Health promotion health education and the publics health
Health promotion, health education, and the public’s health Faculty of Medicine Department of Community Medicine Dr Sudabeh Mohamadi
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3 Health promotion, health equity, and action on the determinants of health Particular attention will be paid to the recent work following up the World Health Organization (WHO) Commission on the Social Determinants of Health, and the renewal of the Ottawa Charter action area of ‘healthy public policy’ in the Health in All Policies global movement, spearheaded by the WHO.
4 ‘Health promotion’ Ottawa Charter for Health Promotion (WHO 1986) defines health promotion as: ‘the process of enabling people to increase control over, and to improve their health’.
5 The expanded definition in the Health Promotion Glossary: Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health.
6 Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. (WHO 1998)
7 The Glossary also emphasizes that ‘participation is essential to sustain health promotion action’, and identifies the three Ottawa Charter strategies for health promotion: Advocacy for health to create the essential conditions for health Enabling all people to achieve their full health potential Mediating between the different interests in society in the pursuit of health
8 These strategies are supported by five priority action areas as outlined in the Ottawa Charter: 1. Build healthy public policy 2. Create supportive environments for health 3. Strengthen community action for health 4. Develop personal skills 5. Re-orient health services (WHO 1986)
9 Health promotion as a process The essence of the health promotion process is a focused shift of power from professionals to the community and to individuals within their communities who historically have had less power.
10 It is crucial that the ‘process’ we focus on is the one that involves negotiating values, principles, ethics, and power, not the less complicated one of transferring a packet of new skills and technical tools to a community that is presumed to lack capacity.
11 In order to achieve this shift in power, health promoters need to begin by examining their own values and assumptions that inform their actions.
12 Beliefs and assumptions underlying health promotion 1. All people have strengths and are capable of determining their own needs, finding their own answers, and solving their own problems. 2. Diversity is positively valued.
13 4. People without power have as much capacity as the powerful to assess their own needs (people are their own experts). 5. Relationships between people and groups need to be organized to provide an equal balance of power (this includes professional/client relationships).
14 6. The power of defining health problems and needs belongs to those experiencing the problem. 7. The people disadvantaged by the way that society is currently structured must play the primary role in developing the strategies by which they gain increased control over valued resources.
15 8. Empowerment is not something that occurs purely from within (only I can empower myself), nor is it something that can be done to others (we need to empower the group). Rather, empowerment describes our intentional efforts to create more equitable relationships where there is greater equality in resources, status, and authority.
16 9. Shared power relations do not deny health professionals their specialized expertise and skills. Rather, professional expertise and skills are used in new ways that result in greater power equity in interpersonal and social relations.
Enabling and empowerment 17 At the time of the Ottawa Charter, the word ‘enabling’ was favoured, although later this tended to be replaced with the more direct and comprehensive concept of ‘empowerment’. A prerequisite for the new approach was that individuals and communities were to directly participate in the planning and implementation of health promotion activities.
18 ‘Enabling’ also referred to the more general process of changing the social, economic, and environmental conditions that made it difficult for people to become empowered.
19 If there is a direct link between human dignity, autonomy, and equity, then all aspects of health promotion must integrate the fundamental perspective of participation.
20 On the positive side, an empowering health promotion process leaves the ownership and control of a health promotion activity or programme in the hands of the community itself.
21 The most effective strategy for change: Allowing people to participate in a genuine way in determining not only what they want but how they want to get it. It is also the only strategy for sustaining progress in improving health and shifting control back to the community and away from a negative dependence on bureaucratic and professional power.
22 What is the ‘health’ in health promotion? The WHO had introduced the positive definition of health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’.
23 The healthcare system plays only a small part in determining health. The ‘lifestyle or behavioural approach to health’: Health was determined by the interplay between human biology, healthcare organization, environment, and lifestyle.
24 The socioecological approach defined health as ‘a resource for everyday life, not the objective of living’. ‘Health is a positive concept emphasizing social and personal resources as well as physical capacities’.
25 In order to reach this state of physical, mental, and social well-being, people must be able to identify and realize their aspirations, to satisfy their needs and to change, or cope, with their environment.
26 If we hold a view that health is the absence of disease, we are likely to talk about disease processes and risk factors and to manage the problem professionally by prescribing a treatment.
27 If we hold a socioecological view of health, we are more likely to focus on the conditions in which the person is living, the factors that are influencing their ability to meet their needs, and to use enabling strategies to assist the person to have more control over their health.
28 The Ottawa Charter strategies to advocate to enable to mediate
29 Advocacy ‘can take many forms including the use of the mass media and multi-media, direct political lobbying, and community mobilization through, for example, coalitions of interest around defined issues.
