Evaluation of the participation of Aretaieion Hospital, Greece in the WHO Pilot Project of Health Promoting Hospitals

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1 HEALTH PROMOTION INTERNATIONAL Vol. 19 No. 4 Oxford University Press 2004; All rights reserved. Printed in Great Britain doi: /heapro/dah407 Health Promotion International Advance Access originally published online on 4 November 2004 Evaluation of the participation of Aretaieion Hospital, Greece in the WHO Pilot Project of Health Promoting Hospitals YANNIS TOUNTAS 1, ELPIDA PAVI 2, KYRIAKI TSAMANDOURAKI 3, NIKOLAOS ARKADOPOULOS 4 and DIMITRA TRIANTAFYLLOU 1 1 Centre for Health Services Research, Department of Epidemiology, School of Medicine, University of Athens, Greece, 2 Hellenic Ministry of Health and Welfare, General Directorate of Health, Athens, Greece and 3 Institute of Social and Preventive Medicine, Athens, Greece and 4 Aretaieion University Hospital, Athens, Greece SUMMARY Aretaieion University Hospital participated in the World Health Organization (WHO) Pilot Health Promoting Hospitals Project from 1993 until 1997, when the Hellenic Network of Health Promoting Hospitals was established. This study is an overall evaluation of the participation of Aretaieion Hospital at the HPH Pilot Project. The evaluation comprised two questionnaire surveys, one among all the professionals, and the other among the patients involved in the subprojects. At the professional s survey, the response was 88.6% (39), while at the patient s survey the response was 62.2% (84). Differences were identified between the perceptions of the professionals who were external collaborators and those who were members of the hospital staff. Problems of the Project were reported to Key words: evaluation; health promoting hospital be lack of funding, lack of time and personnel shortages, lack of health promotion background and lack of incentives. Major successes were reported to be the personnel training, the development of collaboration and teamwork, the improvement of the overall image of the hospital into the community, the improvement of the working conditions of the personnel. Perception of sustainability of the projects by health professionals was found to be related to how interesting they found their subproject and how relevant to the work of their department. The communication strategy was inadequately planned and this resulted in some difficulties in developing rapport with the patients. However, the patients felt that they benefited from the project, a view also held by the hospital staff professionals. INTRODUCTION The concept of the Health Promoting Hospital emerged from the need to adapt to a demanding and constantly changing internal and external environment, as well as the need for hospital based health promotion activities. In this context, hospitals are expected to expand their role beyond the curative services to a pro-acting vehicle for health improvement. Towards this aim, Health Promoting Hospitals target the health of individuals (staff, patients, local community population) but they also promote the health of their organization as well, by creating a sustainable organization, capable of confronting today s challenges (Lobnig et al., 1998). The Vienna Recommendations on Health Promoting Hospitals form the basic set of principles on which the concept is based. 453

2 454 Y. Tountas et al. According to them a Health Promoting Hospital should: Promote human dignity equity, and solidarity and professional ethics, acknowledging differences in need, values and culture of different population groups. Are oriented towards quality improvement, the well-being of patients, relatives and staff, protection of the environment and realization of the potential to become a learning organization. Focus on health with a holistic approach and not only on curative services. Be centred on people providing health services in the best way possible for patients and relatives to facilitate the healing process and contribute to the empowerment of patients. Use resources efficiently, cost-effectively and allocate resources on the basis of contribution to health improvement. Form as close a link as possible with other levels of the health care system and the community. Within the framework of the Health Promoting Hospitals Movement, World Health Organization (WHO) initiated the model project Health Hospital, which further evolved into the European Pilot Project of Health Promoting Hospitals in 1992 (Garcia-Barbero, 1994). Greece participated in this Project in 1992 with Aretaieion Hospital, where health promotion subprojects were carried out, the coordinator being an external scientific non-governmental organization, the Institute of Social and Preventive Medicine (Arkadopoulos et al., 1998). Aretaieion Hospital is a training hospital of the University of Athens with three main departments (Surgical, Obstetrics/Gynaecology and Radiology) and with a capacity of 200 beds. In the period six health promotion subprojects were carried out. These included: Hygiene and safety in the hospital. Control of hospital acquired infections. Health education programme for the training of young mothers on issues of perinatal care. Study of patient satisfaction. Quality assurance of the surgical services. Early diagnosis of neonatal hearing loss and prevention of mutism. Separate evaluation of the subprojects