HEALTH PROMOTION IN CANADA
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HEALTH PROMOTION IN CANADA CRITICAL PERSPECTIVES
SECOND EDITION
EDITED BY
MICHEL O’NEILL ANN PEDERSON SOPHIE DUPÉRÉ IRVING ROOTMAN
Canadian Scholars’ Press Inc. Toronto
Some images and text in the printed version of this book are not available for inclusion in the eBook.
Health Promotion in Canada: Critical Perspectives Second Edition edited by Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman First published in 2007 by Canadian Scholars’ Press Inc. 180 Bloor Street West, Suite 801 Toronto, Ontario M5S 2V6 www.cspi.org Copyright © 2007 Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman, the contributing authors, and Canadian Scholars’ Press Inc. All rights reserved. No part of this publication may be photocopied, reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, or otherwise, without the written permission of Canadian Scholars’ Press Inc., except for brief passages quoted for review purposes. In the case of photocopying, a licence may be obtained from Access Copyright: One Yonge Street, Suite 1900, Toronto, Ontario, M5E 1E5, (416) 868-1620, fax (416) 868-1621, toll-free 1-800-893-5777, www.accesscopyright.ca. Every reasonable effort has been made to identify copyright holders. CSPI would be pleased to have any errors or omissions brought to its attention.
Canadian Scholars’ Press Inc. gratefully acknowledges financial support for our publishing activities from the Government of Canada through the Book Publishing Industry Development Program (BPIDP).
Library and Archives Canada Cataloguing in Publication Health promotion in Canada : critical perspectives / edited by Michel O’Neill ... [et al.]. — 2nd ed. Includes bibliographical references and index. isbn 978-1-55130-325-3 1. Health promotion—Canada—Textbooks. I. O’Neill, Michel, 1951– ra427.8.h45 2007
613'.0971
07 08 09 10 11
c2007-901472-0 5 4 3 2 1
Cover art: “Happy Friends (children)” © Daniela Andreea Spyropoulos. From www.istockphoto.com. Cover design, interior design and layout: Susan MacGregor/Digital Zone Printed and bound in Canada by Marquis Book Printing Inc.
During the course of the year that we spent working together on this book, the circle of life continued to touch our lives. Each of us would like to honour the past and celebrate the future by dedicating this book to the memory or new life of people near and dear to us. Michel would like to honour Laurent Pauzé-Dupuis, who passed away in Beijing on April 3, 2006, and was the best friend of Sébastien Couchesne-O’Neill, his son, to whom he wishes a great journey in his future life as a scholar and sociologist. Ann would like to celebrate the birth of Nicholas Good, her grandson, on October 31, 2005, and to remember the passing of her mother-in-law, Marion Spruston, on February 18, 2006. Irv would like to express joy for the birth of his first grandson, Tobyn Rootman, on September 23, 2005, and to acknowledge the passing of his uncle, Sam Rootman, on February 10, 2006, and his son David’s fiancé, Zoey Quarter, on December 6, 2006. Sophie would like to dedicate this book to the memory of her grandfather, Jacques Champagne, who died on March 22, 2006, and whose passion and dedication to his family and work has always been a great source of inspiration for her.
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TA B L E O F C O N T E N T S
Acknowledgements ...........................................................................................x Foreword: Health Promotion in Canada and the 19th World Conference of the International Union of Health Promotion and Health Education ................xiii Marcia Hills and David McQueen Chapter 1: Introduction: An Evolution in Perspectives ..........................................1 Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman
PART I: CONCEPTUAL PERSPECTIVES ...................................17 Chapter 2: A New Appraisal of the Concept of Health ........................................19 John Raeburn and Irving Rootman Chapter 3: The Promotion of Health or Health Promotion? ................................32 Michel O’Neill and Alison Stirling Chapter 4: Points of Intervention in Health Promotion Practice ...........................46 Katherine L. Frohlich and Blake Poland Chapter 5: Health Literacy: A New Frontier.......................................................61 Irving Rootman, Jim Frankish, and Margot Kaszap Chapter 6: Addressing Diversity in Health Promotion: Implications of Women’s Health and Intersectional Theory .......................................................................75 Colleen Reid, Ann Pederson, and Sophie Dupéré
PART II: NATIONAL PERSPECTIVES .........................................91 Chapter 7: The Federal Role in Health Promotion: Under the Radar....................92 Lavada Pinder Chapter 8: Addressing Health Inequalities in Canada: Little Attention, Inadequate Action, Limited Success....................................................................................106 Dennis Raphael Chapter 9: Developing Knowledge for Health Promotion ..................................123 Irving Rootman, Suzanne Jackson, and Marcia Hills vii
PART III: PROVINCIAL PERSPECTIVES ..................................139 Chapter 10: Health Promotion Program Resilience and Policy Trajectories: A Comparison of Three Provinces ....................................................................141 Nicole F. Bernier Chapter 11: 12 Canadian Portraits: Health Promotion in the Provinces and Territories, 1994–2006 ......................................................................................153 Ann Pederson
PART IV: INTERNATIONAL PERSPECTIVES ........................205 Chapter 12: Promoting Health in a Globalizing World: The Biggest Challenge of All? ..........................................................................207 Ronald Labonté Chapter 13: Canada’s Role in International Health Promotion............................222 Suzanne F. Jackson, Valéry Ridde, Helene Valentini, and Natalie Gierman Chapter 14: The Impact of Canada on the Global Infrastructure for Health Promotion.......................................................................................237 Maurice B. Mittelmark, Maria Teresa Cerqueira, J. Hope Corbin, and Marie-Claude Lamarre Chapter 15: Views on the International Influence of Canadian Health Promotion............................................................................................247 Sophie Dupéré
PART V: PRACTICAL PERSPECTIVES ......................................299 Chapter 16: The Reflexive Practitioner in Health Promotion: From Reflection to Reflexivity ..........................................................................301 Marie Boutilier and Robin Mason Chapter 17: Building and Implementing Ecological Health Promotion Interventions ...................................................................................................317 Lucie Richard and Lise Gauvin Chapter 18: Health Promotion and Health Professions in Canada: Toward a Shared Vision ...................................................................................330 Marcia Hills, Simon Carroll, and Ardene Vollman Chapter 19: Two Roles of Evaluation in Transforming Health Promotion Practice ..........................................................................................347 Louise Potvin and Carmelle Goldberg
PART VI: CONCLUDING THOUGHTS ......................................361 Chapter 20: Health Promotion: Not a Tree But a Rhizome.................................363 Ilona Kickbusch Chapter 21: Has the Individual Vanished from Canadian Health Promotion? ..........................................................................................367 Gaston Godin Chapter 22: Conclusion: The Rhizome and the Tree ..........................................371 Sophie Dupéré, Valéry Ridde, Simon Carroll, Michel O’Neill, Irving Rootman, and Ann Pederson Copyright Acknowledgements .......................................................................389 Index ..............................................................................................................392
AC K N OW L E D G E M E N T S
s was our experience in preparing the first edition, the enthusiasm of the contributors— who numbered over 60 people this time as compared to 25 in 1994—has supported and inspired us throughout the process of putting the book together. We think this support for our project reflects the co-operative culture of health promotion as well as individual contributors’ personal commitment to the field of health promotion. Key ideas for our own analyses emerged through our interactions with all the contributors; however, we are especially grateful to the country and the provincial contributors whom we forced to work within tight space constraints so we could maximize the number of perspectives provided. Everybody worked graciously within tight deadlines and we are also very grateful about that, knowing how everybody is overextended these days. We have released a version of this book in French and would like to release versions in other languages as another way of nurturing the exchanges and alliances we think are so important for the evolution of the field beyond our traditional boundaries within Canada and abroad. We therefore thank CSPI whose enthusiasm and professionalism was as great as if they had been one of our authors, particularly publisher Jack Wayne, who facilitated publication in other languages, and managing editor Megan Mueller with whom we have had an extremely rewarding partnership. We also extend our thanks to the Faculté des sciences infirmières de l’Université Laval, and especially to Carole Laverdière, for providing much appreciated support for many of the operational aspects of the book; to the Réseau de recherché en santé des populations du Québec, which helped the publication through a grant in its scholarly publications program; to the British Columbia Centre of Excellence for Women’s Health for providing support to Ann Pederson’s involvement with this project; and to the Michael Smith Foundation for Health Research for its financial support of Irv Rootman based at the Centre for Community Health Promotion Research at the University of Victoria through a Distinguished Scholar Award. We would also like to thank the two external reviewers who provided us with feedback on the draft manuscript and the large group of reviewers who commented on the first edition; all the feedback has helped us to reflect more critically upon our work and we trust it has improved the quality of the final product. Thanks also to Karine Aubin, Aïssata Moussa-Abba, and Samira Dahi, all doctoral students in the community health program at Laval University, who played a variety of crucial roles in finalizing the manuscript. Finally, we would like to thank our families and friends from whom we borrowed time to complete this book, particularly Francine Courchesne, Barry Spruston, and Barb Rootman.
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A NOTE ABOUT THE FRENCH VERSION Une version française de cet ouvrage est disponsible aux Presses de l’Université Laval, à Québec, intitulée «La promotion de la santé au Canada et au Québec, perspectives critiques» sous la direction de Michel O’Neill, Sophie Dupéré, Ann Pederson, et Irving Rootman. On peut la commander au [http://www.pulaval.com/index.html].
A NOTE FROM THE PUBLISHER Thank you for selecting the second edition of Health Promotion in Canada: Critical Perspectives. The publisher has devoted considerable time and careful development (including meticulous peer reviews at proposal phase and first draft) to this book. We appreciate your recognition of this effort and accomplishment.
TEACHING FEATURES This volume distinguishes itself in several ways. One key feature is the book’s well-written and comprehensive part openers, which add cohesion to the section and to the whole book. The contributors have added pedagogy, including questions for critical thought, annotated further readings, and annotated related Web sites. There are also figures, tables, and boxed inserts throughout the book.
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F O R E WO R D
H E A LT H P RO M OT I O N I N C A N A DA A N D T H E 1 9 T H WO R L D C O N F E R E N C E O F T H E I N T E R N AT I O N A L U N I O N O F H E A LT H P RO M OT I O N A N D H E A LT H E D U C AT I O N Marcia Hills and David McQueen he editors of this book are to be congratulated on revisiting the theme of health promotion in the Canadian context, following up on the successful first edition of the book. This new edition promises to have an even greater impact on the field than the first, given that this is no mere update, but an entirely original set of chapters that push the boundaries of thinking and reflection on health promotion’s place in Canada and Canada’s influence internationally on health promotion. It also arrives on the international health promotion scene at a critical juncture when a resurgence of interest in the social determinants of health presents a great opportunity, but also a great challenge for the future of the field. It will enter the public sphere just at the time that Canada hosts in Vancouver, in June 2007, the 19th World Conference of the International Union of Health Promotion and Education (IUHPE). As co-chairs of the scientific program of the 19th World Conference, we recognize that the questions raised by this book have helped to shape this event, will guide future directions in the field, and are likely to contribute greatly to the crucial discussions raised in Vancouver. The book offers a superb retrospective survey of where health promotion in Canada has travelled in the last decade or so, both at the federal level and in each of the provinces. Readers will learn much about the wax and wane of health promotion’s prospects in the Canadian context and international readers will find these important reflections informative for their own struggles to advocate for policy change and to improve practice in their respective countries. While the latter excellent set of reflections is what a reader might expect of a new edition of a book that did such a good job the first time around, a pleasant surprise awaits in the very substantial new contributions the book makes to strengthening and informing health promotion practice with fresh theoretical perspectives. It is particularly impressive that many of the chapter authors have managed to take up this emerging concern with theory’s role in health promotion and what particular theoretical perspectives might offer for the future of health promotion research, policy, and practice. An innovative addition has been made to one of the original book’s strengths in including international perspectives on Canada’s role in health promotion globally. In the first edition, one of the authors of this foreword (McQueen) was an international contributor, along with two other authors (Larry Green and John Raeburn). The editors have obviously felt that this international perspective needed to be broadened, particularly in expanding beyond the narrow confines of the Anglo-Saxon world (the US and New
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Zealand) and have managed to fashion a much larger section that includes a true diversity of global perspectives on Canada’s role in health promotion. This is a welcome addition that reflects health promotion’s important recent efforts to move beyond a Eurocentric and Western bias in its priorities and concerns as, for instance, in IUHPE’s global program on the effectiveness of health promotion in which both of us are deeply involved. Another innovation that deserves praise and credit is the decision by the original editors to bring in Sophie Dupéré as a fourth editor, signalling an effort to include the emerging leadership in the field and to reflect this inclusion with several substantive contributions from younger authors. This explicit strategy is very important as it addresses a reflection by many senior people in the field that health promotion needs to do a better job in allowing the next generation of health promoters to develop and flourish as the originators of the field pass on the torch in the long-distance struggle to impact systemic change. In conclusion, if the contents of this substantial and insightful book are any indication of where health promotion is moving, then we can be reassured that the field will meet many challenging obstacles, yet has an equally great potential to progress and to further the promotion of health. Once again, this edition shows why Canada has had such an important role to play in the development of health promotion globally and we are convinced that IUHPE’s world conference in Vancouver will be another very significant opportunity to actualize this interface.
CHAPTER 1
I N T RO D U C T I O N : A N E VO L U T I O N I N P E R S P E C T I V E S Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman
he first edition of this book was released in 1994, 20 years after the Lalonde Report, under the title, Health Promotion in Canada: Provincial, National, and International Perspectives. In that book we looked with a critical eye at health promotion in Canada over those 20 years, particularly the period following the release of the Ottawa Charter for Health Promotion in 1986. Today, more than a decade later, we are aware that Canada continues to be regarded as a powerhouse of health promotion around the world. As researchers, students, and practitioners, we want to understand and document what has happened over the last 10–12 years with respect to the evolution of health promotion in Canada, as well as to understand Canada’s role within the field internationally. Accordingly, in contrast to many other books in this field, this book is not a “how-to” book in health promotion, explaining how to develop and/or evaluate effective interventions (e.g., programs, policies, and so on), but rather a book on health promotion as it is practised in Canada and how what happens in Canada links to what is happening throughout the rest of the world. In this introductory chapter, we therefore want to accomplish three things. First, we want to remind the reader of the general evolution of health promotion as a field, internationally and in Canada, using elements from several chapters that appeared in the first edition of the book but do not appear in the second. As we will see—though it may sur-
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prise people who are unaccustomed to thinking of Canada as playing important roles on the global scene—international and Canadian developments in health promotion are closely intertwined. Canada has been—and still is— perceived as an important, if not the leading, country for the development of the field worldwide (though we will argue that this is sometimes for the right and sometimes for the wrong reasons). Second, we want to explain the aim of the first edition of the book and what we achieved. Together, these two elements will frame our third goal, the explanation of the aims of this second edition. Some dates and events will be constantly referred to in the rest of the book; these are the often-recited litany of the main milestones of the field here in Canada and abroad. We want to enunciate these landmarks at this point so the reader has the entire context and story correct at the beginning: 1951, the year of the foundation and the first global conference of the International Union of Health Education (IUHE), sending the signal that health education, as both a professional and scientific endeavour, was sufficiently mature to create its own international organization; 1974, when A New Perspective on the Health of Canadians (the famous Lalonde Report) was released; 1979, the year the World Health Assembly adopted its “Health for All by the Year 2000” resolution as a follow-up to the Alma-Ata conference on Primary Health Care, which had been held the year before; 1986, the year of the 1
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first World Health Organization (WHO) International conference on health promotion, held in Ottawa, at which two major documents were released: an international one (the Ottawa Charter for Health Promotion) and a Canadian one (Achieving Health for All, also known as the Epp Report); 1994, which turned out to be the watershed year between health promotion and population health in Canada when two influential books were published: the first edition of this book (Pederson, O’Neill, & Rootman, 1994) and Why Are Some People Healthy and Others Not? (Evans, Barer, & Marmor, 1996); and, finally, 2007, the year in which the health promotion world will come back to Canada, this time in Vancouver, for the 19th global conference of the International Union for Health Promotion and Health Education (IUHPE) and which we think is the year in which the timid renewal of commitment to health promotion that we observed in Canada over the last two or three years will either flourish or vanish. We will return to these dates and events in the discussion that follows, positioning them within three broad time periods: the years prior to the Lalonde Report of 1974; 1974–1994, which was the period covered by the first edition of our book; and 1994–2007, the period covered by this second edition.
BEFORE 1974: THE HEALTH EDUC ATION ERA In the first edition of the book, Robin Badgley (1994) traced the various types of activities and programs undertaken by the public authorities of Canada (be they local, provincial, or federal), from the early 1600s through to the middle of the 19th century, to promote the health of the “colony’s” population. He argued that, “for a period of some 250 years, a regulatory philosophy was the main means by which government sought to protect and
modify the health of Canadians” (Badgley, 1994, p. 21). According to him, the “dissemination of sanitary information” became an important concern in the 1880s for the provincial, and newly established federal government (following the British North America Act of 1867), but this was in a context in which the need for this information was “[…] so apparent to everybody as not to need proof” (Badgley, 1994, p. 22). This missionary zeal among sanitary reformers dominated the field for several decades, up to the end of World War II. The production of pamphlets and posters, the writing of books and newspaper columns, as well as, later, the production of film strips and the broadcast of radio messages, occupied most of the time, energy, and resources at the central levels, with scarce public health personnel relaying this information in one-to-one or small group situations at the local level. According to Badgley, very little interest was devoted to scientifically grounding or evaluating these activities. Similar developments were underway in most industrialized countries (e.g., see Green and Kreuter [1999] for a discussion of developments in the United States), and it was only in the late 1940s and early 1950s that a more systematic and scientific approach to educating the public on health matters began to emerge. In 1951, in response to the need to link together those working on health education and to promote the exchange of experience and information on these new ways of working, a group of European and North American public health people, under the leadership of two Frenchmen, Léo Parisot and Lucien Viborel, created in Paris what was to become the most important international non-governmental organization in the field: the International Union for Health Education (Modolo & Mamon, 2001). From then until the mid-1970s, in the industrialized world the dissemination of
INTRODUCTION: An Evolution in Perspectives ■ 3
health education information was increasingly targeted toward the professional–patient encounter (primarily the doctor–patient relationship) to make sure that the patient understood and used the information provided. The general public also became the target of the campaigns of health education specialists, initially in order to encourage the proper use of the health services (especially preventive ones) governments were establishing in the post-World War II welfare state era. Over time, it became clear that an epidemiological pattern of so-called “diseases of civilization” was rapidly displacing the earlier pattern of infectious disease in industrialized countries. When it was observed that the risk factors for these new sources of mortality (e.g., cardiovascular diseases, cancers, accidents) were largely behavioural, these “at-risk” behaviours themselves (e.g., smoking, sedentary lifestyles, eating habits, etc.) became the prime targets of health education. What also distinguished this era from the pre-1950s period was a conscious and sustained effort to ground health education interventions scientifically and to recruit other kinds of scholars and practitioners besides health personnel in this task. The 1950s and 1960s thus witnessed the increasing involvement of social scientists (mostly social psychologists and sociologists) and communication specialists in the development of models to try to understand and predict health-related behaviour and/or in the design of health education campaigns. These scientific developments largely occurred in the United States, which did not undergo the post-war reconstruction of the European nations and thus had greater resources available for such purposes. It was during this period, for instance, that the famous Health Belief Model (Becker, 1974), the first of a long series of theoretical models of individual health behaviour, was conceived at the Johns
Hopkins School of Hygiene and Public Health in Baltimore. These developments gradually seeped into the day-to-day practice of health educators in Canada, as elsewhere (Badgley, 1994), and were reflected in programs, manuals (e.g., Gilbert, 1963), and the training of personnel. These practices were built upon a deeply rooted, virtually unquestioned belief that educating the public was intrinsically good; the hope was therefore that health would improve with the help of science and a more systematic way of conducting health education. All this occurred, however, in a context in which public health and health education services, which were almost the only type of health-related governmental intervention up to the 1950s, were quickly dwarfed and eventually marginalized as the governments of Western industrialized societies became heavily involved in establishing public acute medical care systems (Gilbert, 1967).
1974–1994: FROM HEALTH EDUC ATION TO HEALTH PROMOTION It became increasingly obvious during the 1970s that health education was not having the desired effects, and that individuals, though better informed, did not necessarily adopt the healthful behaviours expected of them. A series of events resulted in significant revision to the way health education had been conceived up to that point and led to its transformation into health promotion.
The International Scene Internationally, the mid-1970s marked the end of 30 years—often called the “glorious thirties”—of sustained growth within the Western post-war economies. This economic situation allowed the “welfare state” to flourish in the
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1950s and 1960s. In Canada, as in most Western countries (with the notable exception of the US, which never established the same level of welfare state infrastructure), governments were sufficiently wealthy to become involved in insuring the welfare of their populations through the direct or indirect provision of services to fulfill basic needs, notably in the sectors of health and education. However, a major reorganization of the world economy, triggered by the so-called “oil shocks” of 1973 and 1976, completely changed this picture. The “glorious thirties” were followed by 20 gloomy years of economic stagnation or minimal growth within the Western economies, which deprived governments of taxation revenues and forced them to borrow heavily to maintain the level of public services they had committed to provide to their populations.
It was in this context that the Lalonde Report, released in 1974, received immediate worldwide attention because it was the first document by the central government of a major developed country advocating for the importance of investing resources beyond health services for the health of populations (Lalonde, 1974). As seen in Box 1.1, the “health field concept,” introduced in A New Perspective on the Health of Canadians, identified four sets of factors—later to be called “determinants of health”—that contributed to the health of populations. In contrast to all or so, the report made the novel suggestion that governments stop investing solely in providing more acute care services and instead seriously consider addressing the three other sets of factors through a “health promotion” approach.
BOX 1.1: ELEMENTS OF THE HEALTH FIELD CONCEPT
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In the following months and years, given the macro-economic context alluded to above but seldom made explicit, almost every Western industrialized country produced its own version of the Lalonde Report, encouraging investment in areas other than health systems, which were increasingly difficult to finance through public monies. This context also produced a major international expert conference in 1978, co-sponsored by two UN agencies (WHO and UNICEF), at which delegates proposed that the world stop investing in costly acute care systems, recognizing that after more than 30 years, such systems had not yielded the expected results
in the developed world and had been almost irrelevant for the developing world. The Alma-Ata conference thus suggested a return to the basics—to “Primary Heath Care” (PHC) and to address the set of issues described in Table 1.1. In response to these recommendations, and mindful of the economic context, the ministers of health of most countries of the world gathered in what is called the World Health Assembly (the supreme decision-making body of the World Health Organization), and voted in 1979 for the famous “Health for All by the Year 2000” (HFA) resolution, which proposed a set of measures in keeping with the
INTRODUCTION: An Evolution in Perspectives ■ 5 TABLE 1.1: PRIMARY HEALTH CARE AS DEFINED IN THE ALMA-ATA DECLARATION
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spirit of the Lalonde Report and the Alma-Ata declaration. These measures were further operationalized in a global strategy in 1981 (see Box 1.2).
The Canadian–European Connection The events that took place in Canada from the release of the Lalonde Report to the proclamation of the Ottawa Charter are very well described and analyzed by Lavada Pinder in Chapter 7 in this book, so we will not reproduce them here. What we will highlight, however, is the central role Canada
played in the international developments that followed the HFA resolution of WHO. Ilona Kickbusch, then chief officer of Health Education at the European division of the World Health Organization (WHOEuro) based in Copenhagen, has described a chain of events that began with the implementation of HFA in Europe in the early 1980s and ultimately led to the transformation of Health Education into Health Promotion (Kickbusch, 1986, 1994). Aware that many of the concerns articulated by PHC and HFA (access to clean water, basic immunization of populations, etc.) were
6 ■ HEALTH PROMOTION IN CANADA BOX 1.2: W H O G L O B A L S T R AT E G Y F O R H E A LT H F O R A L L BY THE YEAR 2000
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largely irrelevant in Europe and that health education was the key strategy to address, Kickbusch and her European colleagues toured the world and came to North America. In the US, they looked at the developments
in health education and self-help whereas in Canada they examined the implementation of the Lalonde Report. It was quickly apparent that Canada’s social-democratic political climate was more compatible with Europe
INTRODUCTION: An Evolution in Perspectives ■ 7
than the neo-conservative one that had already begun to take hold in the US (Kickbusch, 1994). A very close collaboration with a few Canadian individuals and institutions was then established, which led to the production by the European Office of WHO of the “Yellow document” on health promotion (WHO-Euro, 1984) and ultimately to
the First International Conference on Health Promotion held in Ottawa in 1986. A key outcome of this collaboration was to demonstrate the importance of environmental factors in health, which—although identified by the Lalonde Report—had received only limited attention in Canada (Labonté & Penfold, 1981) and elsewhere.
F I G U R E 1 . 1 : N E W P U B L I C H E A LT H F O R C E F I E L D
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The health education community had already begun to articulate its own internal critique during the second half of the 1970s (Brown & Margo, 1978; Freudenberg, 1978), conscious that providing health information alone and focusing on individual behaviour could lead to “blaming the victim” for its health problems (Ryan, 1976). Critics charged that changing the environment should become as much a concern for health education as changing individual behaviour if it was to ensure, as Nancy Milio (1986) famously said it, that the “healthiest choice became the easiest choice.” Environments had to become supportive of, rather than barriers to, individual changes. To signal this evolution from a traditional, individually focused health education, the words “health promotion” were key in the ecological, multi-level models that emerged in 1986 following the years of collaboration between Canada and WHOEuro. These models paid particular attention to environmental factors without dismissing the others. This is clear in Kickbusch’s own work (1986) (see Figure 1.1), in the Ottawa Charter (WHO, 1986) (see Figure 1.2), which was the international consensus emerging out of the first international conference, as well as in the Canadian document Achieving Health for All (Epp, 1986) that was launched then (and which is discussed in greater detail in Pinder’s chapter).
1986–1994: The Golden Era of Health Promotion After 1986, health promotion received significant international attention. Following the development of the European program, its main international champion, Ilona Kickbusch, was moved to WHO headquarters in Geneva to develop a global health promotion strategy. The second and the third
international Health Promotion Conferences, aimed at better understanding two of the strategies proposed in the Ottawa Charter— healthy public policy and creating supportive environments—were held in Adelaide, Australia, in 1988 and in Sundsvall, Sweden, in 1991 respectively. It is well documented that the years immediately following the release of the Ottawa Charter and the Epp Report were very important ones for health promotion within Canada (see Pinder’s chapter). Some additional resources were given to the Health Promotion Directorate of Health and Welfare Canada, programs and initiatives to follow up on the Epp Report were started, and a knowledge development strategy was established. Many of these developments were described in detail in the first edition of the book, as well as two important federal initiatives, the Strengthening Community Health project (Hoffman, 1994) and the Healthy Communities initiative (Manson-Singer, 1994), both of which reflect the flurry of activity of the period.
The First Edition of the Book The original intuition that led us to the preparation of the first edition, which analyzed the 1974–1994 period, was a strong sense of cognitive dissonance between what we heard in our travels about the role of Canada in health promotion and what we observed at home. More specifically, while Canada may have been regarded as the world leader in health promotion, we observed a large gap between the international reputation of the federal government and the actual practice of health promotion provincially (the provinces and territories having the constitutional responsibility for health services). We wanted to explore this intuition from a historical and critical perspective using a sociology of knowledge approach. Our view was that
INTRODUCTION: An Evolution in Perspectives ■ 9 F I G U R E 1 . 2 : T H E OT TAWA C H A RT E R
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what happens in a field can be better understood if we observe the various actors who are promoting it or blocking it at one moment in time, and what discourses and instruments of power they use to do so in the general societal context in which they operate. Our intent was to help the field reflect on itself and even-
tually become more aware of these issues and better equipped to deal with them. What we concluded at the end of the first book (O’Neill, Rootman, & Pederson, 1994) was related to both Canada’s position in the global health promotion scene and to the evolution of health promotion within Canada.