30 Often, the same organization or individual will be less effective as a political lobbyist to the extent they are perceived to be directly associated with community mobilization efforts that the powerful are either indifferent to, or actively disfavour.
31 Mediation: ‘A process through which the different interests (personal, social, economic) of individuals and communities and different sectors (public and private) are reconciled in ways that promote and protect health’ (WHO 1986).
32 The Ottawa Charter action areas
33 Building healthy public policy There are three elements of healthy public policy emphasized in the Ottawa Charter: 1. If the determinants of health lay mainly outside healthcare itself, then policy action must come from policy sectors other than health. The health sector would still play an important, but not exclusive, role in public policy action to support health.
34 2. Healthy public policy requires the coordinated use of all policy levers available, including ‘legislation, fiscal measures, taxation, and organizational change’ (WHO 1986). 3. Healthy public policy requires the identification and removal of obstacles to the adoption of such policies in non-health sectors.
35 The global economic crisis brought on by the 2008 financial crash has led to some very regressive shifts in fiscal policy and thus social supports for a healthy public policy; meanwhile, global institutions, such as the WHO, have been increasingly supportive of the conceptual logic of healthy public policy.
36 Creating supportive environments This area forms the basis for what is called the socioecological approach to health. This entails the complex relationships between rapidly changing technologies, working conditions, resource use, climate change, urbanization, and health.
37 In the real world, we are not able to coordinate all the best knowledge sources available. Instead, we are left with tools like ‘health impact assessment’ (HIA).
38 Health impact assessment (HIA): "a combination of procedures, methods, and tools by which a policy, program, or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population. "
39 Strengthening community action Indeed, what we see in this area is the place where the true spirit of health promotion is anchored in community development as a process. Strengthening community action quite simply is community development.
40 Community development according to International Association for Community Development: Way of strengthening civil society by prioritising the actions of communities, and their perspectives in the development of social, economic and environmental policy.
41 The five principles as foundational to community organization or development: ◆ Empowerment ◆ Community competence ◆ Participation ◆ Issue selection ◆ Creating ‘critical consciousness ’
42 Developing personal skills The Ottawa Charter tells us that health promotion ‘supports personal and social development through providing information, education for health, and enhancing life skills’.
43 However, since the Ottawa Charter, health promoters, with some exceptions, have tended to either ignore or aim strong criticism at the developing personal skills area. This has come about for three reasons:
44 First, as part of the critique of health education, it was argued that individually focused education approaches were generally ineffective in bringing about health promoting behavioural change; instead, a switch to an emphasis on the social factors that influence health was necessary to overcome the limitations of traditional counselling and other interventions circumscribed by the discipline of psychology.
45 Second, on developing personal skills was associated with the ‘victim-blaming’ element.
46 Finally, although developing personal skills is a central mechanism for empowering individuals to take control over their own health, many worried that, in this narrow approach, the collective strengthening of communities was adversely effected.
47 Reorienting health services The most complex service for health promotion being the acute care hospital setting. It is possible to practice from a health promotion perspective even within this particularly medically dominated environment, for nurses at least.
48 The Alma Ata Declaration (WHO 1978) was the precursor for the Ottawa Charter. These two documents share the same values, principles, and basic tenets.
49 The Alma Ata Declaration addresses health systems more particularly while the Ottawa Charter has a broader mandate. But it is their relationship that provides the key to reorienting health services. That is, primary healthcare is a place for health promotion to focus its energy in terms of reorienting health services.
50 Primary healthcare refers to the philosophy and principles articulated in the Alma Ata Declaration (WHO 1978): universality: universal access to health services accessibility: the removal of geographic, social, economic, or cultural barriers to access
51 participation: it demands community participation in planning, operation, and evaluation of health services requiring integration across health and other sectors such as housing, education, and employment recognizes the power of multidisciplinary teams working as equal partners for the health of the community
52 essentiality: focuses on a range of services, determined by the community, that include health promotion, primary prevention, rehabilitative, and curative equity and access: demands a commitment to equity concerning issues of power and resources
53 Health promotion: history and influences
Health education 54 Health education: ‘Any intentional activity which is designed to achieve health or illnessrelated learning, that is, some permanent change in an individual’s capability or disposition’. This refers to what knowledge, attitudes, or skills can be acquired by individuals through a variety of health education processes.
55 In relation to health promotion, key health educators have radically restructured the traditional approaches to influencing health behaviour.
56 At the centre of this change has been an adoption of the concept of empowerment and an advocacy for using participatory learning processes that break down the power imbalances between health professionals and lay members of society.
57 The relationship between devolving control, developing self-esteem, and bridging the gap between knowledge, attitude, and behaviour is highlighted.
58 In relation to the overall theme of health equity, the move away from traditional health education models has been critical.