were undertaken (Papastavrou et al., 1996; Tsamandouraki et al., 1996), however, an overall evaluation of Aretaieion s participation at the Health Promoting Hospitals Pilot Project was required, if the future establishment of the Hellenic Network of Health Promoting Hospitals was to be successful (Tountas et al., 1997). This was in accordance with WHO guidelines, which aimed at the establishment of concrete evidence of the effectiveness of a Health Promoting Hospital prior to each country s endeavor in the organization of a National Network of Health Promoting Hospitals (Garcia-Barbero, 1994). Apart from the fact that the evaluative procedure is an indispensable part of every health promotion programme, this evaluative study served additional purposes. It was designed to assess the impact of a five-year programme, which was unique for Greece. There is no history of hospital based health promotion programmes in Greece and therefore the findings of this evaluative study would serve as a benchmark for any future initiatives. This paper presents the results of such an evaluative study. MATERIALS AND METHODS In February 1997, a questionnaire survey was carried out among all professionals involved in the subprojects, and in March 1997 another questionnaire was carried out among the patients who participated in the two subprojects, which involved patients, that is the Health education Programme for the Training of Young Mothers on issues of Perinatal Care and the Programme of Early Diagnosis of Neonatal Hearing Loss and Prevention of Mutism. Both questionnaires were purpose made and consisted of 17 and six questions, respectively. As shown in Table 1, the sample of the professionals survey was 44. Of them, 39 (88.6%) responded. In total, of the 39 professionals who responded, 24 were doctors, 12 were nurses, one was a psychologist and two were medical students. Of the respondents, 15 were employees of the Aretaieion Hospital, and 24 were health professionals from the private sector who worked as external collaborators for the implementation of the subprojects. The questionnaire for the patients had one overall structure, but the wording was relevant to the subproject in which patients had participated. Two mailings of this questionnaire were followed by a telephone reminder.

3 Evaluation of Aretaieion Health Promoting Hospital 455 Table 1: Sample and response at professional s survey Subprojects No of No of participating responses professionals Health and safety in 4 4 the hospital Hospital infections control 10 9 Education of new mothers 8 8 in perinatal careand breast-feeding Patient satisfaction study 5 4 Quality assurance in surgery 7 4 department Early diagnosis of mutism in neonatals Total Table 2: Sample and response at patient s survey Subprojects Cumulative response rate First Second Final (after mailing mailing reminder telephone call) Early diagnosis of 22 (30.1%) 31 (42.5%) 41 (56.2%) mutism in neonatals Education of new 23 (37.1%) 30 (48.4%) 43 (69.4%) mothers in perinatal care and breastfeeding Total 45 (33.3%) 61 (45.2%) 84 (62.2%) The databases of the two subprojects, which involved patients were not complete, given that for 21% of the patients of the early hearing loss detection project, and 28% of the patients of the perinatal care project, address and telephone number were not recorded. Thus, these patients were not included in the study sample. In Table 2 the sample of the patients questionnaire survey is shown. Of the 135 patients, 84 (62.2%) responded. The rather small size of the sample can be attributed merely to the fact that Aretaieion Hospital is a small hospital. The number of professionals, as well as the number of patients from which the sample was drawn was limited. Moreover, as far as the patient sample is concerned, the small participation observed was an additional reason for the small sample size. Nevertheless, since the purpose of this study is not to make extrapolations for other hospitals as well (external validity) but to measure the effects of the project to the limited population it was exposed, the sample can be considered satisfactory. Before the questionnaires were distributed to the study sample, pilot studies were conducted, during which eight subjects from the sample were asked to complete them. The results and the problems that came up during this validation and reliability procedure were discussed and the questionnaires were fine tuned accordingly. Questionnaires of both surveys were coded and analysed using the SPSS statistical package. The 1 5 rating scale used was: 1, very much; 2, much/a lot; 3, average; 4, a little; 5, not at all. Thus, the lower the score, the more positive the view of the respondent was. T-tests, chi-square tests and Pearson s r were carried out. Results are reported in relation to the three conventional levels of significance (0.05, 0.01, 0.001). RESULTS Professional s survey The analysis comparing the responses of the coordinators to those of the members of the project teams is not reported, as no statistical differences or associations could be detected. The response of the hospital employees and those of the external collaborators are reported when found statistically significant. Successes and problems of the subprojects Table 3 shows that the most important success was reported to be the training of personnel, the improvement of the quality of services provided and the development of collaboration and teamwork. Statistical analysis showed that the hospital employees reported as successes at a higher frequency than the external collaborators the training of personnel ( p 0.01), the development of collaboration and teamwork ( p 0.001), the improvement of the health and the work conditions of personnel ( p 0.01), and finally, the improvement of overall image of the hospital in the community ( p 0.01). The hospital employees reported as a problem at a higher frequency than the external collaborators the lack of health promotion background within the hospital ( p 0.01) (Table 4). It is noted that all those who reported as a problem difficulty in collaborating with the

