Introduction to Health Promotion and

Population Health

Presentation by Irving Rootman to SFU Class on Principles and

Practices of Health Promotion

September 13, 2010

Purpose

To provide an introduction to health promotion and population health

Outline

1. Milestones in the development of health promotion and population health

2. Concepts and elements of health promotion and population health

3. Differences and commonalities between health promotion and population health

1. Milestones in health promotion and population health

Milestones

1974:

Health Field Concept (Lalonde, 1974)

Human biology

Environment

Lifestyle

Health care organization

Strategies (Lalonde, 1974)

Health promotion

Regulatory

Research

Health care efficiency

Goal setting

Milestones (Cont.)

1978: Health Promotion Directorate established

1984: Beyond Health Care Conference (Toronto)

Concept and Principles Document (WHO-EURO)

Definition of Health Promotion

“the process of enabling people to increase control over, and to improve, their health” (WHO-EURO, 1984)

Principles of Health Promotion (WHO-EURO, 1984)

Involves population as a whole

Acts on the determinants of health

Combines diverse approaches

Aims at public participation

Health professionals have enabling role

Milestones (Cont.)

1986: First International Conference

Ottawa Charter for Health Promotion (WHO)

Ottawa Charter: Pre-requisites for Health (WHO, 1986)

Peace...shelter....education...

Food...income

Stable eco-system

Sustainable resources

Social justice

Equity

Health Promotion Action Areas (WHO,1986)

Building healthy public policy

Creating supportive environments

Strengthening community action

Developing personal skills

Reorienting health services

Health Promotion Approaches(WHO, 1986)

Communication Education Legislation Fiscal Measures Organizational Change Community Development Spontaneous Local Activities

Epp, 1986

Milestones (Cont.)

1987: CIAR Population Health Program

1990: Determinants of Health Model (Evans and Stoddart)

(Evans and Stoddart, 1990)

Milestones (Cont.)

1994:

Milestones (Cont.)

1994: Health Promotion in Canada

(Pederson, O’Neill and Rootman)

Strategies for Population Health (FPT AC on Population Health)

Determinants of Health (FPT ACPH, 1994)

Income & social status Social support networks Education Employment & working conditions Physical environments Biology & genetic endowment Personal health practices & coping skills Healthy child development Health services

Strategic Directions (FPT ACPH, 1994)

strengthening public understanding of the determinants of health

building understanding of the determinants of health among sectors outside of health

developing comprehensive intersectoral population health initiatives

Milestones (Cont.)

1995: Health Promotion Directorate replaced by Population Health Directorate

1996: Population Health Promotion Workshop and Paper (Hamilton and Bhatti)

Action Statement for Health Promotion in Canada (CPHA)

Population Health Milestones

1998: Population Health-Putting Concepts into Action (Zollner and Lessof, 1998)

Strategies for putting population health into practice (Zollner and Lessof, 1998)

Leadership (securing a champion) Building partnerships across public sector Engaging private sector Putting public health to work Looking for evidence and monitoring success Making population health attractive Raising the stakes towards accountability

Population Health Milestones

1998: Population Health, Sustainable Development and Policy Futures (Hayes and Glouberman)

Conclusions regarding link between population health and sustainable development (Hays and Glouberman, 1998)

Major overlap between population health and sustainable development is connection between social sustainability and socio-economic influences on health

Must consider not only short-term, but also medium, and to some extent long-term goals and outcomes in creating health policy

Development of policy envelope that considers short, medium and long-term policy initiatives separately may be helpful

Milestones (Cont.)

1996: Establishment of Canadian Consortium for Health Promotion Research

1999: Publication of IUHPE Review on Effectiveness of Health Promotion (IUHPE, 1999)

2001: Publication of Evaluation in Health Promotion (Rootman et al., 2001)

Milestones (Cont.)

2005: 6th WHO Global Conference on Health Promotion

Bangkok Charter for Health Promotion

in a Globalized World

Required Actions by Bangkok Charter advocate for health based on human rights and solidarity

invest in sustainable policies, actions and infrastructure to address the determinants of health

build capacity for policy development, leadership, health promotion

practice, knowledge transfer and research, and health literacy regulate and legislate to ensure a high level of protection from harm

and enable equal opportunity for health and well-being for all people partner and build alliances with public, private, nongovernmental

and international organizations and civil society to create sustainable actions

Key Commitments of Bangkok Charter

To make the promotion of health:

1. Central to the global development agenda

2. A core responsibility for all of government

3. A key focus of communities and civil society

4. A requirement for good corporate practice

Milestones (Cont.)

