HEALTH PROMOTION

An Interdisciplinary Perspective

Change is one thing, progress is another; change is scientific, progress is ethical

Bertrand Russell

Overview of Presentation

Definitions & Concepts

Strategies for Promoting Health

Implications of Adopting a Health Promotion Perspective

Recommendations

Definitions of Health Promotion

“Health promotion is the process of enabling people to increase control over, and to improve their health” (WHO, 1986)

“Health promotion is any combination of educational, organizational, economic and environmental supports for actions conducive to health” (Green & Kreuter, 1991)

Key Concepts and Issues

Defining Health and Health Promotion Types of Health Promotion The Evolution of Health Promotion Distinguishing Health Promotion & Population Health Risk vs Protective Factors

Health Definitions

Health is a complete state of mental, physical & social well-being, not merely the absence of disease (WHO, 1986)

Optimal health is a balance of physical, emotional, social, spiritual & intellectual health. (O’Donnell, 1989)

Health is seen as a resource for everyday life, not the objective of living. (WHO, 1986)

Our Definition of Health

“We define health as the capacity of people to adapt to, respond to, or control life’s challenges and changes”

Adapted from Frankish et al., 1997

A "Canadian” Definition of Health Promotion

"Health as perceived in the context of Canadian health promotion has to do with the bodily, mental, and social quality of life of people as determined in particular by psychological, societal, cultural and policy dimensions. Health is seen by Canadian health promoters to be enhanced by sensible lifestyles and the equitable use of public and private resources to permit people to use their initiative individually and collectively to maintain and improve their own well-being, however they may define it." (Rootman & Raeburn, 1994)

Canadian Health Promotion

There is a strong social, community, and self-reliance element, given that the overall model of health promotion is centered around the concepts of self-help, mutual aid and citizen participation.

The history of Canadian health promotion comes from the Lalonde Report so that there are overtones of lifestyle and behavior. However, this emphasis on lifestyle, has of more recent times, been balanced by the influential social model of the Ottawa Charter.

Canadian Health Promotion

There is a strong implicit element of empowerment and efforts have focussed on high priority sectors such as youth, women, disabled, aboriginal populations.

The health concept has a non-medical tone, the biological component of health is not prominent.

The concept of quality of life is at the foundation of Canadian health promotion. Adapted from Pedersen, O'Neill & Rootman (1994) Health Promotion in Canada

How Canadian/European Health Promotion Contrast with the United

States

Social Focus Collective Responsibility Risk Conditions Blame Society Excuse the Victim Green. L. (1994). Canadian

Health Promotion: An Outsider's View From the Inside, in Pedersen et al., Health Promotion in Canada

Individual Focus Personal Responsibility Risk Factors Blame the Victim Excuse Society

Three Types of Health Promotion

Public health/ preventive medicine

Lifestyle/behavioral

Socio-environmental or determinants of health (population health)

Potential Impact of Policies & Programs (Health or Non-health)

EconomicEconomicImpactImpact

HealthHealthImpactImpact

SocialSocialImpactImpact

EnvironmentalEnvironmentalImpactImpact

Eras In the Evolution of Health Promotion

The Public Health Era

Entrenching the Medical Model

Lifestyles - Behavioral Health Education & Social Marketing

Shifting the Paradigm -Health Promotion as Self-Responsibility?

Characterizing Population Health

Concerned with whole communities or populations, not just individuals

Concerned more with distal rather than proximal determinants of health

Concerned with intersectoral action, not just the health sector

Seeks to make populations more self-sufficient, less depend on health services & professionals

Contrasting Individual vs Population Health

Proximal Determinants Individual as Focus Health Sector Behavioral Change Educational & Behavior

Modification Quality of Life as Outcome

Distal Determinants Whole Populations Intersectoral Environmental Change Policy/Organizational

Levers Social Conditions as

Ultimate Outcomes

Implications of a Health Promotion Approach

Redirection of resources Need to adopt new or different roles New stakeholders from diverse sectors New forms of management New or refocused functions to address new targets New foci for evaluation New partnerships and intersectoral collaboration May need to develop new capacities and skills A new "culture" in the health system

Risk Conditions & Health Promotion

Unemployment, Inadequate Housing Minority Status Racial Discrimination Cultural and Language Barriers Low Educational Levels Abuse and Neglect High Levels of Family Stress Social Isolation Constitutional Vulnerability Marital Status

Adapted from Brown (1995). Urban ecological model of subjective well-being among the elderly. Gerontologist, 35(4), 541.

