Health Promotion: Professional Perspectives, Research Paper Example

Introduction

This essay consists of three parts. The first part is a reflective diary which demonstrates my thoughts on issues related to Health Promotion. The thoughts and ideas presented in the diary reflect my understanding on burning issues in the field of health such us health inequalities and the role of school settings in Health Promotion. The second part is a demonstration of a Health Promotion Project that was implemented in a Primary School in Cyprus. The school participated in the European Network of Health Promoting Schools and I was one of the co-ordinators of the project.

The third part of the essay aims to critically discuss and reflect on the content of part one and part two. It shows how my understanding and awareness of the nature of health promotion professional practice has developed over time.

Part One: Reflective Diary

It is not the way people see the world that conditions their social existence but their social existence that conditions their views of the world (Marx, 1971).

Mental health, as defined by W.H.O. (2004 p.12) is something wider than the absence of disease;

‘‘a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”. 

According to the above definition, I wasn’t mentally healthy three months ago; moving to London and have to adjust to the new way of living; work in a new school with totally different policies and teaching approaches that I was used to, cope with university and study plus looking for a place to stay were issues that influence and challenge my mental health… My social network (friends, tutors and people from work) helped me overcome the stressful period without become completely “insane”. But what about less fortuned individuals who cannot rely on friends or their social surroundings for help and support? My own experience make me think about how vulnerable we all are and how changes in our living conditions or our environment and daily routines can be traumatic to our mental or even physical health.

I describe my own experience to address the need of being sensitive, as health professionals or just humans, and take into account that social or environmental situations and changes can influence and determine one’s health.

Sometimes people can influence and change these determinants but often a long term planning and consistent political decisions (about health issues, education, unemployment and so on) are the keys in a successful change.

Successful in terms of being beneficial and contribute to a better standard of living, better health and equity for all. The question is, though, who decides what is beneficial and what is not? What are the “norms” and is it a universal definition about good standard of living?

How beliefs and ideas are formed is a wide philosophical debate and is relevant to many, if not all, subjects. Usually when we try to change behaviours and lifestyles, what we have in mind are the values and “way of living” of the middle class people. But these values and way of living might not be important of other social groups, for example unemployed people or people with low income. As health promoters we should be aware of all the above issues and reflect on our own beliefs and values. It is not my aim to underestimate the value of education and knowledge; it is important for people to have access to knowledge and be educated in terms of health issues but it is also important to give people the power understand why and what is beneficial for them, give them alternative choices and facilitate their choices. Make them understand (and demonstrate ourselves a certain amount of understanding) that often what determines our health is not based solely on our behaviour.

On the other hand, people do not always have the power to make changes in their lives. As health professionals we should acknowledge that the social determinants of health which affect both physical and mental health are key point issues in our field. Designing a successful health promotion programme or intervention needs consideration of the social determinants of health. Viewing the literature reveals that inequalities whereas in health or education achievements (as a teacher I am concern about education progress and inequalities) are associated with the socioeconomic status of a child or adolescence. Indeed, we can extend the theme in terms of learning and construction through an interesting article by Eraut (2000). He notes the factors associated with ‘implicit learning’ and suggests that it affects future behaviour. In other words, that “some selection of lived experience had previously entered long-term memory, albeit not as part of a conscious, deliberate process” (Eraut 2000, p. 116). The association between implicit learning and future action is sub-conscious and forms a part of a “tacit knowledge base which enables future action.” In a sense, this encapsulates and ‘rounds off’ the dilemma, because unspecified and non-conscious past events will contribute to future actions, and these past events are based in our cognitive ‘construction.’ Another relevant area suggested by Eraut (2000, p. 133) is that of “knowledge constructed from the aggregation of episodes in long-term memory,” which further confirms the importance of the arena and circumstances of our upbringing which will determine our future beliefs, actions and associations.

This is scary in a way; our social-economic status, the way we have been raised and our past actions have a profound influence on our health, our academic achievements and our social, emotional and mental development. I have to admit that this fact does worry me; is our “destiny”, our future and our development determine by how much money we have or at which social class we belong? And what can we do about it as professionals, regardless of where we work (in the health sector or the education one)?

