Public Health, Health Promotion & Population Health

Week 3 & 4: Sept. 19-30

Health Promotion Health Promotion “A process of

enabling people to increase control over and improve their health” (WHO, 1984)

Focuses on… Broader determinants of health Intersectoral approaches Environmental change Policy and organizational levels Outcomes such as “social conditions” Empowering individuals and changing

systems (Minkler, 1989)

“Change will demand the attention of all individuals, NGOs, business, communities, all levels of government and all sectors of our Canadian society. Success will require leadership from our prime minister and first ministers, from our mayors, municipal leaders, community leaders, and the leaders of our Aboriginal peoples. A whole-of-government approach is required with intersectoral action embracing business, volunteers, and community organizations. This will not be easy, but it can and must be done. We cannot afford to do otherwise.”

A Healthy, Productive Canada, Senate of Canada, 2009

INTERSECTORAL “The complexities of the social, political,

economic and environmental factors that influence health and inequities in health and the fact that most of these determinants lie outside of the exclusive jurisdiction of the health sector, necessitate working across sectors of government and society.”

Health equity through intersectoral action: An analysis of 18 case studies, PHAC and WHO, 2008

How has the field of health promotion evolved?

The Public Health Era (1827-1938)Medical Model (1944-1970s) Health Promotion Era

Lalonde, 1974 - “A New Perspective on the Health of Canadians” Alma Ata Declaration, 1978WHO adopts ‘Health for All by the Year 2000’,

1980s focus other health determining factors, particularly the environment

How has the field of health promotion evolved?

WHO, 1986 - Ottawa Charter for Health Promotion

Epp, 1986 - Achieving Health for All: A Framework for Health Promotion

Strategies for Population Health, 1994

Population Health Promotion Model 1996

How has the field of health promotion evolved?Themes of “Decentralization” &“Participation”

Integrated programs vs. sum of a number of small scale programs

Multiple goals and sectors

Active participation of both health and non-health sectors

consumer demandcommunity coalitions

Lalonde Report (1974)

“A New Perspective on the Health of Canadians” Lalonde, 1974

Term ‘health promotion’ used for the first time

Identified factors other than health care that contribute to health

No structural reform-health promotion added to the medical system

Led to lifestyle campaigns-healthy eating, seatbelt, impaired driving

Health Field Concept (1974)

Human Biology Lifestyles

EnvironmentOrganization of

Medical Care

Health

Health Promotion Touchstones

1978 - International Conference on Primary Health Care

Canada’s Health Promotion Directorate established

Declaration of Alma-Alta health is a human right gov’ts responsible for health of citizens people have a duty to participate in health

decisions

Health Promotion Touchstones 1980 -- WHO adopted Health for all by

the year 2000

Primary health care emphasis Broad definition of Health Values for health articulated

Health Promotion Touchstones 1986 -- First International Conference on

Health Promotion held in Ottawa

Ottawa Charter for Health Promotion as means towards “Health for All”

Ottawa Charter for Health Promotion, 1986What is the significance?

Defined health promotion as “the process of enabling people to increase control over and to improve their health”

Defined health as “a resource for everyday life”

Belief that the health sector alone cannot create health – intersectoral coordination

Ottawa Charter Five strategies for action:

build healthy public policy strengthen community action develop personal skills create supportive environments reorient health services

Prerequisites for Health Peace Shelter Education Food Income Stable ecosystem Sustainable resources Social justice and equity

Ottawa Charter for Health Promotion, 1986What is the significance?

2nd International Conference on Health Promotion, Adelaide Final Conference Statement

“Peace and social justice, nutritious food and clean water, a useful role in society and an adequate income, conservation of resources and the protection of the ecosystem, are prerequisites for health and social development. The vision of healthy public policy is for achievement of these fundamental conditions for healthy living.”

Achieving Health for All: A framework for health promotion 1986 - Jake Epp -- National Minister of

Health Companion document to the Ottawa

Charter Outlined realistic actions for

government

Epp Report “. . . We cannot invite people to assume

responsibility for their health and then turn around and fault them for illnesses and disabilities which are the outcome of wider social and economic circumstances.”

The Epp Report, 1986

Achieving Health for All, Epp 1986What is the significance?

Outlined realistic action for government Three challenges

Reduce inequities Increase prevention of disease Enhance coping

Health promotion mechanisms identified

Achieving Health for All Framework (Epp Paper)

Strategies for Population Health, 1994What is the significance?

