Mental Health and Quality of Life at Work in Brazil

By Neiva Melamed and Andréa Silveira

The evolution of technology and rapid globalization have contributed meaningfully to the advancement of some sectors in our society. On the other hand, however, new technologies and globalization impose a fragmentary and alienated way of work, where some work processes are divided into different parts, each developed by different persons in the same company. In our practice we see many companies that hire people to do only part of the whole process. So, these persons do not really know the purpose of their job. As a consequence, they do not get involved with the rest of the company team, and most of the time they do not recognize the value of their work. This fragmented work pattern and its resultant alienation sometimes causes depression and very low self-esteem. Teamwork and its interpersonal relationships suffers while the value of work is highly quantified. Workers in these systems often experience mental suffering and psychosocial problems which may be related to pressure from management, to the hierarchical and authoritarian control of workplace tasks, as well as to increases in workload aimed at obtaining equivalent or bigger profits with less employees.

As a consequence, work relations and relationships between workers have been influenced by negative competition among the workers and by anxiety and fear resulting in a social instability. Such patterns potentiate stress and depression levels in workers and foster growth of chemical dependency, bipolar disturbances, schizophrenia and obsessive-compulsive disorders inside the organization, interfering on both the quality of life at work and also in the global quality of life for human beings.

Brazilian Issues

Although in Brazil some laws have been created to guarantee workers’ health, they are inadequate responses to the conditions of work and management in local firms, where many people still have to work with either no technology or with very old machines and without conditions to assure the quality of their work and private lives. Increasingly, these employees are treated with little respect and earn salaries insufficient for survival in Brazil’s rapidly modernizing society. While Brazil is generally regarded as a developing country, the cost of living is not low and most of the people must work 10 to 14 hours a day in bad conditions just to make ends meet at the end of the month. Though these workers are vital to Brazil’s rapid growth, there is no wide support for improved work conditions for them, and so many workers pay for Brazil’s development with their health.

Additionally, with the opening of Brazil’s national market, most of the choices of work are in the new technology sector and with global companies, where too frequently Brazilian workplace standards tend to be lower than the ones practiced in these firms’ countries of origin. The demand level on Brazilian employees is disproportionate to the degree of recognition given for their work, and disproportionate too to firms’ investment in workers’ personal and professional growth. Thus, while more and more Brazilian workers are being required to improve their work, they don’t have access to workplace conditions that may assure their quality of life.

If people’s health conditions express the way a society is organized and how its resources are distributed, then we can deduce that Brazil still has a long way to go before Brazilians may get better conditions and policies for mental health and quality of life. The constant threat of unemployment and the lower conditions of life, mainly in big urban centers are, however, just some of the factors degrading quality of life. Certainly the pressures coming from political and economic disorganization in Brazil also negatively affect mental health and may cause a great proportion of psychosocial conflicts in the country.

Neiva Melamed is a Brazilian psychologist specializing in health promotion, therapeutic psychodrama, and systemic relation therapy. She is President of HUMANA – Research, Consulting, and Projects in Quality of Life.

Andréa Silveira is a psychologist and teaches at the Catholic University of Parana. She is a consultant at HUMANA – Research, Consulting and Projects in Quality of Life, and President of the South session of the Brazilian Association of Social Psychology – South Session.

Both Neiva and Andréa may be contacted at: Humana, Rua Bruno Filgueira, 369 cj. 1505, 80240-220 Curitiba PR Brazil; Email to humana@humana-qvt.com.br or Phone: +55-41-242-1920.

Incorporating Mental Health Into Health Policy and Services: The Global Mental Health Policy and Services Consortium

By Harvey Whiteford and Florence Baingana

Mental disorders are a major and rising cause of disease burden in all countries. The rise will be particularly steep in developing countries that have the least resources to respond. While there are increasingly effective interventions available to reduce this burden, many countries do not have the policy and planning frameworks in place to identify and deliver these interventions, even when resources are available. Both WHO and the World Bank have emphasized the need for ready access to the basic tools for mental health policy formulation, implementation and sustained development. While there is no universally applicable blueprint for formulating and implementing national mental health policy, the number of policy elements (building blocks) is finite and the knowledge base on implementation can be assembled from both the successful and unsuccessful actions of governments in this area.