As far as education, Payne (2005) proposes that the main factors which determine differences between two groups – those whose background lies in generational poverty and the middle class and who come from “hidden rules of the class in which he/she was raised” (Payne 2005, p. 1). Therefore, because middle class ‘norms’ are the ‘hidden’ rules applied in society, the children from ‘generational poverty’ are using and utilising the ‘hidden rules’ that they know and understand. One example comes in language. A child from generational poverty is most likely to have learned a different method of communicating, namely casual rather than formal. In the former, it is usual to go around the subject matter and use casual language to get to a point. Payne (2005, p. 27) speaks of various registers of language and notes that school tests use the ‘formal,’ or middle class ‘formal’ approach. Is like expecting all children arrive to the same end but starting from a different point; some children are far behind others.

In terms of health and health care, I believe that is the same situation. People often assume that all can or have access to the same health services and all have the means to maintain in good health therefore the fault for not having good health based solely on their “bad” choices and decisions. But evidence shows a different case. Socio-economic background and status does influence our choices, our access to health services and so on. With this in mind, Marmot (2005) proposes that the issue of health care should be of concern to “policy makers in every sector, not solely those involved in health care” (Marmot 2005, p. 1099).

Furthermore, social relationships have an influence on individual’s mental health; thus living in an environment which promotes relationships and has a sense of coherence it is also vital in our quality of life. Poor and deprived areas with many incidents of crime and criminal behaviour are not usually places where people can develop relationships. If they are afraid to walk and socialize with each other these will lead to a community that doesn’t really care about the others. Creating safer places, with walk able landscape and playgrounds; keeping them clean is a key point if we wish to improve or promote health. Landscapes with a bonding structure promote social well-being thus health. If I think of my country and the place where I live, that’s definitely the case; people don’t walk at all, actually there are no places to walk and they tend not to care creating a better place for them to live in. It seems that they do not understand the importance of the environment in our health and well-being.

Acknowledging the fact that inequalities do exist, provides insights into the pathway of eliminate them; it is only when a critical view of the uncovered reality is adopted a “solution” can be found. And we as professional in health-related professions need to critically reflect on what we do “right” and what we do “wrong” in terms of promoting health for all. Understanding of “why” something is happening is crucial; giving advice, provide information and answers are the easy parts of our task. But realizing the underpinning cause of an action is important. Empowering individuals, in the context of their own life and health, to take their own decisions according to their situation and listen to them is a move beyond…

Just a thought: thinking about health inequalities a thought crossed my mind. What about death inequalities? The kind of death we will have depends on how much money or what social status we have? I think this is the case for Cyprus. I have notice (as a nurse and as a patient) that nurses and doctors treat people according to their social and economic status.

Moreover, if you have money you can go to a private clinic where you will have a special care and support whereas if you are poor you will end up in the governments’ hospital and die in pain and agony because nobody will actually care about you. Nurses and doctors are so busy that do not have time to give psychological support and sometimes they don’t have time to pay attention to the patients’ needs rather than the basic ones.

Maybe I am negatively influence because of the recent death of my uncle (he died alone in his house because he couldn’t afford to go to a private clinic and the doctors from the government hospital ensure him that he is fine and discharged him from the medical ward- probably due to lack of beds).

Individual Vs Society changes

Is the answer to inequalities based on individual changes or a radical change in social structure is what actually should take place?

A poor family living in a deprived area has no option but to struggle coping with everyday needs and problems. Economic difficulties tend to cause problems in the relationship between the members of the family. As a teacher I have notice that children from low socioeconomic backgrounds often face fights among parents, violence and emotional disorders.

Furthermore parents have no option in choosing what school their child will attend; schools at deprived areas are not usually the best…And it is often the case that even if an individual wants to change his or her situation, his will may not enough. I will talk about myself again since my case is relevant to the above. I was born just after the war in Cyprus. My parents are refugees who lost their houses and their jobs. My father had to struggle and work long hours in order to provide us with the essential. We lived in a poor area with other refugees; my early childhood memories are mainly war stories and poverty. I didn’t have the guidance and support needed for a sensitive child, my parents had to work all day and school teachers where unresponsive. Even thought I was a clever child, I didn’t have enough motivation or support from my environment (both school and family). That’s why I started smoking at the age of 16, neglected school, tried hard to manage to go to the university at the age of 24…

Certainly the problems caused by inequalities require more than policy plans and research. Evidence suggests that strong political will is required in order to promote economic and consequently social development. A starting point might be to address and “force” in a way, governments and decision makers to act in favour of vulnerable people from low social and economic backgrounds.