First time “population health” term is used

The document Summarized the determinants of health Provided a framework to guide policy

development Gave strategic direction for cooperation

and action

The Determinants of Health Income & Social

Status Social Support

Networks Education Employment &

Working Conditions Physical

Environment Biology & Genetic

Endowment

Personal Health Practices & Coping Skills

Healthy Child Development

Health Services Gender Culture

Population Health & Health Promotion Created a rift between health promotion

and population health Population Health Promotion

Model

Primary Health Care Renewal Action for Healthier Nova Scotians – 2003 To improve health by a primary health care

system that is: Community-based, family-focused, person-centred Comprehensive Responsive & flexible Accessible Integrated, collaborative & innovative Accountable Sustainable

Bangkok Charter for Health Promotion in a globalized world, 2005 To complement &

build upon Ottawa Charter

Strategies Advocate Invest Build Capacity Regulate and

legislate Partner

Commitments to health for all

Make the promotion of health: Central to global

development agenda

Core responsibility for all government

Key focus of communities and civil societies

www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/print.html

Inequity or Inequality? Inequality

Refers to health differences that may be reduced but not eliminated; may be due to genetics or aging.

Inequity Refers to differences that are unfair and

preventable; action can be taken to reduce inequities

Stepping it Up, Health Council of Canada, 2010

Inequities in Health Status Does higher income

and social status provide a buffer or defence against disease?

Does lower income and social status undermine the body’s defenses?

Why Higher Income=Better Health?

Higher income improves ability to: purchase basic

needs such as housing & food

make more choices and feel more in control

Inequity and Illness www.unnaturalcauses.org Unnatural Causes: Is inequality making

us sick? Video series – brief online intro

Income & Social Status

Perceived Health Status 47% of Canadians in the lowest income bracket

rate their health as very good or excellent compared to 73% in the highest income group

Lower Income Canadians doubly worse off shorter life expectancies higher burden of ill health during shorter

lifetimes Compared with higher income groups, regardless

of their age, sex, race or place of residence

Income and Social Status Top 20% income bracket vs. bottom 20% Men

live 6 years longer expect 14 more years disability-free life

Women live 3 years longer expect 8 more years disability-free life

Costs of Poverty In 2005, overall poverty rate – 11% Canadians

BUT 26% lone-parent families; 21% work-limited; 19% recent immigrants; 17% off-reserve aboriginals

11.5% of children under 18 live in poverty OECD indicates rate in Canada is 15%

Lowest income quintile (working poor & on social assistance) rates of DM & CVD double those in the richest quintile

Income inequality growing in Canada over past 10 years Now higher than the OECD average

Health Care Costs of Health Inequity Saskatoon Study

Residents from lower SES areas use disproportionate levels of doctor, medication and hospital services Mainly due to higher prevalence of disease Consume 35% more health care resources than

higher income $179 million more than middle-income groups

Health Care Costs of Health Inequity Winnipeg study

Eliminating gap between richest & poorest neighbourhoods could reduce

Heart attacks by 22% Hip fractures by 20% Health care costs by $62 million in 1999 or 15% of

physician & hospital expenses

PHAC working on report on health status & health care cost by income level in Canada To be released in 2011

Economic Downturn:Coping strategies

Economy tops list of concerns (22%) Job security second (13%)

Cut household expenses Out-of-home entertainment (63%) Spend less for new clothes (55%) Switch to cheaper grocery brands (55%)

Eat at home more often now Breakfast (23%); Pack Lunch (26%); Dinner (39%)

Look for deals Only buy when on sale (44%); use coupons (23%);

stock up at sales (18%) Nielsen, 2009

Debt, Obesity, Food Access German study of household spending during

economic downturns People borrow to make ends meet

7.6% over-indebted (over 6 million people) Higher prevalence of overweight, obesity,

depression, tobacco use Authors noted

Depression could lead to increased food intake Eating offers compensation & gratification Less money may limit leisure & sporting activities

resulting in less energy expenditure Obesity might affect job prospects

Muster, et al., (in press), BMC Public Health

Social Support Networks Support from families, friends and

communities Believing that one is valued as a

provider of support for others in need Helps people solve problems, deal with

adversity and give them a sense of control

Results in feelings of satisfaction, well-being and comfort

Social Supports and Health Most NB health protecting feature is

perception of available support Quality more NB than quantity Importance placed on support networks

varies with situation Healthiest support relationship is

reciprocal

Connectedness & Health Review of 148 studies (n=300,000+) by

Brigham Young University on quality of life

Clear that stronger social relationships increased chance of survival by 50%

Effect consistent across age, sex, health status

Social Cohesion -- Roseto Effect Study showed a loss of social solidarity

mutual dependence

AND homogeneity (similarity due to common descent) led to more deaths from heart attacks