Population Attributable Risks Population Attributable Risks (4 health indicators + 10 socio-demographic characteristics)(4 health indicators + 10 socio-demographic characteristics)

age

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smortality

long-term disordersself-rated health

long-term disabilities

0

20

40

60

80

100

PAR (%)

Source: Dutch Public Health Status and Forecasts, 1997

Protective Factors & Health Promotion

Middle or upper class, low unemployment Adequate housing, pleasant neighborhood High-quality health care Easy access to adequate social services Multigenerational kinship network Non-kin support network Family stability and cohesiveness

Core Strategies for Health Promotion

Create Supportive Environments

Develop Personal Skills

Reorient Health Services

Building Healthful Public Policy

Strengthen Community Action

From the Ottawa Charter for Health Promotion, 1986

Population Health PromotionPopulation Health Promotion

Nancy Hamilton &Nancy Hamilton &Tariq BhattiTariq BhattiHealth PromotionHealth PromotionDevelopment DivisionDevelopment DivisionFebruary 1996February 1996

Program & Policy Influences on Health

Policies & ProgramsPolicies & Programs(Health or Non-health)(Health or Non-health)

DeterminantsDeterminantsof Healthof Health

Health ImpactHealth Impact(Outcomes)(Outcomes)

Quality of LifeQuality of Life

Reorienting Health Services for Health Promotion

Ottawa Charter stated: "the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical/curative services"

HPPB has a mandate to improve the health of Canadians and to contribute to a sustainable, high quality health care system" (Health Canada, 1998)

It is important that the Government provide national leadership by highlighting how health promotion has contributed to sustainable, quality health services

SocialEnvironment

SocialEnvironment

PhysicalEnvironment

PhysicalEnvironment

BiologicalEndowment

BiologicalEndowment

IndividualResponse

IndividualResponse

Illness Illness Health Care

Health Care

Health Status & Function

Health Status & Function

Productivity & Wealth

Productivity & Wealth

Canadian Inst.for Advanced Research

DETERMINANTS OF POPULATION HEALTH

+-

Evidence Regarding The Determinants of Health

Illness Care System (20-25%)

Biological Endowment (10-15%)

Physical Environment (10-15%)

Social & Economic Environment (50-60%)

Adapted: Canadian Institute of Advanced Research, Why Some People are Healthy & Others Are Not

Projects Focussing on Reorientation of Health Services

Review of Hepatitis C Services in Canada Prevention Strategy for Hepatitis C in Canada Survey of Multicultural Needs and Use of Crisis Intervention Services Crisis Intervention Training for Multicultural Community Workers Evaluation of Services for Stroke Survivors in British Columbia Evaluation of Mental Health Education & Health Promotion Resources Experiences of Mental Health Patients as Members of Community Boards

and Committees Homelessness in Greater Vancouver Implications of a Population Health Approach for Mental Health System Predictors of Ritalin Use in ADHD Children Role of Community Pharmacies in Health Promotion The Role of Health Promotion in Primary Care Use Population Health Research by Regional Health Authorities

Strengthening Community Action for Health Promotion

Theoretical reasons include: increased responsiveness or accountability so health needs & services are matched; the notion that people have the right to participate in planning, implementing, & evaluating services; the view that community empowerment can lead to a sense of contribution/power in the system.

Practical reasons include: appreciation of untapped community resources and energy; provision of a broader range of inputs to decisions; notions that such participation may lead to more cost-effective decisions; and the belief that lay participation may contribute to more efficient delivery of services.

Political reasons include: loss of faith in the legitimacy and superiority of professional knowledge in decision making; a means of gaining support and the efforts of volunteers; greater awareness of health problems, more appropriate use of health services.