As I realise, the environment has a strong influence on how we feel and how we act; it might has a positive and curing impact or in contradiction it might worsen our mental and physical health. Deprived areas with no green spaces can lead to mental and physical disorders.

The huge gap between different social groups needs is a fact that indicates radical actions; a range of policies in the employment conditions for less advantaged groups, improve housing and access to health services are actions among others that need to be reconsidered.

The economic crisis definitely influences everyone but it has a strong impact on the disadvantaged groups by increasing unemployment among less educated and less qualified individuals. In Greece, for example, unemployment has risen dramatically and even middle class people are struggling for the everyday needs. This has a profound impact on their quality of life and it is a reality we might all have to face at a certain time. Life and living circumstances are not a static, they are constantly changing but all human beings need and deserve a certain amount of stability and life needs to be the least problematic and the least uncertain. Consequently, an effort to “built” strong social networks and fairer system is a priority. Welfare and prosperity leads to improvement of living and human potential.

All the above social changes have consequences on peoples’ health and everyday living. Often individual changes are not enough to tackle societal problems; a wider and organised approach that will change the social construction might be needed. Ideas and beliefs about how society functions and where we each fit into it are built up by assimilated experiences and are cognitively constructed from birth onwards. We may be consciously unaware of these influences on our current behaviour, or they may be some part of a distant memory. We become ingrained in who we are, and sometimes it is extremely difficult to move away from this “mindset”.

Karen Horney, a psychoanalyst, mentioned in one of her books (unfortunately I don’t remember the title) that if we leave a tree without water, in a dark place with no light or air, it will die. But is it wise to blame the plant? The role of individual should not be completely ignored but should be placed in its broaden social context. That will help overcoming victim blaming and understand that health is as much as a social-political responsibility as a personal issue. If we wish to improve reality we need to choose to face reality as it is, even if it does “hurt us” by seemed so cruel or difficult to cope with.

But let’s not act as if these issues do not matter or that they can be overlooked. Let’s agree that inequalities, not only in health, do exist and work towards creating a fairer and healthier society. Governments need to invest in high quality education for all, have a fair tax system, create job opportunities and support people in training programmes. Furthermore, improving the quality of housing since poor housing is associated with poor health and increase the safety of the environment are crucial actions that need to be addressed in policies.

Read not to contradict and confute; nor to believe and take for granted; nor to find talk and discourse; but to weigh and consider. (Francis Bacon, 1561 –1626)

Reflections on my work; what do I need to change?

“And just what are we to make of becoming a reflective practitioner? Are we to learn? Are we to change? Are we to work towards transformation of self and other?” (Watson as cited in Johns, 2004).

I will start by reflecting on my work so far as a teacher actively involved in health education and health programs at schools I can say that I certainly need to learn how to listen to others without trying to give them advise or solutions… I need to stop feeling guilty about everything and stop trying to “fix” everything… stop assuming what others need; pay more attention to what others say about their needs. I think that my work so far was more in favor of trying to change behaviors; due to lack of knowledge probably but also due to my misbelieve that all is needed is for people to change their lifestyles. Helping people express their needs is an essential skill health promoters need to have or develop. Some people find it hard to say what they feel and need. People may have different needs from what we believe they have, so it is essential to be able to listen and promote an honest conversation with people; sometimes just listen without judgements or advices is a good start. And that is exactly what I need to develop personally and professionally….

Especially when it comes to children, teachers often make the mistake not to listen carefully to what a child want to say or express. We assume what is “best” for children and we teach and behave according to our beliefs. But, reflecting on what I have learned so far, I think that we ought to give everybody the chance to express his/her feelings and thoughts and do not underestimate judgment or thoughts.

Teachers involved in health promotion need to move on from established models of health education which intend to bring about behavioural change and give to children the opportunity to understand the social determinants of health. By doing so we raise students’ knowledge and ability to tackle the causes and complexities of health-related behaviours and encourage them to work together in order to bring changes beneficial not only for their health but also for the health of society in general. The role of school in health promotion is crucial and teachers need to be familiar with terms like “social determinants of health” and “overcoming victim- blaming”. The aim is not to make children feel guilty about their behaviour or choices but to promote their critical thinking about their health in accordance to their environment and their social context.