59 Without the concept of empowerment, and the development of capacities and self-esteem, the traditional ‘health action model’ of raising awareness and changing attitudes to health behaviours tended to exacerbate health inequalities, as the ‘prepared’ middle classes quickly adopted the new healthy practices of more exercise, less smoking, and a healthy diet.
60 The efforts to help population groups that had both the worst health outcomes and the most intransigent health-related social conditions have not been nearly as successful.
61 Trinity of counselling: respect empathy genuineness
62 Freire model of empowerment education describes a three-stage methodology: listening participatory dialogue action
63 Freire proposes that the main strategy of empowerment education, critical dialogue, requires us to engage in a process of problemposing rather problem-solving.
64 Problem-posing is different from problemsolving because it does not seek immediate solutions to problems. Rather, generative themes arising from the listening phase are ‘codified’ and posed as problematics to raise group consciousness about specific issues.
65 This process recognizes the complexity and the time needed to create effective solutions to societal issues. ‘An effective code shows a problematic situation that is many sided, familiar to participants and open-ended without solutions’.
66 Freire describes these as ‘generative’ themes because they generate energy and motivate people to act.
67 ‘The goal of group dialogue is critical thinking by posing problems in such a way as to have participants uncover root causes of their place in society—the socioeconomic, political, cultural, and historical contexts of personal lives’.
68 Public health There has been a tendency within health promotion to tell a story of public health as a fall from its original reforming, focus on the social and environmental causes of ill health, to a more restrictive, preventive biomedical era, and finally, to a broader scale but narrower scope in the ‘lifestyles’ approach focused on individual risk factors and behavioural change.
69 The medically dominated healthcare system was only one and perhaps the least significant determinant of health, alongside biology, the physical and social environment, and individual lifestyles.
70 The ‘science base’ of the health field concept is epidemiology and, in this context, health promotion is seen as that type of action that must be taken.
71 Politics and philosophy in public health and epidemiology The roots of the modern public health epidemiologists’ focus on individual risk factors and randomized controlled trials (RCTs) is not in contradiction with or a deviation from the classical public health.
72 Once the environmental risk factors of the major communicable diseases were effectively neutralized, a shift in focus took place to providing preventive, immunization measures.
73 Public health has always been concerned with an economistic and utilitarian approach to the health of the population. Public health shares with economics a default, utilitarian ethics.
74 Recent developments in public health have brought into question the utilitarian approach, finding it inadequate, particularly in relation to the question of health inequity.
75 Social movements Despite its ambitions, health promotion is still not accurately described as a ‘social movement’, but rather a ‘professional movement’. Health promoters have recognized that much of their effectiveness depends on very high levels of social engagement.
76 Health promotion, health inequities, and social justice Health equity is a fundamental and central value for health promoters and is often the touchstone for deciding why, where, and how to enact health promoting practice and policy.
77 Health inequities should be eliminated because they are a set of systematic inequalities in health outcomes that are based on unjust inequalities of access to resources that provide for health.
78 The Health Promotion Glossary describes what equity in health entails: ‘That all people have an equal opportunity to develop and maintain their health, through fair access to resources for health. ’
79 ‘Capabilities’ approach to social justice and equity most nearly matches the health promotion approach to health as a ‘resource for everyday living’.
80 According to this doctrine, the ‘social bases for health’ would count as a primary good, or capability that should, by right, be provided to all citizens.
81 It cannot be assumed that arguments for equity in health are unassailable and intuitively obvious for two reasons. First, without some substance behind what is meant by equity and what kinds of resources are to be distributed equitably, the demand for equity in health can be dismissed as either empty or naively utopian.
82 Second, differing conceptions of what is just will lead to different outcomes in terms of actions to promote health. For example, unless we are very clear, ‘equal opportunity’ can be understood in an absolute minimalist sense and can allow powerful institutions to continue to support vast inequities in resources for everyday living.
83 One emerging global initiative aimed at policy solutions in this area: the Health in All Policies agenda.
84 The political economy of health promotion The ‘political economy of health’: the analysis of how different politico-economic social structures affect health outcomes
85 Analyses of healthcare’: the ‘political economy of the analysis of the effect of different political and economic arrangements on the quality and differential access to health services
86 The three fundamental dimensions to health promotion: empowering communities and individuals building health public policy creating supportive environments
87 Empowerment aims to rebalance existing power arrangements by enabling those currently without power to gain access to the resources necessary to live fulfilled and happy lives.
88 In order to do this, health promoters must do two things: they must have a clear-headed view of existing power structures and relations and how they help, to reproduce them. One way of seriously addressing this issue is to pay more attention to the concepts of class and status.
89 Health promotion, to be successful, must rely on concerted action by governments around the world, both within their own territories and in cooperation to address needs that require global action, such as on climate change.
