CAGE
tions. Impacts on the provider include difficulties mosaic questionnaire contains [45] 4 validated,
and motivational factors in the health care system simple and straightforward items, and is widely
(e.g. reimbursement, availability of prevention used to screen for alcohol-related problems:
procedures, available resources and other incen- C— Have you ever tried to reduce your alcohol
tives or disincentives for providers), generally consumption?
accepted standards of care and the cultural living A — Have you had a problem with your drinking
conditions of the provider, working environment habits in your family?
and personal values. The quality of the physical G— Have you ever felt guilty for something you
environment during care can have a positive effect did under the influence of alcohol?
on the atmosphere of preventive care. Reminders E— Has it ever happened that you started drinking
for caregivers and patients can encourage discus- alcohol in the morning to calm your nerves or be-
sion and appropriate follow-up of prevention inter- cause you felt “weak”?
ventions. Health promotion posters carry positive
prevention messages, contribute to patient educa- Gaining patient co-operation is crucial, thus given
tion, and can serve as a reference for discussion. the sensitivity of patients, it is worth considering
Patient education materials available in a health- the design of screening questions that, for exam-
care setting are tools for patients to take with them ple, questions about alcohol consumption may fol-
to carry out prevention tasks at home. Together, low questions about nutrition.
these approaches form reinforcing messages in a The questions can be introduced in a non-judg-

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

mental way if we say, “I ask these questions to all VII.12. Primary prevention advice
my patients.” Asking screening questions to all pa- The objectives of primary prevention counseling
tients gives the impression of routine. The answers focus on avoiding the onset of lifestyle risk behav-
to the questions to be decided must always be neu- iors or avoiding possible active intervention in the
tral and impartial; the answer cannot be “great” prevention of pregnancy. In pediatrics, practical
or “correct,” because a different answer to anoth- guidelines for parents help with primary preven-
er question may raise a patient’s suspicion that tion, predicting the developmental milestones a
something is wrong with their answer. The patient child is likely to show at a particular stage of de-
should receive accurate, objective feedback on velopment, and providing guidance and support to
their results: “What you told me seems to be (you parents [47].
have a memory problem; you would feel a little Such guidelines can be used at any stage of a pa-
depressed, etc.).” The patient’s feelings about the tient’s life, especially when the risk of initiating
accuracy of the feedback should be checked and unhealthy behaviors increases. For example, older
the rationale for the patient’s situation revealed. adults on the verge of retirement may be at risk of
returning to unhealthy drinking habits, while those
VII.11. Risk assessment experiencing divorce may be at higher risk for
The risk assessment is based on the entire medi- STDs. Thorough psychosocial data are needed to
cal history, and thus the provider’s communication determine the factors that may predict the possibil-
competencies play a crucial role in how explora- ity of unhealthy lifestyle changes. Prior guidance
tory it can be. In order to assess the risk, it is im- and other primary prevention messages should be
portant to assess the level of relevant risk behavior tailored to the patient’s level of development, so-
and to assess the potential environmental exposure cial and cultural background, and family and soci-
to hazardous substances. The discussion about risk etal risk factors.
and risk quantification uses complex and abstract
concepts and is influenced by the communication Suggestions for primary prevention counseling:
attitude and possible bias (both positive and neg- • Ask the patient to express his or her feelings
ative) of the doctor and the patient. For example, and thoughts about the risk behavior (“what
patients have been shown to overestimate the risk do you think about everyday alcohol con-
of developing breast cancer or dying from breast sumption?)
cancer. When asked, 37% of women overestimat- • Ask the patient to take a position on how he/
ed the risk of developing breast cancer and 77% she want to avoid the risk behavior
overestimated the risk of death from breast cancer • Ask the patient to identify any inhibitory or
by 10 or more [45. ]. Too much information pro- supportive factors that may influence him/
vided at one time can also result in patients not her to avoid or try a particular risk-taking
being able to interpret it correctly [46]. behavior (“What would make you try (the
The concepts of absolute and relative risk are diffi- behavior)? What is the reason for not trying
cult to understand and even more difficult to com- it?”
municate. The risk should be accurately assessed
and communicated correctly without unduly in- Find out the patient’s current avoidance strategy
timidating or conveying a false sense of security to • Reinforcing positive behaviors, feelings,
the patient. This requires expertise and experience. values, beliefs, and strategies
The “ask back” technique assesses both interpreta- • Propose additional / alternative strategies
tion and response, asking the patient to respond to • Discuss a mutually acceptable plan
what is said. This allows the physician to correct • Strengthening partnership and support
inaccuracies or misconceptions, and reflection is • Planning for follow-up and control.
helpful in clarifying and treating fears and anxi-
eties.

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Health - related behavior change and problem-solving for the next step toward
The U.S. Prevention Services Task Force [48] behavior change. Alternative strategies, an
recommends counseling about health behaviors if interactive discussion of ways to overcome
there is a strong link between behavior and expo- obstacles, pre-targeting, clear and compre-
sure to the disease or risk. hensible instructions, and guidance on how
It is advisable to advise patients to change ex- to implement the next steps are part of the
isting health behaviors that could lead to serious process.
illness and death. In earlier chapters of this book, • Follow-up is often a neglected key element
Prochaska and DiClemente [49] have already dis- during a short outpatient consultation. Time
cussed the transteoretic model of behavior change, follow-up would allow the caregiver to
and Miller and Rollnick [5] have demonstrated evaluate the successes and setbacks of the
the effectiveness of motivational briefings. Other behavior change process, provide positive
counseling protocols, such as 4As - Ask, Evaluate, reinforcement in effective strategies, and
Advise, and Help [51] also provide a useful frame- help the patient address challenges and frus-
work for planning counseling messages. Coun- trations.
seling methods that help patients change their
health behaviors to promote prevention have the VII.13. Self-examination
same basic elements: assessment, feedback, coun- Teaching self-assessment methodology requires
seling, assistance, and follow-up. both knowledge of testing techniques and its lim-
itations and a practical understanding of effective
The process of assessment: Determining the se- teaching strategies. Self-examinations — exami-
verity of the problem, the patient’s perception of nation of the breast, testicles, and skin — require
the problem, how the behavior has affected the pa- proper technique, tactile and visual skills from the
tient’s life, what they have tried to do in the past, patient. This can be done through demonstration,
what worked and what did not, and how the patient practice (on its own and on demonstration tools)
currently wants to change the behavior. Evaluation and the use of additional educational materials to
is effective when it is done in a supportive way and help patients. The patient should always be given
without judgment. The use of open questions and the opportunity to present the examination proce-
active facilitation is a key element. dure to the physician so that erroneous techniques
• Feedback is important to clarify the issue and misunderstandings can be corrected.
to be addressed and to verify the accuracy
of the data previously collected during the VII.14. Adherence to lifestyle advice
assessment phase and to confirm the con- Adherence to lifestyle changes, risk reduction,
sequences of the patient’s behavior. An im- self-assessment, self-monitoring protocols, and
portant element of effective feedback is the chemoprophylaxis or chemoprevention, they all
establishment of an explicit link between the play important roles in prevention counseling. Em-
behavior of interest and the perceived prob- phasis on adherence to lifestyle advice is needed at
lems and / or personal goals of the patient. all levels of prevention, not only in primary pre-
• Counseling allows the doctor to make clear vention (avoiding risk and / or disease) but also in
recommendations for changing behavior. secondary (early detection) and tertiary prevention
Counseling should be tailored to the pa- (reducing complications by adhering to treatment).
tient’s health and personal goals, the patient’s
available resources, and their willingness to Compliance with lifestyle advice is monitored
change. A list of options or alternatives for to determine if the patient is successfully on the
the patient to choose from facilitates the path assigned to him or her. The easiest way is to
partnership between physician and patient. interview the patient. Further information can be
• Assistance includes both informing patients obtained from laboratory or radiological findings.

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

For the patient, feedback in the event of failure cation. This includes vaccination, blood pressure,
should be non-judgmental and understanding. We blood sugar, but even body weight or abdominal
also need to give the patient feedback on where volume measurement. These screenings also re-
he or she may be wrong in his or her argument quire the same communication technique as a
for giving up his or her commitment to a healthy screening that seems more serious to the patient,
lifestyle. Empathy, legitimacy, respect, support, e.g. colonoscopy. It is also necessary to describe
and partnership are especially important to make the course of the examination and to explain the
the patient feel that they understand, accept, and to results.
avoid the patient’s defensive attitude.
VII.17. Communication in specialist care
VII.15. Referral for screening The communication tasks in specialist care for
Several studies have shown that the recommen- screening tests also depend on the patient’s knowl-
dation of health professionals is one of the most edge or previous experience of the procedure. It is
important factors influencing a patient’s decision important to assess the degree of prior knowledge
to go for a screening test. It may be successful to e.g. with a simple question: “What is your opinion
recommend a screening test to a patient if he or on e.g. Influenza vaccination? ” At the same time,
she understands the importance and effectiveness the caregiver is given a chance to learn and im-
of the screening test in prevention. The following prove the patient’s information, possible little in-
communication elements can help in this situation: formation and misunderstandings. It is also impor-
• Inform the patient about the purpose of the tant to review any past unpleasant experiences so
procedure, what to expect, how to make the that the patient can calm down or the doctor may
necessary preparations (e.g. colonoscopy). suggest behavioral strategies that may help over-
Information about possible side effects, pain, come fear or discomfort during the examination. If
or discomfort will help the patient prepare. the patient has not yet taken part in such an exam-
• Knowing a patient’s biases about the test can ination (e.g. first pelvic examination, cervical can-
help us dispel their fears and convince him cer screening, rectoscopy), the caregiver may ask
or her of the need for the test. what the patient has heard about the procedure and
• Leaflets and patient education information clear up any misunderstandings. The presentation
materials can be an effective help, as these of the instruments and additional information us-
materials “accompany” the patient home, in ing demonstration tools and / or simple diagrams
calm conditions at home, regardless of the will help the patient to understand the procedure.
time factor, it is possible to review the de- Dealing with any discomfort and pain during the
scription several times, which is an impor- examination is a complex communication task.
tant step in coping. It is also important to gain the trust of the patient
• Discussing the results of the screening test that each manual step of the examination should
is an important step in treating the patient, be preceded by an explanation of what is going
even if the finding is negative. In this case, on, what and why the doctor is doing, and what
talk about the date of the next test, what risk it will feel like. Patients should be encouraged to
behaviors He/she should avoid in his/her let their doctor know if they are in pain or uncom-
lifestyle to be negative again. Partnership fortable. Also for the aforementioned reason, it is
and support, positive feedback, they are also often necessary to ask how patients feel and their
important here in the doctor-patient relation- efforts need to be perceived and evaluated. If an
ship [74]. examination is inevitably uncomfortable, patients
should be reassured that what they feel is normal,
VII.16. Communication in primary care it is necessary to pay attention to and respond to
There are also quite a few screening tests in prima- the patient’s facial expression. The patient should
ry care that require proper preventive communi- be treated empathetically if he or she is embar-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

rassed or feels humiliated by the test. also be part of the task of public health communi-
The explanation of the test results depends on cation. One of the most effective means of public
whether or not the results support this pathological health communication is mass communication,
process. If there is no abnormality, “everything is which is realized through the media. The media
fine”, “normal” and “healthy” are good words to generally means television, radio, newspapers and
communicate the results of the tests. However, if magazines. Their effectiveness lies precisely in
there is a suspicion that everything is not right, it is their ability to deliver messages to large masses
important to communicate with the patient that the simultaneously. Their weakness is caused by the
results are ambiguous for the time being. same mass use that the audience they reach is di-
verse and largely undifferentiated. This diversity is
When a problem is detected, adequate time should problematic in that in order for media messages to
be allowed for the patient to understand the mean- be effective, the messages must be designed spe-
ing of the findings, his or her feelings and concerns cifically for that target audience. To put it simply,
should be addressed, and he/she should be given what is for everyone is not really for anyone.
the opportunity to ask questions or raise concerns.
These should then be answered empathetically, The second, somewhat more specific group of me-
using appropriate communication techniques, pro- dia (targeted messages) is the means by which we
viding the patient with relevant information about can send messages to a specific group, which are in
additional screening methods, possible outcomes, the form of newsletters, booklets, self-help guides,
and therapy for any disease [52]. pamphlets, but which, due to their individualized
nature, target a limited number of people.
VII.18. The role of mass communication in
maintaining health However, there are overlaps between the two
There has been tremendous progress in recent years groups, as the distinction between mass and target-
in the innovative use of communication to address ed media messages is partly artificial in that even
public health issues. Public health communication mass messages can be made to some degree cus-
is defined as “the application of communication tomized. The use of the media by the target audi-
techniques and technologies to (positively) influ- ence is called “narrowcasting”, which can best be
ence individuals, populations and organizations to defined as “reaching a specific audience through
promote conditions conducive to human and envi- a special medium” and involves selecting media
ronmental health” [53]. The development of health channels and designing media content to meet the
education can be achieved mostly through health needs of a specific target group. A good example of
communication or public health communication. this is e.g. a television channel for viewers of the
same interest ”[53], e.g. Paprika TV or LifeNet-
According to AWHO’s European Regional Com- work.
mittee in 2011, EPHO (Essential Public Health
Operation) [54] considers communication as: Use of mass communication in public health com-
munication
“Public health communication aims to improve Basically, we distinguish the following uses of
the basic health knowledge and health status of in- mass communication in relation to preventive
dividuals and populations.” health communication.
People with inadequate health education spend
more time in hospital and use the health care sys- It can work:
tem more often than patients with high health edu- 1. in the instructor function,
cation, and have more difficulty following medical 2. in support function,
instructions and judging the authenticity of health 3. in promotional function,
information [55]. Influencing health education can 4. in additional function.

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1. In its function as an instructor, it is the pri- introduce products and services that change
mary and only means of achieving certain health behaviors to members of the commu-
health promotion goals. There is already nity, and to encourage the audience to call,
ample evidence that some messages in the write, or participate in programs. This is per-
media alone can effectively change harmful haps the most common role of the media in
health behaviors or be a good tool in pre- health promotion and is probably best known
vention. During 1984 and 1985, the Kellogg to the public. Regarding a smoking cessation
Company developed a nationwide media program, King et al. [58] examined how par-
campaign to promote high-fiber cereal con- ticipants learned about the campaign with
sumption and the NCI Cancer Information the help of television advertisements for
Service toll-free number. The campaign social purposes, newspaper advertisements,
consisted of seven 30-second television leaflets (in schools, libraries, workplaces,
commercials, public relations materials and GP surgeries). Access via TV was the most
special cereal boxes. NCI’s recommendation expedient.
to consume a high-fiber / low-fat diet was 4. In its additional function, it effectively helps
also highlighted on the boxes and in adver- and supports personal, individual presence
tisements. Every element of the campaign programs. In her research, Flay [59] exam-
has had a huge exposure. During these two ined 40 smoking cessation programs and
years, the number of people who claimed to found that almost all of them achieved a
eat a high-fiber diet to reduce their risk more change in knowledge, attitudes, and changes
than doubled (from 2 to 5%). The prevalence in smoking habits. However, programs were
of information related to the relationship be- more effective in which, in addition to a per-
tween fiber content and cancer prevention sonal presence, handouts were distributed.
has more than tripled (from 9 to 32%). Sales In addition, smoking cessation clinics that
of cereal flakes also jumped, with more than provide printed materials were more effec-
50,000 people contacting NCI for more in- tive than those that did not.
formation [56]. Facilitating changes in communication behavior
2. In the supportive role, it can reinforce in social media can be another important func-
knowledge of health behaviors that have tion. Media strategies and messages can be devel-
previously been communicated in other oped that try to engage family members, friends,
ways, support changes in health behaviors, co-workers and others in a shared conversation
encourage people to sustain changes, or about health issues. Changes in this communica-
simply focus on issues related to healthy tion behavior can affect an individual’s health be-
living. In the Five Cities project [57], infor- havior.
mation was provided in the form of social
advertisements because their audience data VII.19. Mass communication in the event of a
showed that many relapsed smokers were so crisis
afraid of another failure to smoke that they A key advantage, especially in the event of an
would rather not try to quit again, as they acute crisis, is that information can be delivered to
would not. During the project, social adver- users extremely quickly via the Internet. Through
tisements spoke to local residents who had the Internet, health-related information can be
already successfully quit, who talked about made available faster (more up-to-date) through
their motivations, how they coped with the regular updates than traditional information mate-
relapses, and how they started the program rials such as brochures, posters, and encyclopedias
again after a relapse. allow [60,61]. The Internet has developed into one
3. It is used to promote existing health pro- of the most important sources of health information
motion programs in its promotional role, to [62, 63], but it also presents difficulties and chal-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

lenges. The current example of COVID-19 shows health communication to take place instantly, at
how the immediate availability of information on any point in time, and in the natural environment,
the Internet reduces the delay between the occur- that is, in everyday life. In this way, the informa-
rence of an event and public attention and allows tion can be made available when needed.
for timely crisis communication. However, it has In summary, the benefits of traditional mass media
already been shown in previous crises that behav- communication in the field of health communica-
ior and media interest are not necessarily in sync tion, such as long range and high cost-effective-
with each other and therefore do not necessarily ness, can be effectively combined with the benefits
reflect the real risk situation [65]. In addition, the of interpersonal communication (directness and
Internet offers an additional, versatile opportunity personalization of information) when using the In-
for innovative healthcare communication. As a re- ternet, social media or application.
sult, the often one-way communication situation
has become increasingly dynamic and multi-direc-
tional. Social networks such as Facebook, Twitter,
Instagram or Pinterest allow individual people to
network, allowing users to search for, provide,
share, but also comment on and discuss (health-re-
lated) information.This means that recipients can
no longer only “passively” consume information,
but can themselves “actively” produce and dis-
seminate it [61, 62, 63].For example, personal an-
ecdotes and experience accounts (narrative infor-
mation) that are highly persuasive, mostly because
of their high emotionality, can be shared [60, 63,
67-69]. However, as this information is not subject
to peer review, its validity and reliability may be
questioned in some cases.

However, health communication is changing not

only through the growing importance of the Inter-
net and social media, but also through technologi-
cal advances. There are promising opportunities in
health that can be used successfully for prevention
and health promotion. In the U.S., 80% of people
have a smartphone, making access to a wide range
of the population relatively easy and inexpensive
[70]. In particular, smartphone-based applications
are evolving into a much-and-more widely used
strategy for health communication. Various studies
have shown that health applications can indeed be
used to change health behavior [71 - 73]. The re-
sults of a comprehensive meta-analysis show that
nutritional applications induce nutritional health
indicators, such as body mass index, that are effec-
tive in both improving and altering eating habits
[73]. Compared to traditional strategies for health
communication, the use of applications allows

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26. Quine L, Rutter DR (1994): First di- abaly?docid=a0700092.tv
agnosis of severe mental and physical 37. sérültek.hu, [integrálódó kiadvány] : in-
disability: a study of doctor- parent com- formációs portál fogyatékos emberekről /
munication, Journal of Child Psychol. főszerkesztő Horváth László. – Online
Psychiatry 76:1273-87. kiadvány. – 2003. 11. 12. - . – [s.n.], 2001
27. Lüth P (1975): Kommunikation in der 38. Radványi K, (2007): A személyiség fe-
Medizin. Stuttgart: Hippokrates Verlag, jlődését és vizsgálatát nehezítő tényezők
Annu. Rev. Public Health. 1995. 16:219- fogyatékossággal élő személyeknél.
38 Erdélyi Pszichológiai Szemle VIII. évf.
28. Ambady N Bernieri, F (2002): Physical 1. sz. Kolozsvár, 2007. 1-30.o.
Therapists’ Nonverbal Communication 39. Ferrini R, Woolf SH (1998): American
Predicts Geriatric Patients’ Health Out- College of Preventive Medicine practice
comes Psychology and Aging. Vol. 17: policy: screening for prostate cancer in
443– 52. American men. Am J Prev Med. 15:81–4.
29. Schofild PE, Butow PN, Thompson 40. Pinto BM.(1993): Training and main-
JF, Tattersall MH, Beeney LJ, Dunn tenance of breast self-exam skills. Am J
SM (2003): Psychological responses of Prev Med. 9:353–8.
patients receiving a diagnosis of cancer. 41. Leffell DJ, Bolognia J (1993): The
Ann Oncol 14: 48–56 effect of pre-education on patient com-
30. Donovan K (1983): Communicating bad pliance with full-body examination in a
news, WHO Division of Mental Health, public skin cancer screening. J Dermatol
http://whqlibdoc.who.int/hq/1993/ Surg Oncol.19:660–3.
WHO_MNH_PSF_93.2.B.pdf 42. Friman PC, Finney JW, Christophers-
31. Mc. Intosh A (1990): Patient Power in en ER (1986): Testicular self-exami-
Doctor-Patient Communication: What nation: validation of a training strategy
Do We Know? Health Communication for early cancer detection. J Appl Behav
2:122. Anal.19:87–92.
32. Matthews DA (1993): Making “connex- 43. Field MJ, Cassel EK (2007): Approach-
ions”: enhancing the therapeutic potential ing Death: Improving Care at the End of
of patient-clinician relationships. Ann In- Life. American Board of Internal Medi-
tern Med.;118 (12):973-7. cine, Washington, DC
33. Goldberg RJ (1984): Disclosure of in- 44. Ewing JA (1984): Detecting alcohol-
formation to adult cancer patients: issues ism: the CAGE questionnaire. JAMA.
and update.J Clin Oncol. 81:948-55. 252:1905–7
34. Jenkins V (2001): Information needs of 45. Black WC (1995): Perception of breast
patients with cancer: results from a large cancer risk and screening effectiveness in
study in UK cancer centres. Br J Cancer. women younger than 50 years of age. J.
84:48-5. Natl Cancer Inst. 87:720–31.
35. 18/2016. (VIII.5.) EMMI rende- 46. Schwartz J (1997): The role of nu-
let https://net.jogtar.hu/jogszabaly?- meracy in understanding the benefits of

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screening mammography. Ann Intern 58. King A, Flora C (1987): Smokers chal-
Med. 127:996–72. lenge: Immediate and long-term findings
47. Dixon SD (1992): Stein MT. Encounters of a community smoking cessation con-
with Children: Pediatric Behavior and test. Am. J. Public Health 77: 1 340-4
Development. 2nd ed. St. Louis, MO: 59. Flay B (1987): Mass-media and smoking
Mosby cessation: A critical review.Am. J. Public
48. Lorig K (1996): Patient education and Health 77: 1 53-60
counseling for prevention. In: U.S. Pre- 60. Betsch C, Ulshöfer C, Renkewitz F,
ventiveServices Task Force. Guide to Betsch T (2011): The influence of narra-
Clinical Preventive Services. 2nded. Bal- tive v. statistical information on perceiv-
timore, MD: Williams & Wilkins ing vaccination risks. Med Decis Mak
49. Prochaska JO, DiClemente CC (1986): 31:742–753.
Toeard a comprehensive model of 61. Gamp M, Renner B (2016): Pre-feed-
change. In: Miller WR, Heather N (eds). back risk expectancies and reception of
Treating Addictive Disorders: Processes low-risk health feedback: absolute and
of Change. New York: Plenum comparative lack of reassurance. Appl
50. Miller WR, Rollnick S (1991): Mo- Psychol Health Well Being 8:364–385.
tivational Interviewing: Preparing Peo- 62. Chou WS, Prestin A, Lyons C, Wen K
ple to Change Addictive Behavior. New (2013): Web 2.0 for health promotion: re-
York: Guilford Press viewing the current evidence. Am J Pub-
51. NIH Publication (1990): National Can- lic Health 103:9–18.
cer Institute Manual for Physicians. 63. Hesse BW, Nelson DE, Kreps GL,
No.90-3064. Washington, DC: U.S. De- Croyle RT, Arora NK, Rimer BK,
partment of Health and Human Services Viswanath K (2005): Trust and sources
52. Dube´ C, Novack D (2000): Communi- of health information: the impact of the
cation Skills for Preventive Interventions. internet and its implications for health
Academic Medicine Vol 75. No/7 Sup- care providers: findings from the first
plement health information national trends survey.
53. Maibach J: (1995) The Improvements Arch Intern Med 165:2618–2624.
of Public Health Communication Annu. 64. Renner B, Schupp H (2011):The per-
Rev. Public Health 16:219-238. ception of health risks. In: Friedman HS
54. EPHO, WHO (2020):https://www.euro. (Hrsg) Oxford handbook of health psy-
who.int/en/health-topics/Health-systems/ chology. Oxford University Press, New
public-health-services/policy/the-10-es- York, S 637–665
sential-public-health-operations 65. Kreps GL, Neuhauser L (2010): New
55. Mårtensson L, Hensing G (2012): directions in eHealth communication: op-
Health literacy -- a heterogeneous phe- portunities and challenges. Patient Educ
nomenon: a literature review. Scand J Couns 78:329–336.
Caring Science 66. Prestin A, Chou WS (2014): Web 2.0
56. Alexander J, Breitrose, H (1977): and the changing health communication
Community education for cardiovascu- environment. In: Hamilton HE, Chou WS
lar health. Lancet I: 1 1 92-95pp. 429-42. (Hrsg) The Rout- ledge handbook of lan-
New York: Praegcr guage and health communication. Rout-
57. Farquhar L, Fortmann S, Maccoby ledge, New York, S 184–197
N, Haskell W, Williams, P (1985): The 67. Gigerenzer G, Gaissmaier W,
Stanford Five City Project: Design and Kurz-Milcke E, Schwartz LM, Wo-
methods. Am. J. Epidemiol. 1 22:323-34 loshin S (2007): Helping doctors and

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patients make sense of health statistics.