A Global Proposal and its Aims

In October 1999 the Strategic and Technical Advisory Committee of the Global Forum on Health Research supported a proposal for conducting Analytical Studies on Mental Health Policy and Services submitted by the International Consortium on Mental Health Policy and Services (http://www.world-mental-health.net). Additional support is being provided by Australia, the USA and the United Kingdom.

The aims of the work are to identify the reasons behind success and failure in mental health reform, to provide the instrumentation for the development of national mental health policies and services at a cost countries can afford and identify practical examples of such policies in a number of countries. The five key objectives are:

1. To develop the key elements of a national mental health policy.

2. To assess the cost-effective implementation of those policy elements under various socio-economic conditions.

3. To provide tools and methods for assessing the current situation regarding a country’s mental health status, programs, services and care.

4. To generate guidelines and examples for upgrading mental health policy with due regard to the existing mental health delivery system and demographic, cultural and economic factors.

5. To establish a global network of expertise, in terms of institutions and experts, for use by countries prepared to reform their system of mental health policy, services and care.

The project will support and collaborate with countries in applying the tools and instruments developed for decision making in mental health policy and implementation. This information will be in the public domain and available to all countries and agencies such as WHO, the World Bank, multilateral and bilateral donors for their consideration in supporting mental health reform.

A policy template has been developed to describe the elements of mental health policy. The template has been aligned with WHO Report 2000 and defines four major categories that have implications for policy development.

1. Context. This includes the environmental factors in a country that influence the population health and within which interventions are delivered. This includes factors outside the health system that will influence the performance of the mental health elements and determine some outcomes.

2. Resources. These include all specific health as well as non-health inputs that contribute to the mental health of the population. Higher-level issues, such as access, can be determined by considering the availability of human resources, physical capital and financing.

3. Provision. These include all elements that contribute to the delivery of mental health care, prevention, treatment and rehabilitation.

4. Goals. These include all elements that describe the results of the provision of services.

A questionnaire and methodology has been developed and trialed for collection, in common format, information relevant for a country’s mental health program.

Six regional working groups (each one led by a member of the Consortium from Eastern Europe, Africa, East Asia, Eastern Mediterranean, and South East Asia and Latin America) have been established to carry out the fieldwork of the Consortium. Regional meetings are being held in all six regions to review the template and questionnaire and adapt it to the socio-cultural situation of the countries in the Region.

It is expected this will contribute to the further improvement of the instruments for actual use in twelve countries during 2001.

Harvey Whiteford is Kratzmann Professor of Psychiatry, University of Queensland and a Mental Health Consultant to The World Bank. He may be contacted at: P.O. Box 822, Toowong 4066 Australia. Phone: 61 7 3871 1037, Fax: 61 7 3371 1289, Email: hwhiteford@worldbank.org

Developing a Set of Mental Health Indicators for European Union

By Jyrki A Korkeila, MD, PhD

In the 1990s, mental health issues have received increasing attention across Europe and indeed the whole world. Mental ill-health is a major public health concern for two reasons: epidemiological studies conducted have shown that up to one fifth or one quarter of the general population suffer from some sort of mental disorder at a given time; and secondly, up to half of the population may be at risk of having a mental disorder at some point during their lifetime. Disability due to psychiatric disorder has received increasing attention since the Global Burden of Disease report. Of all morbidity, 25% was attributed to psychiatric illnesses and major depression as cause of disability was ranked fifth.

The Key Concepts project supported by the European Commission and the Consultative Meeting "Promotion of Mental health on the European Agenda" proposed the development of mental health indicators as one of the European priority areas of action in the field of promotion of mental health. A two-year action project to establish the indicators for mental health monitoring in Europe, coordinated by Stakes, started in the beginning of 1999 under the EC Health Monitoring Programme. The project has had participants from the Member States of the EU and Norway. A group of Active Partners from seven Member States have collaborated more closely on the definitions and individual indicators to be proposed.

The two-year project has aimed to collect information on existing mental health and well-being indicators and information systems, and agree on harmonised definitions for European mental health indicators, which can be integrated to comprehensive health monitoring systems. The aim has been to create a set of a few good indicators to monitor mental health. Monitoring mental health is conceived here as systematic, repeated measures of matters related to the mental health of the population.