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Immediately prior to our conclusion, though, in a provocative paper, one of the key pioneers of the health promotion movement both in Canada and internationally argued that in 1994 the movement had “won a battle,” but was far from having “won the war” (Hancock, 1994). Hancock argued vociferously that to really make a difference, health promoters should become more political and enrol in party politics, especially in the Green Party as its value base was closest to the one promoted by health promotion. However, as editors, we did not go in the same direction as Hancock. With respect to international developments, we were able to document the impact of the WHOEuro/Canada alliance in the evolution of the field from health education to health promotion, as noted above, and to identify key individuals and institutions. We also noted the beginnings of the mainstreaming of health promotion, as was evident, for instance, in its use in the reconstruction of the health systems of Central and Eastern European countries. We recognized the potential tensions of this transition when, in the words of sociologist Max Weber, the “charisma” of the early pioneers is “routinized” and loses some of its original purity and vision, but is embraced and serves a much larger group of people. Finally, we were convinced that the future of health promotion would be directly influenced by the future direction of the general political economy of the world. With respect to Canada, we were already observing the stagnation, if not the beginning of the decline, of the federal leadership in the field, and we wondered who would champion health promotion in Canada in the future if this decline actually occurred. In comparing and contrasting provincial and territorial developments, we realized how the ambiguity of the health promotion discourse had been used both by
social democratic and conservative political parties to justify their reorganization of the health care system of their respective jurisdiction. Moreover, we saw a persistent, entrenched approach to health promotion as individual lifestyle change rather than the more structural ones espoused in official discourse. Finally, despite the fact that some people may have hoped otherwise, we concluded that health promotion was clearly not a widespread social movement in Canada, despite the growing importance in the general population of lifestyle and quality of life issues. Rather, it appeared to us to be more of a “professional movement” promoted by small groups of public health professionals, academics, and community leaders. Later, and probably supported by other movements with related discourses and ideologies like the feminist or the environmentalist ones, health promotion had proposed (with a certain degree of success) a new discourse on health, which had been adopted by various political constituencies but, as mentioned above, was used in a variety of ways (if at all). We were thus interested in what would happen in the next decade and offered a few predictions for what we thought might happen both in Canada and internationally. We will return to those at the end of this second edition, but let us now consider the time period covered by this book.
1994–2007: HEALTH PROMOTION: DECLINE, TRANSFORMATION, OR RENEWAL? The title of this subsection plays with the titles of some of the papers we have published since the release of the first edition of the book as we continued to track the evolution of the field (O’Neill, Pederson, & Rootman, 2000; Pederson, Rootman, & O’Neill, 2005).
INTRODUCTION: An Evolution in Perspectives ■ 11
It is clear to us that 1994 marked the beginning of an era of weakened support for health promotion both in Canada and abroad. Since then, has it declined or simply been transformed by becoming more mainstream? Is health promotion experiencing a revival at the moment or is it actually fading from the radar screen? Let us examine a few major trends and then address the main intent of this second edition of the book.
Some General Trends Internationally, it is important to note that from the mid-1990s on, the shift away from the welfare state that began in the late 1980s, due to the macro-economic evolution of the world since the mid-1970s, was clearer. The litany of the rhetoric of balanced government budgets, of deficit reduction, of a diminished role for the state and an increased one for the market, of the necessity of global economic competition in a neo-liberal era: all this has been more present and operative. The dominance of this economic view of the world over the more social one that the welfare states had promoted for several decades has had consequences; for example, it has led to a decrease in the importance and influence of most organizations of the United Nations system (such as WHO) and to an increase in the power of transnational corporations and economic global institutions such as the World Bank, the International Monetary Fund, and the World Trade Organization. As described by Ron Labonte in Chapter 12 of this book, these global tendencies, in conjunction with the collapse of the former communist world in the early 1990s, which left the US virtually alone to define the “new world order,” have had important consequences for the evolution of health promotion. In the concluding section of this book, Ilona Kickbusch updates an earlier story she
wrote to describe the evolution of the field and reminds us that in this context, several of the key institutions that had been instrumental in the birth of health promotion almost abandoned it after 1994. For example, after the Sundsvall conference of 1991, instead of continuing its pattern of hosting international conferences almost every other year (as it did initially) to address the three remaining strategies of the Ottawa Charter, WHO was forced to hold them at irregular intervals and on topics that addressed the interest of the host countries rather than its overall strategy. The Djakarta (1997), Mexico (2000), and Bangkok (2005) conferences each reflected this new order of things. Consequently, the global health promotion community publicly voiced its concern about the WHO’s lack of commitment at the Mexico conference (Mittlemark et al., 2001) and about the inclusion of the private sector as a key partner in the Bangkok Charter (see the debate in the series From Ottawa to Vancouver on the electronic journal RHPEO, details of its Web site at the end of the chapter). Moreover after 1994, as fully described in this edition’s Chapter 7 by Lavada Pinder, the federal government abandoned its international and Canadian leadership as the population health approach gained greater currency.
Main Intentions of the Second Edition The general orientation of this second edition remains the same: this is not a book in but a book on health promotion, which looks critically at the evolution of the field since 1994 and at Canada’s engagement with health promotion relative to the rest of the world. Three sets of modifications were made, however, in compiling this new edition. First, following discussion with our new publisher, we agreed that the audience of the book needed to be re-examined. For the first
12 ■ HEALTH PROMOTION IN CANADA
version, we envisioned several audiences: graduate students; scholars; and practitioners, professional or lay, interested in health promotion from a variety of health, social science, and other backgrounds in Canada and abroad. However, over the years, a variety of sources have revealed that the largest group of readers of the first edition has been undergraduate students in health sciences within Canada, with the other groups forming an important, but smaller, audience. We have assumed that this will continue to be the case for this second edition and have therefore addressed this understanding explicitly in the design and content of the book. Without altering the general intent or the rigour of the analysis, we have used a style and format that we hope makes this edition more usable in undergraduate courses, while maintaining an orientation that is also useful for other readers here and abroad. Second, we also realized from feedback on the first edition that we should more explicitly address how and why reflecting on a field is crucial for the practice of this field. We have thus introduced a new section in this edition on “Practical Perspectives.” In this new section, contributors address a series of issues that aim to demonstrate how being or becoming a more reflexive practitioner increases a person’s capacity to be relevant and effective in practice. Hence, in this second edition, we encourage the reader to not only think about but also to apply this thinking to his or her actual practice, whatever and wherever it is. Third, given that health promotion is still a very young field, its original pioneers in many places are still active. For the field to survive and evolve, however, we need to ensure the place of the younger generations as we move from the activism of the pioneers to a more mainstream (although always fragile)
state of affairs. Consequently, to enrich the perspectives proposed in the book, we have made a deliberate effort to introduce a mix of younger and more experienced contributors. To foster diversity, we have also approached a variety of academics, practitioners, students, and policy makers as well as people from various parts of Canada and from a wide sample of countries to contribute to this book. The book is therefore organized into six sections dealing successively with Conceptual, National, Provincial, International, and Practical perspectives followed by some Conclusions, each of which we have tried to infuse with a spirit of critical reflection. As the book’s new subtitle is intended to suggest, these perspectives are “critical” in various ways. First, they introduce what we think are “important or crucial” elements of reflection and analysis. Moreover, they do so with the rigour and the “inclination to criticize,” which are used in “critical social science” not to lay blame but rather to assess without complacency the status of a phenomenon. Two other meanings of “critical” are also relevant here. On the one hand, we use the term “critical” in the sense of its meaning in nuclear reactions; that is, has health promotion reached sufficient “critical mass” to trigger a chain reaction that will make it explode and mushroom both in Canada and internationally? On the other hand, we will also try to determine whether 2007 will be— for both Canadian and global health promotion—a “critical turning point” or juncture as were 1951, 1974, 1986, or 1994. We hope that this book will successfully engage in critical appraisal of the health promotion field, and, in the conclusion, we will synthesize, through an intergenerational dialogue, what the various chapters have told us about the past and the present, and our current vision of the future of health promotion in Canada.
INTRODUCTION: An Evolution in Perspectives ■ 13
REFERENCES Badgley, R. (1994). Health promotion and social change in the health of Canadians. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 20–39). Toronto: W.B. Saunders. Becker, M.H. (1974). The health belief model and personal health behavior. Thorofare: Charles B. Slack. Brown, R.E., & Margo, G.E. (1978). Health education: Can the reformers be reformed? International Journal of Health Services, 8(1), 3–26. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Santé et Bien-être social Canada/Health and Welfare Canada. Evans, R.G., Barer, M.L., & Marmor, T.R. (1996). Être ou ne pas être en bonne santé. In Biologie et déterminants sociaux de la maladie. Paris/Montréal: Les Presses de l’Université de Montréal/John Libbey Eurotext. Freudenberg, N. (1978). Shaping the future of health education: From behavior change to social change. Health Education Monographs, 6(4), 372–377. Gilbert, J. (1963). L’éducation sanitaire. Montréal: Presses de l’Université de Montréal. Gilbert, J. (1967). The grandeur and decadence of health education. Canadian Journal of Public Health, 58, 355–358. Green, L.W., & Kreuter, M. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View: Mayfield. Hancock, T. (1994). Health promotion in Canada: Did we win the battle but lose the war? In A. Pederson, et al. (Ed.), Health promotion in Canada (pp. 350–373). Toronto: W.B. Saunders. Hoffman, K. (1994). The strengthening community health program: Lessons for community development. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 123–139). Toronto: W.B. Saunders. Kickbusch, I. (1986). Health promotion: A global perspective. Canadian Journal of Public Health, 77, 321–326. Kickbusch, I. (1994). Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 8–18). Toronto: Saunders. Labonté, R., & Penfold, S. (1981). A critical analysis of Canadian perspective in health promotion. Health Education, 19(3–4), 4–10. Lalonde, M. (1974). Nouvelle perspective de la santé des canadiens/A new perspective on the health of Canadians. Ottawa: Gouvernement du Canada/Government of Canada. Manson-Singer, S. (1994). The Canadian healthy communities project: Creating a social movement. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 107–122). Toronto: W.B. Saunders. Milio, N. (1986). Promoting health through public policy (2nd ed.). Ottawa: Canadian Public Health Association. Mittelmark, M.B., Akerman, M., Gillis, D., Kosa, K., O’Neill, M., Piette, D., et al. (2001). Mexico conference on health promotion: Open letter to WHO director general, Dr. Gro Harlem Brundtland. Health Promotion International, 16(1), 3–4. Modolo, M.A., & Mamon, J. (2001). A long way to health promotion through IUHPE conferences (1951–2001). Perugia: University of Perugia, Inter university Experimental Center for Health Education. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141.
14 ■ HEALTH PROMOTION IN CANADA O’Neill, M., Rootman, I., & Pederson, A. (1994). Beyond Lalonde: Two decades of Canadian health promotion. In A. Pederson et al. (Eds.), Health promotion in Canada (pp. 374–387). Toronto: W.B. Saunders. Pederson, A., O’Neill, M., & Rootman, I. (Eds.). (1994). Health promotion in Canada: Provincial, national, and international perspectives. Toronto: W.B. Saunders. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future? In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). London: Palgrave Macmillan. Ryan, W. (1976). Blaming the victim (rev. ed.). New York: Vintage Books Edition. UNICEF. (1978). The declaration of Alma-Ata. International Conference on Primary Health Care. AlmaAta: United Nations Children’s Fund and World Health Organization.WHO. (1981). 64th plenary meeting, Resolution 36/43. WHO. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. WHO-Euro. (1984). Health promotion: A discussion document on the concept and principles. ICP/HSR 602 (m01). Unpublished manuscript, Copenhagen.
CRITIC AL THINKING QUESTIONS 1. What have been the four main periods in the evolution of health promotion in Canada? 2. What has been the role of Canada on the international health promotion scene before 1986? 3. Can we consider that the Ottawa Charter for Health Promotion is a Canadian document? Why? 4. Why has the Lalonde Report received so much international attention? 5. Given what you know now, do you think 2007 will be the beginning of a new era in Canadian health promotion?
FURTHER READINGS Modolo, M.A., & Mamon, J. (2001). A long way to health promotion through IUHPE conferences (1951–2001). Perugia: University of Perugia, Inter university Experimental Center for Health Education. A most interesting history of the main international organization in Health Promotion, published on the 50th anniversary of its foundation. Pederson, A., O’Neill, M., & Rootman, I. (Eds.). (1994). Health promotion in Canada: Provincial, national, and international perspectives. Toronto: W.B. Saunders. The first edition of the book, which analyzes the 1974–1994 period of Canadian Health Promotion. The various charters and declarations of the six WHO international conferences on health promotion, including the most famous of all, the Ottawa Charter. Can be found on the WHO Web site indicated in the Web sites section below.
INTRODUCTION: An Evolution in Perspectives ■ 15
RELEVANT WEB SITES International Union of Health Promotion and Education (IUHPE) www.iuhpe.org/
The International Union for Health Promotion and Education (IUHPE) is the only global organization entirely devoted to advancing public health through health promotion and health education. This site is an important source for news and events in health promotion in three languages (English, Spanish, French). Reviews of Health Promotion and Education Online www.rhpeo.org/
The Web site of IUHPE’S electronic journal, the Reviews of Health Promotion and Education Online (RHPEO); see especially the series Ottawa 1986–Vancouver 2007: Should we revisit the Ottawa Charter? World Health Organization www.who.int/healthpromotion/conferences/en
WHO Web site on global Health Promotion conferences, including charters, declarations, etc., as well as the complete text of the Alma-Ata Declaration on Primary Health Care.
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PA RT I
CONCEPTUAL PERSPECTIVES
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C
e qui se conçoit clairement s’énonce facilement et les mots pour le dire arrivent aisément” (What is clearly conceived is easily said and words to say it come easily), said French preacher Bossuet a few centuries ago. And, “There is nothing more practical than a good theory,” said American social psychologist Kurt Lewin a few decades ago. In a nutshell, these two sentences capture why we open this book with a section on conceptual perspectives. While many people, particularly those with practical demands on them, resist conceptual discussions or perceive them as irrelevant intellectual or academic debates of little use in their day-to-day work, we think that addressing conceptual perspectives up front is central to improving our practice. Indeed, it is a consistent observation by health promotion scholars that despite the availability of much solid conceptual and theoretical work, most programs are not developed with a theoretical base, resulting in both less effective and fewer interventions. Hence in this first part we try to address some of the major conceptual issues of the field and how they are relevant to Canada and to reveal some of 17
18 ■ HEALTH PROMOTION IN CANADA
their practical consequences. If we are promoting health, what exactly are we promoting? Is health promotion distinct from health education, or public health, or population health? If not, then there is no reason to have a distinct scientific and practical field by this name, or jobs in health promotion. If so, then we need to clarify and agree on what it is so we can practise it, teach it, and build the scientific base required to understand and improve it. This part deals with these basic and several other related issues. In Chapter 2, Raeburn and Rootman review the dilemmas generated by the enlargement of the concept of health over recent decades, how developments since the first edition of this book in 1994 have had an impact on the concept, and, using the definition of health proposed in 2005 in the Bangkok Charter for Health Promotion, suggest their own way for Canadian health promoters to address these dilemmas. In Chapter 3, O’Neill and Stirling argue that there has been and continues to be a conceptual confusion about what constitutes “health promotion.” After showing some of the very practical consequences of such confusion using work done for the Internet-based Canadian Health Network, they propose a way to clarify the confusion, at the same time showing that there is indeed a specific field of health promotion for which specific skills are needed. In Chapter 4, Poland and Frolich show that health promotion interventions have been traditionally approached either from the perspective of health issues, population groups, or the settings in which people live, work, or play as entry points. They discuss the conceptual and practical consequences of using one or the other or a combination of these entry points and show how the notions of social context and collective lifestyles help clarify how we might enhance our approach to thinking about health promotion interventions. In Chapter 5, Rootman, Frankish, and Kaszap, using the current international developments in health literacy—to which Canadian scholars and practitioners have made significant contributions—illustrate how a new concept moves from theory into research and practice. In Chapter 6, Reid, Pederson, and Dupéré write about the lessons those working in the health promotion field can draw from theoretical and practical developments in the field of women’s health. They specifically point to the value of intersectional theory for addressing issues of diversity, a question that feminists, women’s health researchers, and theorists have been considering for some time. At the end of this section, the reader should thus have a clear idea of the major current conceptual debates in the field of health promotion, should be able to state his or her own positions on these debates, and should be able to see the practical consequences of these positions for her or his work.
CHAPTER 2
A NEW APPRAISAL OF THE CONCEPT O F H E A LT H John Raeburn and Irving Rootman
INTRODUCTION he concept of health we implicitly or explicitly use in our health promotion work provides the whole framework and context for how we think about the health promotion enterprise. In this chapter, we present a point of view about the kind of concept we feel is needed to advance health promotion in Canada and elsewhere in the light of the challenges and new health promotion environment of the 21st century. Considerations of concepts of health in a health promotion context immediately raise a fundamental issue—that of a broad, positive, and predominantly social concept of health versus the more disease-oriented, biomedical concept of health favoured by most of the health sector. We strongly believe in the former. Indeed, we feel that what ultimately distinguishes health promotion from the rest of the health endeavour is its positive nature—its building of healthiness rather than just the prevention or treatment of illness and other negative conditions. What we write here is from this healthiness perspective (the term “healthiness” is the noun derived from “healthy,” defined as “having or showing good health,” where “health,” in turn, is defined as “soundness of body or mind” (Concise Oxford Dictionary, 1982). In a health promotion context, the term “health” can largely be seen as relating to two broad areas. One defines a sector of societal activity, different from other public sectors
T
like education or justice—as in the name “Health Canada.” The other defines an aspect of the human condition, having to do with the status of body and/or mind, as exemplified by the 1947 World Health Organization’s definition of health (see below). It is the body–mind condition version we are mainly concerned with here. Each of these two broad usages of “health” can be construed in positive or negative ways to do with healthiness or illness respectively (we are using the term “illness” loosely here to cover negative conditions of the organism). We would argue that health promotion’s concerns are ultimately to do with promoting healthy states of the human condition, especially the body and mind dimensions. Viewing health this way is, however, a minority position. For example, in 2005, only 5.5 percent of Canadian publicly funded health services were in the category of “public health” (which would presumably include much of health promotion) (CIHI, 2005), so it is reasonable to assume that almost always when one hears the term “health” in the health sector, it actually means “illness,” conceived in a medical/clinical frame. And this is also the case even of public health or heath promotion work, which is generally done within an illness rather than in a healthiness orientation (see Chapter 4, for instance). In this chapter, we thus look briefly at how we considered the concept of health in the first edition of this book, then suggest how influences since that time should be fac19
20 ■ PART I: Conceptual Perspectives
tored into current concepts of health for health promotion. Our sense is that health promotion has languished to some extent in Canada and internationally in the past few years, and that we now need new concepts to reinvigorate it. We believe a meaningful, new, positive, and inclusive concept of health for health promotion in the 21st century is essential to set both the conceptual frame and the goals of our undertakings for the future.
WHAT WE FOUND IN 1994 The 1994 version of this chapter emphasized the multiplicity of concepts of health, describing the territory as a “minefield.” These concepts came from medicine, nursing, the World Health Organization, the Ottawa Charter for Health Promotion, academics, American
holism, and lay people (see Box 2.1). The concept deemed most influential internationally from a health promotion perspective was the 1946 World Health Organization constitution’s definition of health as “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease and infirmity” (World Health Organization, 1946). Probably the other most influential concept of health for health promotion internationally was “the health field concept” from the 1974 Canadian federal government document A New Perspective on the Health of Canadians, dubbed the Lalonde Report (see below) (Lalonde, 1974), discussed next. We concluded that concepts of health were largely determined by their context and who was expressing them. We thus looked at the Canadian health promotion context. The landmark Lalonde
BOX 2.1: S O M E D E F I N I T I O N S O F H E A LT H
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CHAPTER 2: A New Appraisal of the Concept of Health ■ 21
Report, named after the then federal minister of Health (Lalonde, 1974), said that health was determined by more than just health services, and listed four broad contributory factors or “elements” making up the “health field”: human biology, environment, lifestyle, and health care organization. For health promoters, it was especially the Lalonde Report’s introduction of lifestyle and environment into the health determinants discourse that came to be remembered, especially lifestyle, a concept that dominated Canadian and international health promotion thinking and action for a decade, and still lingers on. During the 1980s, there was a move away from individualistic behavioural views of health promotion to more social and policy views. In Canada, 1984–1985 were important for Hancock’s influential concepts of “healthy cities” and the “Mandala of Health” (Hancock & Perkins, 1985), although these tended to focus on disease reduction as an output rather than health. Then, in 1986, came the revolution of the Ottawa Charter, with its concept of health as a resource for living, and its cementing in of a broad social determinants model of health (World Health Organization, 1986). This social model of health was echoed in the 1986 Canadian government document Achieving Health for All: A Framework for Health Promotion (Epp, 1986), albeit with a more personal and friendly tone (using concepts like “self-help” and “mutual aid”), and a strong emphasis on equity, as befits Canadian culture. In 1989, the authors of this chapter tried to combine the health concepts of the Lalonde Health Field Concept and the Ottawa Charter (Raeburn & Rootman, 1989), and in 1993, Labonté (1993) took up the issue of subjective and objective views of health, a precursor of the qualitative revolution to come. The 1994 chapter went on to say that, while the term “health” covered many different concepts, its
common conceptual feature was that it related to a broad domain of life that could be differentiated from other broad domains, such as those of economics, politics, justice, and education. The distinctive feature of this domain was that it related to the human organism’s condition, well-being, and functioning. We concluded by asking whether a concept of health as used by Canadian health promoters could be discerned (“CHP Health” for short), and came up with the following somewhat awkward statement: Health as perceived in a Canadian health promotion context 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 as being enhanced by a sensible lifestyle 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, p. 69)
INFLUENCES SINCE 1994 Much has happened in Canada and the world since 1994, and much has happened in health and health promotion. These changes make what we were talking about in 1994 seem somewhat dated, and we feel it is time to explore new concepts more relevant to the 21st century. We wish to tackle this here by considering some of the changes and developments in the past few years as pointers to how we might reconceptualize health for health promotion in the 21st century. Our choice of influences and how we interpret these are based on our own experience and values as health promoters, and we present what follows as a trigger for discussion rather than as the last word on the topic.
22 ■ PART I: Conceptual Perspectives
Population Health As outlined in Chapter 7 by Pinder, perhaps the greatest single new influence on Canadian health promotion at the national level has been the population health paradigm. It is hard to say what this means in terms of an underlying concept of health. However, Canadian health promotion traditionally embraced core values like empowerment, mutual aid, participation, and “enabling,” and gave primacy to community action. In contrast, the medical-epidemiology ethos of the population health movement seemed to represent a more top-down, depersonalized, and less community perspective (e.g., Poland et al., 1998). According to Poland and several other critics, the centre of gravity has, in spite of population health’s social determinants rhetoric, subtly moved back to a more “old-fashioned” public health and medicalized viewpoint (versus a more socially oriented “new public health”). Our view is that health promotion now needs to reassert its own identity outside the population health paradigm, and return to a more positive, empowering, and community concept of health as its basic frame of reference.
Mental Health Promotion Although the concept of mental health promotion has been around notionally since the 1980s, in the mid-1990s it emerged as a significant new area, spearheaded in Canada and the world by the work of the Mental Health Promotion Unit in Health Canada, Ottawa (Joubert, 1995). In 1996, a trail-blazing international workshop at the University of Toronto on the concept of mental health promotion came up with the following concept of mental health: Mental health is the capacity of each and all of us to feel, think and act in ways that enhance our
ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of equity, social justice, interconnections and personal dignity. (Joubert & Raeburn, 1998; p. 16)
This concept is quite different from the disease-oriented concepts that have tended to dominate the professional and academic mental health field. Certainly, it seems that the time has come for mental health to get more attention in health promotion, even if it seems ironic that we need to use disease statistics to justify this. For example, mental health issues currently comprise five of the top six burden of disease categories in industrialized countries (World Health Organization, 2001). In addition, depression is becoming increasingly evident in developing countries, especially among women, to the extent that depression is predicted to be the second largest global disease burden category by 2020 (Murray & Lopez, 1996). Canada was one of the first countries to put the area of mental health promotion on the agenda; however, it now appears to have fallen behind what is happening in the rest of the world (c.f. Saxena & Garrison, 2004). Although mental health promotion is a distinctive field, it has much in common with conventional health promotion, and the two fields need to look at how each can integrate with the other. An inclusive concept of health could help us do that, as we will illustrate below.
Resilience A particular contribution of mental health promotion to the field of health promotion worthy of mention in its own right is the concept of resilience. Resilience refers to people’s capacity to draw on their own resourcefulness to deal effectively with the demands of life, to return to full functioning after setbacks, and
CHAPTER 2: A New Appraisal of the Concept of Health ■ 23
to learn from such experiences to function better in the future (Mangham, Reid, & Stewart, 1996). This is illustrated in Figure 2.1, a Canadian conceptualization (Joubert & Raeburn, 1998). The concept is also applicable to communities, as discussed some years
ago in a notable Alberta think tank on the topic (Kulig & Hanson, 1996). We feel that such a concept of resilience could be extended to the whole of health promotion as a key marker of healthiness, independent of pathology measures.
F I G U R E 2 . 1 : A schematic representation of resilience as it relates to individuals in a mental health promotion context, where the arrow represents the lifespan from birth to death, and the wavy line the ups and downs of life. Good mental health is seen as flourishing where there are resilient people in supportive environments.
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Quality of Life Related to the above types of concepts are several years of studies in Ontario on subjectively experienced quality of life (QOL) (Renwick, 2004). Although it originated in the developmental disability sector, we think the Ontario concept of QOL is universally applicable, can be applied to whole communities as well as individuals, and can be quantitatively measured. QOL is defined as “The degree to which a person enjoys the important possibilities of his or her life” (Quality of Life Research Unit, 2006), and is represented in nine life sectors grouped as Being, Belonging, and Becoming, as shown in Figure 2.2. What we have here is
a powerful concept to drive health promotion considerations, and the present authors have suggested a concept of “health-related QOL” to do this (Raeburn & Rootman, 1995, 1998).
Capacity and Capacity Building Two of the strongest health promotion concepts to emerge since the mid-1990s regarding a positive rather than a deficit or disease concept of health have been those of “capacity” and “capacity building.” “Capacity” is closely allied to other positive concepts, such as “strengths” (Rapp, 1998) and “assets” (Kretzmann & McKnight, 1993). Of particular interest is the concept of “community
24 ■ PART I: Conceptual Perspectives F I G U R E 2 . 2 : C E N T R E F O R H E A LT H P RO M OT I O N Q UA L I T Y O F LIFE MODEL
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CHAPTER 2: A New Appraisal of the Concept of Health ■ 25
capacity,” and Canada has led the way with studies of community capacity building (e.g., Jackson et al., 2003). Capacity is both quantitatively and qualitatively measurable, with a notable review of measures for community capacity being that of Smith and colleagues in Alberta (Smith, Littlejohns, & Thompson, 2001). “Capacity building” is a term used to describe the development of both personal and social abilities, and there is strong evidence that interventions based on the concept of capacity may be more effective than conventional prevention approaches (Pransky, 1991; Raeburn et al., 2005). It could be argued that capacity building, which is close to the concept of empowerment (Laverack, 2005), is the way of the future for health promotion practice.
Community Development and Community Capacity Building Our sense is that community development (and its more recent manifestation as community capacity building) has been perhaps the most salient characteristic of Canadian health promotion at provincial and local levels for many years. However, the population health approach seems to have weakened the status of this area in that population health tends be primarily concerned with populations larger than communities, and its approach is philosophically different. Yet other than policy development and advocacy, community development/capacity building is arguably the most important single approach available to health promotion practitioners, one that fully embodies the central health promotion principles of empowerment, participation, and a sense of control by ordinary people. We argue that the community development dimension needs to be strongly re-endorsed in current and future concepts of health for health promotion.
Poverty and Equity Of particular importance to health promoters in the new globalized world are the very large numbers of people who are impoverished. It is well known that health declines with poverty, and we believe that issues of poverty should be a primary concern for health promoters. Equity (the gap between rich and poor) seems to have suffered under the New Right regimes seen in Canada and around the world. In Canada, the gap between rich and poor is increasing, and it is known that this is a major predictor of ill health and other negative indicators (Wilkinson, 1996), as well as being a social justice issue. This is part of a larger picture of the consumer and globalized world of the past 15 years, and here, poorer people are especially vulnerable to what in some countries are called “dangerous consumptions” (Adams, 2006), i.e., commercially driven lifestyle forces such as electronic gambling and fast foods, which typically take their greatest toll on the poor and minority groups. Social justice and equity have always been a part of public health and health promotion thinking, and it is imperative that we retain and strengthen this dimension in our future concepts of health.