Education & Literacy Higher education = greater health More opportunities for jobs, job

security, and job satisfaction Improves the ability for individuals to

understand the information that will keep them healthy

Supporting Evidence self-rated health status activity limitations fewer workdays lost to illness or injury

Working Conditions

Variety of factors relate health to employment and working conditions

Underemployment and Overemployment Both issues of concern

Skills not being used Workers around after lay-offs typically have to

work harder or longer than in the past

Employment & Working Conditions People that have more control over their

working environment tend to have lower stress levels and often live longer

Supporting Evidence Between 1991-1995 the proportion of Canadian

Workers who were very satisfied with their work declined; Females = 58% 49%

Women aged 20-24 were most likely to report higher work stress than the average Canadian worker

Unemployment and Health Longer term unemployment

die prematurely suicide rates cardiovascular disease rates

Spouses and children of unemployed workers emotional and behavioral problems

Determinants & Obesity US study released Dec/2010 Poor women more likely to be obese Education level linked for both sexes

NCHS study, 2010

Physical Environments Natural Human-built

Housing and Health Children’s health

affected by overcrowded, poor-

quality housing

Children of low income families more likely to live

in poor-quality housing

Personal Health Practices Individual decisions

people make that directly affect their health

Healthy Child Development Prenatal & early childhood experiences key Child development greatly affected by housing,

neighborhood, family income, and level of parents‘ education, access to nutritious foods, physical recreation, genetic makeup and access to dental and medical care

Supporting Evidence Experiences from conception to 6 yrs have the most important

influence of any time on the life cycle on the connecting and sculpting of the brains neurons.

Gender Gender roles

defined by culture Sex-specific

difference in disease are biology based Impact of gender

NOT due to biology but to societal attitudes

Culture Whole complex of shared values, beliefs,

practices Binds people together Gives sense of who we are & where we belong Shapes our actions Supporting Evidence

Infant mortality rates among First Nations people between 1979 & 1994 were twice as high compared to the Canadian pop. as a whole

Culture How we interact with health care system Participation level in prevention and

health promotion programs Access to health information Health-related lifestyle choices Understanding of health and illness

Culture Determines much of our defn of food, its

symbolic meanings, uses, and the social context in which it is consumed or avoided

Culture is in dynamic interaction with biology, the physical environment, and other social and economic forces

David Himmelgreen, 2002, Nutritional Anthropology 25(1), 2-12.

Biology and Genetics Genetic endowment appears to predispose

certain individuals to a particular disease or health problem

Spirituality That which gives meaning to life Not solely based on religious beliefs Evidence

blood pressure control strengthened immune system coping with disease & death recovery & survival self-worth and self esteem

Health Services Health services, particularly those

designed to maintain and promote health, prevent disease, and to restore health and function contribute to population health

Supporting Evidence Disease & injury prevention activities in

areas such as immunization and mammography are showing positive results

Interrelated Determinants “Income is a determinant of health in itself,

but it is also a determinant of the quality of early life, education, employment and working conditions, and food security. Income is also a determinant of the quality of housing, the need for a social safety net, the experience of social exclusion, and the experience of unemployment and employment insecurity across the lifespan.”

Social Determinants of Health, Dennis Raphael, 2009

Population Health Underlying Assumptions Health determined by complex interactions Health of population closely linked to

distribution of wealth Strategies address entire range of

determinants Focusing on population leads to greater health

gains Improving health a shared responsibility

INTERSECTORAL Best practices for addressing poverty

point to a broad, integrated approach that engages community partners as well as all orders of government . . .

Reducing poverty: An action plan for Newfoundland and Labrador, 2006

Population Health Promotion ModelWhat is the significance?

Health Promotion is a process for enabling people to take control over & improve their healthPopulation Health addresses the relationship between the determinants of health & how determinants influence the health of entire populations

Population Health Promotion ModelWhat is the significance?