As Ewles and Simnett (2003) suggest

“People such as teachers, social workers …all have a role in health improvement, but need to adapt a public health “mind set” with greater appreciation of how their work can make a difference to health and well-being…”

Hence, a crucial question is what role does school have in the promotion of physical, mental, emotional and social health of young people? Do teachers have the power and means to promote health? Since the school environment has a profound impact on children’s development, I believe that schools must have a strategy or a health promotion programme. But every programme needs to be developed in a conductive way with school community and the broaden community. Parents, local authorities, the educational psychology department, the school nurse and so on need to be involved in order to have a succeed and sustainable program. Furthermore the health needs of the specific children (of each school) should be evaluated and should be the core of the programme. Teachers need to see the “bigger picture”; it is not enough to do adapt a classroom programme. A partnership between parents, community and local authorities is needed and that requires an extra effort in terms of time, energy and commitment from teachers. Furthermore, additional skills are required so in-service seminars or workshops for teachers may contribute to a better understanding of health promoting schools.

Another issue that I need to overcome is my sense of confusion; how can I be a health professional work in the Health Promotion field since I smoke? Who am I to give advices about health issues since I don’t follow them? I definitely know that smoking is harmful so why am I still smoking? Do I need help to quit smoking? And if so, then what is stopping me from seeking for help?

Health professionals should behave as “models” for the rest of the people?

My personal issue about smoking is an opportunity for me to understand how difficult is to change our attitudes and habits and that knowledge sometimes is not enough. We need a strong motivation to move to changes in our behaviour and we often need to reconsider and change our beliefs and attitudes which are so strongly rooted in our personality and our actions. But at the end, I do need to stop smoking… I should empower myself that I have control over my health and stop the unhealthy habit. The question is how can I achieve this?

Ethics and Health

All our thoughts, attitudes and behaviors are based on our ethical/moral values and personal beliefs. It is doubtable if any human action can be value-free. So we can’t be able to reflect on our actions if we do not have a true understanding of why or how we act and react in certain circumstances. In other words what are our values and what do we believe is “wrong” or “right”, is “acceptable” or “unacceptable”.

Since I am interested in ethics (even though I don’t have the answers or a clear opinion to many of my questions) I was reading the chapter Ethics and law and health from the book Health Studies (ed. Naidoo and Wills, 2008). In the above chapter there is an example (11.4, page 352) about a lesbian, deaf couple who decided to have a deaf baby (using sperm by a friend with hereditary deafness) that caught my attention. One of the ladies stated that “It would be nice to have a deaf child who is the same as us… A hearing baby would be blessing. A deaf baby would be special blessing. (Glover, 2006, p.5 as cited in Health Studies).

I kept thinking; it would be special blessing for whom, for the ladies or for the child? Do we actually want babies just like us? Why does the lady change her position between a baby that could hear and a deaf baby (“a baby is a blessing but a deaf baby is a special blessing”)? Isn’t a special blessing just to have children? Is choosing or designing children the future of humanity?

I am not arguing about having a deaf child or not; but I am not sure if we have the “freedom” to choose our offspring. If we accept that it is someone’s right to choose what baby would give birth (deaf, hearing, blonde with green eyes, white, black and so on) then what is the difference between eugenics?

If it is all about having babies just like us then we should create clones… I am sceptic about the fact that technology can enable us to design or choose what kind of children we will have.

Where can we possibly draw the fine line between what is acceptable and what is not, concerning the “possibilities” we have with the application of the new DNA technology?

The issue of ensuring that newborn children will have the highest possible state of health it is old and can be seen in ancient Greece where Aristotle’s and Plato’s views about reproductive methods are in favour of eugenics. The aspiration was the city to have strong soldiers and to have control over births. Today, with the technological achievements in the medical field and genetics, we actually have the power to design babies and ensure that they inherit all the “good” genes.

We can diagnose impairments at the early stage of life and choose if we wish to have the baby or not. But is it moral to choose not to have a child with a disability (and have an abortion) or to choose to “design” a child with a disability?

Are our decisions based on social pressure about what is conceived to be “normal”?

Are they based on our misconceptions about disabilities?

Are they based on personal aspirations and extended ego?

Can a tattoo be useful?

I was reading an article about an 83 year old grandmother who wants a tattoo; a tattoo that will reduce one of her great fears. She worries that if she collapsed someone would try to resuscitate her; she therefore wants “Do not resuscitate” tattooed on her chest. She is not ill, she is not depressed, she simply feels that she has had a good life and is ready to leave it whenever nature decides to end her time. She worries about losing her independence, about getting dementia; a sudden collapse would be her perfect death, so why waste the opportunity?