4 456 Y. Tountas et al. Table 3: Five most important successes of programme (multiple responses) Successes n % Training of personnel Improvement of the quality of services provided Development of collaboration and teamwork Improvement of overall image of the hospital in the community No success Improvement of the health and the work conditions of personnel Awareness raising and mobilization Introduction of concept of HP in daily work Base 36 Table 4: Five most important problems of programme (multiple responses) Problems n % Lack of funding Lack of health promotion background within the hospital Lack of incentives for the personnel Inadequate information to the personnel Staff shortage time constraints Difficulty in collaborating with the hospital staff Inadequate teamwork feeling Inadequate management support Patients reserved attitudes Base 39 hospital staff and inadequate management support were external collaborators. Also, all those who reported as a problem the staff shortage time constraints were hospital employees. Perception of success, extent to which the aims were met, interest in the programme, relevance to the hospital department and sustainability of programme A battery of five questions examined professional s perception of how successful the programme was, the extent to which they believed that the aims were met, how interesting they found the programme, how relevant to the work at their hospital department and how sustainable they considered the project to be. The overall mean score of success, aims met, interest, relevance and sustainability are shown in Table 5. Table 5: Mean scores of success, aims met, interest, relevance and sustainability as assessed by respondents Mean scores Significance level Overall External Hospital collaborators staff Success p Aims met p Interest Relevance p 0.05 Sustainability Analysis of the inter-relationships of these attributes (Table 6) shows that there is a positive correlation between success and aims met (r 0.89, n 36), and between relevance and sustainability of the programme (r 0.54, n 33). Also, a positive correlation between interest and sustainability (r 0.46, n 36) was detected, but it was marginally significant (P 0.05). Information visibility of the programme The distribution of responses to the question Have you been informed by other hospital departments about other projects within the framework of Aretaieion Health Promoting Hospital?, is shown on Table 7. None of the external collaborators gave positive answer, in contrast to the 80% of the hospital staff who said that they had been informed ( p 0.001). Respondents were further asked Considering overall the programme of the Aretaieion HPH, do you think that it was visible/discussed about, or it was not really noticed by the medicalnursing personnel, by the managerial personnel, and by the patients?. The distribution of responses is shown in Table 8. As far as differences among the responses of the hospital staff and the external personnel are concerned, all the hospital staff, and only 62.5% of the external collaborators responded that the programme was visible and discussed among the medical nursing personnel ( p 0.05). Moreover, all the hospital staff answered that the programme was visible among patients, while only three (12.5%) of the external collaborators held this view (p 0.001). Interest in continuation of projects and personal involvement When respondents were asked whether they would be interested in being involved in the continuation

5 Evaluation of Aretaieion Health Promoting Hospital 457 Table 6: Inter-relationships of five attributes of the programme, as perceived by respondents Correlation coefficients (Pearson s r) Success Aims met Interest Relevance Sustainability Success 1.0 Aims met 0.89 a 1.0 Interest 0.53 b 0.41 b 1.0 Relevance Sustainability c 0.54 b 1.0 a p 0.001; b p 0.01; c p Table 7: Distribution of participants according to their responses to the question have you been informed by other hospital departments about other projects within the framework of Aretaieion Health Promoting Hospital? Information about the projects Yes 12 (30.8%) No 21 (53.8%) Do not know 6 (15.4%) Total 39 (100.0%) Table 8: Distribution of participants according to their responses to the question Considering overall the programme of the Aretaieion HPH, do you think that it was visible/discussed about, or it was not really noticed by the medical-nursing personnel, by the managerial personnel, and by the patients? Visible/ Visible/ Visible/ discussed among discussed discussed the medical- among the among the nursing managerial patients personnel personnel Yes 30 (76.9%) 10 (25.7%) 18 (46.2%) No 