2005: Federal Health Promotion Centre established in PHAC

2007: 19th IUHPE Global Conference on Health Promotion and Health

Education

Milestones (Cont.)

2008: Report of the WHO Commission on the Social Determinants of Health (CSDH, 2008).

CSDH Principles of Action1. Improve the conditions of daily life—the circumstances in which

people are born, grow, live work , and age

2. Tackle the inequitable distribution of power, money, and resources---the structural drivers of those conditions of daily life—globally, nationally and locally

3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health

(CSDH, 2008, p.2)

Milestones (Cont.)

2009: 7th Global Conference on Health Promotion (WHO)

Nairobi Call to Action

2010:

Questions? Comments?

2. Concepts and other elements of health promotion and population health

Key Concepts of Health Promotion

Health Health Promotion Empowerment Healthy Communities Determinants of Health Health Literacy Quality of Life

Definitions of “health”

“...a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO,1946)

The normal physical state, i.e. the state of being whole and free from physical and mental disease or pain, so that the parts of the body carry on their proper function" (Critchley, 1978, p. 784)

Definitions of Health (Cont.)

“the bodily, mental and social quality of life of people as determined in particular by psychological, societal, cultural and policy dimensions.” (Rootman and Raeburn, 1994)

Definitions of “health” (cont.)

“To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is therefore seen 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.” (WHO, 1986)

Well Being-Being Well Wheel, Circle of Change, 1998

Concept of health for health promotion in the 21st Century

“In the health promotion domain, health is equivalent to healthiness and is related to concepts of resilience and capacity. It refers primarily to mental and physical dimensions of healthiness, has strong experiential and social aspects, and is determined by many internal and external factors, including those of a personal, collective, environmental, political and global nature” (Rayburn and Rootman, 2007)

Definitions of health promotion

a strategy “aimed at informing, influencing and assisting both individuals and organizations so that they will accept more responsibility and be more active in matters affecting mental and physical health” (Lalonde, 1974)

“the implementation of efforts to foster improved health and well-being in all four domains of health” (physical, social, psychological and personal) (Perry and Jessor, 1985)

Definitions of health promotion (cont.)

“the maintenance and enhancement of existing levels of health through the implementation of effective programs, services, and policies” (Goodstadt, et al.,1987)

“the advancement of wellbeing and the avoidance of health risks by achieving optimal levels of the behavioral, societal, environmental and biomedicial determinants of health” (Kar, 1987)

Definitions of health promotion (cont.)

“the process of enabling people to increase control over, and to improve, their health: (WHO, 1984, 1986; Epp, 1986)

“the process of enabling [individuals and communities] to increase control over [the determinants of health] and [thereby] improve their health” (Nutbeam, 1985)

Definitions of Empowerment

“the mechanism by which people, organizations and communities gain mastery over their lives” (Rappaport, 1984)

“a process of helping people to assert control over the factors which affect their lives” (Gibson, 1991)

“where people are unambiguously in control and self-determining”(Raeburn & Rootman, 1998)

Psychological and Community Empowerment Psychological empowerment is “a feeling of greater

control over their own lives which individuals experience following active membership in in groups or organizations” (Rissel, 1994)

“Community empowerment includes a raised level of psychological empowerment among its members, a political action component in which members have actively participated, and the achievement of some redistribution of resources or decision-making favorable to the group or community in question” (Rissel,1994)

Community Empowerment Model (Rissel, 1994)

Healthy Communities “A healthy city is not a finished product created at one point in

time; it is a dynamic place where citizens and government have established relationships and processes that allow them to collaborate in tackling any problems that arise. The healthy city approach calls for collective action, in which all the sectors—local government as well as community, religious and other groups and individual citizens—work together for a common purpose.” (Duhl & Hancock, 1997).

A healthy community works to improve its environments and share its resources so that people can support each other in achieving their highest potential (World Health Organization, 1997)

A Healthy Communities approach integrates four key building

blocks: community involvement, intersectoral partnerships, political commitment and healthy public policy (BC Healthy Communities, 2006)

Determinants of health: definitions

“factors that enhance the health and well being of the overall population” (PFT ACPH, 1994)

The Mandala of Health, (Hancock and Perkins, 1985)

Social Determinants of Health

“ the high burden of illness responsible for appalling premature loss of life arises in large part because of conditions in which people are born, grow, live, work and age. In their turn, poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad policies” (CDOH, 2008, p.1)