90 Health promotion must recognize the limitations and opportunities available and integrate theoretical perspectives and practical actions in regard to one of its key areas: building health public policy.
91 Creating a supportive environment is even more wrapped up in the dynamics of global capitalism than all the other areas combined.
92 The fundamental prerequisites for health as outlined in the Ottawa Charter: peace shelter education food income a stable ecosystem sustainable resources social justice, equity
93 These are the elements that, when in adequate supply, make up many of the properties of a supportive environment for health. Each of these elements is in large part determined by the particular structure and dynamics of our global socioeconomic system.
94 Social theory and health promotion The public health community as a whole, and health promotion by proxy, is still dominated by the narrowly focused methodological lens of epidemiological science.
95 The categories of class and status tend to be conceptualized as epidemiological variables that measure an individual or group’s socioeconomic attributes or properties (e. g. income, education level, wealth, job status), not as social processes that reproduce structural disadvantages for most and accumulate power and privilege for a few.
96 The Health in All Policies Movement Hi. AP: a strategy to help link health and other policy sectors in an over-arching intersectoral approach to improving health and well-being and reducing health inequity
97 It is an attempt to reinvigorate the original emphasis in the Ottawa Charter on healthy public policy, and to follow up on the work done at the WHO conference in Adelaide.
98 Vertical intersectoral collaboration: levels of government, non-governmental and private sector Horizontal intersectoral collaboration: crossministry, inter-departmental
99 Complexity, context, and causality in health promotion research There has been some scepticism about applying the methodological protocols of evidence-based medicine (EBM) and RCTs as the gold standard because of the problems of complexity and context.
100 One emerging alternative has been to use different methods for synthesizing evidence, such as the realist or meta-narrative review approaches. One further potential for advancing beyond traditional EBM-type methods, is in the use of so-called ‘systems thinking’ or ‘complexity science’.
101 Realistic review: A model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging 'realist' approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how.
102 Meta-narrative review is one of an emerging menu of new approaches to qualitative and mixed-method systematic review. A metanarrative review seeks to illuminate a heterogeneous topic area by highlighting the contrasting and complementary ways in which researchers have studied the same or a similar topic.
103 Systems thinking is a management discipline that concerns an understanding of a system by examining the linkages and interactions between the components that comprise the entirety of that defined system.
104 Complexity science is the scientific study of complex systems, systems with many parts that interact to produce global behaviour that cannot easily be explained in terms of interactions between the individual constituent elements.
105 The realist alternative has a direct, philosophical critique of the underlying empiricist-positivism of EBM’s approach to causality.
106 Conversely, systems thinking and complexity science approaches are more concerned with EBM’s inability to take account of the interactive, emergent, and non-linear dynamics of causation that are crucial to understanding health promotion interventions as complex adaptive systems that intervene in the context of settings that are themselves complex adaptive systems.
107 The role of social media A key feature that differentiates social media from more traditional communication processes is its interactive nature, where communications are not a one-way process, and where users also play an active role.
108 This allows the formation of new online communities, which can enable virtual participation and collaboration among its members.
109 Social media is emerging as a key platform for the dissemination of preventive health information. There are risks too that social media platforms could be used as avenues of persuasion by industry and other players who have vested interests in promulgating specific points of view.
110 Social media can also be used as a tool to listen to a much wider range of individuals and groups within the community and internationally. This can balance the traditional, more topdown, nature of public health programming.
111 Social media provides a major platform for health advocacy and activism that could lead to the strengthening of community action, the transformation of personal skills, and draw attention to health issues arising from social inequalities.
112 Conclusion Health promotion finds its core values and principles in the Ottawa Charter which bears careful examination to comprehend the essence of health promotion.
113 The revolution in health education practice is directly connected to the birth of health promotion but beyond this, health promotion has its roots in the deep history of public health and has been invigorated by contemporary social movements.
114 Health promotion is fundamentally about ethics, values, and social justice. Only secondarily is it about technical strategies for behaviour change. The foundational principles of health promotion: equity, participation, and empowerment.
115 Health promotion is a professionally dominated movement. This requires health promotion professionals to be critical and reflexive in their practice. They must acknowledge power imbalances that favour professional dominance and work to restore power to individuals and communities.
116 Health promotion must take its duty to enable people to control the determinants of their health seriously. Health promotion must be aware of the dynamics of the global political economy and its effect on the potential for health promotion.
117 There are many barriers to realizing change in power relations; yet, there also very important opportunities, such as with the Millennium Development Goals and the Commission on the Social Determinants of Health, where there is an increasing clamour for action to redress health inequities through empowering processes.
118 Even the World Bank, often the subject of brutal criticism for exacerbating inequalities, has made significant moves toward recognizing the importance of reducing inequity in human development and has integrated an empowerment approach.
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