Health promotion as a key

strategy for better health –

essence, principles, development.
Nikolai Hristov, MD, PhD
Concept development
• This first publication of health promotion is from the 1974 Lalonde
report from the Government of Canada, which contained a health
promotion 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".
• Another predecessor of the definition was the 1979 Healthy
People report of the Surgeon General of the United States, which noted
that health promotion "seeks the development of community and
individual measures which can help... [people] to develop lifestyles that
can maintain and enhance the state of well-being".
Historical notes
• In year 1984 the World Health Organization (WHO) Regional Office for
Europe defined health promotion as "the process of enabling people to
increase control over, and to improve, their health". In addition to methods
to change lifestyles, the WHO Regional Office advocated "legislation, fiscal
measures, organisational change, community development and spontaneous
local activities against health hazards" as health promotion methods.
• In 1986, Jake Epp, Canadian Minister of National Health and Welfare,
released Achieving health for all: a framework for health promotion which
also came to be known as the "Epp report". This report defined the three
"mechanisms" of health promotion as "self-care"; "mutual aid, or the actions
people take to help each other cope"; and "healthy environments".
The Ottawa Charter
• 1st International Conference on Health Promotion, Ottawa, 1986, which
resulted in the "Ottawa Charter for Health Promotion". According to the
Ottawa Charter, health promotion: "is not just the responsibility of the
health sector, but goes beyond healthy life-styles to well-being"
• "aims at making... [political, economic, social, cultural, environmental,
behavioural and biological factors] favourable through advocacy for
health"
• "focuses on achieving equity in health"
• "demands coordinated action by all concerned: by governments, by
health and other social organizations.
A contested concept
• The concept of health promotion is essentially contested: it has a variety of
meanings and is thus used to describe a number of different activities—many
of which may be based on different philosophies. From the early 1980s, as the
concept of health promotion acquired wider currency, several different
individuals and organizations provided their own definitions and selectively
interpreted the term so that it matched their own agendas, philosophies, and
construction of reality.
• A number of influential publications by the United States Department of
Health, Education and Welfare (1978, 1979) and the Department of Health and
Human Services (1980) contrasted health promotion with 'health protection'
and 'preventive health services'. Health promotion was primarily viewed as
primary prevention and defined mainly in terms of individual lifestyle change.
The American approach
• Still others confused ideology with strategy and characterized health
promotion in terms of the use of vigorous—and sometimes frenetic—
media-centred programmes.
• The more sophisticated of these approaches drew on social marketing
theory for support, making the false assumption that 'marketing health'
was no different from marketing commercial products.
• Many professionals merely substituted 'health promotion' for the
particular variety of health education they had been accustomed to
practice. This has led to such anomalous and even oxymoronic notions
that individuals should be empowered so that they would comply with
medical recommendations.
Health promotion and the health field
• One of the more important influences on the development of health promotion
was a simple model popularized by the Lalonde Report on the health of Canadians
(Lalonde 1974) and described as the 'health field concept'. This simple 'map of
health territory' asserts that there are four main 'inputs' to individual health:
• genetic predisposition
• the health services
• individual behaviours and lifestyle
• environmental circumstances.
• Health promotion is typically involved with three of these inputs: it is concerned to
promote health by seeking to influence lifestyle, health services, and, above all,
environment.
The environment
• The health field concept has led to an increasing acceptance that environmental circumstances
constitute the most important of all the 'inputs' to health. The notion of environment refers to far
more than the physical circumstances in which people live, work, and play but incorporate social,
economic, and cultural dimensions.
• The various environmental influences may be health promoting or health damaging. Higher socio-
economic status is generally health promoting: lower socio-economic status generally militates
against good health. Major inequalities lead to feelings of helplessness and hopelessness; social
exclusion tends to reduce the potential for good health while social support is almost universally
health enhancing. Productive employment fosters good health while unemployment is pathogenic.
• Furthermore, although attempts to change cultural values and beliefs are problematic, the health-
damaging effects of some cultures are a major concern for health promotion. For example, the
culture associated with poverty is a major health hazard, as are those practices associated with the
general oppression of women together with more specific manifestations such as genital
mutilation.
Health education and the ascendancy of
prevention
• Health education is the predecessor of health promotion.
• Over a period of some 150 years, there occurred in 'developed' countries what might be described
as a rise, fall, and resurrection of public health. During this time three phenomena having special
significance for health education and health promotion were recorded. Firstly, there was a
substantial improvement in the health of the population (as measured by increased life expectancy
and a reduction in premature death); secondly, there was a general rise in living standards; thirdly,
the status, power, and cost of curative medicine were significantly enhanced. Health education has
figured at various stages in this 'public health career', if not in a lead then at least in a supportive
role.
• Some form of education (or, more accurately, 'propaganda') was present in the great days of the first
public health movement in the nineteenth century. Typically, this took the form of pamphleteering
and, what would now be called 'advocacy', for the implementation of various social and sanitary
reforms. Health education, however, emerged as a professional activity some time later and its
emergence paralleled an increasing disillusion with what many considered to be the failure of
curative medicine to fulfil its early promise.
The limitations of modern medicine
• Despite substantial developments in theoretical understanding and access to increasingly
sophisticated technologies, medicine failed to acquire the 'magic bullets‘ capable of curing the
'new generation' of chronic degenerative disease.