A mental health indicator should reflect an aspect or determinant of mental health that is important for a chosen target. An indicator should inform its users of changes related to the targets, and whether the targets are being achieved or not. The targets that may realistically be set for mental health and the measures that are available in practice restrict selection of indicators. A mental health indicator may be a survey measure or a proxy for the state of mental health or it may be a survey measure or a proxy for factors predisposing to/or precipitating the onset of mental ill-health or factors protecting from various forms of ill-health. Some of the key determinants (e.g. genetic predisposition), however, still lack, and look like doing so in the near future, the corresponding measures at population level. The overall target for mental health work is to reduce morbidity and mortality, and increase positive mental health. Most mental health indicators available, however, refer to mental health services and describe their structure, processes, quality and outcome.

The project collected information on existing national databases and international organisations (WHO-Euro, OECD and Eurostat) on data pertinent to mental health. Indicators describing aspects of mortality, resources of health care and use of health care services were currently used in all or most EU Member States. As the services differ, not all the data available and reliable at the national level are comparable at an international level, which limits the usefulness of routinely collected statistical information. However, comparable indicators for the state of mental health and for some of the determinants were not found to be in common use in the Member States. There is, thus, a clear need for development regarding the implementation of the proposed set of mental health indicators. The data acquisition for these indicators in need of development necessitates information based on surveys. The instruments proposed are short and could be easily added to European or national surveys.

The project has decided to suggest as mental health indicators relevant mortality and services related data, e.g. measures on social support, life events, chronic stress, future expectations, personal control, psychological well-being, psychological distress, disability due to emotional problems and disease specific morbidity. Also items concerning the self-reported use of services will be added. Some of the measures listed are pertinent for general health as well. Depression was chosen as the most important disease specific category for the reasons stated above. A pilot project for the implementation of the indicators based on survey data has been outlined.

Ultimately the system would be there to help decision-making. It could be used in estimating how the targets set for policies are met, whether there is a measurable decrease in disability, suffering and disease. The indicators could offer possibilities to adequately allocate the resources for interventions, policies and programmes. This information could also be used in evaluating the mental health impact of other policies.

Global Initiatives

Health Canada launches First International Network for Mental Health Promotion

The First International Network for Mental Health Promotion was launched on August 10, 2000 at the Canadian Mental Health Association Conference in St. John's, Newfoundland. The International Network will be the first on-line searchable database to register the work of thousands of mental health promoters around the world and to share the latest developments in mental health promotion.

"Mental health is an essential ingredient to overall health," said Health Minister Allan Rock. "I am pleased Canada is hosting this on-line knowledge network. This tool will be an important source of research and information and will harness the efforts of mental health promotion professionals globally."

The International Network for Mental Health Promotion will connect people working in the mental health community, governments, services, research and in educational and justice institutions around the world. It will help to disseminate important knowledge and to apply projects that foster mental health and well-being in Canada and the rest of the world. Health Canada will host and maintain the Network on its home server.

"It is very encouraging for us to see the momentum of mental health promotion grow worldwide. The future for mental health promotion looks bright as our collective efforts continue to converge," said Ed Pennington, President of the Canadian Mental Health Association. An increasing number of countries are becoming actively involved in promoting mental health. Canada has been invited along with New Zealand, Australia and the United States to a meeting in November to discuss further international cooperation with the member states of the European Union.

For more information about the First International Network for Mental Health Promotion, visit our web site at http://www.mhpconnect.com.

Mental Health Promotion in Africa

Project MHASISA (Mental Health Action Strategies in Southern Africa for Persons with Disabilities) is a three-year project funded by the Canadian International Development Agency (CIDA) in partnership with the Canadian Mental Health Association and four African partner organizations: the WFMH African Regional Council, the Mental Health Association of Zambia, the South African Federation for Mental Health, and the Zimbabwe National Association for Mental Health.

The basic goal is to promote the capacity of the MHAs in sub-Saharan countries to provide leadership in mental health and human services. The objective is to strengthen the four mental health associations to better serve their communities and to contribute towards sustainable and democratic development.

In April 2000 the first phase of the project was launched by a field visit to the four African partners by Edward J. Pennington, general director of the Canadian Mental Health Association. As the WFMH Regional Vice President for North America, Mr. Pennington’s plea to mental health leaders in developed countries is to pursue opportunities with their own overseas aid sources to assist the development of mental health services and programs in developing countries.

"There is a crying need to help our colleague organizations in the Third World," he says. "Now is the time to take advantage of our new knowledge of world-wide mental health needs and to find the resources to promote civil society issues in the mental health field."