Multiculturalism, Minorities, Migration, and Indigenous Peoples Perhaps one benefit of a population health approach is that it alerts us to the various “populations” of which our society consists. Although Canadian health promotion has traditionally given attention to the rights of women, gays, children, and the disabled, the globalization perspective brings to our attention the plight of many ethnic minorities both in Canada and around the world, including those in multicultural settings, indigenous peoples, internally displaced people because
26 ■ PART I: Conceptual Perspectives
of commercial or war pressures, those affected by environmental catastrophes, and the stresses generally of being a migrant or refugee. Canada has generally been very open with regard to immigration and accepting refugees, with the result that multiculturalism is a major Canadian reality. What this signifies, among other things, is that our concepts of health probably have to be pluralistic, since different cultures have distinctive views of health, which are often holistic in nature, and which are tied into the deepest parts of their identity, well-being, and spirituality. Similarly, the concepts and rights of First Nations as indigenous peoples are extremely important to know about and respect, since the power of the mainstream is a constant threat to them. Therefore our concept of health has to be able to accommodate and honour the diversity seen in different cultures and groups, with primacy given by right to First Nations perspectives.
Qualitative Approaches If one thing were to characterize today’s Canadian health promotion to the outsider, it would be a significant investment in university-based research (see Chapter 8). With at least 16 university-based centres of health promotion research, Canada is strong in this area. Increasingly, the realization is that health promotion research is probably best served by a predominantly qualitative research methodology, a trend started in Canada in the early 1990s. Most medical and health science, including most public and population health science outside health promotion as such, is still driven by a positivist paradigm, whereas the more subjective, life experiential, and naturalistic ethos of health promotion is probably better suited to qualitative methods or, at least, to a mix of qualitative and quantitative methods. From a
health concept point of view, a qualitative perspective has a more experiential and personal aspect compared with concepts of health based primarily on disease statistics. If health promotion is to be true to its peoplecentred origins, and since health is largely about how people feel, a qualitative concept of health is probably one that should increasingly dominate health promotion considerations.
The Bangkok Charter At the time of writing, we are still in the early stages of digesting the import of the Bangkok Charter for Health Promotion. While most people will probably focus on the globalization, action, and commitments aspects of the Charter, one of its resounding contributions is its new concept of health. After affirming “the values, principles and action strategies” of the Ottawa Charter, the Bangkok Charter (World Health Organization, 2005) says: “[Health promotion] offers a positive and inclusive concept of health as a determinant of the quality of life and encompassing mental and spiritual well-being.” Although this seems slightly garbled, it does contain some important components that could lead us toward a new overall concept of health for health promotion. First, the concept is “positive.” As stated earlier, although health promotion is ostensibly a positive enterprise, the pressures from the dominant system often lead instead to a focus on disease and deficit rather than “healthiness.” The positive–negative distinction has profound repercussions for how we health promoters conceptualize what we are doing. A positive approach is about capacity building, empowerment, resilience, and QOL, whereas a disease/deficit approach is about dealing with risks and negative states of the organism. Hopefully, the Bangkok
CHAPTER 2: A New Appraisal of the Concept of Health ■ 27
Charter’s clear statement about positivity will put this clearly back on the health promotion agenda. Second, the Bangkok Charter concept is “inclusive,” for which read “ecological” or “holistic.” This is helpful for the same reason as above—that is, it takes our concept of health beyond disease and narrowly conceived risks and determinants. It will hopefully also encourage thinking beyond the current social determinants model of both public and population health in that there are more types and levels of health determinants than are generally represented in this model. These include culture, psychological factors, interpersonal dealings, stress, spirituality, and social behaviour. Hopefully, the use of the term “inclusive” in the Bangkok Charter will open up the rather limited conceptual base for health and its determinants we have lived with in health promotion for many years. Third, the concept of “quality of life” is included. This is, of course, both positive and inclusive. As we saw before, QOL could be a very useful way of conceptualizing what we are dealing with in health promotion, especially when thinking of health as a goal or an output, and its inclusion in the Bangkok Charter should open up this discussion. Fourth, the Bangkok Charter’s concept of health encompasses “mental well-being.” At last, the mental health area gets a mention in a mainstream World Health Organization health promotion document! Moreover, its representation as “mental well-being” encourages us to think beyond “mental illness” when we talk about mental health in a health promotion context. We argued above that mental health is a major issue facing modern health promotion and the allusion to it here puts it squarely on the health promotion agenda. Fifth, and most surprisingly, the Bangkok Charter mentions “spiritual well-
being.” This indeed brings us into the 21st century, where it is clear that spiritual (a term going well beyond “religious”) issues are at the core of health and well-being for a majority of the world’s people (Raeburn & Rootman, 1998), yet spirituality has not been recognized as such in most official health promotion thinking. Indeed, given their fundamental importance to so many, one wonders why there is so much resistance to both mental health and spiritual concepts in conventional health promotion. What does this say about us? In spite of the resistance to acknowledging the role of spirituality among many health promoters, there is a growing research literature that supports the positive role of spirituality in health (e.g., Miller & Thoreson, 2003). Indeed—but this will be going too far for many—one could argue that spiritual health (that is, health at the deepest level of our being, and which is to do with our relationship to the whole scheme of things) is what health promotion is ultimately about. But we may need to wait until the 22nd century before this is accepted! Overall, then, the Bangkok Charter appears to lead us toward a new concept of health, one to which it is likely that Canadian health promotion can relate easily given its established history of interest and leadership in much of what is discussed here.
CONCLUSIONS As stated, we believe a new concept of health for health promotion is necessary for the 21st century to help in a much needed reinvigoration of health promotion, and to make it more relevant to the present and the future. This concept not only needs to incorporate the valued efforts and principles of the past, but needs also to take into account directions that have appeared in recent times, some of which we have covered in this chapter.
28 ■ PART I: Conceptual Perspectives
An overview of what has been said in this chapter suggests that such a concept would need to be: • positive—not based on pathology or deficit • inclusive—with a broader set of determinants and attributes than are customarily used • particularly attentive to the mental health dimension, and inclusive of quality of life and spirituality • able to be used both as a framework and as an overall goal • able to accommodate scientific measurement, while fully capturing the qualitative dimension • able to represent the current realities of what affects health and mental health in Canada and the world of the 21st century • able to inspire and give clear guidance as to where future health promotion should go Taking these points into account, a possible concept of health for health promotion in the 21st century is now given. We have aimed to make this as concise as possible,
while summarizing much of what we have covered here. It is as follows: 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.
We realize that the risk of offering a concept like this is that if it is rejected out of hand, it may therefore seem to invalidate the rest of the chapter. However, we hope that if such rejection occurs, consideration will still be given to our contention that a new concept of health is needed for health promotion, and that the other points made in this chapter still warrant consideration. We close in the hope that what we have offered here will help to stimulate a robust discussion on how we can have a strong, positive, exciting, and relevant concept of health for health promotion, one that will take us forward in the 21st century.
REFERENCES Adams, P. (2006) Identity talk on dangerous consumptions down-under. Addiction Research and Theory, 13(6), 515–521. Alster, K.B. (1989). The holistic health movement. Tuscaloosa: University of Alabama Press. CIHI. (2005). National health expenditure trends 1975–2005. Ottawa: Canadian Institute for Health Information. Concise Oxford Dictionary. (1982). Oxford: Clarenden Press. Contandriopoulos, A.P. (2005). A “topography” of the concept of health. In R. Lyons (Ed.), The social sciences and humanities in health research (pp. 13–15). Ottawa: Canadian Institute of Health Research. Critchley, M. (Ed.). (1978). Butterworth’s medical dictionary. London: Butterworths. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Health and Welfare Canada. Hancock, T., & Perkins, F. (1985). The mandala of health: A conceptual model and teaching tool. Health Education, 24(1), 8–10. Jackson, S., Cleverly, S., Poland, B., Burman, D., Edwards, R., & Robertson, A. (2003). Working with
CHAPTER 2: A New Appraisal of the Concept of Health ■ 29 Toronto neighbourhoods toward developing indicators of community capacity. Health Promotion International, 18(4), 339–350. Joubert, N. (1995) Mental health promotion: The time is now. Ottawa: Mental Health Promotion Unit, Health Canada. Joubert, N., & Raeburn, J. (1998). Mental health promotion: People power and passion. International Journal of Mental Health Promotion (Inaugural Issue), 1(1), 15–22. Kretzman, J.P., & McKnight, J.L. (1993) Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Chicago: ACTA Publications. Kulig, J., & Hanson, L. (1996). Discussion and expansion of the concept of resiliency: Summary of a think tank. Lethbridge: University of Lethbridge. Labonté, R. (1993). Community health and empowerment. Toronto: Centre for Health Promotion. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Health and Welfare Canada. Laverack, G. (2005). Public health: Power, empowerment, and professional practice. Hampshire: Palgrave Macmillan. Mangham, C., Reid, G., & Stewart, M. (1996). Resilience in families: Challenges for health promotion. Canadian Journal of Public Health, 87(6), 373–374. Miller, W.R., & Thoreson, C.E. (2003). Spirituality, religion, and health: An emerging research field. American Psychologist, 58(1), 24–35. Murray, C.J., & Lopez, A.D. (Eds.). (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Global burden of disease and injury, vol. 1. Cambridge: Harvard School of Public Health. Poland, B., Coburn, D., Robertson, A., & Eakin, J. (1998). Wealth, equity, and health care: A critique of a “population health” perspective on the determinants of health. Social Sciences and Medicine, 46(7), 785–798. Pransky, J. (1991). Prevention: The critical need. Springfield: Burrell Foundation & Paradigm Press. Quality of Life Research Unit, University of Toronto. Retrieved July 14, 2006, from www.utoronto.ca/ qol/concepts.htm. Raeburn, J., Akerman, M., Chuengsatiansup, K., Mejia, F., & Oladepo, O. (2005). Building community capacity to promote health. Technical paper for 6th Global Conference on Health Promotion, Bangkok, August 7–11, 2005. Geneva: World Health Organization. Raeburn, J., & Rootman, I. (1989). Towards an expanded health field concept: Conceptual and research issues in a new era of health promotion. Health Promotion International, 3(4), 383–392. Raeburn, J., & Rootman, I. (1995). Quality of life and health promotion. In R. Renwick, I. Brown, & M. Nagler (Eds.), Quality of life in health promotion and rehabilitation: Conceptual approaches, issues, and applications (pp. 14-25). Newbury Park: Sage. Raeburn, J., & Rootman, I. (1998). People-centred health promotion. Chichester: John Wiley & Sons. Rapp, C. (1998) Strengths model: Case management with people suffering from severe and persistent mental illness. New York: Oxford University Press. Renwick, R. (2004). Quality of life: A guiding framework for practice with adult with developmental disabilities. In M. Ross & S. Bachner (Eds.), Adults with developmental disabilities: Current approaches in occupational therapy (pp. 20–38). Bethesda: AOTA Press. Rootman, I., & Raeburn, J. (1994). The concept of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–152). Toronto: W.B. Saunders Canada.
30 ■ PART I: Conceptual Perspectives Rootman, I., & Raeburn, J. (1998). Quality of life, well-being, health, and health promotion: Toward a conceptual integration. In W. Thurston et al. (Eds.), Doing health promotion research: The science of action (pp. 119–134). Calgary: University of Calgary. Sarafino, E.P. (1990). Health psychology: Biopsychosocial interactions. New York: John Wiley & Sons. Saxena, S., & Garrison, P. (Eds.). (2004). Mental health promotion: Case studies from countries. Geneva: WHO/WFMH. Smith, N., Littlejohns, L., & Thompson, D. (2001). Shaking out the cobwebs: Insights into community capacity and its relation to health outcomes. Community Development Journal, 36(1), 30–41. Spector, R.E. (1985). Cultural diversity in health and illness. Norwalk: Appleton-Century-Crofts. Wilkinson, R. (1996). Unhealthy societies: The afflictions of inequality. New York: Routledge. World Health Organization. (1946). Constitution. Geneva: Author. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. World Health Organization. (2001). The world health report 2001—Mental health: New understanding, new hope. Geneva: Author. World Health Organization. (2005). Bangkok Charter for Health Promotion. Geneva: Author. www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html
CRITIC AL THINKING QUESTIONS 1. What concept or concepts of health do you prefer? Why? 2. Do you agree that the concept of health for health promotion needs to be positive and inclusive? Why or why not? 3. Does everyone who is interested in health promotion need to agree broadly on what we mean by “health” in a health promotion context? Why or why not? 4. Do you think we need a new concept of health for health promotion for the 21st century? Why might a new concept of health for health promotion rejuvenate the field? Or should we just leave things as they are? 5. What do you think of the concept of health suggested at the end of this chapter? If you do not like it, can you think of another that would suit you? If there could be only one commonly accepted concept of health for health promotion, what might it be? Why?
FURTHER READINGS Antonovsky, A. (1979). Health stress and coping. San Francisco: Jossey Bass; and Antonovsky, A. (1987). Unravelling the concept of health. San Francisco: Jossey Bass. These two books raise the question of what creates “health” rather than “disease.” Antonovsky suggests and discusses the term “salutogenesis” to encourage more thinking and research about the determinants of health rather than of disease. A recent commentary on the concept has been published by Lindstrom and Erickson (Lindstrom, B., & Erickson, M. (2005). Salutogenesis. Journal of Epidemiology and Community Health, 59, 440–442). Lindstrom has recently established a research centre in Finland built around salutogenic research (see Chapter 16).
CHAPTER 2: A New Appraisal of the Concept of Health ■ 31 Contandriopoulos, A.P. (2005). A “topography” of the concept of health. In R. Lyons (Ed.), Social sciences and humanities health research (pp. 13–15). Ottawa: Canadian Institute of Health Research. This is an interesting article about the concept of health that considers contributions from the social sciences and humanities to thinking about the concept. Also in the same volume is a one-page article (p. 120) by Contandriopoulos and other Canadian colleagues on a proposed project to integrate approaches and perspectives about the concept of health from the social and life sciences. Rootman, I., & Raeburn, J. (1994). The concept of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 139–152). Toronto: W.B. Saunders. This chapter, which appeared in the first edition of Health Promotion in Canada, presents an overview of the development of the concept of health in Canada up to 1994, along with some useful diagrams. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. This Charter is important for all students of health promotion to read and understand. It can be obtained at www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf World Health Organization. (2005). Bangkok Charter for Health Promotion. Geneva: Author. The Bangkok Charter is the most recent international agreement regarding future directions for health promotion. It can be obtained at www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html
RELEVANT WEB SITES Click4HP www.lsoft.com/scripts/wl.exe?SL1=CLICK4HP&H=YORKU.CA
Click4HP is a listserv that was established by the Ontario Health Promotion Clearinghouse in 1996 and is operated by York University. It has an archive of discussions that have taken place since it was established on a wide range of health promotion topics, including the concept of health. Quality of Life Research Unit www.utoronto.ca/qol/unit.htm
This site provides information about the Centre for Health Promotion Model of Quality of Life, including a description of the conceptual framework developed over the last decade by researchers associated with the Centre as well as the tools that have been developed to measure quality of life and how to order them.
CHAPTER 3
T H E P RO M OT I O N O F H E A LT H O R H E A LT H P RO M OT I O N ? Michel O’Neill and Alison Stirling
INTRODUCTION here are several important reasons for having a clear definition of health promotion. In this chapter, we will first explain why we think defining health promotion is so crucial. Second, we will look at two ways in which defining the field has been undertaken. Finally, we will make suggestions about two possible avenues to solve the dilemmas raised by this definitional issue: a more operational one, showing how the health promotion affiliate of the Canadian Health Network (CHN) decided to address and try to solve it, and a more conceptual one by suggesting differentiating “health promoting” from “health promotion” activities. We think the latter has a significant potential to clarify the definitional confusion that has plagued the field for a long time.
T
WHY DEFINING HEALTH PROMOTION IS IMPORTANT Disciplinary and Professional Reasons There is much debate about whether or not health promotion is or should be considered a discipline like medicine, nursing, sociology, or biology (Bunton & MacDonald, 2004). The notion of a discipline is itself a complex one, with scientific and practical dimensions. These concerns, which exist for any domain, are more evident when a professional category of practitioners, which is recognized 32
in a society at one point in time, needs to be considered and legitimized. All health-related professions are caught up in these debates. Let us take nursing as an example to identify the terms of the issue, and then apply them to look at health promotion. In Canada, in all provinces, nursing is currently a profession regulated by specific laws. How a specific group achieves the status of a recognized, and even more, a legally regulated profession in modern societies has been studied by sociologists for decades, with special attention devoted to the health professions, given their diversity and the “dominant” power of medicine in relation to the others (Coburn, 1988; Freidson, 1977). These authors usually agree that a profession is defined by a certain number of features: a specific body of knowledge, a code of ethics, and a self-regulated practice to insure quality control and protect the public from dangerous practitioners (see Chapter 17 for additional elements on professions). In contrast to other countries such as Australia, in Canada, health promotion has not gained the status of a profession. Is this a problem? In the international literature, there is no unanimity (Ottoson et al., 2000). In this debate, we believe both positions have pros and cons. Some people argue that, in order to make sure that the public gets the best possible services, health promoters should be trained properly according to the latest scientific or practice developments, that
CHAPTER 3: The Promotion of Health or Health Promotion? ■ 33
there should be quality-control mechanisms, that it is very important to professionalize health promotion, that specifically identified health promotion jobs exist, etc. On the other hand others believe that health promotion skills should be part of the training of all health professionals and even of some other types of professionals working on the nonmedical determinants of health; for them, there is no need for a specific profession, notably because the current health promotion body of knowledge (at the scientific or the practice levels) does not justify the existence of a distinct profession. When we speak about a distinct body of knowledge, we open up another avenue of reflection on the field of health promotion, notably around the notion of its scientific nature as required to define a discipline, which in our societies is a very important element. Going back to nursing as an example, as for many other health-related professions, its definitions often allude to “the art and the science of,” as is also the case in Winslow’s (1920) famous old definition of public health still echoed in a recent glossary of health promotion: “Public Health is the science and art of promoting health, preventing disease and prolonging life through the organized efforts of society” (Nutbeam, 1998, p. 3). A lot of words have been used in nursing to discuss if, beyond the art of practising it, it is a scientific discipline of its own or if it is a practical field drawing the knowledge it needs to intervene properly from a variety of scientific disciplines and from other sources (e.g., Donaldson, 2000; Thorne, 2005). In an era where science is believed to be a major, if not the major, basis to organize human life in modern societies as reflected in the current and lively debates around “evidencebased” professional practices, the same question can be asked of medicine, public health, and now health promotion (O’Neill,
2003; Raphael, 2000): Are they scientific disciplines of their own or fields of practice drawing on a variety of other sources to do their job properly? We will not enter into these debates here, which have been thoroughly conducted elsewhere (Bunton & MacDonald, 2004; McQueen & Anderson, 2000), but state our own position. Specifically, we think that because they do not have a specific substantive area of study of their own (the main criterion used by epistemologists, sociologists, and philosophers who study what is required to constitute a science), none of the health disciplines mentioned above are sciences; they are rather fields of practice, drawing on a variety of sources, including scientific knowledge from other disciplines, to construct the body of knowledge required to intervene optimally.
Political Reasons If health promotion in Canada is not a profession or a scientific discipline, but a field of practice, does it have a specificity that differentiates it from the other health-related fields of practice? The answer to this question has a lot of consequences that we will qualify here as political and which are a second set of reasons for paying attention to the definition of health promotion. If health promotion has no identity of its own, it becomes very difficult to decide what to include in the training of people who are supposed to practise it and then to justify having programs devoted to it in universities, colleges, or elsewhere. It also becomes very difficult to establish what kind of knowledge needs to be scientifically (through academic research notably) or otherwise developed to properly ground its practice. And this, in turn, will have consequences for whether or not specific skills in health promotion will be required from certain sets of
34 ■ PART I: Conceptual Perspectives
people in certain types of jobs, be they actually labelled health promotion jobs or not. Overall, then, it will have a lot of impact on the amount and the nature of scarce resources that a specific society will be willing to allocate for this purpose. If we look at Canada on that count, since the Lalonde Report of 1974, can we say that health promotion is clearly enough defined as to have found its niche? As is made obvious in the rest of this book, the answer is not really, and not enduringly. Even if there has been a health promotion discourse, health promotion training programs, research endeavours, and even health promotion governmental programs and eventually a few policies, it has never known as much substantial development as other sectors of society or of the health system have; using the image of Pinder in Chapter 6, it has even been just below the radar screen for almost a decade. We think that one of the main reasons for this has been health promotion’s incapacity as a field to properly differentiate itself from neighbouring fields because of its inability to define itself clearly, internally, and for others; it has thus been very vulnerable when others became politically attractive as was the case when population health became trendy around 1994. It is thus obvious that health promotion, if it wants to exist and survive, must go beyond the self-promoting interest of its academic and practitioner community and clearly articulate what it is and what it has to offer the world, otherwise the world might have no use for it.
Practical Reasons The lack of agreement on what health promotion is about and what it does also has practical consequences. Take the example of a health promotion clearinghouse, a type of facility one of us (AS) has been working in
for over 15 years, whose mandate is to support the capacity of people involved in health promotion practice to do their work effectively. Simply trying to organize resources on different definitions of health promotion highlights conceptual confusion on the nature, values, and purpose of the field (Seedhouse, 1997). Should the “practice” of health promotion be organized according to risk conditions, diseases, or issues (e.g., lifestyles and/or living conditions), or by functions and strategies (e.g., education, policy, communication), or by settings (e.g., schools, workplaces, communities)? Of course, the scope of health promotion practice encompasses all of these aspects and much more: principles, processes, causes, cross-discipline approaches (Duncan, 2004; Nyamwaya, 1997; Raphael, 2000). The practitioner needs all of these resources, but may consider health promotion to be limited to one focus, such as “workplace health.” A clearinghouse has thus a double duty: to anticipate the breadth of possible needs for information and resources on what might fall under the rubric of “health promotion” and to assist its users in considering and applying interrelated elements of the field instead of just a single strategy, issue, or setting. In order to be retrieved and made available to practitioners, information has thus to be organized or classified in a way that reflects the core categories and boundaries of a field and still remain understandable. For example, a classification system for health promotion indicators that uses the Ottawa Charter for Health Promotion has been proposed by a European group; it includes systems, structures, and processes in action areas, health capacities, and health practices (Bauer et al., 2003). It is an elegant model in structure and concept, but it would be difficult for users to browse through the terms and know that they are looking at health promotion practice.
CHAPTER 3: The Promotion of Health or Health Promotion? ■ 35
Without the guide of a common definition, how can we expect anyone to search for “health promotion” and get usable results?
APPROACHES TO DEFINING HEALTH PROMOTION If we agree then that, even if difficult, it is crucial to define health promotion, there are many ways to do it. Information science, for instance, would sort out a set of concepts that provide overall structure, pointers, and access for a body of works, which would guide the information searcher into the ideas and knowledge encompassed by a field (Albrechtsen & Jacob, 1997; Kwasnik & Rubin, 2003). We will explore two of these ways here. On the one hand, we will look at what is meant by health promotion in contrast with other closely related concepts or areas, i.e., health education, population health, and public health. On the other hand, we will look at two attempts, mostly undertaken by Canadian experts, to reach a consensus on what health promotion is all about.
Health Promotion versus Other Related Concepts Health Promotion versus Health Education
As seen in Chapter 1, for most people, health promotion as a field emerged as an evolution of the field of health education, which had formalized itself at the beginning of the 1950s and worked from then on to influence individual health-related behaviours. However, at the end of the 1970s, many health educators realized that trying to influence individual behaviours without altering the environments in which they occurred produced very limited results. In the mid-1980s, the field as a whole relabelled itself “health promotion” to signify notably that from then on, just working to change individual lifestyles was no longer a viable option. A
much broader way to see things, soon to be called ecological (see Chapter 18), was seen as required to understand and influence health-related behaviours. For many, the transition from traditional individualistic health education toward a more ecologically oriented health promotion requesting to intervene at a variety of levels was difficult (Green & Raeburn, 1988). For instance, it is only at the very end of 1993 that the main professional and scientific global organization in the field, the International Union for Health Education (IUHE), decided to follow the trend and rename itself the International Union for Health Promotion and Education (IUHPE), keeping the two expressions within its new title. Even today, in several countries like the US or France, the words “health education” have more currency than “health promotion” in many quarters, sometimes to designate the old version of individualistic health education, sometimes using these words to designate the new, enlarged field called “health promotion” elsewhere. Chapter 16 in this book shows several of these variations worldwide. We can thus say: “Health education comprises consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health” (Nutbeam, 1998, p. 4). Box 3.1, written especially for this book by the former editor of one of the most important journals in the field, Health Education Research, shows that the debate is far from over. No wonder people are still confused today when asked how to differentiate the two! Let us conclude this section then by agreeing with most people today that health education is one strategy within the larger field of health promotion.
36 ■ PART I: Conceptual Perspectives BOX 3.1: H E A LT H E D U C AT I O N : Resurrection and Reinvention
Text not available
Health Promotion versus Population Health
The way in which, in Canada, a “population health” vision replaced the health promotion discourse from 1994 on and for about 10 years has been thoroughly addressed elsewhere in this book, especially in Chapter 6. We share Pinder’s conclusion that both have now found their respective niches in the recent structural and conceptual developments that have taken place since 2002. What is worth mentioning, though, is that from its Canadian origins in the early 1990s, the population health vision has globalized to the point that in 2003, the famous American Journal of Public Health devoted a special issue to the topic. So, what differentiates health promotion from population health? Not much, as some of us have argued elsewhere (Pederson, Rootman, & O’Neill, 2005) because, as we will see below, they are slight variations on the theme of the “new public health,” itself the current reincarnation of a public health vision as old as the human species itself. But different enough to have crystallized the belief that population health is theoretical and polit-
ically conservative as well as epidemiologically, economically, and individually driven; in contrast, for many, health promotion is practical, politically progressive, sociologically and policy-oriented, as well as collectively driven (Labonté, 1995; Robertson, 1995). We think, however, that it is caricaturing both orientations and “in general, the proponents of population health can be seen as allies [of health promotion] in the move towards the new public health, particularly since overall, neither framework has significantly challenged the dominance of biomedicine in the health field” (O’Neill, Pederson, & Rootman, 2000, p. 141). Health Promotion versus Public Health
Finally, we will argue here that for most people involved in the field, health promotion is seen as one of the essential functions of public health, as defined above by Nutbeam. Public health functions are usually identified as protection, surveillance, prevention, and promotion as indicated in several recent documents, but especially the ones derived from a large consensus-building process organized
CHAPTER 3: The Promotion of Health or Health Promotion? ■ 37
by the Pan-American Health Organization. In that document, health promotion is defined primarily as: “The promotion of changes in lifestyle and environmental conditions to facilitate the development of a culture of health” (Pan-American Health Organization, 2002, p. 67). It is also interesting to note that health promotion (as symbolized by the Ottawa Charter) has been identified as the “third public health revolution” of humankind (Breslow, 1999); after the first, which had tackled infectious diseases, and the second chronic illnesses, the health promotion era,
according toBreslow, embarks on the journey toward health and not against diverse types of diseases. This is illustrated in Figure3.1, where we can see that with the evolution of humankind, of the epidemiological patterns of disease and of the technological means available, the various functions of public health have successively developed in a series of layers like sediments, the latter not displacing but building on top of the former, which needs the previous ones to continue to function properly.
F I G U R E 3 . 1 : SEDIMENTATION APPROACH TO PUBLIC HEALTH THROUGHOUT HUMAN HISTORY
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38 ■ PART I: Conceptual Perspectives
Defining Health Promotion through Expert Consensus In addition to definition by differentiation from close concepts, expert consensus is another way that has been frequently chosen. A good example of that approach is the socalled “yellow document.” As WHO regularly does, a group of international experts was convened to address a specific topic—the concept and principles of health promotion— and came up with what is the forerunner of the Ottawa Charter (WHO-Euro, 1984). It is also through such a process that a group of the Canadian Institute of Advanced Research, an institution funded mostly through private monies that convenes task forces on topics that are of major importance for the future of Canada, came up with the famous “population health” framework after a couple of years of intensive work (Frank, 1995). We will explore here two of these efforts of experts to define heath promotion, led largely by Canadians: a more systematic one, done in the context of a major reflection on the evaluation of health promotion (Rootman et al., 2001), and a collection of spontaneous ones that emerged over the last 10 years on Click4HP, an electronic international discussion list monitored out of Toronto. Deconstructing Health Promotion
In an exemplary effort to define what health promotion is all about, in order to discuss how to evaluate it, Rootman and his colleagues
identified 13 of the “most important” definitions of the concept and thoroughly analyzed them according to goals, objectives, processes, and activities. At the end of their content analysis, they conclude endorsing the “preeminence” of the definition proposed by the Ottawa Charter (see below) and by the fact that “[…] the primary criterion for determining if an initiative should be considered health promoting, ought to be the extent to which it involves the process of enabling or empowering communities” (Rootman et al., 2001, p. 14). The “What Is ‘Real’ Health Promotion” Debates on Click4HP
The Click4HP (Click for health promotion) listserv started in April 1996 as a short-term pre-conference public discussion on the uses of the Internet for health promotion, but rapidly grew into a long-lasting, vibrant international online forum on the nature of health promotion and its applications. Click4HP has grown from 350 to a constant 1,200 subscribers since 2000, engaging in exchanging information, seeking solutions, and building connections in more than 10,500 postings in 10 years, at an average of 85 postings a month. On top of being used as a platform to exchange information of all kinds to facilitate the day-to-day work of practitioners, more general debates and exchanges have occurred regarding empowerment, advocacy, healthy lifestyles, wellness, illness prevention, and rehabilitation, foundations and values,
BOX 3.2: C L I C K 4 H P : A N E L E C T RO N I C V E N U E F O R D E B AT I N G H E A LT H P RO M OT I O N I S S U E S
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CHAPTER 3: The Promotion of Health or Health Promotion? ■ 39
settings and strategies, and the myriad determinants of health. Regularly, there are vigorous debates on the list on the definitions and the breadth of health promotion. The longest of these was in September 1996 with more than 30 postings on “What is ‘real’ health promotion” (see annotated Web sites below), followed by a 1998 learned discussion among HP scholars on foundations and limits of the field (18 long postings), a lively exchange in 1999, and again in the fall of 2000 on what is HP (contrasting definitions of population health, HP, and prevention), and, finally, a vigorous exchange in 2004, rekindled in 2005, following a question of whether health promotion was dead or heading there. Each time, these debates show that HP is alive and kicking, but at the same time that “health promotion continues to be constrained by the lack of a consistent, clear and usable definition” (Click4HP, 2004), which explains why such debates erupt over and over again on Click4HP and in many other venues.