9 (23.1%) 8 (20.5%) 12 (30.8%) Do not know 0 (0%) 21 (53.8%) 9 (23.1%) Total 39 (100.0%) 39 (100.0%) 39 (100.0%) of the project or in some other new project, 30 (76.9%) of the respondents answered positively, three (7.7%) said no and six (15.4%) said don t know. There was no difference in the answers of hospital staff and external collaborators. Respondents were further asked to justify their response to the previous question. Some of the comments focused on the importance of the specific project, in which the respondent had been involved, for the prevention of disease and the improvement of the services offered to the patients. Other comments referred to respondents beliefs that patients benefited from Table 9: Mean scores of patients benefit patients interest as perceived by profesionals (scale 1 5, where 1 very much and 5 not at all) Mean scores Overall Hospital External staff collaborators Significance level Patients p benefit SD 1.2 SD 0.8 SD 1.7 n 22 n 10 n 12 Patients p interest SD 0.9 SD 0.7 SD 1.2 n 19 n 7 n 12 the projects, found answers to their questions and raised their awareness on prevention issues, so a continuation of the projects will benefit them even more. Other justifications for responses were comments that the projects were not completed, or that there is a need to widen the projects as a means of achieving the aims of service improvement and continuous training and education of personnel. However, there were also some preservations: I do not know whether I want to be involved again, because I consider as a prerequisite the substantial participation and support of the hospital organization, and the commitment of the project team for a long time, so that the project is sustainable. Patients benefit as assessed by professionals The health and other professionals who took part in the two projects, which involved patients (early diagnosis of hearing loss, and new mothers training in perinatal care) were asked their belief as to how much the patients benefited from the project and how much interest they found that the patients expressed in the project. The responses, based on a 1 5 scale are shown on Table 9.

6 458 Y. Tountas et al. Table 10: Mean scores of usefulness and benefit as perceived by mothers (scale 1 5, where 1 very much and 5 not at all) Mean score Programme s usefulness 2.2 SD 1.1 n 84 Programme s benefit 1.9 SD 0.7 n 43 Analysis comparing the views of professionals of the early diagnosis of hearing loss and the new mothers training in perinatal care projects, showed that those involved in the former project believed to a lesser extent that their patients benefited (mean 4.5, SD 0.5, n 9) and were interested in the project (mean 4, SD 0.7, n 9) than those involved in the latter project, the mean scores being 1.4 (SD 0.5, n 8) and 1.8 (SD 0.9, n 8), respectively. Other comments Finally, respondents were welcome to make any other comment they felt like, with respect to the project in which they participated or the overall programme of Aretaieion HPH, or the concept of Hospital Health Promotion. As reported, the concept of hospital health promotion is considered fascinating and revolutionary, it has to be supported in order to ripen. Other comments related to successful aspects of the programme: it succeeded to introduce the philosophy of health promotion in a hospital with no experience in this field, and to establish infrastructure and projects of health promotion which can become a permanent component of the hospital routine. In this direction were most of the comments, referring to the importance of the projects, and describing the prerequisites for a successful future implementation of other projects: the substantial participation of the hospital organization in all the process and the effort involved, and not just the verbal expression of agreement. The careful selection of the members of the project team, so that the active participation of all of them is possible and reassured in all the stages of the implementation, and not just whenever the team member feels like participating. What is required is a very good co-ordination and collaboration among the administrative, medical and nursing personnel. Table 11: Distribution of participants of the two subprojects according to their responses to the question do you believe that they should be adopted on a permanent basis? Prevention of Perinatal care Total early hearing loss Yes 19 (46.3%) 39 (90.7%) 58 (69.0%) No 8 (19.5%) 1 (2.3%) 9 (10.7%) Do not know 14 (34.1%) 3 (7.0%) 17 (20.2%) Total 41 (100.0%) 43 (100.0%) 84 (100.0%) ; d.f. 2; p Other comments focused on the problems that were encountered, and had to be solved: The projects which will be selected for implementation need to have impeccable organization, administratively and scientifically, and unreserved moral and financial support from all those involved. According to my opinion, the attitudes of the administrative and nursing personnel ranged from indifference to hostility, and that was due to the fact that they had not been neither officially nor well informed about the HPH programme. I believe that the information of the public was inadequate, this resulting in patients suspicion and personnel s reluctance. Lack of infrastructure, lack of time due to work overload, and lack of incentives prevented the personnel from participating even if they wanted to. Patient survey The patient survey examined the patients participation and views on the two subprojects involving patients, that is the Health Education Programme for the Training of Young Mothers on Issues of Perinatal Care, the Study of Patient Satisfaction and the Programme of Early Diagnosis of Neonatal Hearing Loss and Prevention of Mutism. All new mothers said that they recalled the programme of the Perinatal Care and the group discussions, and all said that the midwife or the nurse was the health professional who informed them about the programme. Mothers were then asked whether they believed that the programme was good and useful and whether they and their child benefited, and to what extent. Table 10 shows the mean score of usefulness and the mean benefit score (for both subprojects).