CIDA’s approval is conditional on each partner reviewing its goals and objectives, and establishing a results-based management approach to performance reporting within the first six months. The purpose of Edward Pennington’s visit was to communicate these requirements to the African partners and help them decide how to meet them. The partners are:

WFMH African Regional Council

The project objectives are as follows:

• To immediately establish contact with persons and organizations interested or working in mental health services in all African countries.

• To strengthen the weak existing national mental health associations and to establish new ones where they do not exist.

• To hold an all-African regional conference.

The CMHA delegate discussed the development of the ARC with mental health leaders in each of the three countries he visited. He also met with a group of senior ARC volunteers in Lusaka, including the president, Isaac Mwendapole (a mental health volunteer for over twenty years, and a former WFMH Regional Vice President for Africa), and the treasurer, Malvuto Tembo.

Mental Health Association of Zambia

The project objectives are:

• To organize planning exercises for the National Board of Directors which will provide nationwide leadership in promoting the project objectives.

• To plan a national event for the member organizations of MHAZ which will address issues and provide strategies for positive change in Zambian society.

• To initiate community development work with branch volunteers in the MHAZ priority areas of women, consumers and families, youth and children.

The Government of Zambia has created a senior position in the Central Board of Health, the Mental Health Specialist. The post is held by John Mayeya, who participated in most of the meetings during the CMHA field visit. Mr. Mwendapole, who is the vice president of MHAZ, and Petronella Mayeya, the honorary secretary of the local organization, accompanied the CMHA general director on his appointments with senior government officials. MHAZ president Justice Ernest Sakala and treasurer Humphrey Zimba also attended the meetings.

The discussions included broad health issues facing Zambian society, such as HIV-AIDS, physical and sexual assault of women and children, tuberculosis, access to and cost of drugs, and also socio-economic issues such as the incredible number of orphans in the country who have lost their parents to the AIDS virus, the high poverty levels, the inadequate levels of housing, and general lack of community services.

South African Federation for Mental Health

The project objectives are:

• To strengthen the capacity of the South African Federation for Mental Health and its affiliated societies to fulfil their objectives in their most severely under-resourced areas.

• To plan and implement community development activities in certain pilot site communities.

• To create training programs and learning opportunities for citizens in the underdeveloped settlements to promote leadership skills.

The senior SAFMH staff have also identified the need for the development of training tools at the National Directorate which can be used throughout the country for a variety of capacity-building and skill development programs. The CMHA representative met with the SAFMH national director, Lage Vitus, and the national deputy director, Driekie Moutinho, and visited two regional Mental Health Societies, in Mpulumalanga and in the Northern Province.

Zimbabwe National Association for Mental Health

The project objectives are as follows:

• To strengthen the capacity of the Zimbabwe National Association for Mental Health to fulfil its leadership role.

• To organize a national conference on mental health to promote greater communication among affiliates in the field of mental health.

• To organize provincial workshops.

The ZIMNAMH executive director Elizabeth Matare arranged a full program of appointments for the CMHA representative despite unrest in Zimbabwe at the time of his visit. The organization’s executive members held a special meeting to discuss the terms of the project with him. The difficult political circumstances are inextricably linked to the country’s poor economic situation. ZIMNAMH is adversely affected by personnel costs, fuel shortages, and poor market conditions for its workshop and farm products. It has several income sources, including corporate donations, but they are all very modest and none guaranteed for more than a year at a time.

Grantsmanship. For organizations in developed countries interested in pursuing their own partnership projects, a limited number of copies of the 46-page project description are available on request from the Canadian Mental Health Association, fax (416) 484 7750 or email cmhanat@interlog.com. Please note that CMHA is not eligible to apply for any additional grants or contributions from CIDA and regrets its inability to forge new partnerships at the present time.

Country Profiles:

A Concise Survey of Mental Health in Slovakia

By Petronela Praznovska and Pavel Mladonicky, National Center for Health Promotion, Bratislava, Slovakia

Biological, social, economical, cultural factors contribute to the mental health of the Slovak population. These factors tend to be mutually connected, influencing and reinforcing each other, and modeling the nation’s mental health. The individual as a separate unit is exposed to these factors, and profound changes in the Slovak economy and social system brought with new problems in mental health sphere.

In addition to traditional mental disorders, such as, schizophrenia, depression, occurrence of newer disorders has also risen in recent years, especially in a rise in new disorders, such as, drug addiction, anorexia, social phobias, obsessive-compulsive disorder and such.