TRYING TO SOLVE THE DEFINITIONAL DILEMMA The CHN Classification Scheme of Health Promotion In 1998 the Canadian Health Network (CHN) was launched as a federally funded health promotion initiative to provide, through a national bilingual Web site, highquality, credible, and relevant health information for the general public and health professionals. It has been seen as a public sector response to consumers’ increasing use of the Internet to search for health information among a morass of very uneven sources (Cline & Haynes, 2001; Fox & Rainie, 2000; Health Canada, 2000; Korp, 2006). CHN operates through a unique collaboration involving affiliates who are key partner organizations in 22
topic areas and link to hundreds of organizations that contribute electronic resources to the CHN Web site; affiliates select resources, produce feature articles, and respond to health information requests. Why a Definition of Health Promotion Was Needed across CHN
Although CHN was labelled from the outset a “health promotion network,” there had been little consistent vision of what that meant in practice. With the proliferation of health information Web sites by governments and health agencies, CHN needed to make clear what it did differently. In 2003, CHN’s Advisory Board set new strategic directions for 2004–2007, the first of which was to strengthen its focus on health promotion, including all of the determinants of health, across the entire network (CHN, 2003). However, a commitment to health promotion is not enough to ensure consistency in application across so broad an organization. In the 2004 round of affiliate renewals, a new health promotion affiliate was thus established with a dual goal of building the online resources as well as health promotion capacity of CHN as a whole. CHN’s Working Definition of Health Promotion and a Tool to Assess It
A working definition of health promotion was agreed upon through a series of workshops held in 2005. It integrated the Ottawa Charter’s definition with a recognition of levels of intervention and attention to determinants that encompassed the breadth of perspectives given the many affiliates. A simple one-page tool was then developed to assess how this definition could be reflected in all the work of CHN. The health promotion assessment checklist (see annotated Web sites below) uses a matrix-like frame addressing who, where, why, how, and what is considered in an initiative. Each term
40 ■ PART I: Conceptual Perspectives
on the bilingual HP checklist is hyperlinked to a Web-based definition or explanation of what it means in context. The checklist is designed to be concise, comprehensive, and yet simple, customizable by affiliates, and compatible with other forms, tools, and qualitytesting mechanisms required for CHN collection of resources. Testing took place in spring 2006, with a subsequent evaluation and modifications. Is CHN’s Problem Solved?
Integrating a broad health promotion approach that requires considering multiple strategies, determinants, and levels into what used to be a rather individualistic health information service is difficult. It comes at a time when there are pressures for quality assurance of all content on CHN through peer review, evidence-based resource selection, and establishment of standards of practice (Balka, 2005). Demonstration of health promotion “competencies” for all CHN affiliates in staffing and organizational practice is expected for the next round (Fall 2006) of affiliate application process for three-year contracts. As we have been able to observe thus far, for many of the diverse health and social organizations forming the CHN collaboration, there seems to be little difference between their usual work through individual lifestyle behaviour-change messages and the health promotion approach and definition that they now are expected to apply. Consequently, concerns from government and health agencies in CHN that health promotion is not a clearly defined area are likely to continue, at least for a while.
The Promotion of Health versus Health Promotion: A Conceptual Avenue to Solve the Definitional Dilemma? So, is there such a thing as health promotion? Are there ways to solve the confusion that is
pointed out by so many people, even among the most knowledgeable? Our answer is yes, and for this it is helpful, as one of us proposed in the first edition of this book (O’Neill & Cardinal, 1994), as well as in several other venues since then (O’Neill, 1997, 1998, 2003), to distinguish between two things. On the one hand, there is the discourse on the place of health in societies, often called the “new public health” discourse, which we will label here the promotion of health. On the other hand, there is the specialized field of intervention within the broader field of public health, aimed at the planned change of behaviour and environments related to health, which we will call health promotion. This distinction is well illustrated if we contrast two of the best-known definitions of the field, the one from the Ottawa Charter (WHO, 1986, p. 1): “The process of enabling people to increase control over, and improve, their health” with the one (Green & Kreuter, 2005, p. 462): “[…] any planned combination of educational, political, regulatory and organizational supports for actions and conditions of living conducive to the health of individuals, groups or communities.” The Ottawa Charter’s definition, as well as the preface to this book by Kickbusch and most governmental health policy documents in Canada or around the world since the mid1970s, are typical of the reflections on what health is or should be; on the place health should have in societies; and on who should undertake health promoting, health restoring, or health-maintaining endeavours (individuals, governments, civil society, corporations, the health sector—including public health professionals—other sectors, etc.), hence the idea of naming this a discourse on the promotion of health. Basically, it is nothing but the old public health discourse, which has been around for centuries (Fassin, 2000) and which tries to reflect upon what health is in societies
CHAPTER 3: The Promotion of Health or Health Promotion? ■ 41
or populations; what produces or hinders it; and what can be done to improve it, reduce the risk of losing it, or restore it when compromised. The discourse on the promotion of health in modern societies, which has been rekindled by the efforts of the European Office of WHO and is so strongly symbolized by the Ottawa Charter since the mid-1980s, is usually referred to as the “new” (Ashton & Seymour, 1988; Martin & McQueen, 1989) or the “ecological” public health (Chu & Simpson, 1994; Kickbusch, 1989) in order to differentiate it from the more classical discourse of “hygiene” or “old” public health, which is better adapted to traditional societies with an epidemiological pattern of infectious disease. Consequently, it is why we argue here that population health, as it emerged in Canada in 1994, is but a variation of this new public health discourse on the promotion of health. Conversely, if we look at Green and Kreuter’s definition, it is more in line with the idea that health promotion is a specialized subarea, or essential function, of the public health sector of health systems whose specificity is the planned change of lifestyles and life conditions having an impact on health, using a variety of specific strategies, including health education, social marketing, and mass communication on the individual side, as well as political action, community organization, and organizational development on the collective side. If we agree with this, then the planned change skills of properly trained health promoters can be used at whatever stage in the natural history of any illness or health problem (thus in primary or secondary prevention, in acute care, in rehabilitation, or in tertiary prevention) and at any level, from the individual to the societal, including the family and the community. Moreover, a variety of value bases can be used to work with these health promotion skills and, conversely, the value base promoted by
the Ottawa Charter (social justice, participation, empowerment, etc.) is in no way restricted to specialized health promotion interventions, but belongs to anybody working in the new public health era, be they public health, health or other professionals, or even lay people. Finally, if they want to be as effective as they can be, planned change health promotion interventions need to be knowledge-based or even evidence-based when that type of information is available. The relationship between the promotion of health and health promotion is illustrated in Figure 3.2.
CONCLUSION As discussed in this chapter, it is obvious that the two elements are often present together when people use the words “health promotion,” which maintains the confusion and the impression for many that health promotion as a specialized subfield of public health does not exist. This is due notably to the fact that the Ottawa Charter’s definition, and the value base it carries, are by far dominant on the planet when one hears “health promotion.” As seen throughout this book, it gives a very clear and distinct orientation to how people perceive Canadian health promotion, despite the fact that different value bases and different ways of approaching health promotion do exist here as well. Hence, in conclusion, we suggest using the words “new public health” or “ecological public health” when we talk in general about the discourse on the promotion of health, and reserve the expression “health promotion” to designate the specific planned change skills needed to complement the types of skills developed in other subareas of public health practice in order to achieve the results desired by the “new public health” discourse.
42 ■ PART I: Conceptual Perspectives F I G U R E 3 . 2 : T H E P RO M OT I O N O F H E A LT H V E R S U S H E A LT H P RO M OT I O N
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REFERENCES Albrechtsen, H., & Jacob, E.K. (1997). Classification systems as boundary objects in diverse information ecologies. In E. Efthimiades (Ed.), Advances in classification research: Proceedings of the 7th ASIS SIG/CR Classification Research Workshop (pp. 1–13). Medford: Information Today. Ashton, J., & Seymour, H. (1988). The new public health. Philadelphia: Open University Press. Balka, E. (2005). Redefining P3: Political economy, policy, and privacy issues on the Canadian health information highway. In L. Shade & M. Moll (Eds.), Communications in the public interest, vol. 2: Seeking convergence in policy and practice (pp. 512–547). Ottawa: Canadian Centre for Policy Alternatives. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp, U., & Hill, C. (2003). Advancing a theoretical model for public health and health promotion indicator development. European Journal of Public Health, 13(3 Suppl.), 107–113. Breslow, L. (1999). From disease prevention to health promotion. JAMA, 281(11), 1030–1033. Bunton, R., & MacDonald, G. (Eds.). (2004). Health promotion: Disciplines and diversity (2nd ed.). London and New York: Routledge.
CHAPTER 3: The Promotion of Health or Health Promotion? ■ 43 CHN. (2003). Canadian Health Network Advisory Board proceedings. Retrieved November 2003 from www.canadian-health-network.ca/servlet/ContentServer?cid=1086089762068&pagename=CHNRCS/Page/ShellCHNResourcePageTemplate&c=Page&lang=En Chu, C., & Simpson, R. (1994). Ecological public health: From vision to practice. Toronto: Centre for Health Promotion; University of Toronto; Participaction. Click4HP. (2004). Posting made September 27, 2004. Cline, R.J.W., & Haynes, K.M. (2001). Consumer health information seeking on the Internet: The state of the art. Health Education Research, 16(6), 671–692. Coburn, D. (1988). The development of Canadian nursing: Professionalization and proletarianization. International Journal of Health Services, 18(3), 437–456. Donaldson, S.K. (2000). Breakthroughs in scientific research. The discipline of nursing: 1960–1999. Annual Review of Nursing Research, 18, 247–311. Duncan, P. (2004). Dispute, dissent, and the place of health promotion in a “disrupted tradition” of health improvement. Public Understanding of Science, 13, 177–190. Fassin, D. (2000). Comment faire de la santé publique avec des mots. Une rhétorique à l’œuvre. Ruptures, revue transdisciplinaire en santé, 7(1), 58–78. Fox, S., & Rainie, L. (2000). The online health care revolution: How the web helps Americans take better care of themselves. Washington: Pew Internet & American Life Project. Frank, J. (1995). Why population health? Canadian Journal of Public Health, 86(3), 162–164. Freidson, E. (1977). Professional dominance: The social structure of medical care. Chicago: Aldine Publishing Company. Green, L.W., & Kreuter, M.W. (2005). Health program planning: An educational and ecological approach (4th ed.). Boston, Toronto: McGraw-Hill Higher Education. Green, L.W., & Raeburn, J.M. (1988). Health promotion: What is it? What will it become? Health Promotion, 3(2), 151–159. Health Canada. (2000). Blueprint and tactical plan for a pan-Canadian health infostructure. FederalTerritorial Advisory Committee on Health Infostructure. Ottawa: Health Canada, Office of Health and the Information Highway. Kickbusch, I. (1989). Good planets are hard to find. Copenhagen: FADL Publishers. Korp, P. (2006). Health on the Internet: Implications for health promotion. Health Education Research, 21(1), 78–86. Kwasnik, B.H., & Rubin, V.L. (2003). Stretching conceptual structures in classifications across languages and cultures. Cataloging & Classification Quarterly, 37(1/2), 33–47. Labonté, R. (1995). Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health, 86(3), 165–168. Martin, C.J., & McQueen, D.V. (Eds.). (1989). Readings for a new public health. Edinburgh: Edinburgh University Press. McQueen, D.V., & Anderson, L.M. (2000). Données probantes et évaluation des programmes en promotion de la santé. Ruptures, revue transdisciplinaire en santé, 7(1), 79–98. Nutbeam, D. (1998). Health promotion glossary. Geneva: World Health Organization, WHO/HPR/HEP/98.1. Nyamwaya, D. (1997). Health promotion practice: The need for an integrated and processual approach. Health Promotion International, 12, 179–180. O’Neill, M. (1997). Health promotion: Issues for the year 2000. Canadian Journal of Nursing Research, 29(1), 71–77.
44 ■ PART I: Conceptual Perspectives O’Neill, M. (1998). Defining health promotion clearly for teaching it precisely: A proposal. Promotion & Education, 5(2), 14–16. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? SPM International Journal of Public Health, 48(5), 317–326. O’Neill, M., & Cardinal, L. (1994). Health promotion in Québec: Did it ever catch on? In A. Pederson et al. (Eds.), Health promotion in Canada (pp. 262–283). Toronto: W.B. Saunders. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Ottoson, J.M., Pommier, J., Macdonald, G., Frankish, J., & Dorion, L. (2000). The landscape in health education and health promotion training. Promotion & Education, 7(1), 27–32. PAHO. (2002). Public health in the Americas (Technical publication #589). Washington: Pan-American Health Organisation. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). London: Palgrave. Potvin, L. (2005). Présentation dans le séminaire doctoral SAC-66008, Université Laval, octobre 17, 2005. Raphael, D. (2000). The question of evidence in health promotion. Health Promotion International, 15(4), 355–367. Robertson, A. (1995). Theory divides, data unite: Health promotion meets population health. Unpublished manuscript, Toronto. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). Copenhagen: WHO-Euro. Seedhouse, D. (1997). Health promotion philosophy, prejudice, and practice. Auckland: Wiley. Thorne, S. (2005). Conceptualizing in nursing: What’s the point? Journal of Advanced Nursing, 51(2), 107–107. Tones, K., & Green, J. (2004). Health promotion: Planning and strategies. London: Sage. WHO. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. WHO-Euro. (1984). Health promotion: A discussion document on the concept and principles. ICP/HSR 602 (m01). Unpublished manuscript, Copenhagen. Winslow, C.E.A. (1920). The untilled fields of public health. Science, 51, 23.
CRITIC AL THINKING QUESTIONS 1. If you had to define health promotion to the following people, what would you say? • Your uncle Jack in a family gathering • A graduate student in physics • Ms. Jones at the neighbourhood centre community group 2. Do you now personally think that defining health promotion is important? Why? 3. Following the instructions in Box 3.2, browse the archives of Click4HP for at least an hour; after that, do you think you should subscribe to keep current about Canadian developments in health promotion? Why?
CHAPTER 3: The Promotion of Health or Health Promotion? ■ 45
4. Explain the difference between the promotion of health and health promotion. Do you believe it is a useful distinction or not? Why? 5. After browsing the CHN Web site at www.canadian-health-network.ca for at least an hour, do you think it is a health promotion site? Why?
FURTHER READINGS Bunton, R., & MacDonald, G. (Eds.). (2004). Health promotion: Disciplines and diversity (2nd ed.). London and New York: Routledge. One of the key books to reflect on whether or not health promotion can be considered a discipline. Green, L.W., & Kreuter, M.W. (2005). Health program planning: An educational and ecological approach (4th ed.). Boston, Toronto: McGraw-Hill Higher Education. If you had to buy just one book in health promotion in your life, it should be this one for its positioning of the field as well as for its famous PRECEDE-PROCEED planning framework.
RELEVANT WEB SITES Canadian Health Network www.canadian-health-network.ca
A key Canadian Internet resource on health-related issues. Health Promotion Assessment Tool www.opc.on.ca/draft/HPChecklist.htm
Provides the current version of CHN’s checklist to assess if a resource or initiative can be considered a health promotion one. What Is “Real” Health Promotion? www.web.ca/~stirling/c4hpreal.htm
An edited compilation of more than 30 postings made during September 1996 on Click4HP about “What is real health promotion?”
CHAPTER 4
P O I N T S O F I N T E RV E N T I O N I N H E A LT H P RO M OT I O N P R AC T I C E Katherine L. Frohlich and Blake Poland
INTRODUCTION istorically there have been three major points of intervention in health promotion practice: (1) issues; (2) “at-risk” populations; and (3) settings. Each of these approaches to intervention embodies different assumptions about what shapes health outcomes; that is, what is most important and what can most feasibly be changed. As a result, each of these approaches has singled out different aspects of analysis and intervention. In all three approaches there is a more or less explicit acknowledgement that individuals are not completely autonomous decision makers and that the social context has both relevance and importance to what they do. Nevertheless, the ways in which each of these approaches has dealt with the social context differs in important ways. Followup from acknowledgement of the importance of social context to action has not, for the most part, been as systematic or comprehensive as we believe is necessary for an effective and enlightened health promotion. We detail the reasons for believing so in this chapter. We begin by giving a brief description of each of the three traditional approaches to intervention. We then briefly outline how each of these approaches has grappled with the notion of the social context, discussing their strengths and weaknesses. We conclude with some suggestions as to the role that social context could play as a point of intervention in health promotion practice by
H
46
examining some potential avenues for both research and practice.
ISSUES, POPULATIONS, AND SETTINGS AS POINTS OF HEALTH PROMOTION INTERVENTION Issues The Ottawa Charter for Health Promotion (World Health Organization, 1986) set the stage for health promotion practice as we understand it today. While the goal of the Ottawa Charter was extremely broad, covering five large areas of action and multiple conditions and resources for health, one of the areas of action taken up most enthusiastically by the health promotion community, in line with health education interventions (which had been in place since the 1950s), has been that of developing personal skills. Within the Charter, developing personal skills was described as being possible through “providing information, education for health, and enhancing life skills. By so doing, it increases the options available to people to exercise more control over their own health and their environments, and to make choices conducive to health” (World Health Organization, 1986, p. 3). Before the Ottawa Charter, and definitively since then, health promotion practice has shown enormous dedication to developing these personal skills in three major ways:
CHAPTER 4: Points of Inter vention in Health Promotion Practice ■ 47
(1) by focusing on a reduction in the prevalence and incidence of those diseases most burdening the population (cardiovascular disease, diabetes, and HIV/AIDS); (2) by focusing on the reduction of health behaviours linked to the most egregious health problems facing the population (such as smoking, poor eating habits, lack of exercise, lack of condom use), as well as (3) by reducing risk conditions such as homelessness, which is neither a disease nor a health behaviour. While the goals described as the development of personal skills were laudable at the time, these goals have largely been translated into interventions and policies that have ended up focusing on the reduction of the nefarious health lifestyle habits such as smoking, poor diet, lack of exercise, and risky sexual behaviour through information and education programs. A larger focus on increasing the options available to people to exercise more control over their own health and their environments in order to reduce disease prevalence, incidence, and risk conditions has been, for the most part, more evident in rhetoric than in practice. The focus on risk factors in health promotion interventions has a protracted history stemming from health promotion’s historical roots in both epidemiology and health education. Tannahill (1992) explored this relationship between epidemiology and health promotion. He describes the fundamental role that epidemiology plays for health promotion in identifying and prioritizing prevalent health problems and their causes. First, in response to epidemiologic studies and their results, health promotion researchers largely focus their programs and interventions on preventing the problems highlighted by these studies. So, for instance, the focus on cardiovascular disease, diabetes, or HIV/AIDS, driven by epidemiologic studies, has created great impetus for health promotion programs
to address these issues. Second, epidemiologists derive categories of risk factors associated with these health problems, which, if prevented, are presumed to reduce illness and death (Frohlich & Potvin, 1999). These risk factors are then often directly translated into health promotion programs. Because many of these risk factors (high blood pressure, overweight, and risky sexual behaviour) are modifiable through behaviours (exercise, fat content reduction in one’s diet, condom use), the focus of health promotion has often been more on the proximal, supposedly modifiable, individual-level risk factors. Because of its focus on individual-level risk factor reduction, health promotion needed individual-level theories to guide the creation of its intervention programs. These theories, the basis of health education, come largely from models of social psychology, such as the health belief model (Becker, 1974), Bandura’s social cognitive theory (Bandura, 1986), and Ajzen and Fishbein’s theory of reasoned action (1980). These models and theories all focused attention on the major biomedical and behavioural risk factors for developing the major health problems of concern at the time. Underlying these models, population prevalence of adverse risk conditions are thought to be modifiable by providing education and behaviour-change tools to individuals to help them achieve lifestyle changes (Barnett et al., 2005). Where these interventions and theories have acknowledged the social context has thus largely been through the individual and her or his decision making. So, for instance, social context within some individual-level risk factor models tends to focus on the more proximal interpersonal or physical environment (Poland et al., 2006), examining influences such as peers, co-workers, family members, and other role models. Social context is thus understood as being the immedi-
48 ■ PART I: Conceptual Perspectives
ate individual-level influences that come about due to individual social interactions. Interventions addressing these issues have also considered the social context in terms of the influence of social norms on individual behaviour. Huge efforts have been undertaken in many areas of health promotion, most strikingly in the area of tobacco consumption, to de-normalize the practice of smoking. In the context of social behaviours (such as cigarette smoking), de-normalization seeks to change attitudes regarding what is considered normal or acceptable behaviour in order to shape individuals’ views regarding the unacceptability of smoking.
Specific “At-Risk” Populations A second important point of intervention in health promotion, focusing on “at-risk” populations, has largely sought to target particular groups or populations thought to share certain key characteristics. These characteristics are frequently thought to predispose these groups to be at risk for “suboptimal” health outcomes, for instance, disease, compromised resilience/coping, etc. It is sometimes assumed with varying accuracy that populations function as “communities” with shared interests and values, for example, the homeless, the elderly, Aboriginal peoples, or new immigrants. The main advantage of this approach over the former, which focused more specifically on diseases or risk factors, is that this approach provides an opportunity to see how behaviours cluster within populations, and links these behaviours to some of the life circumstances and conditions that they share in common. This approach also fits structurally with how many organizations (governmental and non-governmental) and funding bodies are organized with separate structures for Aboriginal health, organizations working with the homeless, the elderly, etc.
To elaborate on the importance of understanding “at-risk” populations, we draw on the example of Aboriginal peoples in Canada (Adelson, 2005; Frohlich, Ross, & Richmond, in press). Aboriginal peoples are a diverse group of many tribes, languages, and cultures, but they all share a common experience of colonization and all that this has entailed (forced resettlement, residential schools, removal of ancestral lands, rights to minimum services defined according to governmental arbitration of who qualifies as status or non-status Indians, and so forth). The resultant cultural upheaval, family and community breakdown, sedentarization, disrupted connection to the land, etc., has had severe consequences in terms of community and individual mental, social, spiritual, and physical health (examples of the outcomes include issues of addiction, diabetes, suicide, etc.). Aboriginal leaders have long fought, among other things, against the dominant Western cultural paradigm’s tendency to blame the victim (labelling Aboriginal peoples as lazy, stupid, backwards, or uneducated) and to advocate instead for an understanding that places current community health problems in their proper historical context (as impacts of colonization, institutional racism, etc.). In so doing, health promotion practice focuses more on the structural constraints component of the social context for this population.
Settings The final point of intervention to be addressed in this chapter involves the emergence of settings as a key focus and approach in health promotion practice (Poland, Green, & Rootman, 2000). This issue has been driven by both pragmatic and conceptual issues. On the pragmatic side, and under the leadership of the World Health Organization, there has been an alignment of health promotion work with the places in which popu-
CHAPTER 4: Points of Inter vention in Health Promotion Practice ■ 49
lations of interest are to be found (World Health Organization, 1998). Efforts have been made to access relatively captive audiences for health education programming (for example, children are accessed through schools, adults through the workplace, the homeless through shelters, etc.). Note that there are some perverse consequences of this. For example, negotiations may be difficult with the gatekeepers with whom access to “their” populations must be negotiated and may be at odds with those of the health promoter. For instance, the former may want public health to teach their workforce stress-management skills, and the latter may be more drawn to mobilizing workers to demand better working conditions and a living wage. A second thrust behind the recent interest in the settings approach for health promotion practice is a more substantial one from our point of view: It has to do with the realization that behaviour change needs to be supported with environmental conditions that are most favourable to its emergence and maintenance (that is, making healthy choices easier choices). Thus, physical activity requires access to playgrounds for children as well as parks/green spaces and public paths for the entire population; smoking cessation requires access to smoke-free spaces in the workplace and in the community; weight control and healthy eating requires changes to school cafeteria menus, availability of healthy foods in communities, etc. It has further been acknowledged that by altering the social conditions that shape health behaviours, health promotion assists not only in reducing the risk of poor behaviours for those currently at risk, but simultaneously reduces the risk of future generations (Smedley & Syme, 2000). So, for instance, by increasing the number of bicycle paths within a city, one increases the likelihood that people who suffer from obesity might be better able
to exercise in order to reduce their problem of being overweight. At the same time, and by virtue of the bicycle paths existing, children and adults who might later be at risk of obesity are provided with an opportunity (granted they own a bike and know how to ride one!) to exercise daily, thus potentially protecting them from future problems with being overweight. This point addresses the necessary focus on increasing the options available to people in order to exercise more control over their health. A third thrust is through what has been called the social environment approach to social context (Barnett et al., 2005; Emmons, 2000; Marmot, 2003; Smedley & Syme, 2000). Barnett et al. (2005) offer a definition of the social environment: Social environments encompass the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact. Components of the social environment include built infrastructure; industrial and occupational structure; labour markets; social and economic processes; wealth; social, human and health services; power relations; government; race/ethnic relations; social inequality; cultural practices; the arts; religious institutions and practices; and beliefs about place and community. (p. 107)
The advantages of this approach, the authors claim, are that programs and interventions focus “upstream” and thus the onus is not as much on the individual to control or change his or her behaviour, but rather on policies and programs to provide the opportunities for populations to change their practices. As described by Smedley and Syme, the social environmental approach is based on an ecological model (McLeroy et al., 1988; Stokols, 1996; see also Chapter 18). This model assumes that differences in levels of health are
50 ■ PART I: Conceptual Perspectives
affected by an interaction between biology, behaviour, and the environment, an interaction that unfolds over the life course of individuals, families, and communities. This model also assumes that age, gender, race, ethnicity, and socio-economic differences shape the context in which individuals function and therefore directly and indirectly influence health risks and resources. This ecological
model is best operationalized, according to these authors, by a social environmental approach to health interventions. As illustrated in Figure 4.1, this approach emphasizes how individuals’ health is influenced not only by biological, genetic functioning, and predisposition, but also by social and familial relationships, environmental contingencies, and broader social and economic trends.
F I G U R E 4 . 1 : MULTI-LEVEL APPROACH TO EPIDEMIOLOGY
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One of the most cited and successful examples of the social environmental approach has been in tobacco control over the last two decades. An important shift has taken place away from a strict focus on educating individuals about the dangers of smoking and toward changing the social environment. More specifically, and in many provinces, excise taxes on cigarettes have been introduced, changes have been made to laws with regard to smoking in public places, and there has been an attempt to reduce and further regulate the marketing of tobacco. Such social environmental changes have been found to
reduce heart disease mortality (Fichtenberg & Glantz, 2000) and the incidence of lung cancer in California since the state-wide tobacco control program was implemented in 1988 (Barnoya & Glantz, 2004).
WHY FOCUSING ON ISSUES, BEHAVIOURS, POPULATIONS, AND SETTINGS CAN COME UP SHORT WHEN ADDRESSING THE SOCIAL CONTEXT Thus far we have documented three of the most important points of intervention in
CHAPTER 4: Points of Inter vention in Health Promotion Practice ■ 51
health promotion practice. We have addressed some of their successes and described some of the ways in which each of these addresses the social context. We now turn to some of the problems that have been noted with regard to each of these approaches in order to highlight the ways in which an alternative approach to addressing the social context could better enable us to intervene in the future of health promotion.