Integrates health promotion and population health

Uses sectors of population health, the determinants of health, and strategies from the Ottawa Charter to guide action

Who? What? How? Focuses on “whole populations” and “all

factors that determine health” Requires collaborative action

Tips for Better Health:Compare & Contrast

Don’t smoke Follow a balanced diet Be physically active Manage stress Drink alcohol in

moderation Cover up in the sun Practice safe sex

Don’t be poor Don’t have poor

parents Don’t work in stressful

low paid manual job Don’t live in damp, low

quality housing Be able to take vacation Don’t live next to a busy

highway

Hmmm . . . “. . . It is unacceptable for a wealthy

country such as Canada to continue to tolerate such disparities in health.”

Senate of Canada, 2009

Disease Prevention Primary Prevention

How to avoid disease Control of incidence

Secondary Prevention How to cure it Control of duration and hence prevalence

Tertiary Prevention How to appease it Control of further complications

What are the differences between health promotion and disease prevention?

Disease Prevention Health -absence of disease

& medical model Aimed at high-risk groups One-shot strategy Strategies focus on

individuals and groups Responsibility of health

professionals

Health Promotion Health – positive and

multi-dimensional concept & participatory model of health

Aimed at total population in it’s environment

Many strategies and sectors

What are the differences between health promotion and disease prevention?

Disease PreventionLanguage focus – deficitsGoal – problem preventionPeople as problemsEurocentricStrategy – program, contentExternal controlPhilosophy – controlMeets bureaucratic needsFeelings despair

Health PromotionLanguage focus – assets,

strengthsGoal – healthy development People as resourcesMulticultural, inclusiveStrategy – people, placesInternal controlMeets peoples’ needsFeelings hope, motivation

Population Health & Health Promotion: Conceptual Differences

Population Health Conceptual framework for

action and understanding Gone political – links to

economy & productivity Influence agenda of policy

and decision makers Focus on epidemiology &

physiological processes to quantify determinants of health

Health Promotion Focus on action –

strategies for health Health ‘for the sake of’

health Grassroots, community

oriented action Focus on qualitative or

self-perceived indicators of health

Health promotion vs. Disease prevention

Tensions between two are NOT irreconcilable

Needs reorientation of planners of top-down programs

Systematically consider community empowerment goals within planning framework To “unpack” health promotion at each stage

of planning, implementation, evaluationLavarack, & Labonte, 2000, Health Policy and Planning, 15 (3), 255-262.

Key Differences between down-stream and up-stream approaches

Down-stream Up-StreamRoot/metaphor

Approach/ orientation

Defn of Problem

Main methods to effect change

Role of outside agents

Key Differences between down-stream and up-stream approaches Lavarack, & Labonte, 2000

Main decision makers

Community control of resources

Community ownership

evaluation

Health Promotion Strategies

Health promotion strategies used in community nutrition…

(Obert, 1986 in Davis, 1989)

Policy/ Legislation

Advocacy

Environmental MeasuresHealth

Education

Mass Comm./ Social

Marketing

Self-help / Mutual Aid

Comm. Organization

Economic Support

What is Public Health? Protect & restore health through

application of science, practical skills & collective actions.

Scope includes Infectious diseases Chronic diseases Accidents

What is Public Health? Looks at person BEFORE he/she becomes a patient – Upstream

Approach

Strategies focused on: Health promotion

optimal health

Health protection exposure to known contaminants

Disease/accident prevention risk of chronic disease/disability/accidents

Surveillance and data systems patterns of behaviours/attitudes

Public Health & Community Nutrition Assesses needs Plans, organizes, manages, directs,

coordinates & evaluates nt services Establishes linkages

Public Health & Community Nutrition Art & science of promoting population health

status via sustainable & equitable improvements in the food & nutrition system

Based on public health principles comprehensive and collaborative activities inter-sectoral in scope

Public Nutrition Roots: food insecurity & malnutrition in

developing countries Developed countries: slow progress to

improve nutrition of large population segments obesity, diabetes, CVD, nutrition related

cancers, food insecurity Address population not individual levels

Population Health & Public Nutrition

Population Health Approach

Public Nutrition Approach

Focus on the health of population

Focus on the nutrition of populations

Address the determinants of health and their interactions

Address the determinants of nutrition and their interactions

Demonstrate accountability for health outcomes

Demonstrate accountability for nutrition outcomes