Decrease and Stability

Compared to earlier decades, the rate of occurrence for schizophrenic disorders in Slovakia has been stable over recent years – about 1% of the population suffers from them. Clearly, advances in diagnosis and therapy have had a positive influence on the quality of life of a schizophrenic. However, the incidence of schizophrenia among close relatives of Slovaks diagnosed with schizophrenia is higher than the figures for the overall population: 15 to 47%.

Manic-depressive psychosis or bi-polar disease affects only about 0.5 to 1% of Slovakia’s population, but the occurrence of depressive disorders is rising. The lifelong prevalence of depression in the republic is 17%. Depressions in the past occurred episodically, however, at present they appear more as disorders with chronic character. In old age they affect about 15% of people and according to Slovak psychiatrists’ study, in 43% of the cases the depression has a chronic feature.

Suicidal behavior is closely connected to affective disorders. In 25% of suicides a mental disorder had been found. During the first years of the last decade the number of suicides significantly decreased, and in 1994-95 stagnation in suicide numbers was observed. However, since 1995, suicide rates have risen sharply in Slovakia, in part because of the spread of newer mental health disorders, such as drug and alcohol addiction.

New Challenges

In the last decade Slovakia has experienced an upsurge of drug addiction mostly affecting the younger generation, and the incidence of drug addiction is constantly rising, while the expected stabilization in this sphere has yet to occur. Concurrently the numbers of alcohol addicts rose, too. The number of newly registered alcohol addicts exceeds the number of registered drug addicts tenfold. Alcoholism among women especially is rising. About 15 years ago the male/female alcohol addicts ratio was 13:1, at present this ratio has changed to 3:1.

A new culturally contingent syndrome – eating disorders – has come to the fore in Slovakia in recent years and coincides with a proliferation of body images and body standards more customarily valued in free western market economies. The prevalence of anorexia nervosa in young women is 0.5 to 1%, bulimia occurrence is higher, ranging from 1 to 10%.

Additionally, as the population ages, the incidence of dementia rises. As in the rest of the world, mental diseases linked to aging possess great medical and social import in Slovakia. Up to 5% of people older than 60 suffer from Alzheimer’s disease, and with increasing age of the population it is likely that the percentage afflicted with Alzheimer’s will rise, and with little hope of effective therapies on the horizon.

Dr Petronela Praznovska worked for 15 years as a clinical psychiatrist in an establishment for mentally disordered. Now she is with NCHP at the Department for prevention of addiction and mental health promotion.

Dr Pavel Mladonicky spent 15 years as a research worker in brain research. Working for some years in the industry he is back to health field as NCHP administration head devoting himself at present mainly to consultancy in health promotion projects.

Finland

Adapted by Vivian Blaxell from "Mental Health in the Workplace: Executive Summaries" International Labour Office, Geneva

Finland has a population of 5.2 million, and a GDP per capita of 20,100. Approximately 12 percent of the Finnish workforce are unemployed.

During the past decades the occurrence of mental health disorders, especially depression, have risen in Finland, and now constitute the most frequent cause of disability. Job-related burnout and stress are alarmingly high with some 50 percent of Finns reporting symptoms, and 7 percent suffering severe burnout. However, awareness of the scope of the problem has also risen and both occupational health care providers and employers are demonstrating their willingness to address the issue in the workplace.

Much work-related mental disorder appears to stem from the effects of the 1990s recession in Finland. High unemployment, job insecurity, short-term contracts and time pressure have contributed to a rise in levels of stress, burnout and depression. This has resulted in an increased burden on the national economy: in 1994 the total cost of mental health disorders in Finland was calculated at 2 percent of GNP.

Finland does offer extensive municipal and occupational health care services which cover mental health care, but the economic downturn of the early 1990s brought pressure to cut costs and resulted in deep changes in the Finnish mental health care system. Not only has the number of inpatient beds been dramatically reduced, but now the quantity and quality of municipal mental health care services may vary substantially, with significant gaps between needs and available services. Similarly, the occupational health care services find themselves short-staffed and under-resourced.

There are, however, a number of government and employee organizations actively promoting mental health awareness and programs in Finland, and most Finnish employees are able to participate in workplace program which maintain work ability. The Ministries of Labor and Health and Social Affairs, along with the National Research and Development Center for Welfare and Health (STAKES) work together on a range of mental health projects, including several successful nationwide program targeting suicide and depression.