Issues and Social Context: Some Limitations With regard to the approach by issues, one of the most substantiated critiques of the “developing personal skills” approach to health promotion practice has been that most individually based models of behaviour change have actually proven to be ineffective in helping people change their high-risk behaviour. One of the most infamous of these examples is illustrated by the Multiple Risk Factor Intervention Trial (MRFIT). In this study 6,000 men, all of whom were in the top 10–15 percent risk group in the United States due to their high rates of cigarette smoking, hypertension, and hyper-cholesterol levels, were enrolled in a six-year intervention program. The intervention was state-of-the-art: well funded, well staffed, and used the best behaviour-change techniques available. Even so, the results were enormously disappointing: 62 percent of the men were still smoking after the six-year period, 50 percent still had hypertension, and few men had changed their dietary patterns (Multiple Risk Factor Intervention Trial Research Group, 1981, 1982). Among the many reflections that have taken place since the MRFIT experience, one of the most important has been that even if the MRFIT had been a success, it would have affected only 6,000 men and there would always be 6,000+ more men to replace them
as high-risk candidates for cardiovascular disease since the social contextual conditions creating the problem in the first place remain unchanged. The underlying problem with the high-risk behaviour modification approach, if one is truly interested in sustained population change, is that it does not address what has been termed the “fundamental causes” (Link & Phelan, 1995). The fundamental cause posits that one has to understand the factors, as well as the mechanisms, that put people at risk (that is, the social context), and not just focus on risk factors alone.
High-Risk Populations and Social Context: Further Limitations The problem with the high-risk approach has also been articulated in terms of levels of intervention. In order to deal with health promotion concerns, one can address “downstream” individual-level phenomena (such as individual, behavioural factors, or physiologic pathways to disease), “midstream” factors (such as population-based interventions that aim to change either behaviours or some influence that is affecting entire populations), as well as “upstream” phenomena (such as public policies) as illustrated in Figure 4.2, which is derived from Jetté’s (1994) work. The midstream and upstream approaches have received less attention, but are critical for several reasons. First, many of the risks for disease are shared by large groups of people. If we think of the major health problems facing Canada today, we can figure here obesity, cardiovascular disease, and diabetes. Some of the behaviours associated with these health problems, such as poor diet, lack of proper exercise, and smoking, can be addressed using individual behaviour-modification techniques, but these techniques do little to address the reasons why individuals may be eating poorly, exercising less than they should, and smoking.
52 ■ PART I: Conceptual Perspectives F I G U R E 4 . 2 : POINTS OF INTERVENTION FOR PHYSICAL INACTIVITY
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Furthermore, the one-to-one interventions do little to change the population distribution of diabetes, obesity, or cardiovascular disease as new people continue to enter the high-risk category since the causes of these risks have not been addressed. Another critique in relation to interventions focusing on “at-risk” population approaches is that even if one solves the health problems for some individuals within the “at-risk” populations, such as the homeless, Aboriginal peoples, or the elderly, there are population patterns that persist within these groups. This patterned consistency of disease rates among these groups emphasizes the importance of social and other environmental factors in creating disease rates. Again, the question to be asked is: Why are these groups more at risk than others? A final critique of the “at-risk” population approach is that it falls short in terms of its potential to understand what it is that marginalized groups share in common and how social relations are structured in ways that generate non-random distributions of material, social, and health consequences. In other words, the danger of focusing on at-risk populations is that one overemphasizes difference while failing to account for the ways in which
processes of marginalization look remarkably similar across marginalized groups. These similarities have their roots in power relations that are structured in society to create cleavages along race, class, and gendered lines (Grabb, 1997). This is the structured relationships between what Saul Alinsky (1969) would call the have and the have-nots. These are the ways in which power operates through control over material resources, ideological resources, and human resources. So, there is a need to link up across marginalized groups, for example, to understand the larger forces at play as well as the meso- and micro-level forces that cause them to play out as they do for particular subgroups and individuals in particular places and points in history.
Settings and Social Context: Final Limitations In relation to approaches focused on settings, while some of the social environmental approaches have been shown to have positive population-level effects on health outcomes, there is growing evidence, despite these efforts, that health problems, such as tobacco use, are increasingly concentred among the most underprivileged subpopulations in soci-
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ety such as people of lower income and education levels (Health Canada, 2001; US Centres of Disease Control and Prevention, 2001), as well as people experiencing serious mental illness and homelessness (Conner, Cook, & Herbert, 2002; Lawn, Pols, & Barber, 2002). So, while the overall population rates of smoking are going down, the rates are decreasing much less quickly, if not increasing, for the most disadvantaged groups in society. This concentration of smoking among particular subgroups of the population is not a naturally occurring or “random” event, but is tied to how our society is organized. Underlying these inequities are complex social processes fundamental to understanding the continued prevalence and unique social distribution of smoking. This problem raises two important issues. First, it is a well-known fact that the people who benefit the most from health promotion interventions of all types are those who are best off socially and economically. So, while socio-environmental approaches may attempt to reach the population as a whole, in reality many of the interventions tend to reach only those in socio-economically advantaged situations. As mentioned above, this has been evidenced by the efforts and effects of the tobacco-control community. Second, socio-environmental approaches do not really leave room for asking why a health behaviour, such as smoking, is socially distributed in the way that it is, and thus does not ask why the behaviour is more acceptable in some milieus than in others. What this entails is that our interventions may be inappropriate for those who most need them, and indeed may be aggravating the situation of those who are most disadvantaged. Overall then, we propose that among the shortcomings associated with models akin to the social environmental approach is that they are extensions of a classic epidemiological
model to understanding disease and healthrelated behaviour. Indeed, while attempts to define social environment, such as that of Barnett et al. (2005), are laudable, they do not help us explain how the numerous factors listed in their definition—such as wealth, cultural practices, or race/ethnic relations— influence health outcomes. Shim (2002, p. 129) has argued similarly, stating that, “multi-factorial models and accompanying representations of race, class and gender amount to a black box in which ‘individualised’ inputs to epidemiological sociology are routinised, while the interior workings of the black box—how inequality, poverty and powerlessness affect health—remain unexamined.” Shim then further suggests that the epidemiological method distills the effects of social and relational ideologies, structures, and practices thereby rendering invisible the very social relations supposedly responsible for the disease outcomes of interest. We will come back to this point more specifically when discussing issues of power relations.
Shortcomings: A Summary What seems clear is that there are some lacunas with the current points of intervention in health promotion practice. We need to know, more specifically, how social inequities in health are produced, and thus, what exactly it is about the various factors comprising the social environmental model that contribute to ill health; not only what factors are important, but how and why they are important. What is needed is an understanding of how individuals, their behaviours, and their social circumstances interact to bring about the health problems faced by health promotion today. Only by knowing this can we intervene more appropriately.
54 ■ PART I: Conceptual Perspectives
WHAT C AN BE DONE DIFFERENTLY? The Structure/Agency Debate Studies of the social context of health behaviours and outcomes bring us inevitably to a critical discussion as old as Western philosophy—that of individual free will versus structural determinism, or what is today referred to as the structure–agency debate. Proponents of structural explanations emphasize the power of structural conditions in shaping individual behaviour (Cockerham, 2005). So, for instance, if one were to take a structural position to understanding tobacco consumption, one might be particularly concerned with the role of social class (one instantiation of the social structure) in shaping smoking. Advocates of agency, on the other hand, accentuate the capacity of individual actors to choose and influence their behaviour regardless of structural influences. This structure–agency dichotomy was also defined in terms of chances and choices by Max Weber (1922), who was, coincidentally, the first theorist to discuss the term “lifestyle.” Weber viewed life chances as the opportunities that people encounter due to their social situation (their position within the social structure). Choices, on the other hand, are the decisions people make. So, whereas health-related choices are voluntary, life chances either enable or constrain choices, as choices and chances interact to shape behavioural outcomes. What Weber highlighted, then, is that both chances and choices are socially determined, and thus choices cannot simply be individually controlled. In so doing, Weber also underscored the collective nature of behaviours by associating lifestyles with status groups, and not solely with individuals; that is, choices are shaped by one’s position within the social hierarchy. What Weber witnessed was that people from different
social classes tended to share certain behaviours and practices, a position also shared by French sociologist Pierre Bourdieu, who describes a similar phenomenon through his notion of habitus (Bourdieu, 1980, 1992).
Collective Lifestyles as a Useful Heuristic Device to Address Social Context Issues in Health Promotion A theory-based sociological approach to what we call collective lifestyles (Frohlich et al., 2002), building on the ideas of Weber and Bourdieu, has the potential to offer more to health promotion practice than serving as a synonym for patterns of individual risk behaviours and packages of variables. Bear in mind, however, that considerations of the role of lifestyle are far from new in health promotion practice. Green and Kreuter (1999), for instance, pay particular attention to the important role that lifestyle has played in permitting health promotion to move away from its earlier emphasis on health behaviour alone. While these authors were mindful of the collective aspect to lifestyles, they tend to consider them more in terms of practice and behavioural patterns, rather than situating these practices within the social structure as Weber and Bourdieu do. Using a collective lifestyles approach, therefore, can help not only to prevent a reductionist and individual-centred perspective, but with this approach we can also take into account both behaviours and social circumstances (Abel, Cockerham, & Niemann, 2000). Collective lifestyles comprise interacting patterns of health-related behaviours, orientations, and resources adopted by groups of individuals in response to their social, cultural, and economic environment (Abel, Cockerham, & Niemann, 2000, p. 63). Viewed in this way, collective lifestyles are akin to the social environmental approach in that they
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take into consideration the social, cultural, and economic environments in which people live, get sick, and die. There are a number of important differences, however, between these two approaches that make the collective lifestyle option increasingly palatable to a health promotion hungry for change. First, the collective lifestyles framework develops further the issue of choices and chances by adopting current sociological language. Within this framework, therefore, we speak of social practices (Bourdieu, 1980, 1992; Giddens, 1984) (or behaviours) and social structure (or social conditions). Social practices are routinized and socialized behaviours common to groups. Social structure is defined as the way in which society is organized, involving norms, resources, policy, and institutional practices. Similarly to choices, social practices are understood as emerging from the structure, and thus the relationship between structure and practices is always explicit. In this way, an individual behaviour, or social practice, is never divorced from its position within the social structure. Further, this relationship is not unidirectional; the structure is seen to shape people’s social practices, but in turn, people’s social practices are understood to influence the structure by both reproducing and transforming it. So, social practices are embedded within the social structure, but have a critical role in transforming it. Second, social practices are not considered purely in terms of health behaviours. If taking a collective lifestyles approach to obesity prevention, for instance, one would examine not only what people eat and whether they exercise or not, but also people’s other activities that might have a bearing on obesity. Examples might be examinations of the constraints on physical activity such as lack of time, poor neighbourhood infrastructure for practising physical activity, or the replacement of physical activity by video games. One
would seek to further understand the reasons behind the uneven social distribution of these activities such as the roles of race, gender, and class in structuring health experiences, life opportunities, etc. A third component to the collective lifestyle framework, in contrast to past perspectives, is a focus on the constraints on individual capacity (agency) and what the implications of the constraints are for true empowerment to take place. People’s position within the social structure clearly shapes their agency. Approaches that focus on changing health behaviours give attention to agency, but what is often missing is a well-developed analysis of the structural constraints to individual agency; that is, a direct link established between structure and agency. While the Ottawa Charter initially suggested focusing on increasing the options available to people to exercise more control over their health, in practice this has been addressed mostly through environmental change; that is, changing the conditions rather than focusing on how these changes might increase individual control. The collective lifestyle framework suggests that one has to understand people’s agency in relation to the social context of the health problem of concern. Using again the example of obesity, certain groups of people may not have the ability to exercise given lack of money and familial constraints. While they may have the knowledge and desire to exercise, their agency is reduced due to economic and other constraints. Knowledge of this barrier to agency would enable health promotion interventions to address some of these barriers in order to more successfully reach some of these hard-to-reach populations. Fourth, an implicit but underdeveloped aspect to the collective lifestyle framework is the issue of power. Power relations are central to shaping the uneven social distribution of health behaviours and disease outcomes
56 ■ PART I: Conceptual Perspectives
among groups and ultimately in creating and sustaining the social structure. A focus on power relations draws attention to the ways in which the social patterning of health behaviours and disease outcomes mirrors the patterning of other processes of marginalization and disadvantage through both the social structure and social practices. A focus on power further invites us to consider our role, within health promotion practice, as active actors within systems of power. We are, of course, active participants in the social context of health promotion as we influence through our research and interventions the way disease, health, and behaviours are understood. We are also capable of shifting power in society by creating the conditions for some segments of the population to be healthy participants and others not. Reflections and action on such issues are vital for a true focus on social context to be realized. Lastly, the final important aspect of a collective lifestyle framework for understanding the social context is reflexivity with respect to the social location of health promotion as a field (see also Chapter 17 on the importance of reflexivity for health promotion practice). By reflexivity we mean the maintenance of a self-critical attitude and a questioning of the taken-for-granted assumptions regarding the political nature of our work and its intended and unintended effects, as well as the social distribution of these effects (Caplan, 1993; Poland et al., 2006). More concretely this could include: (1) attention to the tacit knowledge and perspectives that practitioners bring to their work; (2) an openness to being transformed by the experience of engaging with individuals who may question the practice of health promotion; (3) a questioning of “received knowledge” (what we hold to be self-evident and true); (4) a curiosity about and openness toward other perspectives and ways of seeing; and (5) an awareness of power
relations and one’s own social location and positionality (how we fit into class and gender relations and how this affects the work we do individually and as a group performing health promotion).
CONCLUSIONS Health promotion has come a long way since the Ottawa Charter in its position on where the points of intervention in health promotion practice could and should be. We have learned much in health promotion practice and research by focusing on issues, “at-risk” populations, and settings. As we have seen, however, there are significant critiques of these approaches that require reviewing. We offer an alternative approach to addressing social context as a point of intervention using some aspects of the collective lifestyles framework as well as issues relating to power and reflexivity. In so doing, we address a number of the critiques discussed throughout this chapter. First, by focusing on social practices and their relationship to the social structure one would no longer focus only on high-risk behaviours, but rather the conditions that structure, and are structured, by behaviours. Second, because the focus of collective lifestyles is on conditions and behaviours, one would address the issue of high-risk individuals replacing those who are no longer at risk, as the conditions are addressed, not just the behaviour alone. Third, the collective lifestyles approach focuses on group influences and thus potentially addresses how to change population patterns of disease and behaviours. And lastly, the collective lifestyles approach focuses specifically on why groups of people partake in the practices they do, and thus a purposive focus is given to ensuring that issues of inequalities are addressed.
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REFERENCES Abel, T., Cockerham, W.C., & Niemann, S. (2000). A critical approach to lifestyle and health. In J. Watson & S. Platt (Eds.), Researching health promotion (pp. 54–77). London: Routledge. Adelson, N. (2005). The embodiment of inequity: Health disparities in Aboriginal Canada. Canadian Journal of Public Health, 96, S45–S61. Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behaviour. Englewood Cliffs: Prentice-Hall. Alinsky, S.D. (1969). Reveille for radicals. New York: Vintage Books. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs: Prentice-Hall. Barnett, E., Anderson, T., Blosnich, J., Halverson, J., & Novak, J. (2005). Promoting cardiovascular health: From environmental goals to social environmental change. American Journal of Preventive Medicine, 29, 107–112. Barnoya, J., & Glantz, S. A. (2004). Association of the California Tobacco Control Program with declines in lung cancer incidence. Cancer Causes Control, 15, 689–695. Becker, M.H. (1974). The health belief model and personal health behaviour. Health Education Monographs, 2, 324–508. Bourdieu, P. (1980). Le sens pratique. Paris: Les Éditions de Minuit. Bourdieu, P. (1992). Réponses: Pour une anthropologie réflexive. Paris: Éditions du Seuil. Caplan, R. (1993). The importance of social theory for health promotion: From description to reflexivity. Health Promotion International, 8, 147–157. Cockerham, W. (2005). Health lifestyle theory and the convergence of agency and structure. Journal of Health and Social Behavior, 46, 51–67. Conner, S.E., Cook, R.L., Herbert, M.I., et al. (2002). Smoking cessation in a homeless population—there is a will, but is there a way? Journal of General Internal Medicine, 17, 369–372. Emmons, K.M. (2000). Health behaviors in a social context. In L.F. Berkman & I. Kawachi (Eds.), Social epidemiology (pp. 242–266). New York: Oxford University Press. Fichtenberg, C.M., & Glantz, S.A. (2000). Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. New England Journal of Medicine, 343, 1772–1777. Frohlich, K.L., Corin, E., & Potvin, L. (2002). A theoretical proposal for the relationship between context and disease. Sociology of Health and Illness, 23, 776–797. Frohlich, K.L., & Potvin, L. (1999). Health promotion through the lens of population health: Toward a salutogenic setting. Critical Public Health, 9, 211–222. Frohlich, K.L., Ross, N., & Richmond, C. (in press). Health disparities in Canada today: Evidence and pathways. Health Policy. Giddens, A. (1984). The constitution of society. Cambridge: Polity Press. Grabb, E.G. (1997). Theories of social inequality: Classical and contemporary perspectives (3rd ed). Toronto, Ontario: Harcourt Brace. Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View: Mayfield Publishing Company. Health Canada. (2001). Smoking in Canada: An overview: CTUMS (Canadian Tobacco Use Monitoring Survey). Annual, February–December.
58 ■ PART I: Conceptual Perspectives Jetté, A. (1994). Designing and evaluating psychosocial interventions for promoting self-cure behaviours among older adults. Paper presented at the National Invitation Conference on Research Issues Related to Self-Care Aging. NIA. Lawn, S.L., Pols, R.G., & Barber, J.G. (2002). Smoking and quitting: A qualitative study with community-living psychiatric clients. Social Science and Medicine, 54, 93–104. Link, B.G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, Extra Issue, 80–94. Marmot, M.G. (2003). Understanding social inequalities in health. Perspectives in Biology and Medicine, 46, S9–S23. McLeroy, K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351–377. Multiple Risk Factor Intervention Trial Research Group. (1981). Multiple Risk Factor Intervention Trial. Preventive Medicine, 10, 387–553. Multiple Risk Factor Intervention Trial Research Group. (1982). Multiple Risk Factor Intervention Trial: Risk factor changes and mortality results. Journal of the American Medical Association, 24, 1465–1476. Poland, B., Frohlich, K.L., Haines, R.J., Mykhalovskiy, E., Rock, M., & Sparks, R. (2006). The social context of smoking: The next frontier in tobacco control? Tobacco Control, 15, 59–63. Poland, B.D., Green, L.W., & Rootman, I. (2000). Settings for health promotion: Linking theory and practice. Thousand Oaks: Sage Publications. Shim, J.K. (2002). Understanding the routinised inclusion of race, socioeconomic status, and sex in epidemiology: The utility of concepts from technoscience studies. Sociology of Health and Illness, 24, 129–150. Smedley, B.D., & Syme, S.L. (Eds.) (2000). Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press. Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10, 282–298. Tannahill, A. (1992). Epidemiology and health promotion: A common understanding. In R. Bunton & G. Macdonald (Eds.), Health promotion: Disciplines and diversity (pp. 42–65). London: Routledge. US Centers for Disease Control and Prevention. (2001). Cigarette smoking among adults—United States, 1999. Morbidity and Mortality Weekly Report, 50, 869–873. Weber, M. (1922). Wirschaft und Gesellschaft (Economy and society). Tübingen, Germany: Mohr Siebeck. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. World Health Organization. (1998). Health promotion: Milestones on the road to a global alliance. Retrieved April 1, 2006, from www.who.int/mediacentre/factsheets/fs171/en/
CRITIC AL THINKING QUESTIONS 1. What are the advantages and disadvantages to the three points of intervention discussed in this chapter? 2. Are there other ways in which we could be intervening in health promotion that would better take into account the social context? 3. Do current interventions in health promotion stand to be improved and, if yes, why? 4. Is there a danger of increasing inequalities in health by intervening in health promotion?
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FURTHER READINGS Emmons, K.M. (2000). Health behaviors in a social context. In L.F. Berkman & I. Kawachi (Eds.), Social epidemiology (pp. 242–266). New York: Oxford University Press. This chapter reviews data on risk factor change and examines some of the factors that help to explain the relatively low rate of long-term change produced by most health promotion interventions. Frohlich, K.L., Corin, E., & Potvin, L. (2002). A theoretical proposal for the relationship between context and disease. Sociology of Health and Illness, 23, 776–797. This article develops the notion of collective lifestyles drawing on the work of Pierre Bourdieu, Anthony Giddens, and Amartya Sen. Poland, B., Frohlich, K.L., Haines, R.J., Mykhalovskiy, E., Rock, M., & Sparks, R. (2006). The social context of smoking: The next frontier in tobacco control? Tobacco Control, 15, 59–63. This article moves beyond the discussion developed in this chapter to include the exploration of social context through the sociology of the body as it relates to smoking, collective patterns of consumption, the construction and maintenance of social identity, the ways in which desire and pleasure are implicated in these latter two dimensions in particular, and smoking as a social activity rooted in place. Poland, B.D., Green, L.W., & Rootman, I. (2000). Settings for health promotion: Linking theory and practice. Thousand Oaks: Sage Publications. This book outlines the history, content, and utility of the settings approach in health promotion interventions. Williams, G. (2003). The determinants of health: Structure, context, and agency. Sociology of Health and Illness, 25, 131–154. Williams reviews the ways in which the concept of social structure has been deployed within medical sociology, paying particular attention to its role in the debate over health inequalities and the role of the social context in shaping these inequalities.
RELEVANT WEB SITES A critique of the settings approach, hosted by University of New South Wales School of Public Health www.ldb.org/setting.htm
Health promotion recognizes the idea that people live in social, cultural, political, economic, and environmental contexts. This acknowledgement may have been new for public health; however, sociologists and social psychologists have been aware of the embeddedness of behaviour into larger contexts for a longer period of time. However, the acknowledgement by public health practitioners that health is developed in the context of everyday life, which itself is structured by its related social system, has not led to a fundamental reconsideration of the social science basis of public health concepts and its incorporation into planning and activity. Health Promotion and Education Online www.rhpeo.org/
RHP&EO is the electronic journal of the International Union for Health Promotion and Education (IUHPE). The journal published an editorial response to the previous
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article, arguing about the conceptualization of “settings” employed in the earlier piece. See Mittelmark, M.B. (1997). Health promotion settings. Internet Journal of Health Promotion, 1997. From www.rhpeo.org/ijhp-articles/1997/2/index.htm.s World Health Organization—Settings Approach www.who.int/mediacentre/factsheets/fs171/en/
This multilingual site describes the history of the WHO Settings for Health approach. Specifically, Settings for Health emphasizes practical networks and projects to create healthy environments such as healthy schools, health-promoting hospitals, healthy workplaces, and healthy cities. Settings for Health builds on the premise that there is a health development potential in practically every organization and/or community.
CHAPTER 5
H E A LT H L I T E R AC Y: A N E W F RO N T I E R Irving Rootman, Jim Frankish, and Margot Kaszap
INTRODUCTION “
ealth literacy is the ability to access, understand, assess and communicate information to engage with the demands of different health contexts to promote good health across the life-span” (Kwan et al., 2006). Fields of study and practice constantly change or evolve. One of the reasons why this happens is the introduction or development of concepts that significantly affect the way in which the field is viewed or the way in which people organize their work within the field. In other words, concepts can help to revitalize or reshape a field. An excellent example of this is how the cluster of concepts introduced by the Lalonde Report into the field of health in 1974, including the concept of health promotion, significantly changed the way in which policy makers, practitioners, researchers, and the public looked at health and led to changes in policies and practices related to health. It also contributed significantly to the development of the field of health promotion itself, as discussed in Chapter 1. Within the field of health promotion, there are also many examples of the substantial influence of new or borrowed concepts on how we view and carry out our work. These include concepts such as “healthy cities,” “healthy public policy,” and “quality of life,” all of which were introduced or developed by Canadians in the context of health promotion. A recently introduced concept to which Canadians have made or are
H
making a contribution is the concept of “health literacy,” which is the subject of this chapter. Specifically, in this chapter we will discuss the history of the development of the concept of health literacy in health promotion, the Canadian contribution to its development, definitions of health literacy, as well as debates over the concept in health promotion and where it is going.
HISTORY OF HEALTH LITERACY CONCEPT International The concept of health literacy first appeared in the literature in 1974 in an article by Simonds (1974), who used the term in relation to health education, particularly in schools. Specifically, he suggested: “Minimum standards for ‘health literacy’ should be established for all grade levels K through 12” (Simonds, 1974, p. 9). For some reason, however, the concept was not embraced with enthusiasm in health education or other fields until about two decades later when, among other things, in 1993, the Council of Chief State School Officers (CCSSO) in the United States established the Health Education Assessment Project (HEAP), which has developed tools to assess health literacy as an outcome of health education efforts in schools (Council of Chief State School Officers, 1998). In the same period, an ad hoc Committee of the 61
62 ■ PART I: Conceptual Perspectives
American Medical Association published a report on health literacy in the context of medicine in the United States (American Medical Association, 1999). This was stimulated by a series of research projects in the US on the impact of health literacy on health outcomes (e.g., Baker et al., 1997; Williams et al., 1995). Following these developments, the US Department of Health and Human Services specified improved health literacy as a health objective for the United States (United States Department of Health and Human Services, 2000). At about this time, the concept made its appearance in print in the field of health promotion in a paper by Ilona Kickbusch (1997) in Health Promotion International. This was followed by its inclusion in a glossary on health promotion (Nutbeam, 1998) and a paper by Don Nutbeam (2000) in Health Promotion International in which he argued that health literacy is a key outcome of health education activity, which should be situated in the broader context of health promotion and which people working in health promotion should be held accountable for. Another article by Kickbusch (2001) in the same journal suggested that health literacy was one way in which we could address the divide between health and education. Several other papers on health literacy have been published in Health Promotion International (e.g., Levin-Zamir & Peterburg, 2001; Ratzan, 2001; Renkert & Nutbeam, 2001; St. Leger, 2001; Zarcadoolas, Pleasant, & Greer; 2005) and various international meetings and workshops on health literacy and health promotion took place, several of which were organized by Ilona Kickbusch. This growing enthusiasm for the concept of health literacy within health promotion has by no means been endorsed by everyone in the field. One vocal critic of its use has been Keith Tones, the former editor of Health Education Research. In an editorial
entitled “Health Literacy: New Wine in Old Bottles,” he argued strenuously against adopting this concept in health promotion. According to him, “the kind of territorial expansion involved in translating limited, but clearly defined concepts into much broader, semantically unrelated constructs is both unnecessary and counter productive” (Tones, 2002, p. 288). After critiquing the expanded definition of health literacy suggested by Nutbeam (1998, 2000), Tones concluded that “there seems little if any justification for extending the original formulation of health literacy and incorporating it in re-packaged versions of existing theoretical formulations” (Tones, 2002, p. 289). On the other hand, the proponents of the concept of health literacy have suggested a number of reasons why it should be pursued in the context of health promotion. For example, in addition to suggesting that health literacy is a key outcome of health education and one that health promotion could legitimately be held accountable for, Nutbeam (2000) also noted that: expansion of the concept is consistent with current thinking in the field of literacy studies; it broadens the scope and content of health education and communication, both of which are critical operational strategies in health promotion; the expanded definition implies that “health literacy” not only leads to personal benefits, but to social ones as well, such as the development of social capital; and it helps us to focus on overcoming structural barriers to health. Similarly, in addition to noting that the concept of health literacy helps strengthen the links between the fields of health and education, Kickbusch (2002) suggested that: health literacy is important for social and economic development; that measuring it could be a major first step in developing a new type of health index for societies; that the expanded view emphasizes the need for public participation in policy development;
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and it allows us to consider the ambiguities of the fit between health promotion strategies and wider social trends. In any case, it has become clear that in spite of Tones’s admonition, interest in the concept has continued to grow within health promotion. Internationally, Kickbusch and colleagues have continued to argue for the recognition of health literacy as “a key competence in the health society” (Kickbusch, Maag, & Sann, 2005, p. 7). They further suggest that it is “critical both in developed and developing societies” (Kickbusch, Maag, & Sann, 2005, p. 10) and that it is a “critical strategy for the empowerment of citizens, communities, consumers and patients” (Kickbusch, Maag, & Sann, 2005, p. 2). Furthermore, according to them, “enhancing Health Literacy will strengthen the direction towards active citizenship for health by bringing together a commitment to citizenship with health promotion and prevention efforts” (Kickbusch, Maag, & Sann, 2005, p. 2). Moreover, their arguments appear to be gaining favour at least in Europe, with one of the European Commission’s policy areas pointing out that “Health Literacy will need to become a key literacy in European societies” (Kickbusch, Maag, & Saan, 2005, p. 2).