7 Evaluation of Aretaieion Health Promoting Hospital 459 The only statistical significant difference ( p 0.001) found regarded the benefit scores reported by the participants of the two subprojects. For the participants of the subproject of early hearing loss the mean benefit score was found to be 2.3 (SD 0.9, n 41), while for the participants of the training in perinatal care subproject the relevant score was 1.6 (SD 0.7, n 43). Table 11 shows the distribution of respondents according to their view as to whether the projects should be adopted on a permanent basis. The significant association detected indicates that participants of the perinatal programme held a positive view, while mothers of the early hearing loss programme tended to be unsure about the permanent adoption of such programmes. Finally, all participating mothers were asked to make any comment they wanted. Most of the mothers of whom the newborns were tested for hearing loss were not aware that this specific test was performed, but they believed that their baby was overall assessed clinically by a pediatrician who informed them about their baby s health. There were a few cases of mothers who were concerned about how painful such a test is for a newborn. If this test were not painful, then they would not object its adoption on a permanent basis. Mothers who had participated at the training in the perinatal care subproject made positive comments, which concerned mainly the usefulness of the group discussions. DISCUSSION Various assessment methodologies have been reported to be used in the evaluation of HPH projects and subprojects, most of them involving quantitative and qualitative tools (World Health Organization, 1998). The methodology adopted in this study was mainly quantitative, but was based on the perception and assessment of the HPH project by those involved. Professional s survey During the initial analysis it was found that there were no significant differences in the views of the medical doctors when compared with those of the nursing personnel or other health professionals. Neither were there any differences between the subproject coordinators and the members of the subprojects teams. Statistically significant differences were identified between the external collaborators and the hospital employees. This finding is in a way expected, since there is a difference in the views and the expectations of a health professional who voluntarily joins a hospital department, and those of an employee of the hospital who has to accept the external collaborators and modify his everyday routine according to the requirements of the project. Also, there is a difference in the attitudes, since the external collaborators worked in the private health sector, while the hospital employees worked in the public health sector. This different background may be a possible explanation of the finding that the hospital employees believed to a greater extent than the external collaborators that the aims of the programme were met. There may be a difference in the understanding of the aims, or in the expectations which may have lead to different criteria against which meeting the aims was judged. It is possible that the external collaborators would set higher standards that have to be met in order to judge the overall programme as having fulfilled its aims. However useful it may be to detect differences in the perspectives held among different professional categories, evaluation procedures should be based on strict and measurable criteria in order to lead to reliable and objective results. It is thus important that evaluation is well planned and forms an integral part of any programme. The different perspectives are also evident in the perception of the success of the programme. Hospital employees emphasized to a greater extent than the external collaborators the personnel training, the development of collaboration and teamwork, the improvement of overall image of the hospital in the community and the improvement of the health and the work conditions of the personnel. These are also characteristic of their interests and concerns as members of the hospital community. Regarding the greater problems encountered, lack of funding, lack of time and personnel shortage are all inter-related. When more resources are available (both financial and human) the subproject work would not be perceived as an additional burden. Effective planning of such hospital health promotion activities is required so that the daily routine is not interrupted. Lack of health promotion background was found to be perceived as a significant problem.