Psychol Sci Public Interest 8:53–96.
68. Steinmeyer L, Betsch C, Renkewitz F
(2018): Können Faktenboxen den Einfluss
narrativer Information auf Risikourteile
verringern? In: Stehr P, Heinemeier D,
Rossmann C (Hrsg) Evidenzbasierte/
evidenz- informierte Gesundheitskom-
munikation. Nomos, Baden-Baden, S
143–154
69. Zillmann D (2006): Exemplification
effects in the promotion of safety and
health. J Commun 56:221–237.
70. Servick K (2015): Mind the phone. Sci-
ence 350:1306–1309
71. Free C, Phillips G, Galli L, Watson L,
Felix L, Edwards P et al (2013): The
effectiveness of mobile-health technolo-
gy-based health behaviour change or dis-
ease management interventions for health
care https://doi.org/ 10.1111/aphw.12076
72. Schoeppe S, Alley S, Van Lippevelde
W, Bray NA, Williams SL, Duncan
MJ, Vandelanotte C (2016): Efficacy
of interventions that use apps to improve
diet, physical activity and sedentary be-
haviour: a systematic review. Int J Behav
Nutr Phys Act 13:127.
73. Villinger K, Wahl DR, Boeing H,
Schupp HT, Renner B (2019): The ef-
fectiveness of app-based mobile inter-
ventions on nutrition beha- viours and
nutrition-related health outcomes: a sys-
tematic review and meta-analysis. Obes
Rev 20:1465–1484.
74. Kaplan SH, Greenfield S (1989): Im-
pact of the doctor–patient relationship on
the outcome of chronic disease. In: Stew-
art M, Roter D(eds). Communicating
with Medical Patients. London, England:
Sage; 228–45.

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Chapter VIII.
PREVENTION OF MAJOR CHRONIC
NON-INFECTIOUS AND INFECTIOUS DISEASES
(ISTVÁN KISS, ZSUZSANNA ORSÓS,
KATALIN NÉMETH)

VIII.1. Introduction VIII.2. The public health significance and main

Despite the fact that the Covid pandemic, which categories of cardiovascular diseases
has recently haunted the world, is still here with us, VIII.2.1. Significance for public health
the leading causes of death in the 21st century are Cardiovascular diseases belong to the leading
clearly chronic non-communicable diseases. The causes of deaths worldwide. According to the
classic major causes of death in most of human WHO estimates for 2019 that the most important
history, such as communicable diseases, infant cause of death was ischemic heart disease: 16.0%
mortality and malnutrition, are declining even in of all deaths were due to ischemic heart disease
most developing countries (although they are still (coronary heart disease). Cerebrovascular diseas-
a major public health priority in many countries), es, the second leading cause of death, accounted
and incidence of tumors, cardiovascular diseases for 11.2% of all deaths. While globally these pro-
and other non-communicable diseases increase. In portions have shown an increasing trend over the
developed countries, the leading causes of death last 20 years (2000: IHD: 13.2%, cerebrovascu-
today are exclusively chronic non-communicable lar disease: 10.7%), in high-income countries the
diseases. trends have been exactly the opposite: 2019: IHD:
It would be difficult to talk about health promo- 16.1 %, CVD: 7.4%; 2000: IHD: 22.5%, CVD:
tion without knowing the diseases that threaten our 10.9%. In developed countries, these two diseases
health and what are the risk factors that increase are also the leading ones, not only in terms of mor-
the risk of developing these diseases, or what are tality but also in terms of disease burden (as mea-
the protective factors that reduce the risks. Health sured by the disability-adjusted loss of life years
is more than just the absence of disease, but the indicator, for example).
health status of a population cannot be charac-
terized by ignoring the burden of disease. It is In Hungary, cardiovascular diseases account for
therefore necessary to talk briefly about some of about half of all deaths (49.4% in 2018; 14,587
the epidemiological features of the major diseases people died of ischemic heart disease this year,
and, in particular, about the possibilities for their and 4,981 from cerebrovascular disease). Unfor-
prevention. As this work is basically not about de- tunately, we are in a very bad position in interna-
tailed epidemiology, the analysis of the risk factors tional comparison with these data. According to
and prevention options of all significant diseases Eurostat’s comparative statistics for 2017, Hun-
would have far exceeded the scope limits. Rather gary ranked second in the EU after Lithuania in
than speaking briefly about all diseases at the level the standardized deaths for ischemic heart disease
of mention - and therefore superficially - we aim (1732/1000000).In order to manage this value in
to write about selected diseases or groups of dis- place, it should be noted that in that year it was
eases that are of outstanding importance in terms below 300/1000000 in six EU countries and below
of mortality or disease burden. 700/1000000 in 20 countries. It is interesting, that

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

at that time, after Latvia and Lithuania, there was significantly hypertension are the same. Thus, with
the third largest difference between male and fe- a well-designed prevention program, we can ef-
male deaths in Hungary. fectively fight diseases that account for more than
80% of cardiovascular deaths. Risk factors are
VIII.2.2. Major cardiovascular diseases presented for coronary artery disease, along with
As has been discussed abovbe, the two most im- a discussion of hypertension, followed by a brief
portant groups of cardiovascular diseases are supplement on cerebrovascular disease.
ischemic heart disease and cerebrovascular dis-
ease. These two diseases account for more than VIII.3. A Risk factors for coronary artery dis-
three-quarters of cardiovascular deaths (VIII.Fig- ease, classification, effects, risk factor-specific
ure 1). prevention
VIII.3.1. Overview, classification
Eleven percent of “other” cardiovascular disease Since ischemic heart disease is the leading cause of
includes a variety of conditions, such as periph- death within the group, risk factors are discussed
eral vascular disease, aortic aneurysm, cardiomy- through this disease and, where necessary, sup-
opathy, heart failure, various arrhythmias, valvular plements are added for other cardiovascular dis-
heart disease, and congenital disorders. These are eases. There are several risk factors for coronary
diseases with a rather heterogeneous etiology, and heart disease, so these are usually organized into
in some of them the possibilities for prevention groups. Of the simpler and more complex group-
are very limited. However, it is very important for ing options, we describe the simplest possible and
the prevention and therefore for the present chap- another, a bit more complex one. The simple solu-
ter that the risk factors for coronary artery disease, tion is to talk about risk factors that can be mod-
the vast majority of cerebrovascular diseases, and ified (influenced) and not modified (not affected).

VIII.Figure 1. Mortality rates of major types of cardiovascular disease in men (a) and women (b)
(WONG et al, Nature Reviews Cardiology 2014 11: 276–289)[1]

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Uncontrollable risk factors include age, gender, presence of conventional factors (hence the term
race, burdensome family history, and other genetic “conditional”). As our knowledge of cardiovas-
factors. The other risk factors belong to the other cular disease continues to grow, the table is not
group, as they are environmental, lifestyle or the “perpetual,” some factors may change or new ones
resulting risk factors, as well as those that can be may appear.
influenced by lifestyle changes and medication.
There are a number of risk factors in this group, VIII.3.1.1. Risk factors
such as physical inactivity, obesity, smoking, and In the course of the discussion, we proceed in the
inadequate lipid levels. order of Table I, but there are also risk factors that
A slightly more complicated categorization is the are not included in the table.
modification of the grouping published at the 5th
Prevention Conference of the American Heart As- VIII.3.1.1.1. Smoking
sociation by Mayo Clinic staff (VIII. Table 1). The cardiovascular risk-increasing effect of smok-
ing has long been known. One of the first and very
According to the original wording, traditional / important findings of the Framingham Heart Study
conventional risk factors are those that are the di- (one of the first major prospective studies in the
rect causal factors of atherogenesis. The increase United States to examine the risk factors for car-
in risk caused by predisposing factors is partly diovascular disease - a milestone in the history of
due to conventional factors, but may also have cardiovascular prevention) in 1962 was that smok-
independent effects. Conditional risk factors may ing increased the risk of heart disease [2].
increase the risk of coronary artery disease in the Smoking is one of the leading health damaging

VIII.Table I. Classification of cardiovascular risk factors

Conventional Predisposing Conditional Novel

Lipoprotein-associated
Smoking Overweight or obesity Homocysteine
phospholipase A2
Pregnancy-associated
Hypertension Physical inactivity Fibrinogen
plasma protein A
Elevated serum Asymmetric
Male gender Lipoprotein (a)
cholesterol dimethylarginine

Family history of early

Low HDL cholesterol Small LDL particles Myeloperoxidase
coronary artery disease

Diabetes Socio-economic factors C-reactive protein Nitrotyrosine

Lifestyle / behavioral Oxidative-stress

factors markers

Allelic variants of some

Insulin resistance
candidate genes

source: American Heart Association

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agent, an addictive disorder which may cause fa- muscle cells in the vessel wall, which also
tal consequences. Lifetime smokers will have a promotes the formation of atherosclerotic
50% chance of dying from smoking. Smokers lose plaque.
about 10 years of their life because of this habit - • Smokers have worse lipid parameters than
compared to 3 years for severely hypertensive pa- non-smokers, such as lower HDL choles-
tients and one year for mild hypertensive patients. terol. The exact mechanism of this is un-
According to the INTERHEART study, smoking known, but it may be due to inhibition of
was responsible for 36% of the population’s ad- lecithin-cholesterol acetyltransferase, which
ditional risk of a first heart attack. The 10-year fa- is responsible for the esterification of free
tal cardiovascular risk of smokers is twice that of cholesterol, or lower levels of cholesterol
non-smokers [3]. ester transfer protein.
We know of a number of mechanisms that explain In previous years, tobacco companies have sought
the health-damaging effects of smoking on cardio- to reduce the amount of harmful substances in
vascular risk; some of them are: cigarette smoke through various solutions called
• The sympathetic activity-enhancing effect of “harm reduction”. To date, all of these factors
nicotine leads to an increase in blood pres- have proven to be of no real use, and some studies
sure, an accelerated heartbeat, and increas- suggest that they may even be harmful.The main
es the oxygen demand of the heart muscle. problem is that skillfully communicated “low
Nicotine also plays a crucial role in the de- risk”, “minimal danger” and the like give smok-
velopment of addiction. Narrowing of the ers false security, which contributes globally to the
coronaries reduces the oxygen supply to the persistence of smoking as an addictive habit, and
heart muscle. downplays the real risks of smoking (including
• The carbon monoxide in cigarette smoke lower-risk products which have a slightly lower
reduces the oxygen-carrying capacity of the but still significant risk-increasing effect). It gives
blood, so meeting the oxygen needs of the the false impression that it is possible to deviate
organs can only be achieved by pumping from the only truly effective solution, which is the
more blood, which puts a significant amount persistent fight against smoking, until it is com-
of extra work on the heart. pletely eradicated.
• Oxidative damage, free radicals. Free radi-
cals contribute to the formation and main- Some thoughts on smoke-free tobacco products are
tenance of oxidative stress, the oxidation of worth sharing. In e-cigarettes, an aerosol formed
lipids. As a result, nitric oxide production (a by evaporating a nicotine-containing liquid (and
molecule with a strong vasodilatory effect) containing many other ingredients) is inhaled by
is reduced, vasoconstrictive effects are fur- users, and in the case of heated tobacco products,
ther enhanced, and free radicals also activate a real tobacco-containing charge is heated so that
coagulation factors and platelets, leading to it does not reach the combustion temperature (in-
a prothrombotic state. All of these, in com- stead of 800 ° C only 350 ° C) to eliminate the for-
bination with the increased likelihood of de- mation of combustion products. In addition, there
veloping insulin resistance due to oxidative are other smokeless forms, of which snus (‘snu’
stress and the inflammatory processes in- - a tobacco product made from steamed tobacco
duced by other toxic substances in cigarette leaves with a special technology and placed in the
smoke, increase the risk of developing endo- mouth) is perhaps most noteworthy in Europe, as
thelial dysfunction. The direct toxic effects it is quite widespread, especially in the Nordic
of many compounds in cigarette smoke on countries. What these tobacco products have in
endothelial cells also contribute to this. common is that they definitely pose a cardiovas-
• Carcinogenic substances in cigarette smoke cular risk because of their nicotine content, and
can also increase the proliferation of smooth we know less about their other ingredients and the

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

health effects of compounds formed during heat- risk decreases steadily over time as a non-smoker:
ing, compared to traditional smoking, which has the cardiovascular risk of ex-smokers approaches
been studied for almost a century. Taking advan- the risk of non-smokers in 10-15 years.
tage of this, tobacco companies have gone so far
as to try to set them up as a “healthy alternative” VIII.3.1.1.2. Hypertension
and, on the other hand, recommend it instead of Hypertension, in addition to being an independent
cigarettes to those who want to quit smoking. The disease with a very significant morbidity and an
problem is that more and more research shows that independent cause of death, is a significant risk
these alternative forms of smoking also pose sig- factor for coronary heart disease and cerebrovas-
nificant risks, with more and more studies study- cular disease [4]. Increase in blood pressure of 20
ing pathophysiological processes and epidemio- mmHg systolic and 10 mmHg diastolic raises the
logical studies showing their harmful effects on risk of death from stroke, heart disease, and other
health. And a significant part of those who want to vascular diseases by approximately twofold. As
quit stop at using heated tobacco products, which hypertension is a very common disease worldwide
means that the advertised goal (helping at quitting and thus in Hungary as well, it is a serious public
smoking) will not be achieved. In addition, new health problem. Hypertension is defined as 140/90
tobacco products unfortunately seem attractive to mmHg (grade 1 hypertension), with 120/80 mmHg
young people, so more and more people are get- being considered optimal. In Hungary, approx.
ting used to these products without any history of 40% of the adult population have high blood pres-
smoking. Overall, alternative experiments current- sure, which about 3.5 million people. Male-to-fe-
ly seem to be a dead end, as the professional orga- male ratios show a predominance of males below
nizations and institutions dealing with the harmful the age of 55, which changes with age and the dis-
effects of smoking say. Among other things, the ease is more common in women over the age of
Department of Pulmonary Medicine of the Profes- 65. As we age, the prevalence also increases, over
sional College of Health clearly states that “Ad- the age of 60 we can count on 60%. Nevertheless,
vertising, promotion and sponsorship of heated the increase in blood pressure with age cannot be
tobacco products should be restricted, as this may considered a physiological process, which is also
promote the social acceptance of smoking.” and supported by the fact that this phenomenon does
“Traditional, heated and smokeless tobacco prod- not occur in natural peoples (although there are
ucts (chewing tobacco, nasal, or oral tobacco prod- now few people truly excluded from civilization
ucts) are both addictive and carcinogenic. Only the in the world).
use of proven methods in smoking cessation and
cessation support shall be justified“ [4]. Hypertension can occur as a result of an illness or
medication (secondary hypertension) or without a
Finally, passive smoking or other exposure to en- clearly identifiable cause (primary hypertension).
vironmental tobacco smoke should be mentioned. The vast majority (80-95%) of those with hyper-
Passive smoking clearly carries all the risks that tension have primary hypertension. In case of sec-
come with active smoking. It should be empha- ondary hypertension, the solution is to cure the
sized that vulnerable groups, such as children and underlying disease (eg phaeochromocytoma) or to
pregnant women, may also be affected by sec- omit the drug that causes hypertension (e.g. ste-
ond-hand smoke - so its health effects at the socie- roids) or to reduce the dose. The rest of this chap-
tal level are very significant. ter on risk factors applies to primary hypertension.
The coronary artery risk-enhancing effect of hy-
The second chapter deals with the strategy to com- pertension is primarily due to the increased intra-
bat smoking, the practicalities to be done, the pro- mural pressure that promotes lipid deposition by
tection of non-smokers, cessation and cessation increasing mechanical stress and shear forces in
support. Quitting smoking is never too late, the the vessel wall, thereby increasing endothelial per-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

meability and contributing to endothelial dysfunc- with all diseases, certain genetic factors and
tion (a key factor in atherosclerosis). Coronary in- allelic variants may increase the risk of hy-
sufficiency is enhanced by frequent left ventricular pertension).
hypertrophy, increasing resistance at the microvas-
cular level, and remodeling of coronaries. VIII.3.1.1.3. Elevated serum cholesterol, low
Elimination of hypertension as a risk factor means HDL cholesterol
an effective reduction in blood pressure. From the Disorders of lipid metabolism and inadequate lip-
point of view of drug therapy, it is not primarily id parameters have long been known to be strong
the combination of drugs in the group that matters, risk factors for atherosclerotic diseases. This is ob-
but that the blood pressure is properly controlled. viously not surprising, as cholesterol plays a key
In milder cases, this can be achieved without med- role in the formation of atherosclerotic plaques.
ication, with lifestyle interventions, and it is cru- Of course, we have already moved away from
cial that lifestyle recommendations are followed the initial, mechanical model, which states that if
by those receiving medication. It is not the task of there is too much cholesterol in the blood, it ini-
this chapter to describe drug therapy. According to tiates plaque formation by sticking to the vessel
current guidelines, lifestyle therapy alone should walls. Now we know that plaque formation is the
be attempted for “elevated blood pressure” (130- result of a complex process involving many fac-
139 / 85-89 mmHg) or grade 1 hypertension (140- tors, including many cell types (e.g. macrophages
159 / 90-99 mmHg) if the subjects do not belong that later develop into foamy cells, endothelial
to high cardiovascular disease risk group (cardio- cells, smooth muscle cells, lymphocytes, dendrit-
vascular risk assessment will be discussed later). ic cells), lipoproteins, matrix proteins, enzymes,
The most important options in the lifestyle therapy antibodies, inflammatory and other cytokines, ad-
and prevention of hypertension and the strength of hesion molecules, antibodies, free radicals are in-
their effect are described in VIII. Table II. volved. A description of the pathomechanism and
a detailed description of the role of lipid, or rather
Other risk factors for hypertension include: lipoprotein, particles would go far beyond the lim-
• Stress (reduction with relaxation methods, its of size in the chapter, so we will mention only a
meditation, proper lifestyle, and if necessary few important facts:
with the help of a specialist) High concentrations of apoB-containing lipopro-
• Economic and social situation. Hyperten- tein particles (eg, LDL-cholesterol) increase the
sion is more common in lower-income so- likelihood of these particles reaching the endothe-
cial groups. This acts through complex and lium. ApoB-containing lipoproteins have a high
indirect mechanisms (e.g., stress, smoking, affinity for proteoglycans in the vessel wall, and
alcohol, nutrition, etc.). One of the main LDL particles become more sensitive to oxidative
tasks of the state is to protect vulnerable so- effects as a result of the interaction. Oxidized LDL
cial groups, to provide adequate security of is able to effectively initiate the processes that lead
life and to effectively guarantee the right to to the transformation of macrophages into foam
health to its citizens. cells and the release of inflammatory mediators.
• Low calcium and magnesium intake. These Small particles (below 70 nm) pass more easily
minerals also help lower blood pressure. through the endothelium and are more retained
• Sleep apnea, sleep disorders - borderline in the vessel wall, so their atherogenic potential
case between primary and secondary hy- is also higher. HDL particles exert protective,
pertension (anatomical disorders leading to risk-reducing effects through a number of mecha-
sleep disorders, elimination of factors lead- nisms (e.g. transport of cholesterol molecules, re-
ing to snoring, consultation with a specialist duction of inflammatory processes, stabilization of
if necessary). plaques, inhibition of platelet activation in plaque
• Familial accumulation, genetic factors (as rupture).

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VIII. Table II.: Strong risk factors for hypertension

To reduce systolic
Intervention Aim blood pressure in
hypertension

Achieving or approaching an ideal BMI. For

Weight Loss every kg of weight loss, approx. a decrease in 5 Hgmm
blood pressure of 1 mm Hg can be expected.

Eating a lot of vegetables, fruits, whole

grains, low-fat dairy products, keeping red
Healthy eating (DASH diet
meat to a minimum, keeping total fat intake
is especially recommended 11 Hgmm
and saturated fat intake low. Maintaining
in hypertension)
an adequate level of energy intake (control:
BMI).