Similarly, in North America, interest in health literacy has continued to grow, partly as a result of a report of the Institute of Medicine Committee on Health Literacy (2004), which was established in response to the findings about the impact of health literacy on health outcomes noted above. Although the report was framed within a medical or health context, the influence of several members of the committee, with a health promotion background or interest (including two from Canada), made the report relevant to health promotion. In particular, as illustrated in Figure 5.1, the committee noted that health literacy is not just an individual phenomenon, but is the result of an interaction between the individual and different health contexts, including health promotion contexts.
Healthy Literacy in Canada The concept of health literacy did not make its appearance in Canada until 2000 when it was introduced into a workshop on research at the First Canadian Conference on Literacy and Health. However, during the 1990s there was a growing interest in Canada in the concept of literacy and health, stimulated by a
FIGURE 5.1: INSTITUTE OF MEDICINE HEALTH LITERACY FRAMEWORK
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64 ■ PART I: Conceptual Perspectives
project with this title carried out from 1989–1993 by the Ontario Public Health Association in partnership with Frontier College, the country’s oldest literacy network. Their first report made the case that literacy and health was an important issue that needed to be addressed by public health and health promotion in Canada (OPHA & Frontier College, 1989). Their second report (Breen, 1993) documented the increasing collaboration between literacy workers, health service providers, and learners on issues related to literacy and health, some of which had been stimulated by the first report. Partly as a result of this project, in 1994 the Canadian Public Health Association (CPHA) established the National Literacy and Health Program (NLHP) with funding from the federal government’s National Literacy Secretariat. Through the NLHP, CPHA has collaborated with 27 national partners to improve health services for less literate consumers. They have carried out several projects, organized conferences, and generated the publication and dissemination of countless “plain language” materials. The NLHP is considered to be a model for raising awareness, exploring issues, developing resource materials, and building partnerships in this field. Its work helped Canada to become recognized as an international leader in literacy and health practice. However, very little research on literacy and health was conducted in Canada in the 1990s. One exception was a study carried out by Bert Perrin for the OPHA/Frontier College project noted above (Perrin et al., 1989). Another was an analysis of data on the relationship between literacy and health among Canadian seniors, which made the case for more attention to these matters (Roberts & Fawcett, 1998). However, none of the research that was done used the concept of health literacy. In Canada, our francophone colleagues
were talking of alpha-santé and alphabétisation à la santé since 1999, and mainly were doing research in health education for lowliterate elderly, as reported in the Quebec journal of nursing L’Appui (Viens et al., 1999) and in a research report (Ajar et al., 1999) for the National Literacy Secretariat. They focused on topics such as: the educational needs of the elderly; the healthy grocery as a new place for health “alphabetization”; a pedagogical kit for heart disease patients; and new technology and health education for people with low literacy (Dubois et al., 2001; Fortin et al., 2002; Kaszap et al., 2000; Viens et al., 2000; see RECRAF Web site below). At the First Canadian Conference on Literacy and Health, the concept of health literacy was introduced by Rima Rudd from Harvard University and Irving Rootman from the University of Toronto. Rudd (2000) presented work being done using this concept in the United States and Rootman (2000) presented a framework for research on health literacy that he had developed based on the research that had been carried out by Perrin et al. (1989) as well as his own reading and participation in international meetings on the topic. Both Rudd and Rootman, however, made the point that health literacy needed to be seen in relation to the broader concept of literacy and health that was dominant in Canada. Following the conference, Rootman embarked on the development of a national program of research on literacy and health for Canada in collaboration with others, including the co-authors of this chapter. Among other things, they were successful in obtaining funding from the Social Sciences and Humanities Research Council (SSHRC) in 2001 and 2002 to develop such a program of research. Doing so has involved conducting a national environmental scan and needs assessment; organizing a national workshop
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to define a research agenda for Canada on literacy and health; organizing a summer school and summer institute on literacy and health research; conducting several workshops on literacy and health at national conferences; making numerous presentations; submitting proposals for funding; conducting several studies, including an evaluation of the National Literacy and Health Program; and publishing papers, including a comprehensive review of the literature on literacy and health research in Canada (Rootman & Ronson, 2005). Detailed reports on most of these activities can be obtained through the Web site established as part of the project (see list of relevant Web sites below). In addition, Rootman and his colleagues have obtained funding for several research projects on health literacy, including two funded by the Canadian Institutes of Health Research (CIHR) to develop new measures of health literacy for different population groups (including students), and one funded by SSHRC to evaluate the impact of a new British Columbia health education curriculum on health literacy. Others in Canada have also undertaken research projects on health literacy, including Doris Gillis and Alan Quigley, who were funded by SSHRC to conduct a study of health literacy in Nova Scotia (see Web site below). Other proposals are currently being evaluated by funding agencies, including a proposal to develop measures of health literacy for the Latin American community in Canada. Thus, since the conference in 2000, there has been a significant growth in research on health literacy in Canada, most of it related to health promotion and in the context of literacy and health. It is likely that these trends will continue for the foreseeable future. Thus, it is useful to explore what the Canadian contribution to work on health literacy has been and is likely to be in the future.
THE C ANADIAN CONTRIBUTION TO HEALTH LITERACY Although it is still early days, Canada has made some contributions to research, practice, and policy in health literacy within the context of health promotion. Some of the key accomplishments are described in this section.
Contributions to Research The Canadian contributions to research on health literacy have so far been mostly at the conceptual level, although we may be able to shortly make a contribution to the development of methodology. With regard to conceptualization, as mentioned, we have done some work to develop a conceptual framework that locates health literacy within the context of literacy and health. Specifically, the preliminary framework that was presented at the First Canadian Conference on Literacy and Health was revised as a result of extensive consultations with researchers, practitioners, and policy makers across Canada and has been published in a special supplement of the Canadian Journal of Public Health (Rootman & Ronson, 2005). As can been seen in Figure 5.2, this framework locates health literacy in relation to general literacy and other kinds of literacies; indicates both possible direct and indirect impacts of literacy on health; suggests that general literacy, health literacy, and other literacies are affected by the broader determinants of health; and that the types of interventions that are used in health promotion also can be used to affect general literacy, health literacy, and other literacies. Although this is by no means a “causal” model, it does place health literacy in a conceptual space that recognizes its perhaps limited contribution in relation to the overall contribution of literacy to health. It also implies that the impact
66 ■ PART I: Conceptual Perspectives FIGURE 5.2: L I T E R AC Y A N D H E A LT H R E S E A R C H C O N C E P T UA L F R A M E WO R K
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of health literacy on health may be more direct than indirect. Thus, the framework that seems to have the broad acceptance of researchers, practitioners, and policy makers in Canada does make some contribution to thinking about the role of health literacy in health and health promotion, which may be of interest beyond Canada. Another conceptual contribution that Canadians are in the process of making is in relation to the definition of health literacy. For example, we have developed an operational definition of health literacy, mentioned at the outset of this chapter, for our work on measurement; it builds on previous definitions and may be of interest beyond the project that we are doing (see Box 5.1). The definition comes from several sources. Firstly, it builds on the
definition of health literacy endorsed by the Institute of Medicine Committee (see Box 5.1) and the idea expressed in the committee’s conceptual framework (see Figure 5.1) that health literacy has to do with the interaction between individuals and different health contexts. It also adopts the goals of promoting health from the Nutbeam glossary definition (see Box 5.1) as well as the idea of “interactive” and “critical” health literacy by using the words “communicate” and “assess.” Finally, it adopts the idea of the importance of “lifelong learning” from the national workshop mentioned above. With regard to our potential contribution to measurement, we are currently testing some new measures of health literacy with seniors. These measures are intended to measure health literacy in a health promotion
CHAPTER 5: Health Literacy ■ 67 BOX 5.1: D E F I N I T I O N S O F H E A LT H L I T E R AC Y
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context. To that end, 229 communitydwelling older adults were interviewed about their experiences in finding, understanding, and communicating information in relation to “healthy aging.” They were also asked to read and respond to questions about passages related to health to test their skill levels in relation to aspects of health literacy. The widely used Rapid Estimate of Adult Literacy in Medicine (REALM) Test was administered as well (Davis et al., 1993). Based on the analysis to date, it appears as if there is little or no relationship between self-perceived health literacy and health literacy as measured by skill tests and that the elements defining health literacy are strongly related to one another. The findings of this study will be used to revise the existing instrument, which will be tested with other samples of older adults and ultimately will be used as a prototype for measuring health literacy in different population groups. Hopefully, the instruments that are developed will be of use to others and will lead to studies examining the determinants and consequences of health literacy in Canada and perhaps elsewhere.
Another contribution to research on health literacy made in Canada is the project carried out in rural Nova Scotia mentioned earlier. Rather than defining health literacy the investigators and their collaborators asked respondents to tell them what they thought health literacy was. This approach led to a rich discussion about the concept as viewed through the eyes of adults with limited literacy, health and literacy practitioners, and community leaders. This experience thus suggests the value of another approach to the study of health literacy that could be used or adapted to other circumstances (see Web site noted below). From these examples, it should be clear that Canadian health promotion researchers have begun to make a contribution to research on health literacy and are likely to continue to do so for the foreseeable future.
Contributions to Practice and Policy The research projects noted above have also contributed to practice and policy related to health literacy within a literacy and health
68 ■ PART I: Conceptual Perspectives
framework. For example, the Nova Scotia project led to action related to an initiative by one of the partner organizations in the project to increase awareness and support of literacy as a determinant of health and well-being, and awareness of literacy issues among service providers. The activities have included: conducting an environmental scan to identify best practices, policies, and training materials that address literacy and health; organizing awareness sessions on health literacy for 185 primary health care providers at five sites and via Telehealth; drafting a health literacy policy; developing a health literacy assessment tool; and developing a health literacy standard for accreditation. The project also led to a provincial consultation sponsored by the Nova Scotia Department of Health in 2004 as well as to the launch of a Nova Scotiawide Health Literacy Initiative and a video on health literacy in 2005. The provincial consultation has been used as a prototype for a provincial consultation in British Columbia and the project is likely to be used as a model for other projects across the country. In addition, the topic of health literacy featured strongly in the Second Canadian Conference on Literacy and Health in October 2004 and led to the articulation of a set of recommendations for policy development in Canada. Specifically, a paper based on the conference suggested, among other things, that governments and others: • support integrated policy and program development across sectors by enabling collaboration among health, education, and other sectors • encourage and fund knowledge translation initiatives about literacy and health that reach practitioners, policy makers, and researchers • support strategies that bring together literacy practitioners and health professionals with adult learners through
participatory research and program development (Chiarelli & Edwards, 2006, p. S-41). The authors concluded by arguing that “this approach to policy development will lead us to a uniquely Pan-Canadian strategic policy agenda that addresses literacy as a determinant of health and health literacy as an important factor in improving the health of all Canadians” (Chiarelli & Edwards, 2006, p. S-42).
ISSUES IN HEALTH LITERACY AND HEALTH PROMOTION It should be clear from this chapter that the concept of health literacy has, in a very short period of time, made significant inroads into research, practice, and policy in health promotion in Canada and elsewhere. It has indeed become a “new frontier” for health promotion. There are, however, a number of issues that remain to be addressed in relation to the concept within health promotion. They include: Is it a useful concept in health promotion? What should be included in the concept in order to measure it? How does it relate to theory? Practice? Policy? How should the concept be developed? With regard to the first question, we obviously have two camps within health promotion: the camp that rejects the use of the concept (as exemplified by Tones) and the camp that accepts it enthusiastically (as exemplified by Kickbusch and Nutbeam). The arguments on both sides have been presented above and it appears as if for the time being at least, the enthusiasts are on the ascendancy. However, given the strong argument presented by Tones (2002), we need to be somewhat guarded in our enthusiasm. At minimum, we need to acknowledge that the
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concept of health literacy is not the answer to all of our problems as a field, but is perhaps a useful tool for addressing some of them. A related issue has to do with whether or not we should frame our interest in “health literacy” as an independent area of interest for health promotion or within the context of the larger concept of “literacy and health,” which is how we have tended to look at it in Canada. One advantage of this larger framing is that it more strongly draws our attention to the importance of the determinants of health in health promotion. However, this too is a matter for further debate. In addition, we need to be clear what we are talking about when we use the term “health literacy.” At this point, all people interested in its development need not use the same definition of health literacy, but at the very least need to specify what definitions they are using. This is especially important when trying to develop measures of the concept. In this regard, it is important that the definitions used explicitly identify the elements of the concept that it is intended to measure. Thus, in the case of the British Columbia Health Literacy Research Team, we intend to measure people’s abilities to “access, understand, assess, and communicate” health information and these elements are therefore part of our definition (see Box 5.1). We see these as the core elements of health literacy, which, in turn, may be related to knowledge, use of information, decision making, health, or other outcomes. In contrast, the recent definition put forward by Kickbusch and her colleagues appears to emphasize decision making as the core element of health literacy (see Box 5.1). Both views are legitimate options, the merits of which could be debated. Some of the criteria to consider in this debate are the relationships of the different views to theory, practice, or policy. One might argue, for instance, that a particular view of
what health literacy is fits better with certain theoretical perspectives in health promotion such as “empowerment theory” or “information processing theory.” In this case, we would suggest that the Kickbusch and company definition fits better with the former, and the Canadian Health Literacy Team definition fits better with the latter. Similarly, a particular approach may be more helpful for practice or policy. With regard to how the concept should be developed, there is an evident need for work that will move health literacy beyond the “conceptual.” This can be achieved by systematically moving through a series of interrelated levels. At a “conceptual” level there remains a need to better map the universe of potential items related to the “concept” of health literacy. Next, there is a need to move from the “concept” to a “construct” of health literacy. That is, we need to operationally define “health literacy” and invoke the elements of validity and reliability that would yield a satisfactory level of “construct validity.” Tests of construct validity would make the notion of health literacy measurable. Following from construct validity, there is a need to develop measures or indicators of health literacy. In parallel, there is a need for new strategies/tests that can be used to measure or assess a given person’s level of health literacy in a specific context. Finally, there is a need to evaluate the relevance and utility of data on health literacy. The above steps yield a set of testable research questions: 1. Is it possible to achieve a measure of health literacy that possesses adequate validity and reliability? 2. What is the general level of health literacy in the Canadian population? 3. Does the level of health literacy vary by factors such as age, gender, education, ethnicity, and income?
70 ■ PART I: Conceptual Perspectives
4. Is a person’s level of health literacy malleable, i.e., can it be improved through interventions? 5. Does a person’s level of health literacy predict or relate to his or her health status, use of health services, and quality of life?
CONCLUSIONS This brings us to the question of where we go next as a field in the new frontier of health literacy. Our view is that we continue our efforts to define and measure health literacy and actively engage in sharing our progress with one another and in an open debate
around the issues that we have noted as well as others that may arise. To this end, members of the British Columbia Health Literacy Research Team have applied for funding from CIHR to develop a dialogue with our international colleagues about health literacy as well as cross-border collaborations. It is expected that this dialogue and collaboration will continue through many means, including the 19th International Union for Health Promotion and Health Education (IUHPE) World Conference on Health Promotion where this book will be launched.
REFERENCES Ajar, D., Fortin, J., Kaszap, M., Ollivier, É., Vandal, S., & Viens, C. (1999). Recherche-action visant l’identification des besoins d’éducation à la santé chez une clientèle âgée faible-lecteur présentant une problématique cardio-vasculaire. (Rapport de recherche préliminaire.) Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. American Medical Association. (1999). Health literacy: Report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Journal of the American Medical Association, 281, 552–557. Baker, D.W., Parker, R.M., Williams, M.V., Clark, W.S., & Nurss, J. (1997). The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health, 87, 1027–1030. Breen, M.J. (1993). Partners in practice: Literacy and health project phase two. Toronto: Ontario Public Health Association and Frontier College. Canadian Index on Adult Literacy Research in French/Répertoire canadien des recherches en alphabétisation des adultes en français (Récraf). From www.alpha.cdeacf.ca/recraf/ Chiarelli, L., & Edwards, P. (2006). Building healthy public policy. Canadian Journal of Public Health, 97(Suppl. 2), S37–S42. Council of Chief State School Officers. (1998). Assessing health literacy: Assessment framework. Santa Cruz, CA: ToucanEd Publications. Davis, T.C., Long, S.W., Jackson, R.H., Mayeaux E.J., George, R.B., Murphy, P.W., et al. (1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25, 391–396. Dubois, L., Viens, C., Vandal, S., Kaszap, M., Beauchesne, É., Ollivier, É., et al. (2001). Rapport de recherche. Évaluation d’un nouveau lieu d’alphabétisation: l’épicerie-santé. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Fortin, J., Viens, C., Kaszap, M., & Ajar, D. (2002). Les perceptions des personnes âgées peu alphabétisées navigant dans le système de santé. Dans à lire, 9, 40–44.
CHAPTER 5: Health Literacy ■ 71 Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington: National Academies Press. Kaszap, M., Viens, C., Ajar, D., Ollivier, É., Leclerc, L.-P., & Bah Yayé, M. (2002). Rapport de recherche. Évaluation de l’applicabilité des nouvelles technologies de l’information et de la communication dans le domaine de l’éducation à la santé des adultes peu alphabétisés atteints de maladies cardio-vasculaires. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Kaszap, M., Viens, C., Fortin, J., Ajar, D., Ollivier, É., & Vandal, S. (2000). Rapport de recherche. Besoins d’éducation à la santé chez une clientèle âgée peu alphabétisée atteinte de maladies cardio-vasculaires: Une étude exploratoire. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Kickbusch, I. (1997). Think health: What makes the difference? Health Promotion International, 12, 265–272. Kickbusch, I. (2001). Health Literacy: Addressing the health and education divide. Health Promotion International, 16, 289–297. Kickbusch, I. (2002). Health Literacy: A search for new categories. Health Promotion International, 17, 1–2. Kickbusch, I., Maag, D., & Sann, H. (2005). Enabling healthy choices in modern health societies. Paper presented at the European Health Forum Bagastein. Kwan, B., Frankish, J., & Rootman, I. (2006). Final report: The development and validation of measures of “health literacy” for different population groups. Victoria: Centre for Community Health Promotion Research. Levin-Zamir, D., & Peterburg, Y. (2001). Health literacy in health systems: Perspectives on patient selfmanagement in Israel. Health Promotion International, 16, 87–94. Nutbeam, D. (1998). Health promotion glossary. Health Promotion International, 13, 349–364. Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st Century. Health Promotion International, 15, 259–267. OPHA & Frontier College. (1989). Literacy and health project phase one: Making the world healthier and safer for people who can’t read. Toronto: Ontario Public Health Association and Frontier College. www.opha.on.ca/resources/literacy1summary.pdf. Perrin, B., et al. (1989). Literacy and health—making the connection: The research report of the literacy and health project phase one: Making the world healthier and safer for people who can’t read: Ontario Public Health Association and Frontier College. From www.opha.on.ca/resources/literacy1research.pdf. Ratzan, S.C. (2001). Health literacy: Communication for the public good. Health Promotion International, 16, 207–214. Ratzan, S.C., & Parker, R.M. (2000). Introduction. In C.R. Selden, M. Zorn, S.C. Ratzan, & R.M. Parker (Eds.), Library of medicine current bibliographies in medicine: Health literacy (vol. NLM Pub. No CBM 2000-1). Bethesda: National Institutes of Health, US Department of Health and Human Services. Renkert, S., & Nutbeam, D. (2001). Opportunities to improve maternal health literacy through antenatal education: An exploratory study. Health Promotion International, 16, 381–388. Roberts, P., & Fawcett, G. (1998). At risk: A socio-economic analysis of health and literacy among seniors. Statistics Canada Cat. no. 89-552-MPE, no. 5. Ottawa: Statistics Canada. Rootman, I. (2000). A framework for health literacy research and practice. Paper presented at the First Canadian Conference on Literacy and Health, Ottawa. Rootman, I., & Ronson, B. (2005). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(Suppl. 2), 62–77.
72 ■ PART I: Conceptual Perspectives Rudd, R. (2000). Health literacy research: Current work and new directions. Paper presented at the First Canadian Conference on Literacy and Health, Ottawa. Simonds, S.K. (1974). Health education and social policy. Health Education Monographs, 2(Suppl. 1), 1–10. St. Leger, L. (2001). Schools, health literacy, and public health: Possibilities and challenges. Health Promotion International, 16(2), 197–205. Tones, K. (2002). Health literacy: New wine in old bottles? Health Education Research, 17, 287–290. United States Department of Health and Human Services. Office of Disease Prevention and Health Promotion. (2000). Healthy People 2010. Washington, DC: U.S. Government Printing Office. Viens, C., Fortin, J., Kaszap, M., Vandal, S., Ajar, D., & Ollivier, É. (2000). Rapport de recherche: Rechercheintervention visant l’élaboration d’une trousse d’éducation à la santé pour personnes âgées peu alphabétisées et insuffisantes cardiaques. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Viens, C., Fortin, J., Kaszap, M., Vandal, S., & Bourdages, J. (1999). Alpha-Santé à l’écoute de l’information transmise aux usagers, une question d’alphabétisation. L’Appui Québec, 12(4), 48. Williams, M.V., Parker, R.M., Baker, D.W., Parikh, N.S., Pitkin, K., Coates, W.C., et al. (1995). Inadequate functional health literacy among patients at two public hospitals (comment). JAMA, 274(21), 1677–1682. Zacadoolas, C., Pleasant, A., & Greer, D.S. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20, 195–203.
CRITIC AL THINKING QUESTIONS 1. What are the main roles that new concepts play in a field? 2. Is the concept of “health literacy” a valuable one from a health promotion point of view? Why or why not? 3. What in your opinion, should be done with the concept of “health literacy” in health promotion? Why? 4. What are the differences between “health literacy” and “literacy and health”? 5. What are the factors that determine whether or not new concepts will be adopted by a field?
FURTHER READINGS Canadian Public Health Association. (2006). Staying the course: Literacy and health in the first decade. Canadian Journal of Public Health, Supplement, pp. S1-S48. This supplement contains a series of articles that attempt to put the proceedings of the Second National Conference on Literacy and Health into a larger perspective, drawing from the literature and other sources. It is a good overview of current thinking on literacy and health in Canada. Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington: National Academies Press. This report of the IOM Committee on Health Literacy presents a conceptualization of health literacy, reviews current literature and practice in relation to health literacy, and recommends directions for future action. Although written primarily for a US audience, it contains much that is relevant for other countries.
CHAPTER 5: Health Literacy ■ 73 Kickbusch, I., Maag, D., & Sann, H. (2005). Enabling healthy choices in modern health societies. Paper presented at the European Health Forum, Bagastein. This background paper written for the European Health Forum contains a discussion of the rapidly changing environment into which health literacy fits, the dimensions and definition of health literacy, and its relationship to key current issues (obesity and migrant health). Although directed at Europe, it contains information relevant for other countries as well. Rootman, I., & Ronson, B. (2005). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(Suppl. 2), 62–77. This paper, originally prepared for an international conference on health disparities, describes the development of interest in literacy and health in Canada, presents a conceptual framework for literacy and health research, summarizes literature in relation to the framework, and makes recommendation for research and practice. Shohet, L. (2002). Health and literacy: Perspectives in 2002. Available at www.staff.vu.edu.au/alnarc/ onlineforum/AL_pap_shohet.htm. This paper discusses the links between literacy and health as they are currently represented in the discourse communities of the medical profession and of adult literacy. After comparing the positions taken by the medical field and the adult literacy field, and examining some selected government policies, the author outlines some directions for the future.
RELEVANT WEB SITES Canadian Index on Adult Literacy Research in French/Répertoire canadien des recherches en alphabétisation des adultes en français (Récraf) www.alpha.cdeacf.ca/recraf/
The Canadian Index on Adult Literacy Research in French contains information on more than 146 research projects on literacy or adult literacy written in French and published in Canada since 1994. Some projects are still underway. CPHA Literacy and Health Program www.nlhp.cpha.ca
This Web site describes the National Literacy and Health Program and its associated services and projects, including the National Literacy and Health Research Program. Harvard School of Public Health, Health Literacy Studies www.hsph.harvard.edu/healthliteracy
This site contains introductions to health literacy, PowerPoint presentations, videos, literature reviews, annotated bibliographies, research reports, health education materials, guidelines on creating and evaluating written materials, curricula, highlights of talks and presentations, news items, insights, and links to related Web sites.
74 ■ PART I: Conceptual Perspectives Health Literacy in Rural Nova Scotia Project www.nald.ca/healthliteracystfx/
This Web site provides a description of the health literacy in the Rural Nova Scotia Project as well as findings, activities, and reports related to it. National Adult Literacy Database www.nald.ca
This Web site describes the National Adult Literacy Database, lists literacy organizations in Canada, presents information about what’s new and events in the field, as well as awards and contacts. It also provides access to literacy discussion groups and to expert advice, newsletters, a literacy collection, full-text documents, a resource catalogue, links to internal resources and to data. National Literacy and Health Research Program www.nlhp.cpha.ca/clhrp/index_e.htm
This Web site provides a description of the National Literacy and Health Research project and access to various reports produced by the project.
CHAPTER 6
A D D R E S S I N G D I V E R S I T Y I N H E A LT H P RO M OT I O N : I M P L I C AT I O N S O F WO M E N ’ S H E A LT H A N D I N T E R S E C T I O N A L T H E O RY Colleen Reid, Ann Pederson, and Sophie Dupéré INTRODUCTION ritish feminist sociologists Daykin and Naidoo (1995) have criticized health promotion practice for reproducing dominant discourses and practices toward women by failing to recognize the social position of women, adopting a traditional approach to women’s health by focusing on women’s reproduction, and by designing programs and interventions that hold women responsible for the health of others through targeted messages and campaigns directed at women’s caregiving activities. They also suggest that health promotion fails to deal with the diversity of women because while all women are affected by health promotion’s reproduction of gender inequalities, women are “also divided by other dimensions of inequality structured by class, ethnicity, sexuality and disability. Both the common characteristics and the divisions between them need to be recognized in health promotion. The current vogue for addressing women as consumers able to exercise personal choice over lifestyles and health care services is inappropriate, given the constraints on most women’s lives” (Daykin & Naidoo, 1995, p. 69). This chapter attempts to update the dialogue between feminist theory and health promotion by addressing the challenge of diversity within health promotion—both in general and as it affects women. Many have argued that health promotion’s theoretical base is still largely dominated
B
by biomedical, psychological, and behavioural models and call for the development of more social theories (Potvin et al., 2005; see Chapter 4). It has been suggested that health promotion should also expand its academic alliances to enrich its theoretical base (Mittlemark, 2005; Ziglio, Hagard, & Griffiths, 2000). Hilary Graham (2004) argues that to be able to tackle health inequalities, we need to build an interdisciplinary science through integrating research on health inequalities, which is mainly based in social epidemiology with research in social sciences and policy that focuses on social inequalities. This chapter argues for greater integration of contemporary theorizing about gender and diversity into the field of health promotion in Canada. Specifically, we argue that health promotion could learn from more dialogue and exchange with feminist scholarship by presenting intersectionality as an important theoretical contribution from women’s studies and other fields (McCall, 2005; Weber & Parra-Medina, 2003). We review some of the links between women’s health, gender and health, and health promotion in Canada, recognizing that while considerable work has been done (e.g., Denton et al., 1999), there has been less theoretical interaction between the fields of health promotion and women’s health than one would expect, given that the Canadian women’s health movement has a long history of recognizing the determinants of health to 75
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understand women’s health (Thurston & O’Connor, 1996). We propose intersectionality as a contemporary theoretical approach that could increase the theoretical rigour and enhance health promotion practice. Finally, we argue for an integrated approach to thinking about health promotion in relation to gender and other dimensions of social experience and suggest some implications for practice in order to improve women’s health.