Finland has actively started to address mental health issues, and awareness of the extent of the problems and their consequences is rising. The political climate and infrastructure (extensive occupational health care services, high rate of unionization, and legislative framework) are favorable to mental health promotion and prevention, and a culture of mental health promotion is evolving.

Conferences

The Promotion of Mental Health and Prevention of Mental and Behavioral Disorder: The Coming Together of Science, Policy, and Programs Across Cultures. Patron: Mrs. Rosalynn Carter. The Carter Center, Atlanta, Georgia. December 5-8, 2000. A Program of the World Federation for Mental Health in Collaboration with the Clifford Beers Foundation. Co-Sponsors: World Health Organization, The Carter Center.

1st Annual International Conference on Health and Productivity. Hosted by the Health Enhancement Research Organization (HERO). Washington D.C., February 12-14, 2001.

XVII World Conference on Health Promotion and Health Education: Health: an investment for a just society. The 50th anniversary conference of the International Union of Health Promotion and Education. Paris, France. July 15-20, 2001.

6th Annual Congress of the European College of Sport Science. Hosted by the German Sport University, Cologne, Germany. July 24-28, 2001.

International Institute for Health Promotion Newsflashes

The IIHP Celebrates Its Five Year Anniversary

by Wolf Kirsten

The IIHP held its 5th annual meeting on the campus of American University from October 18-21. Thirty-four health promotion professionals from 18 countries convened in Washington, DC to discuss the issue of advocacy for health promotion, advance the working committees, share their professional initiatives and develop a plan for the next five years of the IIHP. The participants agreed that more effective advocacy is necessary to move the field of health promotion forward. Two speakers from the United States introduced their advocacy initiatives. Richard Keelor from Be Active America, a non-profit corporation for the purpose of promoting physical activity, emphasized the significance of grassroots change to enhance physical activity and reduce the onset and severity of obesity. Michael O’Donnell of the American Journal of Health Promotion described his targeted efforts of influencing the political establishment in Washington, DC to build health promotion into the national agenda. In spite of the clear relationships between lifestyle and health and between lifestyle and medical care costs, and the fact that health promotion is a critical element of Healthy People 2010, only minimal dollars are being spent on health promotion research or programs. The overriding goal of this national initiative is make health promotion part of mainstream health care. For more information please go to http://healthpromotionconference. org/2001conf/advocacy_effort.htm.

Committee Work Progressing

The committees covered the following four interest areas:

• Training/curriculum,

• Workplace health promotion,

• Global fitness testing,

• Advocacy/communication.

All of the committees drafted work plans for the coming year. Most notable plans are an international workplace initiative within the framework of the Corporate SANGALA project, which comes out of South Africa and is headed by Gert Strydom of Potchefstroom University, and the development of an international fitness test battery for comparison purposes. This initiative is facilitated by Dieter Lagerstrøm of the German Sport University in Germany. It is envisioned that both of these projects will be implemented with the cooperation of large international organizations like the Pan American Health Organization (PAHO) and of multinational corporations. Furthermore, the US and the European academic institutions in the training and curriculum committee are drafting a proposal to receive funding for a transatlantic exchange project.

Broad Range of Professional Initiatives

Due to the interdisciplinary nature of the IIHP network, the brief presentations by the participants covered a wide range of topics in health promotion. Here are some examples:

• Emmanual Owolabi (Botswana): "Health promotion and HIV/AIDS in Botswana: Need for change or strategy?"

• Finn Berggren (Denmark): "National Danish Bicycle Project in Odense".

• Pavel Mladonicky (Slovakia): "The National Program for Health Promotion – Health for All in the 21st century".

• Clark Jwo (Taiwan): " National Health Fitness Promotion Project for students in Taiwan".

Future of the IIHP

The future of the IIHP was scrutinized under the theme "five on five". After the first five years of existence, IIHP members are extremely motivated to become more involved in collaborative projects and gain increased international recognition in the next five years. The meeting participants agreed that the IIHP should maintain its strengths, i.e. informal nature, lack of bureaucracy, flexibility, interdisciplinary forum and American University as the stable base. Nevertheless, the desire was expressed to become more visible and develop strategic initiatives to help countries, thereby evolving into a "health promotion avant garde".

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe.  It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations.  More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation.  Email the IIHP at iihpaa@american.edu.  The IIHP website is http://www.healthy.american.edu/iihp.html.