Reduction of salt intake Less than 5 g NaCl 5-6 mm Hg per day

Abundant potassium intake 3.5-5 g of potassium per day, with food 4-5 Hgmm

At least 150 minutes per week, at 65-75% of

Aerobic physical activity 5-8 Hgmm
maximum heart rate

90-150 minutes / week, 50% -80% of maxi-

Dynamic resistance
mum effort, 6 exercises / week, 3 sets / exer- 4 Hgmm
training
cise, 10 repetitions / set

4 × 2 min, 1 minute rest between exercises,

Isometric resistance
30% –40% of intentional maximum 5 Hgmm
training
contraction, 3 times / week

Reducing alcohol Reducing intake to 2 drinks / day for men

4 Hgmm
consumption and 1 drink / day for women drinking

Smoking cessation Quit smoking 4-5 Hgmm

Source:https://hypertension.hu/upload/hypertension/document/mht_szakmai_iranyelv_2018_20190312.
pdf?web_id=[5]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

The association between total cholesterol or LDL foods)

cholesterol and cardiovascular risk has been clear- • Consumption of ω-3 series polyunsaturated
ly demonstrated in a large number of observational fatty acids from marine fish
epidemiological studies and in randomized con- • Aerobic physical activity (at least 150 min-
trolled intervention studies. The latter demonstrat- utes per week)
ed a risk-lowering effect of lowering cholesterol • Mediterranean diet
(by administering statins). According to this, a 1 • TLC diet. The Therapeutic Lifestyle Chang-
mmol / L decrease in LDL cholesterol leads to a es system was developed in the US specif-
20-25% reduction in cardiovascular mortality and ically to normalize lipid levels and reduce
the incidence of non-fatal myocardial infarction. the risks associated with them. This method,
High lipoprotein (a) levels (Lp (a) or a combina- based on nutritional and physical activity ad-
tion of elevated triglyceride levels and low HDL vice, is now also recommended for healthy
levels, which usually occur in diabetic patients, people for cardiovascular prevention pur-
abdominal obesity, insulin resistance, or the phys- poses. Among the dietary recommendations,
ically inactive, are considered to be particularly fats should be 25-35% of the total energy in-
atherogenic. take, with a maximum of 7% saturated fat,
and the cholesterol intake should be below
Medication or lifestyle therapy, or a combination 200 mg / day (other directives are more per-
of the two, may be used to treat dyslipidaemia missive, and 300 mg per day is allowed for
(which is the primary prevention of atherosclerotic healthy people) [6].
cardiovascular disease). There are two main prin-
ciples: 1. In the case of milder abnormalities, life- VIII.3.1.1.4. Diabetes
style changes alone should only be attempted, and The risk of cardiovascular disease in diabetics is
in the case of more severe lipid disorders, medica- on average twice as high as in non-diabetics, so
tion is required as well. 2. A complex cardiovascu- diabetes is also a prominent risk factor. Cardio-
lar risk assessment should be performed to select vascular prevention in diabetics is essentially the
a treatment modality (this will be discussed soon), same as in non-diabetics, completed with control
and lifestyle therapy may be sufficient for lower of blood glucose level (although due to the inter-
risk individuals, and pharmacotherapy should be action between the three risk conditions / diseases,
considered for higher risk individuals. increased care should be taken to control lipid lev-
els and blood pressure). The prevention bases for
How can lifestyle interventions improve the lipid diabetes and blood sugar levels are as follows:
profile? • The well-known principle that we start with
• Reducing the intake of saturated fats and lifestyle interventions in milder cases and
trans fats use medication only in more serious cases is
• Increasing the consumption of monounsatu- also true for diabetes.
rated and polyunsaturated fatty acids (ie re- • Lifestyle factors focus on smoking cessa-
placing saturated fats with unsaturated fats) tion, low fat intake, high dietary fiber intake,
• Increase awareness of water-soluble dietary regular aerobic physical activity, and com-
fiber plementary muscle training.
• Regular consumption of nuts (4-5 dkg / day, • Carbohydrate intake should focus on qual-
but preferably the energy intake should not ity: aim to consume whole grain products
change) containing dietary fiber and minimize intake
• Increasing soy protein consumption (instead of refined white flour products.
of soy products, even meat) • Care should be taken to reduce salt intake,
• Increasing the intake of phytosterols and alcohol consumption, and intake of saturated
phytostanols (even in the form of functional and trans fatty acids, the use of low-fat pro-

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tein sources, and the consumption of copi- made, and reaching 102/88 cm is an indication of
ous amounts of fruit and vegetables. weight loss. Therefore, the combined use of body
• A significant proportion of diabetic patients mass index and abdominal circumference should
are obese. Reducing energy intake is recom- be considered when assessing obesity [7]. The is-
mended to achieve / maintain optimal body sue of so-called “metabolically healthy obesity”
weight. has long been debated. Some studies have shown
• In terms of cardiovascular risk, the target that certain obese people do not develop metabol-
HbA1c target is <7%, which may be mild- ic complications such as hypertension or insulin
er in some groups (e.g. long-term diabetics, resistance. It is possible that in their case, obesity
the elderly, the weak, and those with cardio- alone is not associated with significantly increased
vascular disease). In non-cardiovascular pa- cardiovascular risk. Examining the phenomenon at
tients with a diagnosis of diabetes or early the level of epidemiological and pathophysiologi-
stage of onset, the target may be 6.5%. cal mechanisms may even result in a change of at-
• Complex nutritional suggestions such as titude in this area. Another, but somewhat similar,
a Mediterranean diet, DASH diet, or veg- phenomenon was that several studies in patients
etarian diet will help manage body weight with coronary artery disease or heart failure found
(control is essential in diabetic patients) and that those with a higher body weight had a low-
blood sugar levels. er risk of death than patients with a normal body
• The starting medicine is usually metformin, weight. In our present view, this is not necessarily
which helps to control your blood sugar and a causal relationship, but rather a reverse causality.
body weight and reduces your cardiovascu- The effect of cardiorespiratory fitness appears to
lar risk. be more important than body weight. To the best of
• What has been said about diabetes also ap- our knowledge, the risk-increasing effect of phys-
plies to prediabetes and insulin resistance, ical inactivity is stronger than that of BMI-based
with some increase in cardiovascular risk. obesity . The latter facts call attention to the fact
that physical activity is absolutely important and
VIII.3.1.1.5. Overweight, obesity has a preventive effect even if the desired degree
An ideal body weight is when the body mass in- of weight loss is not achieved.
dex (BMI; body weight in kilograms divided by
the height of the body in meters) is in the range Obesity is a function of the amount of energy in-
of 20-25 (or 18.5-25 according to other recom- gested / used. The former is determined by diet
mendations). Overweight (BMI≥25) and obesity and the latter by physical activity - a rare situa-
(BMI≥30) are risk factors for a number of car- tion where obesity is specifically the result of a
diovascular diseases (e.g. coronary heart disease, metabolic disease. This is why population-level
cerebrovascular disease, hypertension) and are prevention strategies are based on proper nutrition
also positively correlated with overall mortality. and physical activity. The goals are clear, keep
Substantial (up to 5%) weight loss in overweight both body mass index and abdominal circumfer-
or obese people has been shown to reduce blood ence below the limits mentioned above. It is often
pressure, LDL cholesterol and triglycerides, and the case that weight loss has been achieved, but
blood sugar levels. In addition to the degree of in the long run it will disappear and even weight
obesity, its type (abdominal / visceral / obesi- gain will occur again. Thus, it is important not to
ty carries a much higher risk than localization to try a short, intense diet, but to achieve the desired
the extremities) is also indicated by abdominal weight - possibly in the slightly longer term - by
circumference, which is an excellent marker of making a sustainable change in lifestyle and diet.
cardiovascular risk. In Europe, the limit is 94 cm In addition, great care must be taken to maintain
for men and 80 cm for women, above which it is the results obtained, especially given that the in-
important to ensure that no further weight gain is tensity of metabolism may vary. For example, the

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ACC / AHA (American College of Cardiology / heart rate can be calculated using the approximate
American Heart Association) recommends that formula for approximating 220 minus age. Anoth-
you spend at least 150 minutes of physical activ- er option is to use the so-called Borg scale, which
ity a week during weight loss and at least 2-300 is a scale from 6 to 20 and is based on a subjective
minutes / week of physical activity after a year to sense of intensity. An even simpler (but obviously
avoid regaining weight [8]. only approximate) solution is given in the speech
test described in VIII. Table III.
VIII.3.1.1.6. Physical inactivity
The disease-preventing effects of physical activity In addition to the above, it is recommended to per-
(for many diseases) have long been known. This is form muscle strengthening training twice a week,
also the case in the cardiovascular system, where using the main muscle groups.
physical activity can be considered the basis of The principles described here also apply to older
cardiovascular health. There is a strong, consis- people (over 65). If someone’s state of health does
tent, inverse dose-response relationship between not allow it, it is recommended that they move as
moderate to intense physical activity and ischemic much as their abilities and state of health allow.
heart disease and cerebrovascular disease. Physi- Children and adolescents (5 to 17 years of age)
cal activity has beneficial effects on many of the should have at least one hour of moderate or in-
cardiovascular risk factors, such as lowering blood tense physical activity per day, and the number of
pressure, LDL and non-HDL cholesterol levels, muscle strengthening exercises should be 3 per
weight, and the risk and severity of type 2 diabetes. week [9].
Physical activity recommendations for adults sug-
gest at least 150 minutes of moderate aerobic ac- VIII.3.1.1.7. Nutrition
tivity per week or 75 minutes of intensive aerobic In addition to cardiovascular disease, diet also has
physical activity per week, or an equivalent combi- a significant impact on the risk of tumors and sev-
nation (eg, 100 minutes of moderate to 25 minutes eral other chronic diseases, making it a very im-
of intensive activity). For optimal protective effect, portant determinant of our health. In addition to
it is recommended to apply twice this, ie 300 min- observational epidemiological studies in recent
utes of medium or 150 minutes of intensive exer- decades, large intervention studies have provided
cise per week. This period is preferably distributed valuable data on the role of nutrition (e.g. PRED-
evenly over the week, although the rules are not IMED, TOHP). The importance of energy intake
as rigid as in previous recommendations when e.g. has been discussed before, let’s look at the other
5x30 minutes were prescribed. The weekly dura- essential elements now [10]. The consumption
tion can be completed by assembling any number of fat has an effect partly through energy intake
and length of units, the only criterion being that (since fats are our most energy-dense nutrients),
only activities that are at least 10 minutes in length and we also have to reckon with other specific ef-
can be counted. Intensity can be measured in so- fects. For this reason, we have recently become
called metabolic equivalents (MET), which shows more and more convinced that what fats we con-
how many times our energy consumption during a sume are more important than the amount we
given activity is the resting energy consumption, consume. Although more and more data, results,
which is defined as O2 consumption per kilogram and theories are emerging about the role of fats,
of body weight and per minute. Obviously, this is leading professional societies agree that it is advis-
not easy to measure during a given activity, so we able to limit the intake of saturated fats to as low
use simpler, approximate options to describe the as 10% energy. Trans fatty acids are particularly
activity. The heart rate is a good approximation, high risk, raise LDL and lower HDL cholesterol,
more precisely, what percentage of the the theo- promote endothelial dysfunction, lead to insulin
retical maximum heart rate the person’s heartbeat resistance, inflammatory conditions, and arrhyth-
reaches - this is easy to measure and the maximum mias. Some processed foods (e.g., chips and other

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VIII. Table III. Physical activity categories and their measurement and estimation possibilities

Intensity (absolute) Intensity (relative)

Percentage Perceived
Category MET Example of maximum effort rate Speech test
heart rate (Borg scale)

Walking
Easy 1,1-2,9 50-63 10-11
(<4.7 km / h)

Pace walking (4.7-

6.5 km / h), slower
Breathing is faster,
cycling (15 km / h),
but you can speak
Medium 3-5,9 vacuuming, gardening 64-76 12-13
in full sentences
(eg mowing the lawn),
(but no longer sing)
tennis (in pairs),
dancing
Competitive walking,
running, cycling (Y15
Breathing is very
km / h), heavy garde-
difficult, incompat-
Intensive ≥6 ning (eg continuous 77-93 14-16
ible with normal
digging or hoeing),
speech
speed swimming,
tennis (some)

products fried in partially hydrogenated vegetable coronary heart disease and cerebrovascular dis-
oil) are particularly dangerous because of this, but ease has also been demonstrated. A meta-analysis
fortunately, regulations on trans fats have become of major studies has shown that a 7 g / day increase
much stricter in developed countries. Monounsat- in fiber intake reduces the risk of coronary heart
urated fatty acids (good sources such as olive oil disease by about 9%, and a 10 g / day increase re-
and rapeseed oil) and polyunsaturated fatty acids sults in a 16% lower risk of stroke and a 6% risk of
are considered healthy, and from the latter group type 2 diabetes.
omega-3 fatty acids must be emphasized, espe- There is a clear inverse relationship between salt
cially eicosapentaenoic acid and docosahexaenoic intake and cardiovascular mortality, which is
acid. mainly explained by the hypertensive risk-increas-
ing effect of salt intake. It should be noted that, on
Regarding carbohydrates, a number of studies average, about 80% of salt intake comes from pro-
have shown an increased cardiovascular risk with cessed foods that contain salt, so their consump-
refined carbohydrates and sugary foods (mainly tion should be significantly limited.
beverages, sugary soft drinks) - in brackets, some Among the vitamins, vitamin D is noteworthy, and
studies have found that even the consumption of several recent studies have found a negative asso-
sodas made with sweeteners increases risk. ciation between serum vitamin D levels and car-
The protective effect of dietary fiber against both diovascular mortality.

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In addition to examining each ingredient, there is sumption of red wine and the phytochemicals in it
a wealth of information available about the effects are protective) have changed for a long time, and
of different foods and complex dietary patterns. moderate alcohol consumption was considered the
Consuming 30 g of nuts (eg walnuts, hazelnuts, most optimal. This meant drinking 2 drinks a day
almonds) daily reduces the risk of cardiovascular for men and 1 drink a day for women, most pref-
disease by about 30% (!). erably red wine. Recently, however, many have
questioned the beneficial effects of moderate al-
Consumption of vegetables and fruits has a very cohol consumption, not least because there have
strong protective effect. In this regard, it is also been a large number of sponsored studies among
worth noting that several studies have demonstrat- the studies supporting the hypothesis. Currently,
ed the risk-reducing effect of plant-based nutrition. most professional societies recommend that we
An analysis of one of these studies found that the should avoid drinking alcohol, and if we still do,
smallest increase in risk compared to a diet con- the amount mentioned above should not be ex-
taining only vegetable protein was found in white ceeded. It can be added that it is important to avoid
meat, about three times as much in red meat, and consuming larger amounts of alcohol (3 drinks or
meat products doubled. more a day), consuming concentrated spirits, and
occasional binge-drinking.
The beneficial effects of fish consumption bare
supported by a number of studies. The risk is par- VIII.3.1.1.9. Personality traits, mental factors,
ticularly high in those who do not consume fish at stress
all (or very rarely), which is significant from a pub- Chronic stress - be it e.g. work or family-relat-
lic health point of view, because a relatively small ed - increases the risk of coronary heart disease,
change in populations that consume fish in very and acute stressors can act as triggers in trigger-
small quantities (eg the Hungarian population) ing a heart attack, for example. Some mental ill-
could have a significant preventive effect. How- nesses are also associated with coronary heart
ever, following previous optimism about omega-3 disease, such as depression, post-traumatic stress
fatty acid supplementation, recent studies suggest disorder, anxiety disorders, schizophrenia. People
that the usual daily intake of 500-1000 mg may not with aggressive, hostile, and irritable personalities
even have a significant protective effect. also have higher-than-average risks. Some of the
By taking plant sterols and stanols, a reduction factors related to stress and personality traits can
in LDL cholesterol levels of about 10% can be be changed by learning and applying appropriate
achieved with a daily intake of 2 g. This amount stress management and relaxation methods. Un-
is no longer very easy to consume, so functional fortunately, these opportunities do not receive the
foods fortified with phytosterols are now recom- attention they deserve in the prevention of cardio-
mended. vascular disease in everyday practice.

VIII.3.1.1.8. Alcohol consumption VIII.3.1.1.10. Economic and social status

The relationship between alcohol consumption In developed countries, there is a clear link be-
and chronic non-communicable diseases has twice tween low socioeconomic status and increased
changed in recent decades. The earliest position cardiovascular risk. This relationship is extremely
was that alcohol consumption increases the risk complex and is due to a number of factors, some
of cardiovascular disease. This is definitely un- of which are examples: People with lower levels
questionably true for excessive alcohol consump- of education have less knowledge of health dam-
tion. However, the phenomenon of the so-called aging risk factors; alcohol and smoking may be
French paradox and the explanation for this (that more prevalent instead of appropriate stress man-
in France the mortality lower than expected based agement mechanisms; they consume unhealthy
on the total energy / fat intake due to regular con- foods for financial reasons; worse, unhealthier,

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more stressful working conditions; worse housing features and risk factors, subarachnoid hemor-
conditions, more unfavorable environment; limit- rhage differs from the other types, as it is a rupture
ed recreational opportunities; access to the health of the congenitally weaker section of the vessel
care system is more limited. wall. Risk factors for ischemic and other hemor-
rhagic strokes, on the other hand, are classical ath-
VIII.3.1.1.11. Additional risk factors erosclerotic and hypertensive risk factors. Thus, in
In addition to what has been discussed so far, a the prevention of cerebrovascular disease, we need
number of other risk factors for coronary artery to address the risk factors listed in the section on
disease are known. However, a detailed discussion coronary heart disease, especially hypertension,
of these is less important from a main and practi- which has a strong association with the risk of
cal point of view and is not possible due to their stroke. The importance of common roots is indi-
limited scope. cated by the increasing use of the term “vascular
It is clear that, as with all diseases, hereditary / prevention” today, which refers to the prevention
genetic factors can play a major role in the devel- of ischemic and atherosclerotic diseases, whether
opment of cardiovascular disease, but we cannot of cardiac or cerebral manifestation.
change them at present. The increased risk is due However, another type of relatively common risk
to the higher number of cardiovascular diseases in factor, atrial fibrillation, should be mentioned in
the family and at a young age. Assessing the risk connection with vascular occlusions due to embo-
and determining what needs to be done is a med- lization. Atrial fibrillation causes haemostasis and
ical task. It is also the physician’s responsibility significantly slowed blood flow, making the risk of
to consider whether certain conditions increase blood clots in the atrium very high. Small pieces of
cardiovascular risk (e.g., chronic kidney disease, the resulting atrial blood clot can rupture, causing
periodontitis, sleep apnea) or are predictive (e.g., brain embolization and stroke. Atrial fibrillation is
erectile dysfunction). The situation is similar with the most common serious arrhythmia, occurring in
conditional and recent risk factors according to the 3-5% over the age of 65 and up to 8% over the age
Mayo grouping. of 80.

VIII.3.2. Cerebrovascular diseases VIII.3.3. Cardiovascular risk assessment

When cerebrovascular disease develops, due to On the one hand, cardiovascular prevention is par-
insufficient blood supply to the brain, temporary ticularly important for everyone, but on the other
and later permanent damage to the brain develops, hand, it has a prominent and direct role in high-
leading to changes in brain function. The disease risk individuals. For this reason, risk assessment
occurs acutely in the form of a transient ischemic systems that attempt to quantify vulnerability have
attack (TIA) or, in the most severe case, a stroke long been known in cardiovascular medicine and
(a rapidly developing clinical syndrome caused by prevention. On the one hand, they set prevention
a disorder of the blood supply to the brain that is strategies and priorities, and on the other hand,
commonly referred to as a stroke or stroke). Cere- they make the degree of vulnerability tangible and
brovascular disease can lead to further illnesses understandable for those involved. A limitation of
(e.g., dementia) and stroke is a serious cause of risk assessment systems (but also a practical ad-
death. Stroke is ischemic in most cases with vas- vantage) is that they focus on some key risk fac-
cular occlusion and about 20% is due to bleeding. tors rather than accurately considering the system
Bleeding strokes are approximately three-quarters of many risk factors and the complex interactions
occur in the brainstem and a quarter in subarach- between them.
noid hemorrhage due to rupture of cerebral vascu- The first large and well-known risk scoring sys-
lar aneurysms. Ischemic strokes are mainly due to tem was the Framingham Risk Scoring System.
cerebral vascular thrombosis (approximately 50%) This was developed in the US, primarily based
or embolization. Regarding the epidemiological on data from the Framingham Heart Study [11].

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Later, a more accurate SCORE risk assessment risk (SCORE≥10% or previous / pre-existing car-
system was born in Europe. There were originally diovascular disease or some serious disease) - see
two versions of this (one for high cardiovascular PADOS et al [14]. The essence of risk assessment
risk countries and the other for low-risk ones), but is to show how and how intensively it is neces-
many countries now have their own country-spe- sary to carry out preventive / therapeutic activities
cific SCORE tables. In Hungary, we use a table for in those involved. While lifestyle maintenance /
high-risk regions (VIII. Figure 2). elimination of risk factors is the main strategy in
the first two groups, in the high and very high risk
The SCORE system estimates risk based on age, groups it is / may be supplemented with medica-
systolic blood pressure, total cholesterol, gender, tion, and there are additional differences (eg other
and smoking status. [13]It should be noted that lipid targets, some screening tests / frequency).
factors not listed in the table (e.g., obesity, HDL Finally, the latest developments in cardiovas-
cholesterol, triglyceride, etc.) may further modify cular risk assessment in Europe should be men-
this risk. tioned: announced in 2021, the development of the
From a practical point of view, based on cardio- SCORE2 risk assessment system, which includes
vascular risk, people are usually divided into 4 the incidence of cardiovascular events in addition
groups: Low risk (SCORE <1%), Medium risk to deaths, was completed in four groups of coun-
(1≤SCORE <5%), High risk (5≤SCORE <10%) or tries at different risk levels.
certain diseases or severe risk factors), very high

VIII. Figure 2: SCORE risk assessment system.

The table shows the 10-year risk of fatal cardiovascular events.
Source: http://www.mnsza.hu/szivbeteg/adattar/rizikotabla.htm [12]

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VIII.4. Epidemiology and prevention of cancers and esophageal cancer occurs in the sixth place.
The importance of cancer to public health deserves (VIII. Figure 3).
increasing attention. Both the number of illness-
es and deaths have risen in recent decades and it If we look at the incidence of tumors in terms of
is estimated that this will continue in the future. gender, it is important to note that among men - with
Globocan estimates that there were 18.1 million almost the same number of cases as lung cancer -
new cases and 9.9 million deaths globally in 2020. the second place is prostate cancer, which is fortu-
[15]. A significant change in the incidence of can- nately less severe in terms of mortality, so in the
cer is that, breaking the trend of many years, breast mortality list it is only the fifth in a row. At the same
cancer has now become the most commonly di- time, liver cancer is much more severe in terms of
agnosed cancer, ahead of lung cancer, which has lethality, so it is already ranked second in terms of
been the number one tumor for decades. Thus, the mortality.(Fig.4/B) A change among women is that
order for both sexes by 2020 is as follows: breast cervical cancer is the fourth most common and
cancer, lung cancer, colorectal cancer, prostate fourth most important cause of death. Globally, ap-
cancer, stomach cancer and liver cancer. The se- proximately 600,000 women become ill and more
verity and curability of these diseases are not the than 300,000 women die each year from this fun-
same, so we experience a different order in terms damentally completely preventable type of cancer (
of mortality. In terms of mortality, lung cancer has VIII. Figure 4/C).
been leading for many years, decades, followed by
colorectal cancer, followed by liver cancer with Regarding the spatial distribution of the incidence
much higher lethality, gastric cancer in fourth of tumors, we can say that the incidence of new
place, and the most common breast cancer in fifth cases and the mortality rate are not geographical-

VIII. Figure 3: Global distribution of incidence and mortality from cancer, both sexes, 2020.
Source: Global Cancer Statistics 2020. [16]

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VIII. Figure 4: Tumor incidence and mortality distribution in men and women worldwide, 2020.
Source: Global Cancer Statistics 2020.[16]

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ly uniform. 50% of newly diagnosed cases come The International Agency for Research on Cancer
from Asian and Latin American countries, and this (IARC) estimates that by 2040, the number of new
high rate is also reflected in mortality rates (VIII. cases will increase by 50% worldwide, reaching
Figure 5). 30 million a year, and the death toll is expected to
rise to 16.3 million. It is estimated that the changes
The pattern of cancer shows a strong correlation expected in the next decade will affect the people
with the Human Development Index (HDI), which of the third world and developing countries to a
is calculated on the basis of life expectancy at birth, much greater extent than the industrialized coun-
time spent in education and living standards in a tries. The situation may be exacerbated by demo-
given country. For HDI, there are also significant graphic change, the risks associated with global-
differences in the cumulative incidence of tumor ization and a growing economy, and an inadequate
development and age-specific cancer mortality be- (unsustainable) industrial environment.
tween countries generally classified into 4 groups Their public health significance is further enhanced
(very high, high, medium, and low). While the by the fact that cancer has become the leading
total population of the countries with the highest cause of death among under-70s in many countries
and lowest HDI values is about the same size, the around the world, ahead of cardiovascular disease.
incidence of tumors is significantly higher in coun- The Disability-adjusted life years (DALYs) indi-
tries with high HDI values (41%) than in countries cator, developed to quantify the global burden of
with low HDI values (5.9%). The pattern of lead- disease, illustrates somewhat the burden of the dis-
ing tumor types also differs significantly in these ease on the population, the severity of the disease
two groups. [17]In the high HDI countries, the five and the probability of survival. With regard to can-
most common tumors are breast cancer, prostate cer, the value of DALY is the second highest (Fig-
cancer, lung cancer, colorectal cancer and gastric ure 7), exceeding 233 million years, and in terms
cancer, while in the low HDI countries, breast can- of its distribution, it can be said that it imposes a
cer, cervical cancer, liver cancer, prostate cancer much greater burden on the population in less eco-
and colorectal cancer. (VIII. Figure 6) nomically developed countries.