WOMEN’S HEALTH AND GENDER AND HEALTH IN C ANADA Women’s Health There is a lengthy history of women’s health activism in Canada that is beyond the scope of this chapter to discuss in detail (see, for example, Dua et al., 1994; Morrow, in press). However, it has been suggested that the women’s health movement and health promotion share important core values, priorities, and approaches to practice. Moreover, Thurston and O’Connor (1996) argue that the women’s health movement in Canada, as elsewhere in the world, had embraced health promotion and disease prevention before health promotion became a mainstream activity in Canada. They suggest that this is because women’s health activists and scholars have always recognized the link between the social location of a person or a group and health, as well as advocating individual and community empowerment as processes for improving health. They also observe that those in the women’s health field have long embraced a positive conceptualization of health, one that was formalized in the Platform for Action developed out of the 4th United Nations World Conference on Women held in Beijing in 1995:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Women’s health involves women’s emotional, social, cultural, spiritual and physical well-being, and it is determined by the social, political and economic context of women’s lives as well as by biology. (From www.un.org/ womenwatch/daw/beijing/platform/health.htm)
This definition recognizes that health is socially constructed rather than simply biologically determined or technically produced. This broad definition recognizes the validity of women’s life experiences and women’s own beliefs about and experiences of health in identifying priorities for action and determining the boundaries of what constitutes health. Women’s health is perceived as a continuum that extends throughout the life cycle and that is critically and intimately related to the conditions under which women live. According to some researchers, examinations of women’s health require a social model of health that puts women’s health needs at the centre of the analysis and focuses attention on the diversity of women’s health needs over the life cycle. The traditional oppression and disempowerment of women must also be addressed at both personal and societal levels, thus broadening the approach (Reid, 2004). “Every woman should be provided with the opportunity to achieve, sustain and maintain health as defined by that woman herself to her full potential.” (Ontario Women’s Health Interschool Curriculum Committee; cited in Cohen, 1998, p. 188) Following the Beijing conference, Canada adopted the UN Platform for Action and introduced its own national policy to advance women’s equality, the Federal Plan for Gender Equality (1995–2000), which stated that all subsequent federal legislation and policies were to include, where appropriate, an analysis of the potential differential effects on women and
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men (Hankivsky, 2005, p. 17). “Where appropriate” has turned out to be a sticking point in the implementation of the plan. However, the federal government did commit to a women’s health strategy, which was published in 1999 (Health Canada, 1999), and the creation of five Centres of Excellence for Women’s Health in 1996 (Health Canada, 1996), four of which continue to operate in 2006. Federal government departments, including Health Canada, supported the implementation of the plan by preparing topic-specific guides to assist their staff with understanding gender equity and in implementing gender-based analysis in their own policy arena (see, for example, Health Canada, 2003). Despite these commitments, most federal policies and programs remain genderblind or gender-neutral; that is, policies and programs are developed and articulated in ways that fail to examine or address meaningful differences in their impact on women and men. A number of important concerns persist in Canadian society as a recent report on gender equality shows (Canadian Feminist Alliance for International Action, 2003). Examples include: the high percentage of Canadian women who live in poverty and report poor health status; the persistence of violence against Canadian women; the diminished status of immigrant and refugee women; the vulnerability of Aboriginal women who are the “poorest of the poor,” to name a few. While we can appreciate the improvements in reducing overall inequality between men and women over the last decades, we have also witnessed the increased feminization and racialization of poverty in Canada, which reflects gender-based and racial discrimination (Galabuzi, 2004). An entire industry has arisen to develop and prepare gender-based analyses of key health (and other) policy areas, including wait times (Jackson, Pederson, & Boscoe, 2006),
mental health (Salmon et al., 2006), and health research (see Greaves et al., 1999) and/or responding to federal government documents that fail to incorporate gender considerations into their work (e.g., National Coordinating Group on Health Care Reform and Women, 2003). These analyses consistently demonstrate the myriad ways that gender matters.
Gender and Health Integral to the development of the Federal Plan for Gender Equality was the recognition that gender, as a key concept, needed to be differentiated from focusing specifically on women’s issues. The concept of gender is related to how women and men are perceived and expected to think and act because of the way society is organized, not because of their biological differences (World Health Organization, 1998). Gender is a complex concept that includes: understanding that men and women are typically thought of as different types of social actors with different types of bodies; awareness that power is differentially associated with men and women in any given society; and an appreciation that these differences have led to important differences in the kinds of work that women and men typically do, their roles in the household and with respect to children, their access to social resources such as income and decision making, and to differences in their health. These differences determine differential exposure to risk, access to the benefits of technology, information, resources, and health care, and the realization of rights, all of which can influence health. Indeed, women’s everyday experiences must be understood within the context of the larger social organization and ideological structures generated from outside experience. Paradoxically, gender inequality translates not into increased mortality but into increased
78 ■ PART I: Conceptual Perspectives
morbidity for women (Aïach, 2001; Denton, Prus, & Walters, 2004). As McCall (2005) suggests, we should ask ourselves if all women are better off than all men, and then question the differences that exist among women. McCall presents the results of a study conducted in several locations in the United States and shows that when gender inequality is broken down by social class and race, we see the emergence of other patterns of inequalities that also vary across different geographical and social contexts. Others have also highlighted the dynamic and complex relationships between gender inequality and health and the diverse intersections with many other factors such as class, ethnicity, sexuality, age, and disability (Aïach, 2001; Denton, Prus, & Walters, 2004; Doyal, 2000). This prompts us to look for theoretical tools, research designs, and methods that will permit us to seize the complexity and intertwined nature of social inequalities affecting not only women but other groups and individual as well.
HEALTH PROMOTION AND WOMEN’S HEALTH: MISSED OPPORTUNITIES, POSSIBLE CONNECTIONS? Both the Ottawa Charter (1986) and the Bangkok Charter (2005)—the first and most recent international charters on health promotion respectively—mention gender, but they refer to it in distinctly different ways. The Ottawa Charter observes that the aims of health promotion itself, namely, to enable people to achieve their fullest health potential by increasing control over those things that determine their health, “must apply equally to women and men,” whereas the Bangkok Charter observes that “women and men are affected differently” by the economic and demographic changes that affect “working conditions, learning environments, family patterns, and
the culture and social fabric of communities” (World Health Organization, 1986, p. 2). Moreover, the Ottawa Charter calls for women and men to become “equal partners” in the planning, implementation, and evaluation of health promotion activities—a clear call for gender equality in health promotion. These contrasting references to gender and gender differences reflect important changes that have occurred in the past 20 years. From an acknowledgement of power as a function of gender relations, we have shifted to a discourse about gender that focuses on difference. In so doing, the field of health promotion has followed mainstream health research and policy making, but reduced some of the impact that a gendered analysis could have on the field. By adopting the discourse of gender as “difference,” health promotion is contributing to downplaying the challenge of addressing important social cleavages that constrain individual and collective action to improve health, and minimizes the role of power in gender relations. Health promotion is an interdisciplinary field in which diverse disciplines meet and borrow concepts from each other. These exchanges could be potentially enriching; however, these “concept transfers” from one field to another frequently occur and are operationalized without an in-depth understanding of the theoretical and epistemological basis underlying the concepts. In the public health literature, the concept of “social capital” is a recent example (Forbes & Wainwright, 2001). Krieger and Fee (1994) point out that although gender and sex are two distinct concepts, they have been used interchangeably in public health literature. There is a tendency to treat gender as a biological category instead of a social one that leads to reductionist and individualist explanations (Krieger & Fee, 1994). Krieger also argues that the public requires a better understanding of the concept of gender
CHAPTER 6: Addressing Diversity in Health Promotion ■ 79 BOX 6.1: D I S T I N G U I S H I N G S E X A N D G E N D E R
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alongside a clear differentiation between how sex and gender affect health (Krieger, 2003). In the early years of the women’s health movement, health concerns were seen to be so fundamental to women that they cut across race and class lines. Health was conceptualized as a powerful link that could unite all women into a strong and unified social movement. However, in time criticisms came to be levelled against White, middle-class feminists for generalizing the needs of dominant groups of women to all women, which resulted in race and class being identified as the second and third “axes” of domination. Extensive theorizations about the “additive,” “multiplicative,” or “interwoven” nature of the gender, race, and class triumvirate resulted (Reid, 2004). More recently, some feminist researchers argue that “any naming or categorizing tends to call attention to similarities and to neglect differences, and any human or social phenomena can be understood in countless different ways.” Although feminists affirm diversity, it remains difficult to be certain that this means gender, race, and class to all women. How do we know that diversity does not mean being fat, religious difference, involvement in an abusive relationship, disadvantage at the workplace, or
decisions made by girls in high school that attract them to female-dominated, lower paying jobs? The very categories we have assumed a priori (race and class) to be definitive of our differences may in fact be less significant than some others. Indeed, feminists continue to grapple with the substantial theoretical challenge of how to honour and appreciate diversity, while also recognizing how difference is constructed. Some researchers argue that gender is distinct from but interactive with other social features like social class or race/ethnicity. All these social factors combine to determine power relations in society that lead not only to inequalities between women and men, but also to inequalities within different groups of women and different groups of men (Ostlin, George, & Sen, 2003). Intersectional theory is based on the idea that “different dimensions of social life cannot be separated into discrete or pure strands.” When attempting to understand social inequalities, an intersectional analysis focuses on social relationships of power instead of focusing on differences in resources. An intersectional analysis examines social experiences and how they intersect at multiple forms of oppression, and what
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happens at these intersections. Intersectional theory was developed most prominently by Black feminist social scientists emphasizing the simultaneous production of race, class, and gender inequality, such that in any given situation, the unique contribution of one factor might be difficult to measure (Collins, 1989; Fonow & Cook, 1991). This approach— an advance over earlier models that assumed that advantage and disadvantage simply accumulate to produce “double jeopardy”—suggests that the content and implications of gender and race as socially constructed categories vary as a function of each other (Mullings & Schulz, 2006). For example, whiteness and blackness are gendered, and masculinity and femininity are “raced” within particular cultural contexts. It is often difficult to pinpoint how the interaction, articulation, and simultaneity of race, class, and gender affect women and men in their daily lives, and the ways in which these forms of inequality interact in specific situations to condition health (Mullings & Schulz, 2006). Intersectional theory suggests that we need to move beyond seeing ourselves and others as single points in some specified set of dichotomies, male or female, White or Black, straight or gay, scholar or activist, powerful or powerless. Rather, “we need to imagine ourselves as existing at the intersection of multiple identities, all of which influence one another and together shape our continually changing experience and interactions.” According to Weber (2006), feminist intersectional scholarship, driven foremost by the pursuit of social justice, takes a researcher stance of engaged subjectivity and reflexivity, critically reflecting throughout the research process on the impact of the social locations of the researchers and the researched. A collaborative relationship more closely resembling a partnership between researchers and researched is seen as ideal.
Research methods focus less on measurement and quantification and more on identifying and holistically representing meanings in the lives of the researched and in institutional arrangements. Multimethod approaches are valued, often mixing ethnographic, historical, and community-based qualitative approaches with surveys and other tools. Inequalities are conceived as social constructions situated in social contexts and structures beyond the individual—in societies, institutions, communities, and families—and are characterized as power, not simply resource, differences between dominant and subordinate groups (Weber, 2006). Intersectional scholarship arose primarily to understand and address the multiple dimensions of social inequality (class, race, ethnicity, nation, sexuality, and gender) that manifest at both the macro-level of institutions and the micro-level of the individual experiences of women who live at the intersections of multiple inequalities. The focus is on identifying the meanings of multiple inequalities in these women’s lives and in institutions. Intersectional scholarship is not limited by typical disciplinary boundaries that examine these inequalities in separate studies and generate different theories about each dimension (Weber, 2006). Nor is it restricted by the methodological conventions dominant in health research that require large sample sizes in order to examine multiple dimensions of inequality in the same study. “By seeking social justice for those situated in multiply subordinated locations, intersectional scholars have looked for ways of facilitating liberatory dialogue across race, class, gender, and sexuality divides” (Weber, 2006, p. 31).
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IMPLIC ATIONS FOR HEALTH PROMOTION PRACTICE What remains is the challenge of “operationalizing” an intersectional analysis to further and enhance how health promotion is practised. In order to consider this challenge, we asked: “What would interventions look like, or how would they be different, if we applied an intersectional analysis? What might this mean for health promotion practice?” We developed the following insights that intersectionality theory brings to the practice of health promotion, and invite women’s health, gender and health, and health promotion researchers and practitioners to join this conversation. • Shift the focus of intervention: An intersectional analysis invites us to target not only the individual but to take into consideration and even address explicitly social structures, social processes, and the underlying relationships of power. From this perspective we can better understand health from the framework of power and oppression and conceptualize alternative health interventions. This would involve developing more upstream inter-
ventions (i.e., taking action on the macro determinants of health such as poverty) (see Chapter 4); adopting ecological approaches (see Chapter 17); and ideally implementing approaches that seek to transform gender roles, reach equity, and empower women and men. • Change outlook on individual characteristics: An intersectional analysis would shift our focus from “immutable” individual characteristics (i.e., sex, ethnicity) to “mutable social realities” (i.e., those that can be targeted by intervention). Gender and race are not simply biological categories but also are social ones (Krieger, 2003). • Reframe the concept of health: This is consistent with contemporary reflections on the health promotion field (see Chapter 2) as well as intersectional analyses. An expanded conception of health would include refocusing on a broad framework of social relations and would locate health in families and communities and not only in individual bodies. • Utilize community-based and participatory approaches: Research methodologies that
BOX 6.2: I M P L I C AT I O N S O F I N T E R S E C T I O N A L I T Y T H E O RY F O R P RO G R A M S
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privilege the perspectives of oppressed and marginalized groups will further intersectional analyses. These kinds of approaches will also facilitate increased forms of activism that see activism for social justice as part of the knowledge acquisition process. • Adopt a holistic approach: A holistic approach invites us to look into the areas of intersection among multiple oppressions and to address them. An intersectional analysis examines social experiences and how they intersect at multiple forms of oppression, and what happens at these intersections (McCall, 2005). This approach would also involve necessarily intersectoral practice (i.e., bridging research, community, organizations, etc.) • Encourage reflexive practice: Intersectional theory invites us to pay attention to social processes, social dynamics, and the role of power in producing and sustaining social inequalities. As Poland (1998) has argued, failing to address the root causes of social inequalities in health promotion research, practice, and policy could lead us to unwittingly reproduce these inequalities. This perspective encourages reflexive practice (see Chapter 16) because it invites the researcher-practitioner to connect her or his personal and political identities, and to become aware of her or his own power and privilege. Adopting a reflexive practice can help prevent health researchers from unknowingly perpetuating, sustaining, and reinforcing harmful stereotypes (Reid & Herbert, 2005).
CONCLUSIONS With the mounting critiques of the atheoretical nature of health promotion research
and practice (see Chapter 4) and calls for health promotion, public health, and health science researchers to increase the theoretical rigour of their work in order to better inform and direct practice and policy, we advocate intersectional theory as a sophisticated and nuanced way toward addressing these gaps because it challenges us to think about conceptualizations of the content, context, and boundaries of social groups (Mullings & Schulz, 2006). However, there has been little discussion about its methodology. Intersectional analyses understand gender, race, and class as social relationships reproduced within local contexts, though methodological questions remain about how to accomplish this due to the complexities involved (McCall, 2005). According to Hankivsky et al. (2005), methods of doing research, and even the research questions themselves, too often fall short of creating genuinely inclusive, safe, and unbiased spaces of relevance for people whose life experiences are generally considered marginal. Health promotion and intersectional analyses are marginalized in mainstream health science venues and institutions, including academia, health care, and the community. The challenge is twofold—to push health promotion researchers, practitioners, educators, and advocates to understand the complexity and diversity of health through an intersectional analysis, and to develop strategies for moving a more theoretically informed health promotion into the mainstream. There is an opportunity and appetite for the reinvigoration of health promotion, though for this reinvigoration to be successful, it needs to pay attention to the more nuanced and complex understandings of women’s health that have been recently advanced by many feminist and intersectional scholars. An intersectional analysis of women’s health could enrich health promotion. In
CHAPTER 6: Addressing Diversity in Health Promotion ■ 83 BOX 6.3: I N C O R P O R AT I N G A N U N D E R S TA N D I N G O F G E N D E R I N TO H I V / A I D S P RO G R A M S
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84 ■ PART I: Conceptual Perspectives
many ways, there are already strong synergies, for example, their mutual commitment to an ecological approach to understanding health and developing health programs (see Chapter 17; also Krieger & Fee, 1994) and the commitment to multiple methods. But intersectional analysis reminds health promotion researchers, theoreticians, and practitioners that we must have a theory of power if we are to understand health inequalities and redress them. Indeed, a recent review of program evaluations in reproductive health demonstrated improved outcomes from programs that explicitly addressed both issues of gender equity and health (Interagency Gender Working Group, 2004) (see Box 6.3). This brings us to the question of what health promotion offers women’s health. We
suggest that it is the importance of being explicit about the need to empower people to change themselves, their lives, and their communities that health promotion can contribute to advancing the health of women and girls. Health promotion, as described thoroughly in this book, is fundamentally a practical endeavour. As such, it has a tradition of action and engagement that can be useful to those in the women’s health field who may get caught up in critique and theorizing at the expense of practice. By learning from one another, the fields of health promotion and women’s health (informed by intersectional analysis) can both contribute to reducing health disparities and improving the health of girls and women.
REFERENCES Aïach, P. (2001). Femmes et hommes face à la mort et à la maladie, des différences paradoxales dans Femmes et hommes dans Aiach, Cèbe, Cresson et Philippe, Le champ de la santé: Approches sociologiques. Anderson, J.M. (1987). Migration and health: Perspectives on immigrant women. Sociology of Health and Illness, 9(4), 410–438. Bangkok Charter for Health Promotion in a Globalized World. (2005). Geneva: World Health Organization. Retrieved November 15, 2005, from www.who.int/healthpromotion/conferences/6gchp/ bangkok_charter/en/index.html Brah, A., & Phoenix, A. (2004). Ain’t I a woman? Revisiting intersectionality. Journal of International Women’s Studies, 5(3), 75–86. Brower, V. (2002). Sex matters: In sickness and in health, men and women are clearly different. European Molecular Biology Organization (EMBO) Reports, 3(1), 921–923. Brydon-Miller, M. (2004). The terrifying truth: Interrogating systems of power and privilege and choosing to act. In M. Brydon-Miller, P. Maguire, & A. McIntyre, Traveling companions: Feminism, teaching, and action research (pp. 3–19). Westport: Praeger. Canadian Feminist Alliance for International Action. (2003). Canada’s failure to act: Women’s inequality deepens. Ottawa: Canadian Feminist Alliance for International Action. Retrieved April 4, 2007, from www.fafia-afai.org/en/node/164. Celayir, S. (2002). Is there a “bladder sex”? The relation of different sex hormones and sex hormone receptors in bladder in childhood. Medical Hypotheses, 59(2), 186–190. Cohen, M. (1998). Towards a framework for women’s health. Patient Education and Counselling, 33, 187–196.
CHAPTER 6: Addressing Diversity in Health Promotion ■ 85 Collins, P.H. (1989). The social construction of Black feminist thought. Signs: Journal of Women in Culture and Society, 14(4), 745–773. Daykin, N., & Naidoo, J. (1995). Feminist critiques of health promotion. In R. Bunton, S., Nettleton, & R. Burrows (Eds.), The sociology of health promotion: Critical analyses of consumption, lifestyle, and risk (pp. 59–69). London and New York: Routledge. Denton, M., Hadjukowski-Ahmed, M., O’Connor, M., & Zeytinoglu, I.U. (Eds.). (1999). Women’s voices in health promotion. Toronto: Canadian Scholars’ Press Inc. Denton, M., Prus, S., & Walters, V. (2004). Gender differences in health: A Canadian study of the psychosocial, structural, and behavioural determinants of health. Social Science and Medicine, 58(12), 2585–2600. Doyal, L. (2000). Gender equity in health: Debates and dilemmas. Social Science and Medicine, 51(6), 931–939. Dua, E., FitzGerald, M., Gardner, L., Taylor, D., Wyndels, L. (Eds). (1994). On women healthsharing. Toronto: Women’s Healthsharing. Fonow, M.M., & Cook, J.A. (1991). Back to the future: A look at the second wave of feminist epistemology and methodology. In M.M. Fonow & J.A. Cook (Eds.), Beyond methodology: Feminist scholarship as lived research (pp. 1–15). Bloomington: Indiana University Press. Forbes, A., & Wainwright, S.P. (2001). On the methodological, theoretical, and philosophical context of health inequalities research: A critique. Social Science and Medicine, 53(6), 801–816. Galabuzi, G.E. (2004). Social exclusion. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Graham, H. (2004). Social determinants and their unequal distribution: Clarifying policy understandings. Milbank Quarterly, 82(1), 101–124. Greaves, L., Hankivsky, O., Amaratunga, C., Ballem, P., Chow, D., & De Koninck, M. (1999). CIHR 2000: Sex, gender, and women’s Health. Vancouver: Centre of Excellence for Women’s Health. Greenberger, P. (2001). News from the Society for Women’s Health Research: FDA doing poor job of monitoring drugs for sex differences. Journal of Women’s Health and Gender-Based Medicine, 10(9), 829–830. Hankivsky, O. (2005). Women’s health in Canada, Beijing, and beyond. Winnipeg: Canadian Women’s Health Network. From www.cwhn.ca Hankivsky, O., et al. (2005). Research methodologies in women’s health/gender and health research. Simon Fraser University, Vancouver. Health Canada. (1996). Centres of Excellence for Women’s Health Program. Fact sheet prepared for the Canada–USA Women’s Health Forum. Ottawa: Women’s Health Bureau. Health Canada. (1999). Health Canada’s women’s health strategy. Ottawa: Women’s Health Bureau. Health Canada. (2000). Health Canada’s gender-based analysis policy. Ottawa: Health Canada. Health Canada. (2003). Exploring concepts of gender and health. Ottawa: Women’s Health Bureau, Health Canada. Hunt, K., & Annandale, E. (1999). Relocating gender and morbidity: Examining men’s and women’s health in contemporary Western societies. Introduction to special issue on gender and health. Social Science and Medicine, 48(1), 1–5. Interagency Gender Working Group. (2004). The “so what?” report: A look at whether integrating a gender focus into programs makes a difference in outcomes. Washington: Population Reference Bureau. Jackson, B.E., Pederson, A., & Boscoe, M. (2006). Gender-based analysis and wait times: New questions, new knowledge. Prepared for the Federal Advisor on Wait Times. From www.hc-sc.gc.ca/hcs-sss/ alt_formats/hpb-dgps/pdf/pubs/2006-wait-attente/index_e.pdf.
86 ■ PART I: Conceptual Perspectives Krieger, N. (2003). Genders, sexes, and health: What are the connections—and why does it matter? International Journal of Epidemiology, 32(4), 652–657. Krieger, N., & Fee, E. (1994). Man-made medicine and women’s health: The biopolitics of sex/gender and race/ethnicity. International Journal of Health Services, 24(2), 265–283. Lockshin, M.D. (2001). Genome and hormones: Gender differences in physiology: Invited review: Sex ratio and rheumatic disease. Journal of Applied Physiology, 91(5), 2366–2373. Martin, J.R. (1994). Methodological essentialism, false difference, and other dangerous traps. Signs: Journal of Women in Culture and Society, 19(3), 630–657. McCall, L. (2005). The complexity of intersectionality. Signs: Journal of Women in Culture and Society, 30(3), 1771–1800. Mittlemark, M. (2005) Global health promotion: Challenges and opportunities. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 48–57). New York: Palgrave Mcmillan. Morrow, M. (in press). “Our bodies our selves” in context: Reflections on the women’s health movement in Canada. In M. Morrow, O. Hankivsky, & C. Varcoe (Eds.), Women’s health in Canada: Critical perspectives on theory and policy. Toronto: University of Toronto Press. Mullings, L., & Schulz, A.J. (2006). Intersectionality and health: An introduction. In A.J. Schulz & L. Mullings (Eds.), Gender, race, class, and health: Intersectional approaches (pp. 3–17). San Francisco: Jossey-Bass. National Coordinating Group on Health Care Reform and Women. (2003). Reading Romanow: The implications of the final report of the Commission on the Future of Health Care in Canada for Women. Winnipeg: Canadian Women’s Health Network. Ostlin, P., George, A., & Sen, G. (2003). Gender, health, and equity: The intersections. In R. Hofrichter (Ed.), Health and social justice: Politics, ideology, and inequity in the distribution of disease (pp. 132–156). San Francisco: Jossey-Bass. Poland, B. (1998). Social inequalities, social exclusion, and health: A critical social science perspective on health promotion theory, research, and practice. Conference presentation, Bergen, Norway. Potvin, L., Gendron, S., Bilodeau, A., & Chabot, P. (2005). Integrating social theory into public health practice. American Journal of Public Health, 95(4), 591–595. Rao Gupta, G. (2000). Gender, sexuality, and HIV/AIDS: The what, the why, and the how. In XIIIth International AIDS Conference, July 12, 2000, Durban, South Africa: International Center for Research on Women (ICRW). Retrieved July 18, 2006, from www.icrw.org/docs/ durban_hivaids_speech700.pdf Reid, C. (2004). The wounds of exclusion: Poverty, women’s health, and social justice. Edmonton: Qualitative Institute Press. Reid, C., & Herbert, C. (2005). “Welfare moms and welfare bums”: Revisiting poverty as a social determinant of health. Health Sociology Review, 14(2), 161–173. Ruzek, S.B., Clarke, A.E., & Olesen, V.L. (1997). Social, biomedical, and feminist models of women’s health. In S.B. Ruzek, A.E. Clarke, & V.L. Olesen (Eds.), Women’s health: Complexities and differences (pp. 11–28). Columbus: Ohio State University Press. Salmon, A., Poole, N., Morrow, M., Greaves, L., Ingram, R., & Pederson, A. (2006). Integrating sex and gender in mental health and addictions policy: Considerations and recommendations for federal policy development. Vancouver: British Columbia Centre of Excellence for Women’s Health. Thurston, W.E., & O’Connor, M. (1996). Health promotion for women: A Canadian perspective. Paper prepared for the Canada–USA Women’s Health Forum, August 9–11, 1996, Ottawa, Ontario.
CHAPTER 6: Addressing Diversity in Health Promotion ■ 87 United Nations. (1995). The Platform for Action. Division for the Advancement of Women, The United Nations Fourth World Conference on Women. Beijing, China: United Nations. Retrieved February 5, 2007, from www.un.org/womenwatch/daw/beijing/platform/health.htm. Weber, L. (2006). Reconstructing the landscape of health disparities research: Promoting dialogue between feminist intersectional and biomedical paradigms. In A.J. Schulz & L. Mullings (Eds.), Gender, race, class, and health: Intersectional approaches (pp. 21–59). San Francisco: Jossey-Bass. Weber, L., & Parra-Medina, D. (2003). Intersectionality and women’s health: Charting a path to eliminating health disparities. In M.T. Segal & V. Demos (Eds.), Gender perspectives on health and medicine: Key themes (pp. 181–230). London: Elsevier. Women’s Health Bureau. (2003). Exploring concepts of gender and health. Ottawa. Health Canada. World Health Organization. (1986). Ottawa Charter for Health Promotion. Health Promotion International, 1(4), 405. World Health Organization. (1998). Gender and health: Technical paper. Geneva: World Health Organization. Retrieved July 18, 2006, from www.who.int/reproductive-health/publications/ WHD_98_16_gender_and_health_technical_paper/WHD_98_16_table_of_contents_en.html World Health Organization. (2005). The Bangkok Charter for Health Promotion in a Globalized World. Retrieved November 15, 2005, from www.who.int/healthpromotion/conferences/6gchp/ bangkok_charter/en/index.html Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion development in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.
CRITIC AL THINKING QUESTIONS 1. What is the difference between sex and gender? 2. Apply a “gender analysis” to understanding the prevalence of common health problems (e.g., heart disease, arthritis, and so on) through distinguishing it from an approach focused solely on “sex” differences. 3. Describe how gender interacts with health disparities, health inequalities, and social inequalities. 4. How has the “women’s health movement” or “women’s health activism” advanced understandings of gender and health and women’s health? 5. What can the women’s health movement and health promotion learn from each other?
FURTHER READINGS Andrew, C., Armstrong, P., Armstrong, H., Clement, W., & Vosko, L.F. (Eds.). (2003). Studies in political economy: Developments in feminism. Toronto: Women’s Press. This book brings together a collection of articles from Studies in Political Economy, a Canadian journal, to illustrate and explore the development of analyses regarding contemporary political economic theory and feminist theory. In particular, the articles look at the ways that class and gender intersect through studies of the workplace, long-term care for the elderly, the crisis in nursing in Canada, and violence against women. The collection was originally developed as a teaching aid and should help introduce students to the current theorizing and research.