8 460 Y. Tountas et al. This highlights the necessity on the part of the hospital organization to adopt the principles of hospital health promotion officially, and set aims and priorities for health promotion. This would also increase the probability that more resources are allocated to health promotion activities. However, communicating an intangible concept like generalities about health promotion has been reported as an obstacle and problem in other health promoting hospital, while collective staff ownership of HPH project and effective communication strategies, seem to contribute to success (O Riordan, 1998). It is thus important, that the project team sets out clear aims which can be understood and accepted by the hospital organization, increasing the probability for gaining the support (in terms of resources) required for effective implementation of a project. The issue of incentives has to be taken into account during the planning phase of a programme, of which it has to form an integral part. The strongest incentives would be the financial ones; however, in the particular hospital environment under study, either they are not possible or it is better to be avoided. However, incentives like support for attending seminars or conferences for presentation of hospital work and achievements should be considered. Furthermore, participation of the hospital staff at decision-making committees of the projects makes their commitment and involvement more important and rewarding. Empowerment of the personnel is highly important in creating a workplace environment conducive to health promotion (Kristenson et al., 1998). Inadequate information of the hospital staff about the hospital health promotion activities is a problem deriving from the lack of an effective communication policy. If the hospital administration adopts the principles of hospital health promotion, then, it has to formulate an active communication policy targeting all the members of the hospital community (medical, nursing, managerial and auxiliary personnel, as well as the patients). If the hospital community s awareness about hospital health promotion is raised, and if the hospital community realize that the administration supports and considers important all these activities, then it is most probable that the effectiveness and efficiency of the subprojects as well as the quality of services and image of the hospital will be improved. Thus, organizational changes have to be based upon the importance of health outcomes, as opposed to mere service management (Nutbeam, 1991). Taking into account that only two-thirds of the health professionals (external collaborators and hospital staff) believe their subproject as sustainable, it seems that the perceived sustainability of a project relates to how interesting it is found and how relevant to the work of the hospital department it is found. To ensure sustainability new professional roles, new communication structures, and training of staff have to be established (Nowak and März, 1998). The negative relationship between the extent to which it was perceived that the aims of a project were met and how interesting it was, may be attributed to higher expectations and thus a stricter judgment among those who have a personal interest in a project. The interest of the majority of health professionals (76.9%) to participate in future activities allows us to be optimistic about the implementation of more health promotion programmes. Patient s survey The success of every study, which involves patients who had, at some time in the past, been hospitalized or had participated at a project, relies to a great extent on the existence of an accurate and updated database or register. Overall, there was a difficulty in locating the patients, a problem which delayed the completion of the study. Given such difficulties, the response rate achieved for both projects (62.2%) is considered satisfactory. Results suggested that patients have a positive attitude towards screening programmes, given that, although they expressed the abovementioned reservation, they replied that they found the programme good and useful (if test not painful), at a similar level to mothers who had participated at the perinatal project. It is obvious that, on such a receptive attitudinal background, patients information would have proved very effective. Women who had participated at the perinatal care programme had a positive attitude, which shows that an intervention, which targets a health problem of concern, with a participative methodology, may be more effective and acceptable by the target population. This is also evident from the response of the patients themselves, the majority of whom say that these programmes have to run on a permanent basis.