VIII. Figure 5. Spatial distribution of cancer (incidence and mortality) worldwide, 2020.
Source: Global Cancer Statistics 2020 [16]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Figure 6: Different patterns of cancer as a function of HDI values

Source: https://www.worldcancercongress.org/sites/congress/files/atoms/files/T3-121.pdf [18]

In Hungary, 49,803 men and 53,402 women be- presence of late-onset, already palpable and pain-
came ill with cancer in 2017, and 17,716 men and ful nodules in the breast and in metastatic breast
15,128 women died of malignancy in the same cancer. In developed countries, there is a free
year. screening program for the affected population for
In terms of cancer, the following seven types of women over 40 or in some places over 45 years of
cancer are responsible for more than 50% of all age. Unfortunately, the uptake of screening tests is
cases, so these types of cancer are described in quite low even in this case.
more detail below:
The American Cancer Society recommends that
Breast cancer mammography be performed annually on request
As we have read before, the most commonly di- for women between the ages of 40 and 45.It is
agnosed type of cancer today is breast cancer. Its recommended to take part in screening every year
incidence is growing strongly in developing coun- between the ages of 45-54 and every 2 years over
tries. The incidence of breast tumors is increasing, the age of 55. In Hungary, organized breast cancer
especially in developing countries, with the spread screening covers the examination of women aged
of urbanization and Western-type lifestyles. Al- 45-65 every two years. Early detection can also
though mammography is an excellent option for be promoted by regular breast self-examination,
early diagnosis of breast cancer, it is unfortunate- but this is in no way a substitute for regular mam-
ly not sufficiently available to the population in mographic screening.
low- and middle-income countries, so most of the
disease can only be diagnosed at a late stage. As The most important genetic risk factor for the
with all tumors, the likelihood of survival depends development of breast cancer is the BRCA1 and
largely on the stage at which the disease is diag- BRCA2 genes. These tumor suppressor genes are
nosed. The 5-year survival of asymptomatic breast likely to induce the development of the disease
cancer detected by mammography is 93%, while through their germ cell mutations. Inherited breast
the likelihood of survival is reduced to 22% in the cancer manifests itself at a much earlier age and,

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Figure 7: Distribution of disability-adjusted life years by main groups of deaths.

Source: https://ourworldindata.org/burden-of-disease [19]

generally, in case of BRCA1 mutation, not only been proven to have anticarcinogenic (anti-cancer)
breast cancer but also ovarian cancer, and in case effects. 1 g of soy protein contains 3.5 mg of iso-
of BRCA2 gene mutation prostate and pancreatic flavones. Plant phytoestrogens are natural estrogen
cancers are more common. BRCA genes can also receptor modulators that have both estrogen-like
be damaged by external influences, in which case and antiestrogen properties. High soy intake has
we are talking about a somatic mutation, in which been shown to reduce the incidence of breast can-
case the tumor usually appears at an older age. It cer and has also had a beneficial effect on survival.
is important that women with a family history of Numerous studies have shown that a soy-rich diet
breast, ovarian, fallopian tube, or peritoneal cancer has a beneficial effect on LDL-cholesterol levels,
are considered to be at increased risk and should which is why its consumption is also recommend-
definitely be screened or have genetic counseling. ed from a cardiovascular point of view.
Several risk factors are known for the develop- It is important to emphasize that the protective ef-
ment of breast cancer. These can also be hormonal, fect of soy has been demonstrated for soy-contain-
lifestyle and environmental factors [20]. ing foods and not with dietary supplements of ar-
tificial origin, which is why experts are cautionary
Prevention: about supplementation. In Western countries, soy-
It is important to learn a proper, balanced diet as bean intake is extremely low among the general
early as possible. Adequate vegetable intake is not population. According to a US survey, isoflavone
just necessary for vitamin and fiber content. The intake was 2.5 mg / day. For comparison, a serv-
incidence of breast cancer in Asian women is quite ing (250 ml) of soy milk contains approximately
low. Research has shown that this is due to the high 25 mg of isoflavones. In the Western world, soy
soy intake that underlies Asian cuisine. Soybeans is added to foods in minimal amounts as an addi-
and foods made from them (such as tofu, miso, soy tive due to its functional properties (stability en-
milk, soy yogurt, or tempeh) are excellent sources hancement, texture improvement), so its excellent
of vegetable protein. In addition, soybean protein anti-carcinogenic properties do not prevail.
contains all the essential amino acids, which is Health-conscious nutrition is placing increasing
why it is also recommended for vegetarians. Soy is emphasis on soy-based nutrition, and it is recom-
also uniquely rich in phytoestrogens, which have mended to consume 2 servings of soy-based food

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VIII.Table IV. Risk factors affecting the development of breast cancer

Hormonal risk factors: (associated

Life style factors Environmental factors
with increased estrogen exposure)
Ionizing radiation (X-rays,
Early menarche Smoking
MRI)
Late menopause Obesity

Childlessness Low physical activity

Having a child at a later age (over 30) High ω-6 fat intake

Having few children Low phytoestrogen intake

Not breastfeeding Alcohol consumption

Post-menopausal hormone therapy Vitamin D deficiency

source: https://www.cdc.gov/cancer/breast/basic_info/risk_factors.htm [2021.04.20.]

per day. However, it is important to know that 80 the role of smoking in the development of
percent of the isoflavone content of soy products the disease is put at 90%. With regard to
is inadvertently removed during processing, so try smoking, it is important to emphasize that
to buy traditional, low-processed soy products. secondary or environmental exposure to
For soy, the Chinese and Japanese recommenda- cigarette smoke is similarly harmful to the
tions recommend 15 g of soy protein and 50 mg body.
of isoflavonoids per day, the U.S. dietary recom- • Radon: Radon is a colorless, odorless radio-
mendations, as well as the Eastern countries to rec- active noble gas found in small amounts in
ommend 25 g / day of soy protein to lower LDL nature in uranium-containing rocks and in
cholesterol. soil and river water. During its natural decay,
radioactive isotopes (polonium 218, poloni-
Lung cancer um 214, lead 214) are formed, which can be
Lung cancer has been the leading cause of cancer added to airborne dust or smaller particles,
deaths in industrialized countries for many years e.g. they enter the body in connection with
and, unfortunately, Hungary has the highest inci- the components of tobacco smoke. Inhaled
dence and mortality on the world (Table V). The radon-containing air enters the air sacs in
number of new diseases has been on a declining the lungs, where it exerts its DNA-damaging
trend since the 1990s, probably due to rules re- effects with direct alpha radiation. The con-
stricting smoking. The 5-year median survival is centration of radon in the e open air is neg-
very low, at only 13% based on EUROCARE-5 ligible, it is not a problem, but in buildings
data [21]. built of such rock, the concentration of radon
indoors can be harmful to health, which can
Risk factors: be reduced by frequent, regular ventilation.
• Smoking: The most important risk factor for • Asbestos: Asbestos was a widely used build-
developing the disease is smoking. In men, ing material due to its excellent thermal and

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VIII. Table V: Age-standardized mortality data, lung cancer, men.

Lung cancer

Age-standardised rate
Rank Country Mortality
per 100,000

World 1.796.144 18,0

1. Hungary 8.920 42,4

2. Serbia 7.084 40,0

3. Frenc polinesia 129 36,0

4. Turkey 37.070 35,9

5. Guam 86 35,1

Source: https://www.wcrf.org/cancer-trends/lung-cancer-statistics/ [22]

sound insulation properties, while inhalation costly, so they are unlikely to be introduced as an
of airborne asbestos dust after decades of la- organized screening.
tency has been shown to cause severe lung
damage, most commonly mesothelioma. Colon and rectal cancer
According to the WHO, asbestos exposure Significant differences in the incidence of colorec-
is also observed in half of lung cancer pa- tal tumors can be observed globally. Developed
tients. The use of asbestos in the construc- countries have the highest values, while in Africa
tion industry has been banned in Hungary and South Asia the weight of the disease is not as
since 2005, and all construction waste gen- high. Hungary is also among the leading Europe-
erated during the demolition of old buildings an countries in terms of incidence and mortality,
is considered hazardous waste. and unfortunately we are world leaders in terms of
age-standardized mortality (VIII. Table VI).
Prevention:
In order to prevent the development of lung can- Approximately 30% of colorectal tumors show fa-
cer, the most important thing is to quit smoking milial accumulation. Some of these cases (approx-
and create a smoke-free environment. imately 5% of all colorectal tumors) are caused
by congenital mutations. Among the genetic fac-
One of the pivotal points in the treatment of lung tors, germ cell mutations in the mismatch repair
cancer is the early detection of the disease. Effec- (MMR) genes and the APC tumor suppressor gene
tive, organized screening for high-risk individuals are noteworthy. MMR gene mutations are more
(smokers with a construction background) is not likely to induce hereditary nonpolyposis colorec-
yet available. Low-dose CT scans capable of early tal cancer (HNPCC) at a young age, also known as
detection of lung cancer show very promising re- Lynch syndrome. Germ cell mutations in the APC
sults. Unfortunately, these investigations are quite tumor suppressor gene leads to the development

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VIII. Table VI: Age-standardized mortality rates,

colorectal tumors, both sexes

Colorectal tumors

Age-standardised rate
Rank Country Mortality
per 100,000

World 935.173 9,0

1. Slovákia 2.584 21,0

2. Hungary 4.880 20,2

3. Croatia 2.320 19,6

4. Moldova 1.187 17,6

5. Serbia 3.356 16,7

Forrás: https://www.wcrf.org/cancer-trends/colorectal-cancer-statistics/ [23]

VIII. Figure 8.: Distribution of incidence and mortality of colorectal tumors

in different HDI populations.
Source: https://www.wcrj.net/wp-content/uploads/sites/5/2019/11/e1433-Worldwide-incidence-and-mor-
tality-of-colorectal-cancer-and-Human-Development-Index- HDI-an-ecological-study.pdf
[24]

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

of familial adenomatous polyposis (FAP) disease, • Family history of colorectal cancer

which, like Lynch syndrome, exhibits autosomal • Obesity: Overweight and obesity are com-
dominant inheritance. The disease, which is asso- mon in welfare societies. This is due to high
ciated with the development of hundreds of adeno- energy intake and physical inactivity. In
matous polyps, can manifest as early as the 1930s, terms of energy intake, fat intake (including
so colonoscopy is recommended every 1-3 years saturated fat intake) and alcohol consump-
in these cases. Among those who have inherited tion should be emphasized. According to the
the APC mutation, the lifetime prevalence of col- latest nutritional recommendation, saturated
orectal tumor development is 100%. fats can give max. 10% of the daily energy
intake (Dietary Guidelines for Americans,
Approximately 70% of colorectal tumors are spo- 2020-2025). Typical foods high in saturated
radic, and lifestyle factors are mainly responsible fatty acids are lard, butter, fatty cheeses and
for their development. In addition to age (Figure red meats. In terms of energy intake, alco-
9), the most important risk factor is overweight hol consumption should also be considered.
and the closely related physical inactivity. Breaking down 1 g of alcohol releases 7 cal-
ories. Due to its high energy content, moder-
Risk factors: ate consumption of 100% fibrous soft drinks
• Age: The incidence of colorectal cancer in is recommended, and similarly, reduction
those over 40 years of age is gradually in- of daily consumption of sports and energy
creasing, affecting men and women to al- drinks without physical activity should be
most the same extent. (Below 40 years, its considered, and the consumption of sugary
development is typical only with hereditary soft drinks should be limited.
factors). • Excessive consumption of meat products

VIII. Figure 9: Rate of colorectal disease by age based on US data from 2004-2013. Source: https://
www.uptodate.com/contents/image?imageKey=ONC%2F111996&topicKey=ONC%2F2606&source=-
see_link [25]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

and red meat: Consumption of ham, sala- Prevention:

mi, sausages, hot dogs, cold cuts or canned Screening plays an extremely important role in the
meat is also a risk for the development of prevention of colorectal tumors. The most effec-
tumors. These products are smoked, salted, tive way to do this is colonoscopy, which involves
fermented or pickled for preservation, im- a full instrumental examination of the intestines.
provement or flavor enhancement. During With the help of an endoscope, the specialist can
these procedures, the nitrite content of meat also take a tissue sample for further examination,
products increases, which may be responsi- or even remove the polyps on the intestinal wall
ble for the development of colon tumors. In immediately. Unfortunately, the advantages of
2014, the IARC classified meat products as colonoscopy are associated with the relatively
proven to be carcinogenic (1A), while red high cost of training, which is due to the need for
meat (beef, veal, lamb, pork) was classified a qualified specialist and the need for a properly
as a potential carcinogen (2A). Recent rec- equipped surgery.
ommendations limit red meat consumption
to a maximum of 70 grams per day. In Hungary, according to Decree 51/1997 (XII.18.)
• Low dietary fiber intake: Consumption of ad- NM, the organized, targeted public health popula-
equate amounts of vegetables, which covers tion colon screening covers men and women aged
a daily intake of 25-30 g of dietary fiber, is of 50-70 with an average risk. The first step in the
paramount importance for colorectal tumors. screening is a blood test on the stool using an im-
This amount is necessary to help the intesti- munological stool blood test for hemoglobin (iF-
nal tract function by shortening the passage OBT or FIT), followed by a colonoscopy as a sec-
time, thus not only promoting the rapid bind- ond step. The downside of this method is that if
ing and excretion of harmful substances, but sampling does not occur when the tumor is bleed-
also reducing intestinal wall irritation. Plant ing, a false negative result is obtained, which pro-
fibers also have a protective effect on blood vides false safety for an asymptomatic but already
fat composition and increase the feeling of sick person [26].
fullness, so it is really important to consume
at least daily 400 g, preferably as many fresh Liver cancer
vegetables as possible. The incidence of primary liver cancer is on the rise,
• Inadequate fat intake: Nutrition plays a key with its average 5-year survival, although much
role in the development of colorectal tumors. improved in recent decades, still only 20% today.
In a proper, balanced diet, the ratio of poly- [27]). In the presence of distant metastasis, surviv-
unsaturated omega-6 series to omega-3 fatty al is critically low at around 3%.The problem is
acids is 4: 1. Unfortunately, the Western-type exacerbated by the fact that liver damage and liver
diet is significantly different. Omega-3 fatty cancer have been extremely asymptomatic for a
acids are found almost exclusively in cold long time, and the diagnosis is mostly due to tests
sea fish, with the exception of flaxseed oil, for other diseases. Hepatitis virus infections and
which is a very good alternative for those on high alcohol consumption should be considered
a plant diet. in the development of primary liver cancer. About
• Physical inactivity 80% of all liver cancers occur in Asian and African
• Smoking countries, and their high incidence is clearly due
• In case of inflammatory bowel diseases to a lack of hepatitis vaccination. Liver cancer is
such as Crohn’s disease or ulcerative coli- three times more common in men than in women.
tis, chronic inflammation of the colon may
increase the chances of developing colon Risk factors:
cancer. • Hepatitis B virus infection: Hepatitis B vi-
• Vitamin D deficiency rus that enters the body causes death of liver

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

cells or chronic hepatitis. After infection, the and occasional heavy drinking is especially
pathogen is present in all body fluids, so the dangerous when more than 6 drinks are con-
infection can be spread through sexual con- sumed at one time. Incidentally, this pattern
tact, blood and blood products, medical de- is typical of young people who do not regu-
vices contaminated with tissue fluid, intrave- larly drink alcohol.
nous drug use, and the infected mother can
pass it on to her baby during childbirth. Due Prevention:
to the screening of blood products, infection Hepatitis B vaccination plays a key role in pre-
in healthcare facilities can be ruled out. vention. It has been mandatoryage related vaccine
• Hepatitis C virus infection: The most com- in Hungary since 1999. Occupational vaccination
mon transmission is intravenous drug use. for healthcare workers and students is mandatory.
• Alcohol: Alcohol is the most important risk Hepatitis B vaccination is recommended for those
factor for liver cancer in industrialized coun- living in promiscuity. In Hungary, the problem is
tries. Although acetaldehyde formed during rather the high alcohol consumption.
its metabolism is a definite carcinogen, its
consumption is still acceptable to humans. Stomach cancer
As alcohol is broken down mainly in the liv- Gastric cancer was the leading cause of cancer
er, so this is the primary location of damage, deaths in the 20th century until it was preceded by
and alcohol consumed over the years induc- lung cancer in the 1980s. The most important risk
es cirrhosis over time, which is found in two- factor is Helicobacter pylori. With the discovery of
thirds of hepatocellular tumors and contrib- its etiological role, serious efforts have been made
utes greatly to the development of primary to eradicate the pathogen, resulting in a significant
liver cancer. According to the dietary recom- reduction in the incidence of gastric cancer, but still
mendations, alcohol consumption should be one of the leading causes of cancer deaths. Half of
limited to 1 drink per day for women and 2 the development of stomach cancer is mostly due
drinks per day for men (1 drink corresponds to lifestyle and nutritional factors. 5-year survival
to about 14 g of pure alcohol) (V.Figure.10). is between 20-30%, for late diagnosis the median
Unfortunately, the average per capita alco- survival is 1 year. The prognosis depends on age,
hol consumption in Hungary is much higher pre-existing diseases, localization, and stage. The

VIII. Figure 10: Alcoholic beverages corresponding to 1 unit of beverage.

Source: https://www.vox.com/2018/4/24/17242720/alcohol-health-risks-facts [28]

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

disease is twice as common in men as in women they have helped to increase the consumption of
[29]. Familial accumulation is observed in 10% fresh fruit and vegetables, so that the consumption
of gastric cancers, in which case mutations in the of canned foods was significantly reduced. Proper
Cadherin genes (CDH1) are observed. consumption of fresh vegetables and fruits, con-
Known risk factors for the disease: sumption of whole grains provides the right source
• Helicobacter pylori infection: Helicobacter of vitamins and minerals for the proper function-
pylori is a feco-oral bacterium that enters ing of the body. In addition, proper fiber intake
the body through foods contaminated with contributes to the development of proper body
feces. Thanks to improved hygienic condi- weight by creating a feeling of fullness, which is
tions, Helicobacter transfection is now much also extremely important for stomach cancer. Sev-
lower. The International Agency for Re- eral studies have shown a positive correlation with
search on Cancer has classified Helicobacter the rate of green tea consumption.
pylori as a proven carcinogen since 1994.
• Epstein-Barr virus (EBV): The ethiologi- Prostate cancer
cal role of EBV has been demonstrated in a The incidence of prostate cancer is increasing in
number of human tumors, as it has also been proportion to the increase in life expectancy at
described in Hodgkin’s lymphoma, Burkitt’s birth. Abnormal prostate enlargement and malig-
lymphoma and nasopharyngeal carcinomas, nancy are typical diseases of old age; the mean
but its exact role in carcinogenesis is not age of the patients at the time of diagnosis was 66
yet known. 10% of gastric cancers are EBV years. The 5-year survival of the disease is over
positive. Although the prevalence of EBV is 80%. The number of prostate cancers in developed
higher in men, EBV-positive gastric cancer countries has virtually doubled in the last 20 years,
is more common in women. largely related to the two most important risk fac-
tors in Western life, nutrition and physical inactiv-
Nutrition: Smoked and salted foods are known to ity [30,31].
increase the risk of gastric cancer.
• Alcohol consumption Risk factors:
• Smoking • Nutrition: In addition to the aspects already
well known, it should be emphasized
Prevention: · High saturated fat intake
Although Helicobacter infection has decreased · Low intake of polyunsaturated ome-
significantly in developed countries, the bacterium ga-3 fatty acids
has not disappeared from natural waters and soil. · high red meat consumption
Raw vegetables, especially leeks, various salads · Calcium intake or supplementation
and cabbages, should always be eaten after wash- above 2000 mg / day
ing, thus reducing the risk of infection. • Physical inactivity
Appropriate antibiotic treatment of pre-existing • Smoking
Helicobacter infection is necessary even if we • Alcohol consumption
have no symptoms. Nutrition plays an extremely • Chronic inflammation of the prostate, pres-
important role in prevention. In the past, the only ence of prostatitis
way to preserve and store food was by salting and • Male sex hormones
smoking, which resulted in a very high salt intake • Sexually transmitted diseases
of the population, which is an important factor in • Certain occupations (e.g .battery produc-
stomach cancer. With the advent and spread of tion, soldering, rubber production)
refrigerators, they have replaced salt-based pres-
ervation and also reduced the possibility of bac- Prevention:
terial and fungal infections in food. In addition, Regarding the prevention of prostate cancer, it