Is her concern justified? Will it be ethical for the paramedics not to resuscitate the lady since that is her wish? This ethical question cannot be easily answered of course. Who is going to take the responsibility to end a life?

I argue that we ought to live our lives and die in dignity and respect. Being a nurse for three years I came across some patients suffering for a long period in the hospital, wishing to die. But doctors, acting their duty, kept them in life, giving them medicines without any actual improvement on their health but to prolong life… keeping patients breathing and suffering.

I will always remember a cancer patient who was in terrible pain, not being able to eat or do anything except wishing to die. We were trying to comfort her physical pain but do almost nothing to ease her anxiety and her wish to die. She died after two or three weeks in horrible pain… At the end, can we avoid the unavoidable?

Euthanasia and assisted suicide (when a patient suicides with the assistance of a physician) are controversial issues which generate a lot of debate. Whereas we will assist a suicide or operate euthanasia depends primarily on our moral values and our ethical beliefs. Is all about values; what do we mean by ‘good life’ and ‘good death’? Is it a moral action to keep someone suffering? Is it better to release him/her from pain or help him/her have a painless death?

Well I suppose it depends on our values and moral or religious beliefs. From my point of view, I cannot judge someone who doesn’t want his/her beloved person to be in suffering and pain. I believe that is more ethical to help someone die peacefully than see him/her suffering to death.

Alice was the grandmother of hippies; whenever she was low she took the pill and became high… (Kusama, Japanese painter).

Is the solution to our problems relies on a small (or big…) bill or on a cocktail of pills? Wake up and feeling sad; take the red pill… feeling tiered during the day? Consume the green pill and so on and so forth… or have a drink (and two and three…). A huge industry is based on producing medicines that we might not actually need but their appealing promises are too good to be ignored. Vitamins and herbs that help our immune system, pills that make us feel happy, fat burners and so on. Not to mention the alcohol consuming that is increasing, especially among young people.

What force us to use (often abuse) all these substances (pills, alcohol and so on) in order to be in “good mood” and have “fun”? Which are the underpinning reasons for this kind of actions? And what are the consequences in both personal and societal level?

The cost of excessive alcohol use in the United Kingdom is brought to my attention by The Institute of alcohol Studies (2009), and they give some revealing statistics. For example, the number of mental disorders related to alcohol abuse rose from 37,692 in 1995/6 to 57,142 in 2006/7 and the number of admissions to hospital for alcoholic liver failure rose from 9,058 in 1995/6 to 39,896 in 2001/2. The total cost of alcohol treatment in 2003/4 was estimated to be £217 million (Institute of alcohol Studies 2009, p. 10), thus the NHS initiated a campaign named ‘Know Your Limits’ at an initial cost of approximately £2 million in 2007.

The targets of the campaign were 18-24 year old people in England and the “core message for the campaign focuses on influencing young people’s thinking about their behaviour when drunk,” with slogans accompanied by pictures such as “You wouldn’t start a night like this, so why end it that way?” The campaign planning document (Home office 2007) then goes through a number of carefully planned steps for local organisers to get to grips with the campaign. These include recruiting local partners such as borough councils, community safety partnerships, the local constabulary, and specialist health promotion units. The next four steps are to confirm a launch date, define the target audience, confirm objectives and agree the key messages. Several more steps then follow, including media planning, evaluating and ‘branding’ (Home Office 2007).

The activities suggested include street dramas around the theme of drunkenness, the display of life-sized mannequins of young men and women in drunk-looking poses, projecting the campaign logo onto buildings etc. in busy areas and making floor stickers for pavements (Home Office 2007).

Without saying more, other than that alcohol consumption in the United Kingdom continues to rise to the extent that there were 1,057,000 alcohol related admission to hospitals in 2009/10, an increase of 12 per cent over the previous year (NHS Information Centre 2012), and the government is currently considering putting a minimum price on alcohol.

Maybe it should be better, instead of trying to “convince” people not to drink, to find out why certain groups of people drink. Work with them involve and engage them in an intervention that will have a positive impact. Do not “spray and pray” but work with each group of people individually.

On the 14^th of March we had an interesting lecture about social marketing. I have to confess that it was the first time I have heard about social marketing.