““ActualActualneeds”needs”

Public’sPublic’sperceived needs,perceived needs,

prioritiespriorities

Resources,Resources,feasibilities,feasibilities,

policypolicy

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Three Worlds of Planning

From Green & Kreuter, 1991

Projects Focussing on Strengthening Community Action

Community Workbook for Participatory Health Promotion Research Community Survey of Attitudes toward Adolescent Drug Use Community Participation in Health Care Decision-making Development of Measures of Community Health for the Canadian

Community Health Survey Health Impact Assessment as a Tool for Health Promotion and Healthy

Public Policy Health-Care Decision-Making and Community Health Councils Lay Report of Injury Prevention Projects with Native Populations Lifestyle Services for Low-Income Women Measuring the Health of Communities Measurement of Mental Health in the NPHS Royal Society of Participatory Research in Health Promotion

Projects Focussing on Development of Supportive Environments

Environmental Scan & Needs Assessment of Persons with Spinal Injuries A Review & Evaluation of Smoking Cessation Strategies Analysis of Community Health Plans Analysis of Tobacco Advertising and Health Impacts Community-Based Programs & Policies Dealing With Septic Field Failure Counter-Advertising and Health Messages Evaluation Strategy for the BC Heart Health Promotion Project Literature Review of Injury Prevention Projects with Native Populations Risk Behaviour Prevention Projects with Adolescent Populations Mental Health, Active Living & the Determinants of Health Pediatric Antibiotic Resistance School, Community & Nutrition Project Study of Health Empowerment in West End Youth Project

Projects Focussing on Development of Personal Skills

Adolescent depression and suicide; the role of social inadequacy Assessment & Treatment Program for Heart Surgery and Patients Assessment Protocol for Evaluation of the Back Injury Prevention Project Assessment of Needs of Single Parents Survey Attitudes to Health Promotion and Illness Prevention Questionnaire Cardiovascular Psychophysiology, Psychosocial Factors in Heart Disease Dance/Music Therapy on Quality of Life in a Disabled Population Dietary Screening as a Predictor of Anaemia Effect of Weight Training on Bone-Density in Adolescent Girls Pre-Admission Education on Anxiety and Hospitalization in Heart Patients Health Promotion Behaviours and Adherence to Exercise Prescriptions Health Promotion in a Hearing-impaired Adult Population

Projects Focussing on Development of Personal Skills

Hyperventilation Treatment for Panic Disorder Injury Prevention Skills for Parents Psychosocial Factors in Coping and Health Outcomes among Disabled Social Assertiveness and Psychopathology Stress and Coping in Student Mothers Survey of Measures of Health and Well-Being Test Anxiety and Performance in Statistics

Projects Focussing on Building Healthful Public Policy

Barriers to Health Policy: Evaluation of Smoking Bylaws in BC National Study of the Implementation of Provincial Health Goals Policy Regarding the Use of Retail Warning Signs for the Tobacco

Reduction Strategy Development of a Policy Document for the BC Tobacco Reduction

Strategy Case Study of the Development of BC's Health Goals

STEP 1: Creating the Motive

What have we done so far:

Heightened public awareness, changes in beliefs, changes in knowledge

What remains to be done:

Continued public and professional educationEducation of policymakersBuilding the public and political will

STEP 2: Enabling the Change

What have we done so far:

Developed educational resources, some enhanced skills, some changes in the environment

What remains to be done:

Increased availability/accessibility of resources for health promotion and disease prevention

Creating supportive environments

STEP 3: Reinforcing the Effort

What have we done so far:

Not enough, limited, unclear incentives for engaging in prevention for individuals, businesses, health professionals

What remains to be done:

Creation of clearer incentives and rewards for engaging in health promotion/disease prevention

Development of supportive structures, policies and legislation

Summary Recommendations

Short-Term: development of educational resources for the general public, patients, volunteers, health professionals and service providers

Intermediate: creation of resources for use by policy makers and planners, development and rigorous evaluation of pilot demonstration projects

Long-Term: advocacy for policy, structural changes, and allocation of resources toward health promotion, disease prevention and population health