• The disappointing lack of success in curing disease had, nonetheless, been accompanied by both
increasing lay expectations of medicine—and by dramatically escalating cost.
• Moreover, curative pretensions were associated with an unacceptable level of iatrogenic disease
and, arguably, with a diminution of medicine's traditional caring function.
• Accordingly, it was asserted, that what might not be cured should be prevented. Furthermore,
since human behaviour is intimately implicated in the aetiology and management of preventable
disease, prevention could be achieved by the deployment of appropriate behaviour change
strategies.
• Education was, therefore, appropriated by preventive medicine in order to persuade people to
adopt lifestyles and behaviours that would prevent and simultaneously save money for an
increasingly budget-conscious health service.
Promotion and prevention
• Health education, then, became closely involved with preventive medicine. Its twofold task was
to prevent disease at primary, secondary, and tertiary levels and to promote the proper use of
medical services.
• In order to achieve these goals, it was expected to cajole or coerce people into adopting
lifestyles which, according to contemporary epidemiological wisdom, would prevent the onset
of any given disease. People should also be persuaded to use appropriate screening services to
detect precursor deviations from normality and asymptomatic disease. They should also learn
how to deal with signs and symptoms in an approved fashion, for example by presenting
treatable conditions to a medical practitioner at an early stage while accommodating to 'trivial'
or self-limiting conditions and/or subscribing to sensible self-medication.
• In addition to its secondary prevention function, health education also had a role in tertiary
prevention. This would include such measures as fostering compliance with medication in order
to prevent relapse and helping people readjust to normal life after having experienced some
disabling condition.
Health promotion and the WHO
• The preventive model described above has been subjected to sharp criticism
for a number of reasons. While the importance of preventing disease has not
been challenged, the traditional preventive approach to health education is
considered to be of very limited effectiveness. Moreover, its ideological
foundation—the values and assumptions about people and society on which
it is based—are considered to be inappropriate to a modern democratic
society. Accordingly, the present course adopts the definition of health
promotion developed by the World Health Organization (WHO) in its 'Health
for All' movement, of which health promotion could legitimately be called the
'militant wing'.
• It subscribes to the original conceptualization (WHO 1984) and to the
philosophy embodied in the seminal Ottawa Charter.
The 4 principles of the WHO
• Health is a positive state; it is an essential commodity which people
need in order to achieve a socially and economically productive life.
• Health is not just an individual responsibility. To seek to cajole
individuals into taking responsibility for their own health while
ignoring the social and environmental determinants of health is
fundamentally unethical.
• Substantial progress in health promotion depends on achieving equity
and rectifying inequalities in health within and between nations.
• The success of health promotion depends on the achievement of
individual and community empowerment.
The holistic perspective of the WHO
• The holistic definition of health enshrined in the WHO's constitution still
underpins current philosophy. It asserts that health is concerned with well
being and not merely the absence of disease. Its purpose is to make it
possible for people to achieve socially and economically productive lives.
While the definition has been criticized as vague and unworkable, the
reality of its existence and importance is regularly recognized by health
promotion workers who have to deal with the complexities of society and
human behaviours and their multifaceted influences on the clients they
are seeking to help.
• This holistic dimension is powerfully illustrated by the holistic formulation
of 'personhood' British Journal of General Practice (Sweeney 1998).
Personhood
• Includes personality and character; a past with life experiences that provide a
context for illness; a family with ties that may be positive or negative; a cultural
background; a variety of roles and relationships; a body and a self-image of that
body; a secret life of fears, desires, hopes, and fantasies; a perceived future
and... a transcendental dimension (that is some sort of life of the spirit, however
that is expressed). . . . [Each aspect of personhood is susceptible to injury and
damage, and ...this injury is what causes suffering. . . . Suffering can occur in
relation to any aspect of a person and it occurs when the person perceives his or
her impending destruction or disintegration. The sort of injuries that cause
suffering are the death and suffering of loved ones, powerlessness, helplessness,
hopelessness, the loss of a life's work, deep betrayal, isolation, homelessness,
memory failure, unremitting fear, and physical agony.
The pursuit of equity
• The importance of equity for the promotion of health is now almost
part of conventional wisdom.
• The primacy given by the WHO to the achievement of equity has
recently been reiterated and re-emphasized in the visionary strategy
Health for All in the Twenty-first Century (WHO 1998a).
• It asserts that: 'Equity underpins the concept of Health for All'.
• This is essentially 'a call for social justice' and 'requires the removal of
unfair and unjustified differences between individuals and groups'.
Empowerement
• The 'empowerment' of communities and individuals figures prominently in
WHO's lexicon of health promotion principles. Indeed, the capacity of
individuals to gain control over their lives and their health is often cited as
the single most important goal of health promotion. Apart from acquiring
control at an individual level, people should become actively involved in
fostering the health of their communities. Additionally, as part of the
related process of demedicalization, there should be a shift in the balance
of power between doctors and other health professionals and their clients.
• Co-operation and empowered patient choice should replace the traditional
emphasis on 'compliance'. Concern for human dignity, quality of life, and
quality of care should be central to the delivery of health services.
The essential strategies for success of the
WHO (Ottawa Charter – Jakarta Declaration)
• Build healthy public policy
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Reorient health services