9 Evaluation of Aretaieion Health Promoting Hospital 461 Regarding the perception of benefit from participation at these two subprojects, it is interesting to compare the responses of the health professionals as to their belief that the patients benefited, and the responses of the patients themselves. The findings suggest that health professionals of the perinatal care subproject, who had developed good communication with their patients, perceived the benefit of patients to be similar to the benefit perceived by the patients themselves. In contrast, health professionals involved in the prevention of mutism subproject, who did not have any communication at all with mothers, did not have the same perception of benefit as the patients. These health professionals believed that the patients did not really benefit, while the patients themselves believed that they benefited. This finding suggests that while doctors and other health professionals are interested in the health of their patients, they may have different expectations and perceptions from the ones held by the patients. What is required is better communication between these two players. The main conclusions that can be drawn from the results of the evaluation of Aretaieion Hospital concern first of all the need for an evaluation methodology, which incorporates both external and internal evaluators. The differences observed between the ratings of these two categories emphasize the need for external evaluators in order to obtain more objective results, and for internal evaluators who can provide a more participatory approach in accordance with health promotion philosophy (Thorogood and Coombes, 2000). The results also indicate the need for more resources in order to run additional health promoting activities properly. Money, time and personnel have to be dedicated to these activities since Aretaieion Hospital, as almost all hospitals operate in an intensive labour environment of limited resources (Tountas, et al., 2002). It is also evident, that human resources have to be specially trained in running and evaluating health promotion activities. The lack of such personnel was found to be one of the most important drawbacks of the project. The differences observed between personnel who were active in the subprojects or who had a personal communication with the patients involved, and those who did not, raise once more the need for participatory procedures, which are an integral part of the central issue of empowerment in health promotion (Downie et al., 1999). Part of the empowerment issue is the need for visibility and information in order to raise awareness and motivation in all hospital personnel. The limited visibility and information of the project observed in Aretaieion Hospital, can be considered as a second major constrain. Additionally, planning hospital health promotion programmes should take into account various critical factors like the endorsement of health promotion principles by the hospital organization, the different perspectives and interests of the various professionals involved, the availability of accurate and reliable patient records or registers, and the provision of activities which are of concern for patients and for personnel. The above conclusions and the fact that the overall evaluation of the participation of Aretaieion Hospital at the Health Promoting WHO project can be considered as positive, provide the motivation and the means for a successful expansion of the project to other Greek hospitals. Address for correspondence: Yannis Tountas Centre for Health Services Research Department of Epidemiology, School of Medicine University of Athens, Alexandropoleos Str Athens Greece chsr@med.uoa.gr REFERENCES Arkadopoulos, N., Tsamandouraki, K., Pavi, E., Tountas, Y. and Papadimitriou J. (1998) Aretaieion Health Promoting Hospital: a Southern European Hospital in Transition. In Pathways to a Health Promoting Hospital, HPH Series Vol. 2. G. Conrad Health Promotion Publications, Gamburg-Germany. Downie, R. S, Tannahill, C. and Tannahill, A. (1999) Health Promotion Models and Values. Oxford University Press, Oxford, New York. Garcia-Barbero, M. (1994) The health promoting hospital movement. The Journal for European Private Hospitals, Kristenson, M., Rainer, G. and Vang, J. (1998) The University Hospital in Linköping, Sweden. In Pelikan, J. M., Krajic, K., Lobnig, H. (eds) Feasibility, Effectiveness, Quality and Sustainability of Health Promoting Hospitals Projects. G. Conrad Health Promotion Publications, Gamburg. Lobnig, H., Krajic, K. and Pelikan, J. M. (1998) The International WHO-Network of Health Promoting Hospitals: State of Development of Concepts and Projects In Berger, H., Krajic, K. and Paul, R. (eds) Health Promoting Hospitals in Practice: Developing

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