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has been debated for years whether prostate-spe- the female reproductive system is thought to
cific antigen (PSA) produced by the prostate can become more susceptible to HPV, so having
be used as a tumor marker for early screening for more children is at risk for developing cervi-
prostate cancer. The problem is that elevated PSA cal cancer.
levels are not a specific marker of prostate cancer.
Elevated PSA levels can be measured after active Additional risk factors:
exercise (eg, cycling), inflammation of the pros- • Smoking
tate, or benign prostate tumor. Recent recommen- • Weakened immune system (because a
dations suggest that PSA screening, with a few well-functioning immune system is needed
exceptions, has fewer benefits for most men than to eliminate HVPV infection, thus any dis-
the number of adverse side effects and complaints ease that weakens the immune system, such
associated with mistreatment of men with a posi- as AIDS, increases the incidence of cervical
tive PSA result. The few exceptions apply to men cancer.
who have a family history of prostate cancer or are • Chlamydia infection
of the African American race. However, over 70 • Taking birth control pills for a long time
years of age, PSA screening is by no means rec-
ommended [32]. Prevention:
One of the most effective ways to prevent the de-
Cervical cancer velopment of cervical cancer is to avoid HPV in-
Today, it is still the fourth most common female fection. The HPV vaccine was introduced in Hun-
cancer in the world, killing more than 300,000 gary in September 2014, which, when used before
women each year. The WHO aims to eliminate the start of sexual life, protects against HPV in-
cervical cancer deaths from 21st century public fection with 93% effectiveness. Vaccination is
health problems. Regular screening, introduced in age-related but not mandatory. Parents can apply
developed countries as early as the 1960s, has led for free for girls over the age of 12. From 2020,
to a significant reduction in cervical cancer deaths. free vaccinations will be available for boys. There
The number of cervical cancer deaths in Hungary are 3 registered vaccinations available in Hun-
is high, with more than 400 deaths per year. Its gary, all of which can be given from the age of
main risk factor is Human Papillomavirus (HPV), 9. [34,35]. Gardasil, which can be given to boys,
which is a necessary but not sufficient risk factor protects against HPV serotype 9, which protects
for cervical cancer [33]. The sexually transmitted not only against cervical cancer but also against
virus is encountered at a young age, it enters the genital warts. Using the vaccine before having sex,
body through microinjuries, where it lurks for de- it protects against HPV infection with 93% effec-
cades, and then it is not known exactly under what tiveness. To offer the vaccination is mandatory for
conditions, but it activates and leads to cervical primary school children, but is the parents can
cancer under various pre-cancer conditions. Fac- decide whether or not to vaccinate their child. It is
tors that increase the risk of HPV infection con- important to emphasize that vaccination does not
tribute to the development of the disease: replaces cervical cancer screening.
• Sexual activity started at a young age Cervical cancer develops over many decades.
• Multiple partners Smear tests performed during this period are able
• A partner who is infected with HPV or who to detect morphological changes in the cells, so the
has had multiple sexual partners in the past development of cervical cancer can be prevented
• First childbirth / childbirth at a young age by early intervention even in the pre-cancerous
(before 18 years) stage. Since 2003, cervical cancer screening of
• Childbirth of 3 or more children (probably women aged 25-65 has been mandatory in Hunga-
due to hormonal changes, the immune sys- ry every 3 years during a gynecological visit [36].
tem becomes weaker during childbirth, and Due to the very low participation, cervical cancer

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screening for nurses has also been introduced in stance use patterns, particularly in South
recent years. The advantage of this is that there Asia and the Pacific. Betel nuts are most
are nurses in almost all settlements, and the ac- often consumed alone, but sometimes with
ceptance of nurses is generally higher than that of tobacco. In both cases, there is an increased
mostly male gynecologists. risk.
• Ultraviolet radiation: Due to the harmful ef-
Head and neck tumors: fects of UV-B exposure, attention should be
Malignant tumor types of various origins in the paid to the time spent in the open air. This is
head and neck region are collectively referred to as especially important for white skinned peo-
head and neck tumors. Tumors of the oral cavity, ple who are more sensitive to light. Sunlight
oropharynx, hypopharynx and larynx give 90% of poses a serious risk to agricultural workers
cases. Less common tumors are of the nasophar- and fishermen, with a much more frequent
ynx, nasal cavity, paranasal sinuses, and small and diagnosis of lip cancer.
large salivary glands. Early diagnosis is complicat- • Human Papillomavirus (HPV): Of the hu-
ed by the lack of specific symptoms. The primary man papillomavirus with hundreds of ste-
reason for this is that the lesions in the region can reotypes, serotype 16 is detected in 75% of
have a wide variety of localizations. The largest oral tumors. The most common transmission
group of head and neck tumors is oral tumors, so is oro-genital.
we will focus on these tumors in the following. • Herpes virus
• Epstein-Barr virus
Tumors of the lips and mouth • Oral hygiene: Unfortunately, we do not pay
A tumor of the lips and oral cavity is defined as a proper attention to oral hygiene. Perforated
pathological change in the lips, mouth, tongue, pal- or broken teeth, untreated periodontitis are
ate, gums, salivary glands, sublingual area, phar- at increased risk. In Hungary, ahabits of den-
ynx, or mucous membranes covering the mouth. tal visits are not very encouraging, which
Unfortunately, Hungary is also at the forefront of would be important for early diagnosis.
mortality statistics in Europe and the world. • Occupational exposures: Occupational ex-
The most important risk factors are smoking and al- posure to dust and chemicals may occur, es-
cohol consumption. When these two factors occur pecially in the textile, wood and metal indus-
together, a synergistic effect occurs and the risk of tries, as well as in the construction industry.
developing the disease is significantly increased. • Low socio-economic status
Heavy smoking and increased regular alcohol in-
take increase the risk of developing the disease by Prevention:
35-40%. It is estimated that the combined occur- First and foremost, it is essential to reduce or elim-
rence of these two factors is responsible for almost inate the use of smoking in all its forms. Regarding
75% of tumors in the lips and mouth [37]. alcohol consumption, follow the international rec-
ommendations to not consume more than 14 units
Additional risk factors: of alcohol per week (max. 2 units of drink per day)
• Smoke-free tobacco products: Applying to- and also avoid the occasional heavy drinking cat-
bacco directly to the mucous membranes egory (6 or more drinks / occasion). Unfortunate-
(snus, snuff) is very popular in North Amer- ly, this is a very typical pattern of young people’s
ica or the Scandinavian country. Chewing drinking habits.
tobacco is mainly used in India. These forms Improving habits related to the visits of dentists
of smoking also increase the development of cannot be overemphasized, but it is especially im-
oral cancers. portant to see a doctor immediately if you experi-
• Betel nut chewing: We are probably talking ence any abnormalities in the head and neck, even
about one of the oldest psychoactive sub- a painless little swelling. Important signs may be

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vocal cords, persistent hoarseness for no reason, a we are, the better our skin needs to be pro-
white or red spot in the mouth, or pain or numb- tected. Snow and the surface of the water re-
ness during chewing or swallowing. flect UV rays, so in such an environment we
Adequate antioxidant and vitamin intake and green have to reckon with even higher radiation.
tea intake can be important protective factors. During the summer, we should limit or avoid
being in the open air from 11 a.m. to 3 p.m.
Skin cancer • Light skin type, blue or green eyes, blonde
Although mortality from skin cancer is negligible, or red hair, freckled skin: People with these
it is important to know that it is the most common marks should pay close attention to protect
cancer in the Caucasian white population and its their skin and avoid sunburn.
incidence is steadily rising. The cause of this that • Solarium: Solariums mostly tan the skin with
the ozone layer around the Earth is getting thin- the help of UVA rays, which is less harmful
ner, thus the exposure to the sun’s harmful rays than UVB radiation, but damages the deeper
is greater. Among the skin cancers, melanoma layers of the skin, thus contributing to skin
malignum should be highlighted. Melanoma is an aging.
abnormal cell proliferation that originates primar- • Atypical moles (moles of abnormal shape or
ily from melanocytes in the skin, sometimes the color, often larger):
eyes, meninges, or other mucous membranes. Ear- • Many moles: Most moles are never a prob-
ly detection is difficult because it does not cause lem, but those who have many moles are
a complaint, and itching is also rare. It most often more likely to develop melanoma. In all cas-
develops from pre-existing skin lesions, moles and es where a birthmark changes, see a derma-
freckles, but it can quickly appear on a skin sur- tologist immediately!
face free of visible lesions. In terms of localiza- • The so-called ABCDE rule, often supple-
tion, it usually occurs on the back in men and on mented by the letter F, makes it easy to check
the legs in women. our moles. In the event of a change in the
shape (A: asymmetry), boundaries (B: bor-
Risk factors: der), color (C: color), diameter (D: diameter)
• High ultraviolet radiation: Sunlight contains or any evolution (E: evolving) of the mole,
varying degrees of ultraviolet rays that can plus if the moles have any unusual, new
damage DNA, depending on the season, the (burning) , itchy, painful (F: feeling), contact
weather, the altitude, and the distance from a specialist immediately. (Figure 11).
the Equator. UV radiation also depends on
cloud cover and topography. So the higher

Figure 11: ABCDE rule for early detection of melanoma malignum.

Source: https://www.skinvision.com/articles/abcde-melanoma-self-check/ [38]

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Prevention: most important factors in premature death and dis-

There are many ways to protect against UVA and ability-adjusted life years.
UVB radiation today. For those with more sen- Chronic inflammation of the airways is caused by
sitive skin, it is also recommended to use a wide inhaling some irritative particle. This results in
range of sunscreens in winter. When buying our chronic bronchitis with bronchoconstriction and
glasses, look for a version with a UV filter. In sum- increased secretion. At the same time, the walls of
mer it is worth wearing a hat and umbrella. We can the air sacs involved in the gas exchange gradual-
also buy window protection film for our home and ly snap, causing the respiratory surface to shrink
car windows. and emphysema to develop. These events do not
cause typical complaints for a long time, most of
In addition to the above, regular and thorough the time we only notice a decrease in our physical
self-examination is important. Melanoma can not endurance. The progress of lung damage is well
only develop on the surface of the skin exposed indicated by the characteristic shortness of breath
to the sun. It can often form on the scalp, under that occurs with less and less physical exertion.
the nail or on the sole, or even between the fingers The disease rarely affects children and adoles-
[39]. cents, more so in middle-aged people. The disease
is most often diagnosed at a late stage. This is due
VIII.5. Respiratory diseases to the fact that the appearance of symptoms indi-
Chronic respiratory diseases have become more cating the early stage is considered by those con-
common in the past 50 years, along with indus- cerned to be the natural consequences of smoking,
trialization and urbanization, and are now one of the most important risk factor for the disease. The
the most important public health issues. Respi- symptoms are as follows:
ratory illness can be caused by infections, smok- • Cough after waking up, which occurs more
ing, including exposure to ambient smoke, and air and more often during the day and later be-
pollution. In terms of quality-corrected life years, comes a chronic cough
respiratory diseases include asthma, chronic ob- • Increased mucus production (often spit)
structive pulmonary disease (COPD), pulmonary • Shortness of breath (during sports, work,
fibrosis, pneumonia, and lung cancer. physical activity)

Chronic Obstructive Pulmonary Disease The disease is associated with irreversible damage
(COPD) to the airways, and is an incurable disease with sig-
Chronic obstructive pulmonary disease, or COPD, nificant mortality. The presence of COPD doubles
is the third leading cause of death worldwide. In the risk of lung cancer, in which case the chanc-
2019, more than 3 million people died from the es of lung cancer survival are significantly worse.
disease associated with airway obstruction and pa- With proper treatment, the quality of life of COPD
renchyma destruction due to airway inflammation. patients can be improved, and oxygen therapy is
Incidence and prevalence have also risen sharp- often used to reduce shortness of breath.
ly over the past 30 years, with further increases
likely to occur in the next decade. The number of Key risk factors:
patients with chronic obstructive pulmonary dis- • Smoking (active and passive): Smoking is
ease worldwide is approx. 300 million people, that undoubtedly the most important and com-
number is important not only for morbidity and mon cause of COPD. 85-90% of patients
prevalence, but also for health expenditure [40]. are smokers or ex-smokers. Thousands of
chemicals found in tobacco smoke weaken
Eighty percent of COPD patients live in 80% of the lungs’ resistance to infections, narrow-
low- and middle-income countries, and the disease ing the airways and destroying the air sacs.
very often remains undiagnosed. It is one of the These processes contribute to the develop-

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ment of COPD. A smoker has more than ten munity, allowing for early diagnosis of the disease
times the chance of developing the disease despite the rather nonspecific early symptoms.
than a non-smoker. This is because treatment initiated at an early stage
• Passive smoking / environmental smoke ex- can significantly slow down the progression of the
posure: Smoking during pregnancy increas- disease compared to untreated cases.
es the risk of preterm birth. A child born with
a lower body weight in a more immature Asthma
state has a worse life expectancy and is more The incidence and prevalence of asthma have in-
likely to develop COPD in their lifetime. If creased exponentially in recent decades and have
people smoke in the children’s environment, become the most common chronic non-communi-
they are more likely to become smokers and cable respiratory disease to date. Its global prev-
probably at a much earlier age, which is alence is in excess of 250 million, although the
more likely to lead to the disease later on - in disease is often underdiagnosed in low- and mid-
addition to the consequences of direct lung dle-income countries [41].
damage from passive smoking.
• Outdoor air pollution from wood and coal Asthma is a chronic inflammation of the airways
fuels and other biomass fuels that causes hyperactive mucus production and
• Indoor air pollution is a very significant risk bronchoconstriction. Fluid from the bronchi nar-
factor, especially in developing countries rows the lumen, the air is difficult or impossible
where open stoves are used. to reach the air sacs in the lungs. Due to chronic
• Indoor and outdoor air pollutants: chemi- inflammation, the airways undergo smooth mus-
cals, smoke and dust exposure cle structural changes, and the epithelium may
• Certain occupations (miners, asphalt work- be damaged. As the process progresses, the air
ers). flowing out of the increasingly narrowed airways
makes a characteristic whistling sound. Then the
Asthma changes that have been reversible for a long time
• Respiratory infections in childhood. Pneu- become irreversible.
mococcal vaccination and optional influenza Very often, no specific allergen can be detected
vaccination are extremely important in pre- in the background of asthma. [42]Often, cold air,
venting these infections. physical exertion, or stress trigger an increased re-
• Genetic predisposition: In rare cases, due to action in the body and causes inflammation. Prob-
a deficiency of the alpha-1-antitrypsin gene ably of great importance in the development of
in the background of COPD, a functional al- asthma is the fact that in recent decades we have
pha-1 antitrypsin protein is not synthesized used antibacterial cleansers too often to protect our
to protect the air sacs in the lungs, in which children, and with these efforts we inhibit the de-
case emphysema is caused by the hereditary velopment of a normal immune system. In order
genetic factor. for children to develop a healthy immune system,
• Age it is necessary for the body to be exposed to the
• Low socio-economic status right amount of antigen at an early age. Therefore,
The key factor in preventing the disease is clearly the current recommendations suggest a close-to-
the avoidance of smoking and second-hand smoke. nature lifestyle for children rather than an overly
Appropriate protective equipment can be used to clean, sterile environment. It is also important to
reduce exposure to respiratory irritation. Vaccines mention the proper use of antibiotics. Antibiotics,
for the prevention of respiratory diseases, such as which we unfortunately use quite often today, also
annual influenza vaccinations also help control the destroy the bacterial flora that is essential for the
disease. “COPD awareness” is also important for efficient functioning of our body. For the proper
both potential stakeholders and the medical com- functioning of the immune system, the microbi-

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ome composition of our body must also be pre- strong protective factor is the rural environment,
served, in which the suppression of unnecessary / encounters with a wide variety of animals, and
excessive use of antibiotics can play an important multiple microbial exposures. In addition to the
role. direct effect on the immune system, the above also
enhances the diversity of the intestinal microbiota,
Asthma is the most common chronic disease in and other factors with similar effects (e.g. dietary
children. It is more common in boys, but as the fiber intake, consumption of fermented foods) also
age progresses, gender differences level off and have a protective effect.
may reverse. We also distinguish allergic asthma,
in which case pollens and allergens cause inflam- Allergic rhinitis (hay fever):
matory obstruction of the bronchi. Although it is not an important cause of death, the
disease makes the lives of many people perma-
Risk factors: nently bitter, so we talk about it differently in this
• Asthmatic disease of family members (par- chapter. Allergic rhinitis is one of the most com-
ents, siblings) mon respiratory diseases. Its prevalence is rising
• Allergy in the family (allergic rhinitis or ec- year by year. In industrialized countries, nearly
zema) 40% of children under the age of 18 suffer from
• Low birth weight, preterm birth, cesarean the disease. As you age, the disease gets better.
birth, maternal stress, and some other peri- Excessive immunoglobulin E (IgE) -mediated im-
natal factors mune responses to otherwise harmless environ-
• Exposure to tobacco smoke and use of e-cig- mental allergens, leading to inflammation of the
arettes mucous membranes and nasal mucosa, can often
• Air pollution / exhaust exposure disappear in adulthood. Its prevalence in adults is
• Common respiratory viral infections in similar in different geographical regions, ranging
childhood from 15 to 25%, but it should be noted that aller-
• Environmental allergens (indoor and out- gic rhinitis is not diagnosed in cases with a milder
door air pollutants: house dust mites, mold, course, and there are large differences in the di-
smoke, dust, chemicals, animal hair, wood agnosis of the disease. Typical symptoms of the
dust, flour) disease are sneezing, runny nose, nasal conges-
• Strong scents (perfumes, chemicals) tion, tearing, itchy eyes, conjunctivitis, sore throat,
• Cold air itchy throat.[43]). Two types of allergic rhinitis are
• Strong emotions / stress distinguished according to whether the symptoms
• Overweight, obesity occur continuously or only intermittently.
• Reflux disease
• Certain occupations (hairdresser, painter, ag- 1. We talk about perennial allergies, i.e. those
ricultural work) that last all year round, if the triggers that cause
• Genetic factors that increase sensitivity to the allergy are constantly present in our environ-
the above external factors ment. This type accounts for about 40% of cases.
Asthma is not curable, but it can be treated very House dust mite allergy: Perennial allergies are
well. Asthma attacks can be reduced by avoiding most often caused by the presence of house dust
irritants or by using different steroid or bronchodi- mites. The trigger is not caused by the animal it-
lator inhalers. self, but by its microscopic-sized feces. The house
The risk of developing asthma can be reduced by dust mite Dermatophagoides pteronyssus and Der-
eliminating the listed risk factors or reducing their matophagoides farinae feed on dead human epithe-
incidence / level. Several studies have shown a lial cells and therefore accumulate in places where
clear negative association between breastfeeding you can find large amounts of epithelial cells (bed-
and the incidence of childhood asthma. Also a ding, pillows, mattress pads, upholstery, carpets).

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To prevent the disease, we need to pay attention to: by ventilating several times a day, even just a few
• In case of allergies, it is advisable to switch minutes, possibly with a crossover. To reduce high
to anti-allergenic bedding. If this is not pos- humidity, it is advisable to use a tumble dryer to
sible, it is recommended to wash the bedding prevent moisture from drying clothes from enter-
and pillows in water at least 60C at least ing the air. By the way, molds also occur outdoors.
once a week. Concentrations of mold spores increase in summer
• Exposure can also be reduced by replacing and autumn, especially in wet, changeable weath-
carpets. er. In compost, collected firewood, under dead
• Reduce the number of objects that can be leaves we can almost always count on it.
good sources of dust (e.g. plush toys).
• Vacuum cleaners with HEPA filters and air 2. A seasonal or intermittent allergy is when
conditioners / air filters can reduce the num- triggers that elicit an enhanced immune response
ber of airborne particles (e.g. animal hair). occur only intermittently, exclusively during the
materials pollen season. Seasonal allergies account for about
• By using air conditioners, the humidity in 20% of all allergic rhinitises. In the remaining 40%,
the apartment can also be reduced, which re- seasonal and perennial rhinitis occur together.
duces mold The first pollens appear in early spring and we
• Regular cleaning, preferably not by the per- can find high concentrations of pollen in the air
son suffering in allergy to dust. If so, use a until late autumn - you can find out about these
nasal mask! periods from pollen calendars on many places on
• Always use wet dusting in the apartment the Internet. Today, we can easily find out about
• Ventilate regularly the current pollen exposure, as it is part of almost
• Do not comb in the bedroom every weather report. Ragweed (Ambrosia arte-
misiifolia) is of the greatest importance in Hunga-
Pet hair and feather allergy: Contrary to its name, ry. The European Food Safety Authority (EFSA)
allergic reactions are caused not only by the hair classified ragweed as one of the world’s first 100
and feathers of pets, but also by the saliva and invasive, harmful and dangerous plants in 2010. In
urine. By caressing the pets kept in the apartment, Hungary, the 221/2008. (VIII. 30.) prescribes the
we can easily carry these allergens on, so we wash eradication of ragweed indoors and outdoors, thus
our hands after touching and caressing the ani- contributing to the suppression of ragweed allergy
mals. Avoiding carpets is also important in case of [44].
pet hair allergies. If you stick to a rug, it is import- In the case of seasonal allergies, we can improve
ant that your pet is not in a room that is covered our well-being by reducing pollen exposure.
with a rug. The HEPA filter vacuum cleaner, air • Observe the pollen concentration! In case of
conditioner, effectively reduces pet hair exposure. high pollen concentration it is better to stay
indoors.
Mold allergy: Molds often settle in wet areas. The • After the appearance of pollen, keep the
kitchen and bathroom provide an excellent living windows closed, if possible, ventilate using
space for mold. In addition to wet blocks, they also air conditioners to remove pollen from the
settle behind wet walls, wallpapers and textiles. living space
Sometimes the spores spread through the apart- • When you return home, change your clothes,
ment as black spots, and sometimes invisibly, just as pollen inevitably sticks to them in the
causing a musty smell. open air and is a constant exposure for us
indoors as well.
In terms of prevention, monitor the humidity in • Wash your hair before going to bed every
the apartment, it should stay between 40 and 60 night
percent. High humidity can be effectively reduced • Ventilate in the evening or after rain when

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the pollen concentration is lowest ment is extremely high. In Hungary, about twice
• Try to schedule your vacation and travel for as many people die from cirrhosis of the liver as
a period when the pollen concentration in on average in the EU-27. [46]. Patients are 3: 1
your place of residence is high male. It requires long-term, continuous liver dam-
• There is no proper way to prevent the de- age. When healthy liver cells are damaged, the
velopment of allergic rhinitis, as the immune structure of the liver is rebuilt and connective tis-
system responds incorrectly to completely sue-scar tissue develops, which inhibits blood flow
ordinary things. The risk of developing the in the liver. Although the amount of functional
disease is increased by the following factors: liver tissue is constantly decreasing (as the name
• Genetic predisposition: If a parent is in- of the disease suggests, the number of functional
volved, the child is much more likely to be- liver cells is decreasing, i.e. shrinking), the dis-
come allergic. If one of the parents is aller- ease is asymptomatic for a long time or produces
gic, the children should be approx. by 25%, only general symptoms: fatigue, loss of appetite,
if both parents are allergic, children are 50% abdominal pain. Later, when the liver damage be-
more likely to develop an allergy than if nei- comes much greater, the characteristic symptoms
ther parent is involved. appear: jaundice, itchy skin, bleeding in the skin
• Lack of breastfeeding (ascites), ankle edema, dilated veins that can also
• Excessive use of cleaning products in the en- penetrate the skin, abdominal varicose veins, rem-
vironment of infants and young children (see iniscent of capuchin (caput medusae).
hygiene theory) The liver has an extraordinary reserve capacity.
• Smoking It is practically able to perform its function even
It is important to draw attention to the phenome- when only 10% of the liver cells are functioning.
non of cross-allergy. The body of an allergic per- Thus, when symptoms appear, the increase in dys-
son produces antibodies to protect against the pol- functional lobular scar tissue may be so great that
len of the allergenic plant. Unfortunately, in many the liver becomes palpable. There is currently no
cases, the consumption of foods containing similar way to reverse the structure of the liver, and only
antigens also triggers the immune response and liver transplantation can solve the patient’s sur-
triggers an inflammatory reaction to the histamine vival. According to the factors responsible for the
released from the body (such combinations can be development of liver cirrhosis, we distinguish 3
listed, for example [45]. types of the disease:

VIII.6. Gastrointestinal disorders Alcohol-induced liver cirrhosis: Prolonged, reg-

Diseases of the gastrointestinal tract include a ular, and significant alcohol consumption is the
number of diseases of various organs with differ- leading cause of liver cirrhosis in industrialized
ent etiologies, symptoms and prognoses. It would countries. The first stage of alcohol-induced liver
be pointless to summarize or attempt to summarize cirrhosis is fatty liver, when the liver accumulates
the epidemiology and prevention of all this, given significant amounts of fat, causing liver enlarge-
the size limits, because it would not be possible ment. This process can be reversed even without
to explain the relevant information. Instead, we alcohol, without medical intervention. The second
confine ourselves to the more important, relevant stage is hepatitis, the prognosis of which depends
diseases selected taking into account the domestic on the degree of liver damage. The third stage
conditions. is cirrhosis hepatis, when the death of liver cells
leads to such a degree of liver failure that surviv-
Cirrhosis of the liver al without liver transplantation can be up to 3-5
Cirrhosis of the liver is a progressive disease that years. The stage of cirrhosis of the liver develops
develops slowly over many years. According to in about 10-15% of cases due to long-term and
the latest data from Eurostat, Hungary’s involve- regular alcohol consumption.