Marketing, nowadays, means identifying what does the target population need and “create” a product according to the specific needs. Similarly, social marketing aims to influence the behaviour of a specific population by focusing on the specific needs and desires of the target population. It is about knowing and understanding the culture and beliefs of a specific group in order to design and implement a successful strategy according to these.

Extra emphasis is also given on the evidence-based evaluation of each intervention.

As I understood from the lecture, there is a kind of debate between health promoters and social marketers whether social marketing interventions are “appropriate” methods since they focus mainly on facilitating behavioural changes.

Social marketing interventions, though, are designed according to the needs, beliefs and cultural influences of the target group. Therefore, it can be said that the social determinants of health are taken into consideration and since an intervention does have a positive result on peoples’ health and health attitudes, I can’t see the reason of such a debate.

Overall our aim is to promote better understanding about health issues, facilitate healthy choices and empower individuals to have control over their health.

From my point of view, if social marketing has a positive contribution to the health promotion field then debates are unnecessary.

Terminology as I understood it…

Studying Health and understanding the nature of health is a complex and difficult process. According to Duncan (2007, p.65): “This is due to three components: competing ontological and epistemological disputes; professional ideologies, beliefs and values feeding these; and academic disciplinary diversity”. What is needed, for a health care student or professional, is to develop a critical analysis and critical reflection to examine disciplinary discourses related to the concept of health (Duncan, 2007). I will attempt to reflect (briefly) on the concept of health…

Aggleton (1990) divides the ways of defining health into two types. There are the official definitions which are the views of health professionals and the lay beliefs which are the perceptions of health of those who are not professionally involved in health professions.

Lay perspectives of health are personal matters and might be in contrast with the professional perspectives. Lay perspectives however, are important for health professionals. By examine what people think about health issues, how they perceive health and what are their needs, we can design and implement a health strategy or project according to their specific needs and beliefs and we can “work” on possible misconceptions.

On the other hand, there are many professional definitions of health which we might categorise (in my opinion) in two main types: the narrow view of health, where health is defined as the absence of disease. In contrast there is the broaden view where health is defined as something more than the absence of disease; a physical, emotional, social wellbeing which it can be determinate by social and personal factors. The former definition is connected to the medical model of health whereas the latter is accepted and it is used by the health promotion field. Health promotion concept is an “umbrella” term including, among others, empowering individuals and communities to have control over their health, considering the social determinants of health as crucial issues, work collaboratively with each social group in order to facilitate an improvement to health and provide health education and knowledge; education that gives power to people…

I believe that health is definitely more than the absence of disease; humans are too complex creatures so defining their health with such a simplistic way is inappropriate…Antibiotics or medical interventions are not enough and cannot “offer” us the feeling of wellbeing neither do they satisfy our needs in order to feel healthy and productive members of a society. I would suggest that governments should invest more money in Health Promotion since their investment would be a profitable one; it would reduce the amount of money spent on treatments and hospitalization…

Reference

Aggleton, P (1990). Health. London and New York: Routledge.

Duncan, P (2008) Ethics and Law and Health chapter 12 in Health Studies: an indroduction. Edited by Naidoo Jennie and Wills Jane Pelgrave MacMillam new York

Eraut M. (2000), Non-formal learning and tacit knowledge in professional work, British Journal of Educational Psychology Vol. 70, pp 113–136

Ewles, L. and Simnett, I. (2003). Promoting Health. Edinburgh: Bailliere Tindall.

Institute of alcohol Studies (2009), The impact of Alcohol on the NHS, Fact Sheet

Johns, C. (2004). Becoming a reflective practitioner. Australia: Blackwell

Marmot M. G. (2005), Social determinants of health inequalities, The Lancet, Vol. 365 NHS Information Centre 2012, http://www.ic.nhs.uk/pubs/alcohol11

Payne, R. K. (2005). A Framework for understanding poverty (4th ed.). Highlands, TX: RFT Publishing.

The Home Office (2007), Alcohol – Know Your Limits, https://docs.google.com/viewer?a=v&q=cache:Jq6IOJuONgoJ:www.alcohollearningcentre.org.uk/_library/Resources/KYL/FINAL_KYL_pack.pdf+Know+your+limits+camp

World Health Organization. (2004). Promoting Mental Health: Concepts, Emerging Evidence , Practice. Geneva: WHO.