Social Determinants of Health

“ The Commission focuses on the ‘causes of the causes’—the fundamental global and national structures of social hierarchy and the socially determined conditions these create in which people grow, work, live and age” (CSDH, 2008, p.42)

Social Determinants of Health

“Social determinants of health are the economic and social conditions that shape the health of individuals, communities and jurisdictions as a whole” (Raphael, 2009,p. 2)

Health Literacy “the cognitive and social skills which determine the motivation

and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health” (Nutbeam, 1998)

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (I.O.M., 2004)

The degree to which people are able to access, understand, appraise and communicate information to engage with the demands of different health contexts in order to promote and maintain good health across the life-course (B.C. Health Literacy Research Team, 2006)

Quality of Life

“The degree to which a person enjoys the important possibilities of his or her life” (Quality of Life Research Unit, 2006)

(Renwick, 2004)

(Renwick, 2004)

Integration of HP practice(Goodstadt, 1999)

Health promotion practice

should be guided by:Values

Determinants of health

Theory

Evidence

Health promotion action areas

Health promotion strategies

HEALTHPROM OTION

PRACTICE

INTEGRATION OF HEALTH PROMOTION PRACTICEMichael Goodstadt Ph.D., Centre for Health Promotion, University of Toronto, November 10, 1998

Theory

HPstrategies

Evidence

Values

Determ inantsof health

HP Actionareas

Health Promotion Values

Empowerment Participation Social Justice/Equity Respect Priority to common good Choice Positive health

Health Promotion Theories

Intrapersonal Health Behavior Models/Theories

Interpersonal Health Behaviour Models/Theories

Community and Group Intervention Models/Theories

Planning and Ecological Models/Theories

Health Promotion Action Areas (WHO,1986)

Building healthy public policy

Creating supportive environments

Strengthening community action

Developing personal skills

Reorienting health services

Health Promotion Approaches(Ottawa Charter, 1986)

Communication Education Legislation Fiscal Measures Organizational Change Community Development Spontaneous Local Activities

Ottawa Charter: Pre-requisites for Health (WHO, 1986)

Peace...shelter....education...

Food...income

Stable eco-system

Sustainable resources

Social justice

Equity

Determinants of health (FPT ACPH, 1994)

Income & social status Social support networks Education Employment & working conditions Physical environments Biology & genetic endowment Personal health practices & coping skills Healthy child development Health services

Health Promotion Evidence

Multi-source Multi-disciplinary Multi-approach Multi-methods

Ethical Issues in Health Promotion (McLeroy, et al.,1987)

Blaming the victim

Marketing health promotion

Determining whose side we are on

Tenets of Population Health (Frank, 1995)

1.The major determinants of human health status…are not medical care inputs and utilization, but cultural, social and economic factors—at both the population and individual levels

2.At the population level…societies in which there is both a high level and relatively equitable distribution of wealth enjoy a higher level of health status…

Tenets of Population Health (Frank, 1995)

3. At the individual level, one’s immediate social and economic environment and the way this environment interacts with one’s psychological resources and coping skills, has much more to do with the determination of health status than was recognized in early epidemiological studies of chronic disease etiology

4. Causal pathways…link the early childhood environment…to cardiovascular and other major illnesses and deaths health half a century later

Tenets of Population Health (Frank, 1995)

5.Extremely important that health policies take a broad multi-sectoral view…rather than focusing on the effective, efficient and equitable provision of health services alone

6.New research insights concerning the current determinants of health are more likely to come from a rich mix of interdisciplinary skills applied to human problems at both the individual and societal levels

Questions? Comments?

3. Differences and commonalities between health promotion and population health

3. Differences between Health Promotion and Population Health (Labonte, 1995)

Health Promotion: Questions economic

rationalism Draws from broad range of

social sciences Health is uncoupled from

disease Community focus Emphasis on Prerequisites

for health Bottom-up

Population Health: Espouses economic

rationalism Draws heavily from

economics Forces health back into

continuum with disease Population focus Emphasis on Determinants

of Health Top down

Commonalities between Health Promotion and Population Health (Labonte, 1995)

Health Promotion: Rejects professional

dominance

Explicitly concerned with values and a preferred future

Values citizen participation

Aims to increase people’s control over DOH

Focus is upstream Aim is health of people and

communities

Population Health: Challenges medical

professions privileged place in health sector

Moves epidemiology and health economics toward socio-economic focus

Values citizen participation

Recognize importance of control

Focus is upstream Aim is health of people and

populations

Population Health Framework (Hamilton and Bhatti, 1997)

Questions? Comments?