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It is very difficult to define who is considered to eliminating the relevant risk factors. In do-
be at high risk for alcohol consumption. Alcohol mestic context, this means fighting alcohol-
consumption is part of our daily lives, so we are ism in particular, which is a societal task.
often not aware of the danger of drinking some Combating obesity is also a complex activ-
alcohol on a weekly or daily basis, even though ity - discussed in detail in other chapters. In
experts say this habit is also a risk for liver dam- the prevention of hepatitis, the fight against
age. As real alcohol consumption remains hidden intravenous drug use (e.g. needle exchange
in many cases, it is only possible to estimate how programs) and appropriate (safe) sexual be-
many people consume alcohol on a regular basis. havior are of paramount importance.
According to some estimates, the number of alco-
holics in Hungary (who have already developed Inflammatory Bowel Disease (IBD)
physical addiction) is about 1 million, while the The two main types of inflammatory bowel dis-
number of heavy drinkers is 2.5 million. Accord- ease are:
ing to the latest survey in 2019, 20.2% of the Hun- • Ulcerative colitis (ulcerative colitis): It is
garian adult population are moderate drinkers and considered by many to be an autoimmune
5.2% are heavy drinkers. Binge drinking is more disease because it is caused by an overac-
common in men; 9.3% of men and 1.5% of women tivity (disorder) of the immune system. The
are heavy drinkers in Hungary [47]. exact mechanism is still unknown today; but
the immune system does not recognize and
Hepatitis virus-induced liver cirrhosis: Hepati- attack the bacteria that improve digestion
tis B vaccination has been mandatory in Hungary in its own gut flora. Other hypotheses sug-
since 1999, depending on age. Thus, this method gest that a real infection occurs that activates
is no longer typical of us or in industrialized coun- the immune system, failing to turn it off on
tries. However, there is no vaccine against Hepati- just one fault, so it continues to overactive-
tis C infection. The most common transmission is ly function after infection. The disease can
intravenous drug use. develop at any age. It is characterized by
chronic inflammation of the colonic muco-
Non-alcoholic steatohepatitis: The most import- sa, which causes small wounds and ulcers.
ant risk factor for its development is obesity. Obe- It usually affects the surface of the colonic
sity is a common disease in developed countries. mucosa in a contiguous area starting from
According to the latest survey, 34.3% of the adult the rectum. This is the main difference from
population is overweight and 23.9% are obese Crohn’s disease, where inflammation affects
[48]) With a lifestyle change, the process can not only the surface of the mucosa but its en-
even be completely reversed. tire thickness. There is currently no known
cure for the disease, the symptoms can be
Additional risk factors for liver damage: controlled somewhat.
• Fungal poisoning: The most significant fun- • Crohn’s disease: In Crohn’s disease, the in-
gal poisoning is caused by the alpha-am- flammation extends to the entire thickness
anitine toxin of the killer agaric (Amanita of the intestinal wall. Intact and diseased in-
phalloides), which is primarily responsible testinal sections alternate (segmental inflam-
for lethal liver and kidney damage. Fortu- mation). Inflammation can occur anywhere
nately, there are only few deaths in Hunga- in the entire intestinal tract, from the oral
ry each year. The toxin of the killer agaric cavity to the anus, but is often localized to
cannot be neutralized in any way, there is no the appendix, where the small and large in-
antidote to poisoning. testines meet. The symptoms then resemble
• Medicines appendicitis, often recognizing the disease.
• Prevention of the disease is possible by Inflammatory abscesses, ulcers and perfora-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

tion are common. the severity of the symptoms, and it is definitely

The incidence of ulcerative colitis and Crohn’s recommended to learn some stress management
disease has increased exponentially in recent de- technique.
cades.
Ulcer disease
Risk factors may include: The prevalence of ulcer disease varies worldwide.
• Genetic factors, hereditary predisposition In recent decades, the incidence of the disease has
• Immune system dysfunction (hygiene theo- decreased significantly due to the identification of
ry) its most important etiological factor, Helicobacter
• Inadequate nutrition (low fiber diet, con- pylori. In a healthy body, the gastric juice produced
sumption of finished products) by the gastric mucosa and the pancreatic juice pro-
• Stress duced by the pancreas protect the mucosa from the
• Smoking corrosive effects of acidic digestive enzymes need-
• Changes in microbiota composition e.g. due ed for digestion. If, for whatever reason, this pro-
to frequent use of antibiotics tective mechanism does not work perfectly, small,
• Environmental factors (chemical com- difficult-to-heal sores and ulcers will form.
pounds from plant protection products, vari- Peptic ulcers can occur mainly in the esophagus,
ous infections) stomach, or proximal duodenum. The incidence of
• Unfortunately, the possibilities for specific feco-oral Helicobacter pylori infections has been
prevention of inflammatory bowel disease significantly reduced with improved hygiene, al-
are quite limited. What we can do is avoid though Helicobacter infestation is relatively high
the known risk factors (listed above) that can even in industrialized countries. Ulcer diseases oc-
reduce the risk somewhat [49]. cur in about 10 percent of the adult population in
industrialized countries, most commonly between
Irritable bowel syndrome. the ages of 20 and 50, and affect men twice as of-
It is considered one of the most common gastro- ten as women. Symptoms of peptic ulcer include
enteral diseases, a disease of civilization. Its inci- abdominal pain around the pylorus, which is often
dence is 10-15%.It usually appears in early adult- exacerbated by eating. Anorexia, weight loss, nau-
hood. The exact cause of the disease is not known, sea, vomiting may occur. Bleeding ulcers may in-
no specific organ change can be detected, but it is clude regular dizziness, bloody vomiting, or black
almost always associated with some kind of psy- stools [50].
chological problem. Known risk factors include Untreated ulcer disease can cause severe perfora-
stress, mental health problems (past trauma), mal- tion with acute pain on the one hand, and severe
nutrition, certain risk behaviors (smoking, alcohol, blood loss due to continuous internal bleeding on
drugs, lack of exercise), and poor bowel habits. the other. Scar tissue is often formed along micro-
According to some hypotheses disorders of nerves injuries, making it difficult for food to pass through
that regulate sensation and muscle contraction in the digestive system.
the intestinal wall and hormonal effects also cause
the characteristic symptoms: abdominal cramps, Important risk factors:
diarrhea, or constipation. These symptoms occur • Helicobacter pylori: It settles on the sur-
regularly or recur from time to time. Irritable bow- face mucosal layers of the gastric mucosa.
el syndrome is twice as common in women as it is It is most often a mild problem, but can also
in men. Stressful situations usually cause or exac- cause inflammation of the deeper layer of
erbate symptoms. For prevention, proper nutrition the gastric mucosa. Through its urease activ-
is recommended, especially for fiber intake. Fre- ity, it produces ammonia, which neutralizes
quent but small meals are recommended. You have gastric hydrochloric acid, allowing it to live
to learn to live with the disease, which may reduce in the gastric mucosa for many decades. Its

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

metabolites and toxins are responsible for tion. Lactose intolerance affects the population of
damage and inflammation of the gastroin- Asian and African countries the most. In the ab-
testinal mucosa. It spreads from person to sence of lactase, lactose is no longer broken down
person through food contaminated with the from the milk and milk products consumed. Un-
pathogen or through contact infection. In digested lactose enters the colon, where bacteria
most cases, we overcome Helicobacter in- in the intestinal flora produce lactic acid, methane,
fection in early childhood with insignificant and hydrogen to cause unpleasant gastrointestinal
symptoms, while in a small number of peo- symptoms (bloating, diarrhea, nausea, stomach
ple it causes chronic gastritis, ulcer disease cramps). Adult milk consumption is not typical in
or stomach cancer [51]. these societies [52].
• Aspirin, ibuprofen and other non-steroidal While the lactase gene is inactive in 90% of adults
anti-inflammatory drugs: their use has in- in African and Asian countries, the LCT gene re-
creased significantly in recent decades, part- mains active for a lifetime in a significant pro-
ly due to the fact that some of them are avail- portion of European and Western populations,
able without a prescription. and these people are able to utilize lactose with-
• Other medicines, e.g. steroids, anticoagu- out complaint, so these countries have become
lants milk-consuming societies. [53] There are two
• Smoking types of lactose sensitivity:
• Significant alcohol consumption Primary lactose intolerance: The most common
• Blood type 0 form in which the lactase gene is genetically in-
• In the past, stress and spicy foods were also activated at 2-5 years of age, as described above.
thought to be risk factors, but epidemiologi- As the level of the enzyme lactase decreases, it
cal studies in recent years / decades have not becomes more and more difficult to digest milk,
confirmed this. However, in ulcer patients, and the unpleasant symptoms only appear in adult-
increased stress can worsen the condition hood.
and increase the pain. Secondary lactose intoleranceis caused by anoth-
Thus, the most important lifestyle prevention erdisease (e.g. Crohn’s disease, celiac disease) or
options are to reduce the overuse of NSAIDs, to impairment (surgery, chemotherapy).
quit smoking, and to avoid excessive alcohol con- Prevention: Although the genetic cause itself can-
sumption. In the field of unnecessary medication, not be eliminated, fortunately there are particular-
the health care system also has a job to do. The ly effective options for preventing the symptoms
need for possible Helicobacter eradication (with of lactose intolerance. Fermented dairy products
an appropriate antibiotic) will also be decided by can be consumed because they have a minimal lac-
a specialist. tose content. It is also possible to take lactase-con-
taining tablets when lactose-intolerant people con-
Lactose intolerance: sume dairy products - so digestion is carried out by
Lactose sensitivity develops when someone is un- an enzyme ingested from the outside.
able to digest the milk sugar in milk, i.e. lactose.
This is because he/she does not have the functional Gastroesophageal Reflux Disease (GERD):
lactase enzyme needed for this. The enzyme lac- Gastroesophageal reflux disease, or GERD for
tase produced in the small intestine is vital during short, is the most common gastrointestinal disor-
breastfeeding, as it breaks down lactose in breast der that occurs when acidic stomach juice (possi-
milk into D-galactose and D-glucose, making it bly stomach contents) flows back from the stomach
useful for the baby. In mammals and 65-70% of into the esophagus. GERD can occur in all ages. It
humans, the LCT gene on the long arm of chro- is caused by weakness and inadequate peristaltic
mosome 2 is inactivated a few years after breast- of the lower esophageal sphincter, and increased
feeding, thus minimizing lactase enzyme produc- abdominal pressure. The typical symptoms of re-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

flux disease are: reduce reflux (lying worsens the symptoms

• Acid bloating of stomach juice or stom- in many people, while standing usually im-
ach contents, which can cause bad breath, proves them)
mouthfeel and cough • Creating the right body weight (if necessary,
• Heartburn weight loss)
• Increased salivation • Regular exercise (but exercising too hard
• Corrosive, burning sensation in the esopha- can make complaints worse)
gus • Reducing smoking and alcohol consumption
• Painful swallowing due to inflammation of
the esophagus VIII.7. Infectious diseases and their prevention
• Oesophageal stenosis, feeling lumpy Infectious diseases and epidemics have always
played a significant role in human history. A more
The following factors contribute to the develop- accurate understanding of infectious diseases and
ment of the disease and the maintenance of symp- the fight against them led to significant success-
toms: es in the 18-19th centuries for the first time. As a
• Overweight, obesity (due to increased ab- result of advances in public health, hygiene, mi-
dominal pressure) crobiology, and medicine, infectious diseases have
• Pregnancy declined. The greatest success of mankind in the
• Smoking fight against infectious diseases is the eradication
• Some medicines (e.g. due to their irritation of smallpox. Although classical infectious diseases
to the gastric mucosa or through the relax- have receded, the changes of the 20th-21st century
ation of the sphincter) (globalization, technical and technological devel-
• Nutritional factors, e.g. too spicy or acidic opment, migration, pollution, climate change, etc.)
food and drink, too big meals, bigger meal promote the re-emergence of infectious diseases
just before bed. In some individuals, cer- already believed to have been defeated and the
tain foods and beverages may trigger reflux emergence and spread of new infectious diseases.
based on individual sensitivity (e.g., choco-
late, coffee, alcohol, fatty, or fried foods). VIII.7.1. Basic epidemiological concepts
• Slower than average gastric emptying Epidemiology is the science of the laws of the ep-
• Some diseases, mainly of the connective tis- idemic process, the emergence and cessation of
sue (e.g. scleroderma, rheumatoid arthritis) diseases and epidemics. It researches and analyzes
• Hiatus hernia the causes of the epidemic, examines the factors
Based on the above, lifestyle changes can be used that sustain the epidemic process, the course and
to prevent the disease and reduce the symptoms cessation of the disease. Based on this knowledge,
(however, medication is often needed, which typ- it is responsible for developing procedures that are
ically means antacids, H2-receptor blockers and suitable for the prevention, control and eradication
proton pump inhibitors): of certain communicable diseases.
• Nutrition
• Take fewer portions several times VIII.7.1.1. The course and types of infectious dis-
• Main meals should not be shifted late into eases
the evening, meals should be smaller An infectious disease is a disease caused by a spe-
• Evening meals close to bedtime should be cific infectious agent or its toxic products. The dis-
smaller ease can spread directly or indirectly from person
• Last meal should be taken at least 2 hours to person, from animal to human or from animal to
before bedtime animal. An infection is the penetration of a patho-
• Avoid irritating foods and beverages gen into the body, but it does not always cause
• Adequate posture after eating to prevent / illness. The host’s response to infection is high-

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are not specific to the disease (eg fever, headache,

loss of appetite, lethargy, etc.)
Period of classic clinical symptoms: disease-spe-
cific symptoms (eg, typical rash in chickenpox)
appear. In terms of duration, the disease can be
acute, subacute, or chronic.
Reconvalence: The period of recovery.
The outcome of the disease can be complete re-
covery, the disease can be cured with complica-
tions (e.g., orchitis associated with mumps), per-
manent consequences (e.g., paralysis of the limbs
following poliomyelitis), and finally, the disease
can be fatal. (1,2)
Latency: from the time of infection to the devel-
opment of infectivity (VIII.Figure13)

Spatial and temporal types of infectious

diseases
VIII.Figure 12: Different stages of infectious
The occurrence is sporadic if the individual cases
diseases
are scattered in space and time.
Source: own editing
Outbreak (epidemic): the occurrence of a particu-
ly variable, with a number of factors influencing lar infectious disease in a given area significantly
whether the disease develops. It depends, among more frequently than expected or above a certain
other things, on the virulence of the pathogen, the threshold level. In an epidemiological sense, two
mode of penetration, the condition of the body and related cases are also considered epidemic if the
its resistance. link can be substantiated by epidemiological ev-
Clinical manifestations of the infection: idence.
inapparent infection: the infection is asymptomat-
ic. An infectious disease is endemic if it occurs reg-
aborted infection: mild, asymptomatic course ularly and permanently in a defined geographical
manifest / symptomatic infection: the infection area or population with a high incidence and prev-
produces classic clinical signs characteristic of the alence (e.g. malaria).
infectious disease Pandemic: an epidemic that spans several coun-
tries, continents, or the world.
Incubation time: the time between the entry of the Seasonality: some infectious diseases occur in
pathogen into the body (infection) and the onset greater numbers during certain seasons (e.g. influ-
of the first clinical symptoms. During this time, enza in the winter-early spring months).
the pathogen multiplies in the body and spreads Cyclicity: Some infectious diseases cause higher
(possibly producing toxins). The length of the in- incidence at regular intervals over several years
cubation time varies, data specific to the infectious when a sufficient number of susceptible individ-
disease (Table VIII.7). Knowledge of the incuba- uals are found in the population (e.g., diphtheria
tion time is important for contact detection during every 12 years) [54, 55].
epidemic investigation and for determining the du-
ration of epidemiological surveillance. Epidemic curve
Graphical representation of the appearance of cas-
Prodroma: Introduction of general symptoms that es in a coordinate system where the number of cas-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VIII.Table 7: Incubation time for some infectious diseases

Pathogen Clinical picture Incubation time

Salmonella fever, abdominal cramps usually 6 to 48 hours

Varicella zoster virus chickenpox 10 to 21 days, usually 14 to 16 days

Treponema pallidum Syphilis 10 to 90 days, usually 3 weeks

Hepatitis A virus Hepatitis 14 to 50 days, with an average of 4 weeks

Hepatitis B virus Hepatitis 50 to 180 days, usually 2 to 3 months

HIV AIDS <1 - 15+ years

Source: own editing

VIII.Figure 13. Dynamics of infectivity and disease

Source: Principles of Infectious Disease Epidemiology Epidemiology Notes [M.Tevfik DORAK][56]

es is plotted on the y-axis and the detection time is food). The number of cases increases rap-
plotted on the x-axis. It provides information on idly, reaches a peak and then gradually de-
e.g. the time course of the epidemic, the time dis- creases. The majority of cases occur within
tribution of the cases, the size and spread of the the incubation period of the disease. (e.g.
epidemic, the time of exposure [57]. food poisoning, VIII.Figure.14):
There are three main types: Extended source:
Point source: In the event of an outbreak from a continuous com-
All of the cases became infected at almost mon source, exposure may last for days, weeks,
the same time as a common source (e.g., or even longer. Not all cases occur within a sin-

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VIII. Figure 14: Outbreak graph of Bacillus cereus

Source: Epinfo Volume 22 No. 9 [58]

gle incubation period. The curve is steadily rising, an infectious disease nor an epidemic can devel-
relatively flat, (suggesting no human-to-human op. These are called the primary (or direct) driving
spread) and may show a characteristic plateau, the forces of the epidemic process (VIII.Figure 19).
number of cases may decrease rapidly if the com- However, there are also factors that greatly influ-
mon source is removed [56] (VIII.Figure 17). ence the frequency and severity of infectious dis-
eases, the extent and duration of epidemics, but
Propagated outbreak: do not play a role in their occurrence and mainte-
There is no common source because the epidemic nance. These natural and social influencing factors
is spread from person to person. The starting point are called the secondary (or indirect) driving forc-
for the outbreak is the index case (first identified, es of the epidemic process [54].
identified case). The epidemic curve shows grad-
ually increasing peaks, each peak being one incu- V.7.1.2.1. The primary driving forces of the epi-
bation time apart. (e.g. measles outbreak in closed demic process
communities. V. Figure 18) [57,62] Reservoir: the living or non-living medium in
which the pathogen lives and multiplies and from
V.7.1.2. Driving forces of the epidemic process which it can infect healthy individuals.
The simultaneous presence of three factors is re- The source of infection can be:
quired for the establishment, survival and spread - The sick person
of the epidemic process: - The person carrying the pathogen:
1. source of infection • A healthy pathogen carrier that has under-
2. the possibility of the infection spreading gone an infectious disease without clini-
3. susceptible organism cal signs.
If any of these three factors are missing, neither • An incubation carrier that discharges

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VIII. Figure 15: Extended source

(source: https://sciencecases.lib.buffalo.edu) [59]

VIII. Figure 16: Propagating epidemic (source: Centers for Disease Control and Prevention. Measles
outbreak — Aberdeen, S.D. MMWR 1971; 20:26.)[60]

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VIII. Figure 17. Chain of Transmission

Source:Introduction to Infection Prevention and Control (IPC) | OpenWHO www.openwho.org [61]

pathogens during the latent phase of the animate medium. The medium may be living or
disease. inanimate.
• A reconvalescent pathogen carrier that
has recovered clinically but is still excret- Inanimate mediator:
ing pathogens. - air: by inhalation of aerosols (≤5 µm) con-
- The infected (sick or pathogenic) animal taining pathogen
- Inanimate medium (e.g. air conditioning - - water: drinking water, bathing water, sewage
legionellosis) - food
- soil
Ways of spreading the infection - objects: utensils, medical devices
Direct spread: the pathogen enters the susceptible
organism directly from the infectious source Live mediators: vectors
- contact e.g.: sex, kiss, handshake - mechanical transmission: the vector as a
- direct droplet infection: coughing, sneezing, passive means of transport (e.g. housefly)
etc. Saliva droplets (> 5 µm) containing the - biological transmission: the pathogen multi-
exiting pathogen enter the susceptible organ- plies or develops in the vector (e.g. malaria
ism over a short distance (before settling) - mosquito)
(e.g. pertussis, meningococcus). [56]
- transplacental transmission The susceptible organism
An organism which does not have effective pro-
Indirect spread: the pathogen enters the suscepti- tection against a given pathogen is susceptible.
ble organism indirectly, using some living or in- We can distinguish between individual and pop-

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

ulation susceptibility. The former depends on the Primary task:

individual’s defenses and the factors influencing it - isolation of the source of infection,
(e.g. age, underlying disease, immunosuppression, - non-transmission,
etc.), the latter depends on the proportion of pro- - reducing the susceptibility of the individual /
tected and unprotected individuals in the commu- population
nity and their random distribution [54, 55]. VIII.7.2.1 Epidemiological measures in the event
Indicators used to characterize susceptibility: of an infectious disease:
Infectivity index: shows the number of infected in- In Hungary, legislation prescribes the epidemio-
dividuals in 100 susceptible individuals exposed logical tasks to be followed after the detection of
to the infection. an infectious patient:
- 18/1998. (VI.3.) NM Decree on the epidemio-
Contagiosity Index: Shows the number of patients logical measures necessary for the prevention of
who become ill out of 100 susceptible individuals communicable diseases and epidemics
exposed to infection (e.g., measles: 95%, polio: “In the event of an outbreak, the doctor who de-
1-2%) [54]. tects this must take the necessary immediate mea-
sures to prevent the spread of the infection and
Elemental Reproduction Number (R0): shows the inform the district office immediately of the mea-
average number of times a person passes the infec- sures taken.”
tion on to others (susceptible individuals) over the - 1/2014. (I. 16.) EMMI Decree on the reporting
course of their infection. (R0 is an average value, system for communicable diseases
so it is not necessarily an integer.) If R0> 1, the
number of infections multiplies quickly and an ep- VIII.7.2.2 Epidemiological measures to be taken
idemic develops. If R0 <1 the epidemic goes out. with the patient:
The value of R0 also depends on the characteris- Reporting: by law the healthcare provider is
tics of the disease and the current social conditions obliged to report and register infectious patients
in society. Its value can be reduced by a number and persons suspected of having an infectious dis-
of epidemiological measures (e.g. vaccinations, ease.
closure of schools, restaurants, etc.). The resulting Isolation: The purpose of isolation is to allow the
value is called the effective reproduction number patient to come into contact with as few suscepti-
[63]. ble individuals as possible during the period of in-
fectivity. Highlighting and isolating the infectious
VIII.7.1.2.2. Secondary driving forces of the epi- source from the epidemic process is the fastest,
demic process most effective, cheapest way to prevent the spread
They can generally be divided into two groups: of the epidemic.
Environmental factors: weather, climate, tempera- Microbiological examination: It may be used to:
ture, natural disasters - Clinical microbiological diagnostic test: to de-
Social factors: housing conditions, work environ- termine and apply appropriate individual therapy
ment, quality of health care, unemployment, mi- based on individual diagnosis
gration, etc. - Microbiological diagnostic testing in the interest
of epidemiology: the aim is to identify and analyze
VIII. 7.2. PREVENTION OF INFECTIOUS population-level risks as early as possible and to
DISEASES establish population-level interventions for pre-
Looking back at Figure 2, we can see that the de- vention purposes;
velopment of the epidemic process can be prevent- - Release test: a microbiological screening test to
ed primarily by interrupting the chain at any point, determine the infectivity of a person recovering
eliminating any of the primary driving forces from from a disease;
the process. Disinfection: any procedure used to destroy or

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

eliminate infectious pathogens released into the Infection source research: Mandatory in some cas-
environment. es. (e.g. in case of iatrogenic exposure, cumulative
- Preventive disinfection: disinfection of places occurrence or epidemic)
and objects that are particularly dangerous for the Detection of the distribution medium: Mandatory
spread of the infection, regardless of whether there for certain infectious diseases (e.g. if the distribu-
is an infectious patient at the given place and time. tion medium is food for human consumption, the
- Continuous disinfection: must be carried out con- competent food chain inspection body must be no-
tinuously throughout the period of infectivity, with tified in order to take the necessary measures) [64]
the aim of destroying pathogens that are continu- Epidemiological surveillance
ously or intermittently removed from the body of It synthesizes the task of epidemiological surveil-
the infectious patient. lance, prevention, and control at a higher level. It
- Final disinfection: used to kill pathogens left in monitors the morbidity and mortality of infectious
the environment after the infected patient has re- diseases, the circulation of pathogens in the popu-
covered (removed, died) [64]. lation, and monitors the immune status of the pop-
ulation. It uses various epidemiological methods
VIII.7.2.3. Epidemiological measures in the pa- and GIS to analyze the factors that may contribute
tient’s environment: to the spread of infections. It examines ecologi-
Searching for contact with the patient: In some cal, environmental and demographic conditions
cases, it is mandatory to search for people who on site. In possession of this data, he outlines the
have been in direct contact with the patient (e.g. situation of the infectious disease, develops, im-
COVID-19, syphilis, meningitis epidemica) or to plements and evaluates preventive measures.
search for people exposed from a common source
(eg dengue fever, viral haemorrhagic fever). VIII.7.3. VACCINATIONS
Microbiological screening for epidemiological The most important factor in reducing susceptibil-
purposes: screening of persons who have been in ity is to increase defenses. Defenses can be non-
contact with an infected patient during the incuba- specific and specific.
tion period or who are asymptomatic; Aspecific defense: the sum of all the mechanisms
Epidemiological surveillance: When required that inhibit the growth and invasion of a pathogen.
by law for a given communicable disease, per- Specific defense: means the body’s resistance to a
sons who come into contact with an infectious particular pathogen.
disease should be placed under epidemiological It can be congenital or acquired. Both can be pas-
surveillance to prevent the transmission of the in- sive or active.
fection. The duration of observation is the same During passive immunity, ready antibodies are de-
as the incubation time of the given disease. The livered to the body. Natural passive immunity is
competent public health authority shall prohibit a maternal immunity when immunoglobulins enter
person placed under epidemiological surveillance the fetus or infant transplantally or during breast-
from engaging in occupations specified in special feeding. Artificial passive immunity is the admin-
legislation and from visiting places where it may istration of immunoglobulins.
cause a mass infection for the duration of the sur- Active immunity is the body’s own immune re-
veillance. In some cases, stricter epidemiological sponse to a given antigen. Its natural form is an
surveillance (short-circuiting) may be ordered. immunity developed during infection, its artificial
Post-exposure prophylaxis: In some cases, persons form can be created with an antigen-containing
under epidemiological surveillance should receive vaccine, which causes the body to produce its own
antibiotic prevention (e.g. diphtheria, meningitis immune response and antibodies (VIII.Figure 20).
epidemica), chemoprophylaxis (e.g. avian influen-
za), active / passive vaccination (e.g. hepatitis A, In Hungary, the knowledge required for the prac-
hepatitis B). tical implementation of vaccinations in the given

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

VIII.Figure 18: Types of immunity

Source: https://commons.wikimedia.org/wiki/File:Immunity.svg

year is determined by the methodological letter is- • those belonging to the environment of a pa-
sued by the national chief medical officer for the tient with typhoid fever;
vaccination activities of the given year [65]. • those living in the vicinity of a diphtheria
patient;
• those living in the vicinity of a patient with
Grouping of vaccinations pertussis
1. Compulsory age-related vaccinations: At pres- • in the environment of a measles patient;
ent (2022) in Hungary, children are vaccinated • rubella in the patient’s environment;
free of charge against 13 communicable diseases • those at risk living in the vicinity of the
within the framework of continuous and campaign mumps patient;
vaccinations: • persons at risk of tetanus infection;
• persons exposed to rabies;
• - tuberculosis, • hepatitis A specific group of vulnerable peo-
• - pertussis, ple living in the patient’s environment.
• - diphtheria,
• - tetanus, 3. Free unpaid immunizations to prevent the risk
• - poliomyelitis, of disease:
• - Haemophilus influenzae B - mumps • Influenza vaccinations
• - rubella, • Vaccination against hepatitis B.
• - Morbilli • Vaccination against human papillomavirus
• - hepatitis B (HPV)
• - Pneumococcus
• - HPV 4. Job-related vaccinations: In order to reduce the
• - varicella risk of illness, the employer must provide vaccina-
tions for workers in the endangered job as a condi-
2. Mandatory vaccination in case of disease: In tion of employment.
case of acute risk of infection, vaccination should • influenza,
be given as soon as possible: • typhoid fever,

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

• tick-borne encephalitis, • Viral infections

• hepatitis A and B respectively • Influenza
• rabies, • Avian Influenza
• varicella, • Varicella
• meningococcal disease, • Mononucleosis infectiosa
• diphtheria • Respiratory Giant Cell Virus (RSV)
• immunization against tetanus • Coronavirus (SARS-coronavirus)
• Morbilli
5. Vaccinations related to travel abroad: Vaccina- • Mumps
tions for travelers abroad, including yellow fever, • Rubella
are provided by health care providers maintained
by county government offices and licensed to per- General precautions:
form international vaccinations. Proof of vaccina- • regular, thorough handwashing with soap or
tion against yellow fever is compulsory on entry alcoholic hand sanitizer for at least 20 sec-
into a country where there is a risk of yellow fever onds
or if that country requires such vaccination. [65] • wearing a mask in crowded places where
protective distance cannot be maintained or
6. Recommended vaccinations in places required by law
• Pneumococcal vaccines • keep a protective distance of at least 1.5-2 m
• Meningococcal vaccines from others
• Vaccines against tick-borne encephalitis • avoid contact with face, eyes, mouth
• Rotavirus vaccines • regular ventilation
• Varicella vaccines • adherence to cough and sneezing etiquette
• RSV vaccine (use of paper handkerchief, elbow bend)
• Human Papilloma virus vaccines • routine cleaning and disinfection of fre-
• COVID-19 vaccinations quently touched areas

VIII.7.4. Classification of infectous diseases Enteral infectious diseases: pathogens are trans-
and main preventive measures mitted by the feco-oral route, through inadequate-
Infectious diseases that spread through the ly heat-treated food of animal origin (milk, eggs,
airways: the pathogen leaves the body when you meat) or contaminated food, but flies can also be
exhale (cough, sneeze, talk) and is inhaled into included in the transmission as passive carriers.
the other person’s airways. These infections are [54]
extremely easy to spread, common, and difficult
to control. [54] Vaccination is the most effective Several pathogens can cause enteric infections:
means of control. • Bacterial infections
• Campylobacter enteritis
Major respiratory infectious diseases: • Salmonellosis
• Bacterial infections • Coli enteritis (EPEC, ETEC, EHEC, etc.)
• Diphtheria • Yersiniosis
• Haemophilus influenzae meningitis • Dysentery
• Pertussis • Cholera
• Tuberculosis • Typhus
• Scarlatina • Paraatyphus
• Legionellosis • Viral infections
• Meningitis epidemica • Norovirus infections
• Streptococcus-pneumonia • Rotavirus infections

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

• Hepatitis A and E Malaria

• Adenoviruses Leishmaniasis
• Poliovirus
• Worm infections Prevention:
• Ascariasis • vector control
• Enterobiasis • personal protection (use of appropriate
• Hymenolepiasis clothing, repellents)
• Trichuriasis • screening of blood products and organ do-
• Protozoon infections nors
• Ameobiasis • screening of individuals at increased risk
• Giardiasis (e.g. IV drug users, prostitutes)
• safe sex
General preventive measures: • vaccination (e.g. tick-borne encephalitis)
• Adherence to personal and food hygiene
regulations Infectious diseases that spread through the
• Appropriate kitchen technology outer covering: There are many diseases in this
• Proper storage and heat treatment of food group. In some diseases, the pathogen penetrates
• Adherence to occupational hygiene regula- the body through the skin, but the actual disease
tions: health, hygiene, protective clothing, process is created in an internal organ. [54]Main
safety shoes, safety regulations, correct tech- diseases:
nology • Bacterial: Tetanus, Edema malignum, Toxic
• Expanding knowledge, health education shock syndrome
• Vaccination (e.g. typhus, rotavirus) • Protozoan infections: Trichomoniasis
• Worm infections: Ancylostomiasis, Schis-
Haematogenic Infectious Diseases: These in- tostomiasis, Strongyloidosis
fectious diseases enter the body mostly through • Arthropods: Pediculosis, Scabies
blood-sucking vectors. They are endemic in the ar-
eas where the vector needed to spread them lives. Prevention:
Also included in this group are diseases that enter • compliance with hospital hygiene rules
the body through blood, blood products, medical • Adequate wound care
interventions, or intravenous drug use. [54] • Observe personal hygiene rules
• Vaccination
Bacterial infections
Lyme disease Zoonoses (animal-to-human diseases): These in-
Febris reccurens fections can be spread through direct contact with
Pest infected animals, their secretions, bites from ani-
Viral infections mals, consumption of milk and meat from infected
Tick - borne encephalitis animals, vectors, or airway transmission [54]
West Nile fever • Bacterial infections: Anthrax, Brucellosis,
Crimean Congo hemorrhagic fever Ornithosis, Q fever, Tularaemia
Dengue fever • Viral infections: Rabies, Hanta virus infec-
Yellow fever tions, Lassa disease
Hepatitis B, C, D • Protozoa: Toxoplasmosis
Worm infections • Worm infections: Echinococcosis, Taeniasis,
Filariasis Trichinellosis
Onchocerciasis
Protozoon infections Prevention:

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

• compliance with veterinary, occupational

health and nutrition measures and regula-
tions
• personal hygiene,
• vaccination against certain zoonoses

Sexually Transmitted Infections: Close physi-

cal contact is required for infection. Mixed infec-
tions are common. Through vertical transmission,
a pregnant woman infects / may infect her fetus
during intrauterine life or during childbirth. Its
complications pose significant health, epidemio-
logical, economic, and population policy issues.
[54]

It can be caused by:

• Bacteria: Neisseria gonorrhoeae, Treponema
pallidum, Chlamydia trachomatis
• Viruses: Herpes genitalis. Human papilloma
virus, Hepatitis B, HIV
• Protozoa: Trichomonas vaginalis
• Ectoparasites: Phthirus pubis, Sarcoptes sca-
biei
• Fungi: Candida albicans

Prevention:
• Health education, information, counseling
• Improving personal hygiene and sexual hy-
giene
• Condom use
• Early diagnosis and treatment
• Finding, informing and, if necessary, treat-
ing sexual partners
• Pre-exposure prophylaxis (PrEP) to reduce
the risk of HIV infection
• Vaccination (HPV, HBV)

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

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1. Wong et al, Nature Reviews Cardiology eases [2021.04.25]
2014 11: 276–289 20. https://www.cdc.gov/cancer/breast/ba-
2. Keys A., Taylor HL., Blackburn H. et sic_info/risk_factors.htm [2021.04.20.]
al.: Mortality and coronary heart disease 21. https://www.cancer.org/cancer/lung-can-
among men studied for 23 years. Archi- cer/detection-diagnosis-staging/surviv-
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tral.com/articles/10.1186/s12872-019- 25. h t t p s : / / w w w. u p t o d a t e . c o m / c o n -
1223-z [2021.04.25] tents/image?imageKey=ON-
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cal-activity-guidelines-for-americans 26. https://www.antsz.hu/data/cms41690/
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l e y. c o m / d o i / 1 0 . 3 3 2 2 / c a a c . 2 1 6 6 0 news/az-uj-ajanlasok-el-
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34. A., Pakai ; R. Mihály-Vajda ; Zs. Kívés, diseases/7317-lactose-intolerance

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; M., Zrínyi ;A. Olah; , Siket Újváriné 53. https://www.ncbi.nlm.nih.gov/pmc/arti-
(2022), Predicting Cervical Screening cles/PMC4586535/ [2021.03.21.]
and HPV Vaccination Attendance of 54. Ember I. (2007): Népegészségügyi or-
Roma Women in Hungary: Community vostan. Dialóg Campus, Budapest
Nurse Contribution is Key, BMC Nursing 55. Kertai P. (1999): Megelőző orvostan – A
22 : 1 népegészségügy elméleti alapjai. Medici-
35. https://oltokozpont.hu/hu/oltas/20/hpv na Könyvkiadó, Budapest
[2021.04.22.] 56. Principles of Infectious Disease Epide-
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head-and-neck-cancer [2021.04.24.] 57. V. Hajdú P.-Ádány R. (2003): Epidemi-
38. https://www.skinvision.com/articles/abc- ológiai szótár. Medicina Könyvkiadó,
de-melanoma-self-check [2021.04.24.] Budapest
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melanoma [2021.04.24.] 59. https://sciencecases.lib.buffalo.edu)
40. https://www.who.int/news-room/fact- [2021.03.20.]
sheets/detail/chronic-obstructive-pulmo- 60. Centers for Disease Control and Preven-
nary-disease-(copd) [2021.04.24.] tion. Measles outbreak—Aberdeen, S.D.
41. https://www.who.int/news-room/fact- MMWR 1971;20:26 [2021.03.20.]
sheets/detail/asthma [2021.04.23.] 61. Introduction to Infection Prevention and
42. https://www.webmd.com/asthma/asth- Control (IPC) | OpenWHO www.open-
ma-risk-factors [2021.04.23.] who.org [2021.03.20.]
43. https://my.clevelandclinic.org/health/ 62. https://www.cdc.gov/training/Quick-
diseases/8622-allergic-rhinitis-hay-fever Learns/epimode/ [2021.03.20.]
[2021.04.25] 63. Ferenci T.: A magyarországi koronavírus
44. https://net.jogtar.hu/jogszabaly?do- járvány valós idejű epidemiológiája
cid=a0800221.kor [2021.04.25] https://research.physcon.uni-obuda.hu/
45. https://www.allergiakozpont.hu/keresz- COVID19MagyarEpi/ [2021.03.20]
tallergia [2021.04.22] 64. 18/1998. (VI.3.) NM rendelet a fertőző
46. http://appsso.eurostat.ec.europa.eu/nui/ betegségek és a járványok megelőzése
show.do?dataset=tps00131&lang=en érdekében szükséges járványügyi intéz-
[2021.04.25] kedésekről
47. https://www.ksh.hu/sdg/1-15-sdg-3.html 65. A Nemzeti Népegészségügyi Központ
[2021.04.25] módszertani levele a 2022. évi
48. https://www.ksh.hu/docs/hun/xstadat/ védőoltásokról https://www.antsz.hu/
xstadat_eves/i_fek008.html [2021.04.25] data/cms101372/VML_2022_NNK.pdf
49. https://www.thelancet.com/journals/lan-
gas/article/PIIS2468-1253(19)30333-4/
fulltext [2021.04.25]
50. (https://www.nhs.uk/conditions/stom-
ach-ulcer/ [2021.04.25]
51. https://my.clevelandclinic.org/health/
diseases/21463-h-pylori-infection
[2021.03.21]
52. https://my.clevelandclinic.org/health/

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IX. GLOSSARY
IX.1. Basic concepts inextricable link between social and economic
conditions, the physical and social environment,
Public health individual health behaviors and skills, and health.
Public health is the organized activity of society These relationships provide the key to a holistic
to develop, protect, improve and, where necessary, understanding of health, which is central to the
restore the health of individuals, specific groups or definition of health promotion. A comprehensive
the population as a whole. It is a combination of understanding of health means that all systems
sciences, skills, and values ​​that operates through and structures that manage the determinants of
collective social activities and includes programs, health must take into account the impact of their
services, and institutions designed to protect and activities on individual and collective health and
improve human health. well-being. This increasingly includes concerns
about the health of the planet - this is called plan-
Public health is a social and political concept that etary health [1].
aims to improve health, prolong life, and improve
the quality of life of the entire population through Health determinants
health promotion, disease prevention, and other Health determinants are the range of personal, so-
forms of health intervention. The Ottawa Charter cial, economic, and environmental factors that af-
supports significantly different approaches to de- fect the healthy life expectancy of individuals and
scribing and analyzing health determinants and the population.
ways to address public health issues. These meth-
ods include the strategies and areas for action of Conditions that affect health are diverse and in-
the Ottawa Charter [1]. teractive. Some determinants of health cannot be
modified (e.g., age, place of birth, and inherited
Health traits). Health promotion is fundamentally about
Health is a state of complete physical, social, and measures to address the full range of determinants
mental well-being, not merely the absence of dis- of potential health modification, not only those re-
ease or weakness. The WHO considers health to be lated to the actions of individuals, but also those
a fundamental human right. Accordingly, all peo- factors that are largely beyond the control of in-
ple should have access to basic health resources. dividuals and groups. These include, for example,
In the context of health promotion, health is seen income and access to resources, education, em-
as a resource that enables people to live produc- ployment and working conditions (often referred
tive lives individually, socially and economically. to as social determinants of health), access to
The Ottawa Charter for Health Promotion defines adequate health services, and environmental de-
health as a resource for everyday life, not an ob- terminants of health. Health promotion addresses
ject of life. It is a positive concept that emphasizes this wide range of determinants through a com-
social and personal resources as well as physical bination of strategies, including the promotion of
abilities. Health in All Policies and the creation of a sup-
In line with the concept of health as a fundamental portive environment for health; and strengthening
human right, the Ottawa Charter emphasizes cer- personal health literacy and skills. Measures to ad-
tain preconditions for health, which include peace, dress health determinants are inextricably linked
adequate economic resources, food and shelter, to health inequalities and fundamentally address
education and social justice, and a stable ecosys- the distribution of power and resources within the
tem, sustainable development and resource usage. population [1].
Recognition of these preconditions highlights the

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Health promotion velopment and maintenance of health and the pre-

Health promotion is the process that allows people vention of diseases, on the one hand, and to restore
to increase control over and improve their health. the health status of patients as soon as possible,
Health promotion is a comprehensive social and by raising the level of health culture and shaping
political process. It includes not only measures to lifestyles [3, 5].
strengthen the skills and abilities of individuals,
but also measures to change the social, environ- Well-being
mental and economic determinants of health in or- Well-being is a positive state experienced by indi-
der to optimize their positive impact on public and viduals and societies. Like health, it is a necessary
personal health. Health promotion is the process resource for everyday life, determined by social,
of enabling people to individually and collective- economic and environmental conditions.
ly increase control over the determinants of health Well-being includes the quality of life and the
and thereby improve their health. ability of people and societies to contribute to the
The Ottawa Charter sets out three basic strategies world according to their worldview and goals. Fo-
for health promotion. These are the following: cusing on well-being supports the monitoring of
• advocating for health in order to create the a fair distribution of resources, overall well-being
above-mentioned basic conditions for health; and sustainability. The well-being of a society can
• enabling all people to reach their full health be observed in terms of its resilience, its ability to
potential; act and its readiness to overcome challenges [1, 2,
• mediation between the different interests of 6].
society in the pursuit of health.
• The Ottawa Charter identified five priority Quality of life
areas for action: Quality of life is a set of conditions that contrib-
• developing a healthy public policy; ute to the well-being of individuals and the ex-
• creating a supportive environment for health; ploitation of their potential in social life. Qual-
• strengthening community action for health; ity of life includes both subjective and objective
• developing personal skills; factors. Subjective factors include perceptions of
• reorganization of health services [1, 2] the physical, psychological, and social well-being
of individuals. Objective factors involve material
Health education well-being, health and a harmonious relationship
According to the WHO definition, health educa- with the physical and social environment [4, 5, 6].
tion is a set of consciously created learning oppor-
tunities that help the individual and the community Equity
to promote their health by expanding their knowl- The term fairness is used as a specific concept - not
edge, shaping their lifestyles and behaviors. as a principle - by social security in the event that
Health education covers several disciplines: med- a senior official of the insurer authorized by law
icine, pedagogy, psychology, education and so- authorizes an additional benefit based on an indi-
ciology. The scope (content) of health education vidual fairness assessment. Health equity is the
thus expands significantly: it takes into account a absence of unfair, avoidable or remediable differ-
person’s biological condition (physical, organiza- ences in health status between socially, economi-
tional health) as well as his or her mental (men- cally, demographically or geographically defined
tal, emotional, aspiring) characteristics and social populations.
status resulting from social coexistence (materi- Health equity means that everyone must have a
al-economic situation, family harmony) , social fair chance of achieving full health and that no
integration disorders) and judges what needs to be one should be disadvantaged in achieving those
done in their combined system of effects. opportunities. Health equity is fundamentally in-
The aim of health education is to promote the de- fluenced by the social determinants of health.

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Approaches to addressing social determinants of ernment, civil society and health services, must
health and promoting health consistently and sus- provide access to reliable information in a form
tainably focus on health equity and social justice. that is understandable and usable by all people.
Health promotion is a comprehensive and adaptive These social resources for health education include
response to the unfair distribution of opportunities the regulation of the information environment and
in societies and supports measures that address the media (oral, print, broadcast, and digital) in which
determinants of health that cause this distribution people access and use health information. Health
of inequality. A fundamental strategy for health literacy means more than being able to access
promotion is to enable all people to reach their full websites, read brochures, and follow prescribed
health potential through fair and equitable access health-seeking behaviors. It includes the ability to
to health resources. critically evaluate health information and resourc-
Similar concepts are health difference (disparity) es, and the ability to express and act on personal
and health inequality. Health inequality refers to and social health promotion needs by improving
actual differences, health inequality to avoidable people’s access to understandable and reliable
differences, and health inequity to unfair differ- health information and their ability to use it effec-
ences. Deciding what is fair and what is not is ex- tively. Health literacy is crucial both in enabling
tremely difficult and definitely requires judgment. people to make decisions about their personal
Theories of social justice, such as egalitarianism, health and in participating in collective health pro-
utilitarianism, etc., may provide some clues to this motion activities that address health determinants.
[1,7]. According to the Integrated Model, we interpret
the concept of health education based on the fol-
Adherence lowing definition:
The WHO definition of adherence is “the behavior At the heart of the design is the process of health
of an individual in accordance with recommenda- education, which requires four competencies:
tions agreed with a health professional in the ar- 1. Access refers to the ability to request, search
eas of medication, diet, and lifestyle change”. The for and access health information.
word adherence comes from the English word ‘Ad- 2. Comprehension covers the ability to under-
herence’ (adherence, strict adherence) and shows stand the health information we receive.
how well the patient interacts with the healthcare 3. Assessment is the ability to interpret, filter,
professional. It has three components: starting, judge, and evaluate the health information re-
taking / continuing and stopping medication. This ceived.
approach assigns an active role to the patient and is 4. The application refers to the ability to commu-
an important part of self-motivation and self-reg- nicate and use information to make decisions
ulation to adhere to treatment. Lack of adherence in order to maintain or improve our health
negatively affects both mortality and hospital costs [1,8,10,11].
in a society [3].
Health gains
Health Literacy Health gains are changes in health status, which
Health literacy is crucial to making informed deci- may lead to
sions and empowering people and communities. It - prolongation of life-span, and / or
is based on inclusive and equitable access to quali- - may cause an improvement in the quality of
ty education and lifelong learning. It is the observ- life.
able result of the part of health promotion, health Intervention that triggers change can be the use
education. Health education is mediated by cultur- of health technologies and changing the external
al and situational needs of people, organizations, environment affecting health for health purposes.
and society. It is not the sole responsibility of indi-
viduals. All information providers, including gov-

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An integrated model of health literacy

Source: Csizmadia P , (2016) Health Education, Health Development, LVII. year, / 3.

Disease burden Premature death

Disease burden is a measure of the difference be- One measure of premature mortality is the number
tween the current state of health of a population of years of life potentially lost, which is the num-
and the optimal state when all people reach full ber of years not lived out of the life expectancy
life expectancy without suffering from a serious determined by mutual agreement in 70/75 years.
illness. Manageable mortality includes death that can be
Disease burden analysis is an important and wide- prevented with appropriate treatment. Prevent-
ly used tool that allows decision makers to identify able mortality means the type of mortality that
the most severe health problems in the population could be avoided with proper prevention [3].
at present and the burdens expected in the future.
This can be expressed in lost healthy life years Number of years of life in health:
(HeaLY), disability-adjusted life years (or lost The number of years of life spent in health takes
healthy life years) (DALYs), quality-adjusted life into account not only life expectancy but also
years (QALYs), or adjusted combinations of these quality of life, making it one of the key measures
metrics. Disease burden data also provide a basis of well-being. The value of the indicator express-
for determining the relative contribution of differ- es the average number of years of healthy life
ent risk factors and may be useful in determining expectancy that a newborn can expect in a given
the relative importance of health determinants in year (with age-specific probabilities of death). It is
the broader general health of the population. Dis- calculated on the basis of the CSO’s demographic
ease burden data can be used to clarify the unequal data on the total population and its definition based
effects of risk factors and health determinants on the collection of representative health data.
and can be used to highlight measures needed to Hungary is 3 years behind the EU average and the
achieve greater health equity. These data and an- regional differences are much larger [3].
alyzes can be used to prioritize health promotion
measures within countries [1,3]. Health value
The process of our daily life is given by the fact
that we separate essential and insignificant tasks

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Regarding the territorial distribution, the figure below shows the significant difference, Source CSO

Number of years of life expectancy at birth for females (2016)

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

from each other and perform our tasks based on some kind of health activity for cure or prevention
it. We distinguish between good and bad, which [1, 3, 16].
plays a role in shaping our opinions. It becomes
clear to our decisions, choices and others what is IX.2. Activities
of value to us and what is not. So there are values Community health promotion
behind people’s activities. In the light of the results By communities we mean connected networks
of the research, health is among the core values. of people based on their place of residence (set-
This makes our lifestyle healthy or unhealthy. De- tlement, neighborhood), their occupation (educa-
fining the concept of value is not easy, as there is tional institutions), their work (workplace), their
no uniform consensus on its definition [12, 13, 14, age (children), their demographic characteristics
15], and its connection to different disciplines also (women) and their common problems. they “orga-
justifies the difficulty of defining it. nize” along dimensions seeking common answers
Health as a value has also emerged in the minds (self-help groups). The existence of these commu-
of members of primitive human communities, as nities is, on the one hand, a gift (for example, in
evidenced by early lifestyle research. In general, it the scenes where people live their daily lives), and,
refers to the factors and operations that appear as on the other hand, they are really organized volun-
asset values in achieving, maintaining, and restor- tarily or externally for the sake of some interests
ing health. By asset value is meant the desired be- and goals [5, 17].
haviors that serve to achieve the target value. Ac-
cording to current government documents, health The scene-based approach
as a value is paramount. The Basic Law clearly The arena is the place or social environment in
states that everyone has the right to physical and which people engage in everyday activities in
mental health. The law interprets that achieving which the interaction of environmental, organi-
this basic value can be achieved with the right en- zational, and personal factors affects health and
vironment, health care, sports, food, drinking wa- well-being, such as schools, workplaces, hospitals,
ter, and public health. In addition to work, home, villages, and cities (WHO, 1998) [17].
family and order, health is also a goal in the Na-
tional Cooperation Program, just as the “Healthy TIE - Whole school health promotion concept
Hungary 2014-2020” program also confirms the (WSHPC)
government’s commitment to the value of health The strategy, entitled “Healthy Hungary 2014-
[12, 15]. 2020” adopted in 2015 defines the main public
health goals and tasks in accordance with the Ba-
Disease sic Law, among which one of the most import-
A disease is a deviation from a socially accepted ant interventions is comprehensive institutional
picture of health / school health development (hereinafter: TIE).
• that reduces life expectancy or impairs qual- TIE is a summary of institutional / school activ-
ity of life (ie causes death or dysfunction and ities that promote the preservation and develop-
/ or pain), and ment of health, the effective prevention of disease,
• that is perceived by the individual or their health-conscious behavior, and a health-based
environment (including the perception of the approach. TIE has been a requirement in pub-
care system, diagnostic tools). lic education legislation since 2012 for all public
According to this definition, what is considered education institutions (in addition to school, kin-
a disease and what is not may vary from culture dergarten and college), but is also supported by a
to culture. Deviating from the accepted picture number of other relevant legislation.
of health also means that the individual or soci-
ety wants to do something about it. In this sense, a Workplace health promotion - the joint efforts
disease is a condition that has the ability to initiate of employers, employees and society to improve

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the health and well-being of workers, which can ment of the disease:
be achieved by improving and developing the • usually by non-medical means (elimination
workplace organization and working environment of adverse health effects, development of a
by encouraging active and individual participation health-conscious lifestyle, etc.)
[17]. • based specifically on medical activity (eg
vaccination).
Active Aging / Healthy Aging Its activities cover all areas of health education
People are living longer across Europe. It is ben- (health pedagogy) and health education.
eficial for both the individual and society to en-
sure that these years can be spent actively and in Secondary prevention
good health by the elderly. To promote healthy ag- Its aim is to detect diseases at an early, hidden
ing, EU-funded projects support the maintenance stage that has not yet caused a complaint. In this
of health and activity in old age and ensure that way, the patient has a good chance of being treated
health care is tailored to the needs of an increas- with less damage and a lower cost. Secondary pre-
ing number of older people. Healthy aging has a vention is typically done through medical devices
positive impact not only on individuals but also (see screening) but also includes self-monitoring
on society, as health care spending is reduced and by lay people.
people can remain economically active. There are
also new opportunities for innovation to meet the Tertiary prevention
health and well-being needs of a growing group in Its aim is to prevent damage caused by diseases,
society [19]. causing a permanent health deficit - deteriorating
the quality of life; prevention of conditions caus-
Health-conscious behavior ing dysfunction, lasting pain, long - term care. Its
Health-conscious behavior is the totality of an in- tools include effective, up-to-date, uncomplicated
dividual’s attitude, behavior and activities in order treatment and early rehabilitation to prevent the
to stay healthy as long as possible. In doing so: he/ development of definitive injuries [3, 6, 17].
she considers the health aspects important in the
decisions and actively participates in his/her own Disease
and - in his/her narrower and wider - environment, A disease is a deviation from a socially accepted
by consciously controlling his/her habits (e.g.: picture of health that
proper nutrition, exercise, sexual habits; avoiding • which reduces life expectancy or impairs
unhealthy behaviors, etc.) participates in the de- quality of life (i.e. causes death or dysfunc-
velopment of their health, acquires the skills of lay tion and / or pain), and
help and self-help, develops and applies informed • what the individual or their environment
consumer behavior in relation to health care sys- perceives (including the perception of the
tem: care system, diagnostic tools).
o the knowledge of his/her disease and its pos- According to this definition, what is considered
sible outcomes, a disease and what is not may vary from culture
o knowledge of the care system and access to culture. Deviating from the accepted picture
possibilities, of health also means that the individual or soci-
o knowledge of patients ‘ rights ety wants to do something about it. In this sense, a
o health consumer protection knowledge [6]. disease is a condition that has the ability to initiate
some kind of health activity for cure and preven-
tion [3,6].
Primary prevention
It focuses on the general protection and promotion Vaccination
of health, with the aim of preventing the develop- Vaccination is a health activity in which a vaccine

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 Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

is given to the body for active or passive immuni- that food and consumer goods, goods and services
zation to develop and enhance specific protection placed on the EU market are safe, that the EU’s
against a given disease. internal market works to protect consumers’ inter-
In the case of active immunization, the vaccine ests, and that the EU supports projects that protect
contains either non-infectious bacterial or viral and improve the health of its citizens.
components or whole pathogens, but is so attenu- It aims to protect and improve the general health
ated that they cannot cause infection. The body’s of people, to ensure the safe and wholesome nature
defense system responds to the vaccine by produc- of food, to protect animal and plant health, to pro-
ing substances (antibodies and white blood cells) mote animal welfare and to promote the interests
that recognize and attack the bacteria or virus in of consumers, within the general objectives of the
the vaccine. From then on, these antibodies and European Commission.
other substances are produced naturally whenev-
er an individual encounters the same bacterium or OECD
virus. The OECD, the Organization for Economic Co-op-
eration and Development, began its work in 1961
In the case of passive immunization, there are under the OECD Convention, the legal successor
specific antibodies against a certain pathogen (the to the OEEC (Organization for European Econom-
already finished antibody) in the vaccine. Passive ic Co-operation), which was originally established
immune protection is given to people whose im- in 1948 as Marshall Aid to facilitate post-war eco-
mune systems are unable to respond adequately to nomic consolidation.
the infection or who are not vaccinated when they
get the infection (for example, when they come It has now, since September 2010, brought togeth-
across the rabies virus). Passive immunization can er thirty-three countries committed to democracy
also be used to prevent illness when exposure to and a market economy. Hungary became a full
the pathogen is expected but there is no time to member of the OECD in 1996.
administer the full series (eg when traveling to The OECD is based in Paris.
distant countries). Passive immune protection lasts
only a few days or weeks until the vaccinated anti- Its main objectives are to promote economic
bodies are cleared from the body. growth, a high level of employment, a higher stan-
Vaccines play a major role in the prevention of dard of living and financial stability in the Mem-
infectious diseases worldwide. The goal of each ber States. Its main activity is the collection of
country is to have a favorable epidemiological comparable statistics, the publication of analyzes
situation, and to this end, it will adapt its vacci- and forecasts. The OECD Health Data database is
nation system (vaccination schedule, vaccination about the health care and health systems of OECD
calendar) taking into account the epidemiological member countries. It analyzes the financial sus-
situation. tainability of health care systems, the efficiency
18/1998 (VI. 3.) NM Decree on epidemiological and quality of health care systems in the member
measures necessary for the prevention of commu- states, and examines the environmental conditions
nicable diseases and epidemics [3, 20]. affecting health care.

IX.3. Organizations WHO

EU Directorate-General for Health and Con- The World Health Organization (WHO) is the
sumer Protection (DG SANCO) UN’s specialized governing and coordinating
The activities of the EU’s Directorate-General for body for health.
Health and Consumer Protection cover health and The main goal of the WHO is to provide for all
well-being activities that directly affect the daily people the highest possible level of health. Ac-
lives of European citizens. Their job is to ensure cording to the WHO Constitution, health is a state

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of complete physical, mental and social well-being Centers for Disease Control and Prevention
and not merely the absence of disease or infirmity. (CDC)
There are 6 main areas in the WHO program: The primary purpose of the Center is to protect
1. Promoting health promotion: improving the public health and safety through the prevention of
health of poor, vulnerable groups in society, illness, injury, and disability in the United States
preventing and treating chronic diseases, and worldwide. The CDC focuses its attention on
and combating neglected tropical diseases. the development and application of disease control
2. Improving health security: tackling health and prevention. It pays special attention to com-
threats and risks originating from, for exam- municable diseases, foodborne pathogens, envi-
ple, urbanization, pollution, food production ronmental health, occupational safety and health,
and trade, and the misuse of antibiotics. health promotion, and injury prevention mainly
3. Strengthening health systems: improving ac- for educational activities to improve the health of
cess to health care in particular . Target ar- U.S. citizens. The CDC also conducts research and
eas: Ensuring a sufficient number of suitably provides information on non-communicable dis-
qualified medical staff , sufficient funding, a eases such as obesity and diabetes and is a found-
system for collecting vital statistics, access ing member of the International Association of
to appropriate technologies and essential National Institutes of Public Health. [25]
medicines .
4. Promoting research, information, and evi- IX.4. Persons
dence-based health policy: WHO provides Ferenc Pápai Páriz (Deés, May 10, 1649 - Nagy-
credible health information for setting norms Enyed, September 10, 1716)
and standards, making evidence-based He was a doctor of philosophy and medicine at the
health policy decisions, and monitoring the Bethlen College in Nagyenyed, where he was ad-
global health situation. mitted to the toga students and, under the careful
5. Strengthening partnerships: with other UN guidance of the eminent teachers of the time, made
bodies and other international organizations, such a considerable progress in the sciences that
donors, civil society and the private sector. he was sent to foreign universities. March 1672
6. Improving performance: WHO is involved he set out for Boroslo, Leipzig, where he studied
in reforms to improve efficiency and effec- medical sciences; thence to Oder-Frankfurt, where
tiveness , both internationally and within he spent the longest time, and then moved to Hei-
countries. delberg via Marburg, where he was inaugurated as
The WHO is based in Geneva. WHO has 6 region- a doctor of philosophy; he modestly rejected the
al offices that deal with health problems in a given teaching of the philosophical sciences with which
region. he was offered at the Heidelberg Academy. In
1673 he traveled from Heidelberg to Basel, where
European Health Observatory he spent two years. He was promoted to the rank of
The European Health Observatory is a partnership doctor of medicine, and at the same time received
organization that brings together different policy the honorable title of “head of the Basel medical
perspectives to identify the health systems and school” in 1674. He returned to his homeland, De-
policies that European decision-makers need. The brecen, in 1675, where he was invited to be a doc-
center then produces and shares the evidence in tor by the city council, but he did not accept this.
printed, ‘personal’ and online form, meaning that He was also invited to be a doctor in Nagyenyed,
it acts as a mediator of knowledge as it seeks to but he did not take this job. Mihály Teleki invited
bridge the gap between theory and practice. [24] her to be the court physician of Princess Anna Bor-
nemissza, and in 1678 she was offered the Depart-
ment of Greek Language, Philosophy and Natural
Sciences at the Bethlen College in Nagyenyed,

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which he accepted and in January 4th 1680. He was János Zsoldos, (Köveskál, May 2, 1767 - Pápa,
solemnly inducted into his office. After the death May 12, 1832)
of Anna Bornemissza,he became a general prac- Chief physician of Veszprém county, born. May
titioner of Prince Mihály Apafi. During the teach- 2nd1767 In Köveskál (Zala county.), where his fa-
ing of Nagyenyed, which he wore for 40 years, ther was a Reformed priest. He studied in Sopron
he suffered constant unrest in various wars. His and Debrecen, then in 1790–92 he was a teacher
main work, Pax corporis, on the causes and nests in Halas. In 1792 he traveled to the University of
of the ailments of the human body and the way to Jena to study medicine. 1794. He went to Vienna
cure them (1747), was published by András Papai to continue his studies, where he was inaugurat-
Pariz, Kolozsvár,, which focuses on the prevention ed as a doctor in December 1795. From 1796 he
of diseases, ie the prevention of health [26, 27]. worked in Pápa as the chief physician of Vesz-
prém county. His significant work was a summary
István Mátyus Kibédi (Kibéd, 1725 - Ma- of the health advice given to students, which was
rosvásárhely, May 24, 1800) used by teachers even in the 20th century in the
István Mátyus (Kibedi), was a regular chief physi- form of health advice taken into verse. Dietetics
cian of Küküllő and Marosszék. He studied at the or policies to maintain health and prevent disease.
evangelist college and in 1754 went to the Uni- (1814) Győr, 1814. (2nd ed. Pest, 1818). Diaetet-
versity of Utrecht, where he obtained a doctorate ica or Regulations for the Maintenance of Health
in medicine two years later. He was in Göttingen, for Schools (1818) by doctor János Zsoldos, Sáro-
Marburg and Vienna for further training and med- spatak [26,27].
ical practice. He returned in 1757 as a practitioner
and settled in Marosvásárhely. After a short time Lajos Markusovszky (Csorba, April 25, 1815 –
he became the chief physician and panel judge Abbázia-Opatija, April 21, 1893)
of Küküllő county and Marosszék.In 1765 on the He was a doctor, military doctor, one of the or-
18th of April, Maria Theresa elevated him to the ganizers of modern Hungarian health education,
nobility of Transylvania. He has written several a member of the Hungarian Academy of Scienc-
books, reflecting the preventive approach in both es. He became an assistant to János Balassa at the
his works: University of Pest, and then was one of the orga-
nizers of the advanced medical group around Bal-
Diaetetica, is: a book that fundamentally lec- assa, which developed plans to raise the profile of
tures on how to maintain good health. (1762-66) medical education, medicine and public health in
Kolozsvár-Cluj-Napoca, Two volumes. and the Hungary. He was the member of the National Pub-
Old and New Diaetetica is the reckoning to the lic Health Council (1867),and President (1868).
maintenance and guardianship of life and health, He was a founding member and vice-president of
the more remarkable natural means given from the National Public Health Association (1886–).
God, as they were given to them, and from the very He edited the Medical Weekly from June 4 1857 to
beginning men have lived with them to their det- the end of 1888. In medical healing, he is the sci-
riment or benefit, in which he explained in more entific founder of the preventive approach. [26,27]
detail the first piece of his earlier diaethetic; and
he enlightened people with many of the old cus- József Fodor (Lakócsa, July 16, 1843 - Budapest,
toms and notable stories which belonged here, and March 20, 1901)
at the same time he broke the ice in many places He was a hygienist, university professor, member
for the holy places of nature; so that, in so many of the Hungarian Academy of Sciences (l. 1878, r.
respects, this work could also serve as a natural 1883), honorary doctor of the University of Cam-
history. (1787-93), Pozsony-Bratislava, Six vol- bridge. He studied in Vienna and Pest, in 1865 he
umes [26,27]. was a doctor of medicine, and from 1866 he was
an assistant professor in the Department of State

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Handbook for Health Promotion and Prevention of Chronic Diseases for Health Science Students

Medicine. In 1869 he was the chief autopsy officer so-called model procedures, a unified state system
of a hospital, a private teacher of medical proce- of health care work (Green Cross Labor) was de-
dures for health officers. After a study trip abroad veloped. He described the essence of his work in
in 1872 in Kolozsvár-Cluj-Napoca he was a retired his book “Gyógyul a magyar falu”, published in
professor of the State Medical School. In 1874– several languages. Under his secretariat, he draft-
1901, he was the retired professor of the public ed several public health bills in 1935-44. After
health department at the University of Budapest. In World War II, there were unfounded attacks on his
1894-95 he was rector of the university. He is not previous work as secretary of state and because of
only the first Hungarian educator and practitioner his foreign scientific connections. He has received
of public health, but also one of the founders of numerous recognitions and honors [26,27].
it internationally. He organized the National Pub-
lic Health Association with Lajos Markusovszky.
He was one of the first to show the role of water
in spreading typhus. His name is associated with
the organization and management of the School
Physician and Secondary School Health Teacher
Training from 1885 until his death (at the Medical
Universities of Budapest and Kolozsvár-Cluj-Na-
poca). He has written several books, including the
Health Textbook, which has been used the most in
high school health education [26,27].

Béla Johan (Pécs, September 6, 1889 - Bp., April

11, 1983)
He was a doctor, pathologist, microbiologist, Sec-
retary of State. He moved to Budapest in 1907, and
in 1909 he was a demonstrator at the 1st Institute
of Anatomy and then an intern. He obtained his
medical degree from Antal Genersich in 1912 to
the Institute of Pathology as an unpaid trainee. In
1913 he was an award-winning trainee, in 1914 an
assistant teacher, in 1924 an assistant professor. He
was habilitated as a university private teacher in
1919, and in 1927 he was awarded the universi-
ty teacher title. During World War I, he produced
large quantities of cholera and typhoid vaccines
for the military. In 1922 he was invited to the Unit-
ed States, the first Rockefeller Fellow. He worked
alongside the world-famous coroner, Mallory. He
spent a year in the U.S. and then for the next two
years studied vaccine production, public health
laboratory work, and its system in various states in
Europe. In Hungary, the plans for the building of
the Institute of Public Health were made according
to his idea. In 1925 he was appointed director of the
institute. Under her leadership, the village health
service (Green Cross nurses) was organized. In the

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IX.4. Bibliography ef.v57i3.68

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