88 ■ PART I: Conceptual Perspectives Doyal, L. (1995) What makes women sick? Gender and the political economy of health. London: Macmillan. In this classic volume, Lesley Doyal illustrates the value of a political economy approach to understanding and acting on women’s health. The book examines in detail the impact of sexuality, fertility control, reproduction, domestic labour, and waged work on women’s health and well-being by linking how gender divisions in economic and social life affect women’s experiences of illness, disability, and mortality. The final chapter draws from Professor Doyal’s extensive international experiences to illustrate how women around the world are meeting the challenges to their health. Morrow, M., Hankivsky, O., & Varcoe, C. (Eds.). (in press). Women’s health in Canada: Critical perspectives on theory and policy. Toronto: University of Toronto Press. Women’s health in Canada: Critical perspectives on theory and policy brings together an interdisciplinary group of scholars and practitioners who lay out the methodological and theoretical foundations for the interdisciplinary study of women’s health. The book emphasizes analytical and constructive directions in theory, practice, and policy from critical, feminist, and anti-racist perspectives. Ruzek, S.B., Clarke, A.E., & Olesen, V.L. (1997). Women’s health: Complexities and differences. Columbus: Ohio State University Press. This volume, from the United States, argues for integrated models of women’s health that address contributions of culturally and socially constructed concepts of caring and curing as well as health practices, medical care, and social investments in the prerequisites for health. These conceptualizations of health differ radically from narrow biomedical models that only acknowledge prevention, detection, and treatment of disease. This volume is divided into seven parts, including: (1) what is women’s health; (2) what we share and how we differ; (3) health practices, working and living conditions, and medical care; (4) culture and complexities; (5) intersections of race, class, and culture; (6) power and social control; and (7) challenges and choices for the 21st century. Schulz, A.J., & Mullings, L. (2006). Gender, race, class, and health: Intersectional approaches. San Francisco: Jossey-Bass. This volume aims to provide opportunities for dialogue or mutual exchange across the disciplines and paradigms that inform empirical efforts to understand and address inequalities in health. It brings together an interdisciplinary group of scholars from the social sciences and public health to examine the ways that gender, race, and class are mutually constituted and interconnected. The goal is to inform theory, research, and practice focused on the elimination of health disparities. The volume is divided into five parts: (1) intersectionality and health; (2) race, class, gender, and knowledge production; (3) the social context of health and illness; (4) structuring health care: access quality and inequality; and (5) disrupting inequality.
RELEVANT WEB SITES Bureau of Women’s Health and Gender Analysis www.hc-sc.gc.ca/ahc-asc/branch-dirgen/hpb-dgps/pppd-dppp/bwhgabsfacs/index_e.html
The Bureau of Women’s Health and Gender Analysis is the focal point for women’s health within the federal government. It provides policy advice and leads initiatives to
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advance women’s health and to increase our understanding of how sex and gender affect health over the lifespan. It builds departmental capacity by coordinating the implementation of gender-based analysis and reports on the development of gender-sensitive legislation, policies, and programs at Health Canada. The bureau, through the Centres of Excellence for Women’s Health, Working Groups, and the Canadian Women’s Health Network, ensures policy-relevant research and information dissemination. The bureau maintains ongoing relationships with provinces and territories, major women’s organizations, health researchers, and others to promote women’s well-being. Centre for Social Justice www.socialjustice.org/
The Centre for Social Justice is an advocacy organization that seeks to strengthen the struggle for social justice. The centre is committed to working for change in partnership with various social movements and recognizes that effective change requires the active participation of all sectors of the community. Through the centre research, education and advocacy is conducted toward narrowing the gap in income, wealth, and power. It aims to bring together people from universities, unions, faith groups, and communities toward the pursuit of greater equality and democracy. Centres of Excellence for Women’s Health www.cewh-cesf.ca
Canada’s Centres of Excellence for Women’s Health are funded through Health Canada’s Women’s Health Contribution Program. The centres were established in 1996 as part of the women’s health strategy and conduct and/or facilitate research on the determinants of women’s health and its translation into policy and accessible health information. The centres are associated with the Aboriginal Women’s Health and Healing Research Group (www.awhhrg.ca/index.php), Women and Health Care Reform (www.cewh-cesf.ca/healthreform/index.html), Women and Health Protection (www.whp-apsf.ca/en/index.html), and the Canadian Women’s Health Network (www.cwhn.ca/). CWHN is a voluntary national organization dedicated to improving the health and lives of girls and women in Canada and the world by collecting, producing, distributing, and sharing knowledge, ideas, education, information, resources, strategies, and inspirations. In 2006, there were four Centres of Excellence: • • • •
Atlantic Centre of Excellence for Women’s Health (www.acewh.dal.ca) British Columbia Centre of Excellence for Women’s Health (www.bccewh.bc.ca) National Network on Environments and Women’s Health (www.yorku.ca/nnewh) Prairie Centre of Excellence for Women’s Health (www.pwhce.ca)
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PA RT I I
NATIONAL PERSPECTIVES
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f we consider Canada as a whole, major actors or groups of actors have had a significant impact over the evolution of health promotion during the last 10-12 years. The federal government is clearly a significant force in health promotion from the perspective of funding, programming, and policy making. In Chapter 7, Pinder argues that although Canada’s federal government was the undisputed world leader from 1974 to 1994, it then abandoned the field for about a decade before beginning very recently to reclaim it, notably through the creation of the new Public Health Agency of Canada in 2004 and renewed interest and support for interventions on “healthy living.” In Chapter 8, Raphael illustrates how the policies of a national government have a major impact on the health of populations through the inequities that are produced or curtailed through such policies. Comparing Canada to other countries, notably the United Kingdom, Raphael shows that we are now lagging behind in addressing inequities, having been at the forefront of these issues at one time. Chapter 9 shows how another group of actors, Canada’s universities, have had an influential role over the last decade through training, capacity building, and the production and dissemination of knowledge related to health promotion. Rootman, Jackson, and Hills show how, in the absence of federal government leadership, the Canadian Consortium for Health Promotion Research became a major player in Canadian health promotion. By championing a certain vision of health promotion, however, the Consortium has created some debates within the research community that reflect some of the definitional dilemmas presented in the first section of the book. At the end of this section, the reader should thus be able to understand some of the major mechanisms that have operated within Canada as a whole from 1994 on and that had an impact on health promotion as a field and on the health of the population.
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CHAPTER 7
T H E F E D E R A L RO L E I N H E A LT H P RO M OT I O N : U N D E R T H E R A DA R Lavada Pinder
INTRODUCTION rom 1974–1994 the federal government played a prominent role in establishing Canada as a leader in health promotion. Internationally this reputation was undisputed. Closer to home there were reservations, but, even here, its contribution was acknowledged and respected. Beginning in 1994, however, the federal government appears to have quite willingly, even deliberately, given up its claim to leadership. At the federal level, it virtually vanished from the radar screen, replaced by the “population health approach.” Recently, there is reason to believe health promotion is beginning to regain its place as part of a renewed focus on public health. This raises many questions. Why was the leadership role given up? Were advances made with a new approach? Was the approach really new? Why is health promotion re-emerging at this point? Was health promotion operating under the radar, waiting for the right moment to resurface? The story of health promotion at the federal level needs telling. Writing about the role of the federal government in the first 20 years was relatively straightforward, drawing heavily on the first edition of this book (Pinder, 1994). It is the story of the third decade, however, that reads as a cautionary tale urging decision makers and practitioners alike to reflect, to acknowledge the past, and to build on successes. This chapter will attempt to tell this
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story by describing the development of health promotion and its rise to prominence, examining the policy shift from health promotion to population health, reviewing the impact of the population health approach, and, finally, discussing the renewed attention to health promotion as it is currently positioned within a public health context.
THE FIRST TWO DEC ADES Laying the Groundwork Action following the release of A New Perspective on the Health of Canadians (Lalonde, 1974) focused on lifestyles as applied through what would be known as the health promotion strategy, rather than dealing with all four elements of the health field concept presented by Lalonde. The first concrete indication of commitment was in 1978 with the establishment of a Health Promotion Directorate (HPD), thought to be the first of its kind in the world. Ron Draper, its first director general, brought together planning and research capacity, content knowledge (e.g., tobacco, nutrition, child health) and delivery skills (e.g., training education, social marketing) plus the community development expertise of five regional offices (Atlantic, Quebec, Ontario, Prairies, Western) to form program teams. This structure and approach to development and delivery was maintained, by and large, throughout the life of the HPD.
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In 1982 a submission to Cabinet by HPD sought a mandate for a comprehensive program focused on issues, target groups, and country-wide strategies that involved: (1) informing and equipping the public to deal with lifestyle issues; (2) promoting a social climate supportive of healthy lifestyles; (3) supporting self-help and citizen participation; and (4) promoting the adoption of health promotion programs within health care, social welfare, and other established programs (Draper, 1989). The program was approved with so few new resources, however, that its scope was reduced to tobacco, alcohol, drugs, and nutrition. The public face of health promotion, therefore, was associated with lifestyle programs. Few people were aware of the development of school and workplace health, heart health, child health, and a national health promotion survey. By the mid-1980s, growing criticism from within the HPD and from the field concerning the narrowness of the approach was captured by the term “victim-blaming” (Labonté and Penfold, 1981).
Redirecting Health Promotion At about the same time, a fundamental redirection in health promotion was articulated in Europe through Health Promotion: A Discussion Document on the Concept and Principles (World Health Organization, 1984). This little eight-page piece (also called the “yellow document” given the paper on which it was printed) defined health promotion as “a process of enabling people to increase control over, and to improve, their health” (p. 2)1 and introduced the principles of involving the population as a whole and directing action to the determinants of health. In 1985, these ideas found their way into a Canadian federal policy review initiated by bureaucrats and supported by the Honourable Jake Epp, the
minister of Health. As part of setting a new direction, the minister agreed to host the First International Conference on Health Promotion in Ottawa in collaboration with the World Health Organization (WHO) and the Canadian Public Health Association (CPHA). The conference produced the Ottawa Charter (World Health Organization, 1986) and the Canadian government released its own discussion paper, Achieving Health for All: A Framework for Health Promotion (AFHA) (Epp, 1986). The Epp Report (1986) was distributed and promoted throughout the country with a mixed response. While the conceptual framework of both AFHA and the Charter were welcomed by most, pragmatic souls raised doubts about capacity and political will to tackle healthy public policy. In fact, the skeptics were right. Efforts to obtain a mandate and resources to act on a broader view of health were not successful. Instead, HPD received significant new resources to undertake programs related to drug and alcohol abuse, tobacco use, nutrition, and AIDS. However, to their credit, the resulting strategies were designed to reflect many aspects of the new health promotion. They were intersectoral and involved partnerships with other federal departments, provincial and territorial governments, non-governmental organizations, and the private sector. Social marketing programs set a positive, non-judgmental tone; educational materials were developed to train professionals and augment school programs; qualitative research explored living and working conditions; and the regional offices of HPD delivered community action funds in response to locally defined needs. In an effort to balance the emphasis on these strategies, core funds were again directed to school and workplace health, and the Canadian Heart Health Initiative was launched in 1987 in collaboration with the
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National Health Research Development Fund (NHRDP). A knowledge development strategy, developed under the leadership of Dr. Irving Rootman, then a director in HPD, included negotiations with NHRDP and the Social Sciences and Humanities Research Council (SSHRC), resulting in a five-year support program for health promotion research centres in six universities. It is fair, then, to say that for two decades the federal government played a significant role in the development of Canadian health promotion. Documents redefining health and its determinants were written by bureaucrats and championed by ministers of health. A fledging infrastructure was put in place that reached beyond the federal level to the provinces and territories, universities, local public health units, and community health centres. An intersectoral, collaborative style of program development and delivery was pioneered. The federal government also took a prominent role internationally, hosting the First International Conference on Health Promotion and supporting subsequent conferences. Celebration of these achievements must be tempered, however, with the realization that health promotion never took its place as a cornerstone in the health system as envisioned in AFHA (Epp, 1986). It did not receive high-level support from either the federal government or federal/provincial/territorial committees. It did not acquire resources (beyond funds for risk reduction strategies) that would permit the research necessary to identify and explain the correlation between levels of socio-economic status and many measures of health status (Hayes & Glouberman, 1999). In fact, the work done equated health promotion with lifestyles. By the early 1990s, the popular view that health promotion was merely a series of lifestyle programs based primarily on social marketing was a perception that could not be shaken.2
Only keen observers appreciated health promotion as a set of values and action strategies designed to improve living and working conditions.
MOVING ON IN THE 1990S: PLUS ÇA CHANGE, PLUS C’EST PA R E I L ? In the early 1990s the work of the Canadian Institute for Advanced Research (CIAR) seemed more to the point. A respected group of researchers went beyond the concepts in the Lalonde Report (1974), the Epp Report (1986), and the Ottawa Charter (1986) to provide evidence needed to pursue a broader view of health. In masterful presentations to federal/provincial/territorial (F/P/T) meetings and publications such as Producing Health: Consuming Health Care (Evans & Stoddard, 1990) and Why Some People Are Healthy and Others Not (Evans, Barer, & Marmor, 1994), population health gained currency by providing a coherent set of analyses and priorities. The provinces of Quebec, British Columbia, Manitoba, Ontario, and Saskatchewan were the first to take up the notion of population health, and their influence on colleagues in F/P/T meetings gained support from the federal government. By 1992, the population health framework under development by the CIAR won the attention of the F/P/T Conference of Deputy Ministers of Health, which created an Advisory Committee on Population Health (ACPH) to reflect this new focus (Legowski & McKay, 2000).
Another Milestone Document? The ACPH got to work. A document outlining a national goals framework was prepared under contract in an effort to put a policy focus on population health (McAmmond, 1994).
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There was, however, little appetite for health goals among politicians and senior bureaucrats and even fewer resources to support their development. Instead the goals framework became the basis for a discussion paper, Strategies for Population Health: Investing in the Health of Canadians (Federal, Provincial, & Territorial Advisory Committee on Population Health, 1994). In quick succession the paper was approved by the F/P/T Conference of Deputy Ministers of Health in June 1994 and by the F/P/T ministers of Health in September 1994. Three years later, in 1997, in response to a memorandum developed with participation from 18 departments, the federal Cabinet agreed to adopt the population health approach to guide health policy (Legowski & McKay, 2000). Strategies for Population Health (1994) identified nine determinants of health: (1) income and social status; (2) social support networks; (3) education; (4) employment and working conditions; (5) physical environments; (6) biology and genetic endowments; (7) personal health practices and coping skills; (8) healthy child development; (9) and health services—and outlined three strategic directions—strengthening public understanding of the determinants of health; building understanding of the determinants of health among sectors outside of health; and developing comprehensive intersectoral population health initiatives. There is no doubt this document was pivotal in the federal government’s move from health promotion to the “the population health approach.” With the exception of one reference to the Lalonde Report (1974), it made no mention of 20 years’ of work in health promotion. It also marks the point when intellectual ferment within the federal government ceased and policy development moved into the F/P/T arena. Whether it ranks with the Lalonde and Epp reports or
the Charter as a milestone document is not the issue. What is at issue, in this chapter, is its impact on the federal government’s role in health promotion, on federal programs, and on federal efforts to take action on the determinants of health.
Getting Things Done in the 1990s In hindsight, the federal government may have moved quickly to adopt the new approach without fully appreciating the challenges. Moving beyond rhetoric is difficult at the best of times, but the environment created by the massive structural changes and budget cuts that affected the federal governments of the 1990s made the task exceptionally difficult. Defending scarce resources and self-preservation became the order of the day. In the summer of 1993 the Department of National Health and Welfare became Health Canada, and welfare was moved to a new Human Resources and Labour Department. A change of government in the fall of 1993 was followed by Program Review in 1994–1995 and Business Lines in 1995–1996. Subsequently, there was a limited reorganization in 1995–1996 to reflect the need to “do more with less” and, as significant new funds became available in 1999–2000, a more far-reaching one occurred in 2000 (Health Canada, 2000). Program Review was an exercise in which every program in the federal government was examined to establish the core role of a modern and affordable government. Each program was assessed according to criteria that included public interest, the number of partnerships, and whether the program was more suitable to the provincial role. Many programs did not pass this test and were “allowed to sunset.” Health promotion programs, without a legislative base and suffering from an image of high-cost
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social marketing activities, were either terminated or severely cut. Business Line working groups, established following program review, scrutinized health-related federal expenditures. A working group discussion paper, Population Health: From Rhetoric to Action (1996a) presented ideas on possible roles for Health Canada and contained a list of federal departments responsible for key determinants. It is a formidable list that in itself signalled how difficult it would be to turn rhetoric into action. Subsequent planning documents, while well crafted, were aimed at program officers and had little impact on policy development (Health Canada, 1998, 2001).
Impact on Health Promotion In March 1995, as part of reorganization, the Population Health Directorate was created to replace HPD. A Health Promotion Development Division in the new Directorate was ultimately reduced to one officer. With the champions gone, institutional memory fading, and no identifiable unit, health promotion began its descent as a policy and program focus, replaced by the “population health approach.” The health promotion field did not have a problem with the focus on the determinants of health. There were, however, concerns that promises to contribute to prosperity, to a vibrant economy, and to a reduction in health and welfare expenditures (Federal, Provincial, & Territorial Advisory Committee on Population Health, 1994) pandered to the hard-nosed approach demanded by the fiscal climate and avoided the importance of socioeconomic inequalities (Coburn & Poland, 1996). Moreover, the ideas seemed to support a top-down approach and stand to lose health promotion’s focus on community and advocacy. Ron Labonté (1995) suggested that health
promotion might possibly be “a stale concept in need of re-invention. [But if] population health is to be its phoenix, let it rise from the ashes of health promotion’s diversity in social critique and empowering practices” (p. 167). Unwilling to see health promotion reduced to ashes, Health Canada made a serious effort to integrate population health and health promotion into a common framework. A discussion paper, Population Health Promotion: An Integrated Model of Population Health and Health Promotion, was prepared by the Health Promotion Development Division (Hamilton & Bhatti, 1996). At a round table, following distribution of the paper, 26 participants, representing the who’s who of both fields, agreed there was common ground and expressed a willingness to work together (Health Canada, 1996b). Some years later Evans and Stoddard (2003) suggested the framework was useful and appropriate in its recognition of both health promotion and population health. Inside the bureaucracy in 1996, however, there was little traction. Health Canada had put its money on population health as the great leap forward and was not about to complicate matters. At the same time, Health Canada funded a Canadian Public Health Association (CPHA) project, Perspectives on Health Promotion. In 1995 CPHA established a working group, which commissioned a background document, undertook a key informant survey, held consensus-building workshops across the country and a national workshop at the CPHA annual meeting (Canadian Public Health Association, 1996a). The resulting Action Statement (1996b) contained strategic principles, confirmed health promotion concepts, and proposed a renewed emphasis on healthy public policy, strengthening communities and reorienting the health system. The process was important to a field that was feeling insecure with the ascendancy of population health, but,
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by the time the action statement appeared, there were no funds to promote it. Efforts to support development of a health promotion training and research infrastructure, represented in the early 1990s by funding for selected university-based health promotion centres, became increasingly ad hoc later in the decade. This story is presented in detail in Chapter 9 of this book.
Impact on Programs The federal government may seem to have abandoned health promotion, but, having survived the deficit cutting of the mid-1990s, Health Canada did not stop producing and continues to produce a host of health-promoting programs (Health Canada, 2002). Some are a continuation of earlier health promotion programs; others are newer. The topics cover issues such as tobacco and HIV/AIDS, population groups such as children and seniors, and settings such as the workplace and schools. Even a little digging reveals that most are built on the foundation laid down in the first two decades of health promotion. Prime examples are the Federal Tobacco Control Strategy (FTCS) and the Canadian Diabetes Strategy. The Tobacco Strategy, for instance, renewed and improved many times over the years, is, in many ways, the gold standard for intersectoral, collaborative strategies. Smoking rates have declined dramatically since it was first launched in 1987, testifying to the fact that change takes time, a clear focus, and significant investment to make a difference (Health Canada, 2005b). New programs such as the Canadian Health Network (CHN) and the Pan-Canadian Healthy Living Strategy are also reminiscent of earlier programs, i.e., Health Promotion OnLine and the Health Canada-Participaction programVitality/Vitalité. The difference is they reach further, are better funded, more
technologically sophisticated, and, most important, have the support of governments at all levels. The CHN (Health Canada, 2004) is a bilingual, Web-based information service intended to help Canadians make healthy choices. It provides practical information through links to more than 17,000 Web-based resources and monthly features on current health issues. Information on a variety of topics, including health promotion, is provided by affiliates. The Centre for Health Promotion at the University of Toronto, for example, in partnership with the Ontario Prevention Clearinghouse, provides expertise and training in health promotion for CHN affiliates working in other subject areas The Integrated Pan-Canadian Healthy Living Strategy is the result of an agreement reached by the F/P/T ministers of Health in September 2002 to use a common approach to addressing the risk factors known to contribute to non-communicable diseases. Following cross-country consultations in 2003, the F/P/T ministers of Health approved a framework that included a Healthy Living Network, research, surveillance and best practices, options for an intersectoral fund, and further dialogue with Aboriginal stakeholders (Health Canada, 2005b).
Impact on Policy: The Determinants of Health In a recent book on the social determinants of health, Raphael (2005a) observes that, “strengthening social determinants of health would reduce health inequalities, thereby improving the population health of Canadians. This being the case, it would be expected that governments would be responsive to these ideas. This may not be the case.” Others agree that recently in Canada, it is difficult to find examples of policy shifts addressing the social
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determinants of health carried through to implementation, although the National Children’s Agenda (1999) and the National Child Benefit (1998) are positive moves in that direction (Evans & Stoddard, 2003). The role of Health Canada in leading intersectoral strategies has been well honed over the years. Other sectors do not have a problem in collaborating on issues that are clearly health related, but tackling the social determinants where the policy changes clearly lie in sectors outside of health is quite another matter as well identified in Rebalancing at the Societal Level (a paper in volume II of the final report of the National Health Forum (1997b): The health sector can play a very effective role as an advocate or, a partner in, strategies which act on the basic determinants of health. But we must resist the temptation of taking on too broad of a mandate for achieving health objectives. We should not hold health authorities accountable for reducing inequities in health. But we should hold them accountable for identifying needs, clarifying connections, and telling the truth about why some people are healthy and others are not. (p. 18)
This seems simple enough until the idea is explored in terms of research needs, analysis, policy tradeoffs, mechanisms, and the tools necessary to conduct health impact analysis of relevant policies. In fact, strategies to act on the social determinants call on just as much, if not more, investment, strategic thinking, persistence, and long-term thinking as the tobacco strategy. Efforts to set up mechanisms such as the 1997 Interdepartmental Reference Group, made up of senior officials from several departments, were short-lived. Senior staff was quickly replaced with junior officers when it became clear that no real mandate would be given to such a structure.
PUBLIC HEALTH FINDS ITS RIGHTFUL PLACE Reports, Reports, but Finally Some Respect Had it not been for a SARS epidemic that had major economic consequences and recommendations from several commission reports, the decade of the 1990s that started out with a paper entitled, Producing Health: Consuming Health Care, could have closed with one called Producing Action: Consuming Rhetoric. But there is no question that the SARS outbreak of 2002–2003 and concern about mad cow disease (BSE) and West Nile Virus put public health front and centre in the public, political, and bureaucratic mind at the beginning of the new century, even more so than the reports of several federal commissions. Deliberations on health futures started with the National Forum on Health, launched by the Right Honourable Jean Chrétien in 1994. The 24 volunteer members went further than the provincial commissions of the 1980s in trying to find a balance between the national preoccupation with health care and the need to deal with other health determinants. For a year following the final report in 1997, the federal government monitored progress on the recommendations. Perhaps as a consequence of this special effort, there was significant institutional response to the recommendations concerning research, information, and Aboriginal health. The Population Health Initiative was created as part of the Canadian Institute for Health Information; a National Aboriginal Health Institute was established; and several of the 13 Canadian Institutes for Health Research, a new major funding mechanism for health research created in 2000, cover issues relevant to health promotion: population and public health, gender, aging, nutrition, and human development (National Forum on Health, 1997b).
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Two highly anticipated reports had much less impact on public health. The Kirby Report, The Health of Canadian—The Federal Role (2002), devoted a section to health promotion and disease and recommended funds for prevention of chronic disease. The Romanow Report, Building on Values: The Future of Health Care in Canada (Health Canada, 2002) concentrated on health care, despite briefs from the public health community and several consultations From a health promotion perspective, however, the Naylor Report, Learning from SARS: Renewal of Public Health in Canada (Health Canada, 2003), was the most important document. First, it recommended the creation of a Canadian agency for public health and the appointment of a chief public health officer for Canada; and, second, in line with some work done for the Americas by the Pan-American Health Organisation, health promotion was identified as one of five essential public health functions, the others being health protection, health surveillance, disease and injury prevention, and population health assessment. These functions are also consistent with those outlined by the Institute of Population and Public Health and the Association for the Care of Children’s Health. It is worth noting that population health assessment is described as “the ability to understand the health of populations, the factors which underlie good health and those which create health risks. These assessments lead to better services and policies”(p. 47). The description of health promotion, on the other hand, is as follows: Public health practitioners work with individuals, agencies, and communities to understand and improve health through healthy public policy, community-based interventions, and public participation. Health promotion contributes to and shades into disease prevention
by catalyzing healthier and safer behaviours. Comprehensive approaches to health promotion may involve community development or policy advocacy and action regarding environmental and socioeconomic determinants of health and illness. (p. 47)
These descriptions are interesting on two counts. First, a clear distinction is made between population health and health promotion. The former is seen as having mainly a research/assessment role and the latter is seen as action-oriented, in line with the Ottawa Charter. Second, the description of health promotion comes with a footnoted warning that the more “expansive” aspects of health promotion—i.e., addressing the determinants of health—may be criticized as “health imperialism” or “social engineering.” It would be ironic, indeed, if health promotion, once accused of being limited to social marketing, would now take the rap for being too broad. The Canadian Coalition for Public Health in the 21st Century (the Coalition) complements the recommendations in the Naylor Report (Health Canada, 2003) and represents a non-governmental approach to strengthening public health. The Coalition is the result of a think tank on the future on public health sponsored by the Institute for Population and Public Health just prior to the annual meeting of the Canadian Public Health Association (CPHA) in May 2003. In its advocacy role it should be a force in sustaining the renewed federal government’s commitment to public health (Frank, DiRuggiero, & Moloughney, 2004).
The Public Health Agency of Canada In September 2003, in the wake of the reports mentioned above, the F/P/T Conference of Ministers of Health recognized the need to
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give public health top priority, improve public health infrastructure, and increase institutional, provincial, territorial, and federal capacity. In December 2003, a federal minister of state for public health was named, the Honourable Carolyn Bennett. By June 2004, the federal government had established the Public Health Agency of Canada (PHAC) and announced the creation of six National Collaborating Centres for Public Health dealing with the determinants of health (Atlantic), public policy and risk assessment (Quebec), public health methodologies and tools development (Ontario), infectious diseases (Manitoba), environmental health (British Columbia), and Aboriginal health (British Columbia) (Public Health Agency of Canada, 2004). In September of the same year Dr. David Butler-Jones, former chief medical officer in Saskatchewan and former president of the CPHA, was named Canada’s first chief public health officer (Public Health Agency of Canada, 2004). Further acknowledgement of the need to strengthen public health can also be found in The 10-Year Plan to Strengthen Health Care, a statement from the First Ministers’ meeting in September 2004. The Plan is perhaps best known for the $41 billion health care agreement with the provinces, but the careful reader can find a commitment to the creation of a new Public Health Network, continuing work on development of a Pan-Canadian Public Health Strategy, and the development of health goals and targets (Federal, Provincial, & Territorial First Ministers Conference, 2004). The PHAC is central to all of the recent and planned efforts to strengthen in public health, including again, in a significant way, health promotion without dismissing population health. With its mission “to promote and protect the health of Canadians through leadership, partnership, innovation and
action in public health” and a clear identity, the PHAC is firming up its leadership role (Public Health Agency of Canada, 2006). For example, it has led the federal government participation in developing the PanCanadian Public Health Network (the Network) and public health goals. The final report of the F/P/T Special Task Force on Public Health, Partners in Public Health (2005), outlines the role and structure of the Network. The role includes information sharing and dissemination, helping jurisdictions facing emergencies, and providing advice to the F/P/T Deputy Ministers of Health. Expert Groups made up of experts nominated by each of the jurisdictions report to a council of F/P/T representatives, who, in turn, report to the F/P/T Conference of Deputy Ministers. Health promotion is one of the six expert groups and it is expected the Ottawa Charter (1986) will frame its work. After 15 years of advocacy, particularly by the CPHA, a single phrase in the First Ministers’ 10-year plan, plus an enthusiastic Minister of State for Public Health, got the process underway and completed in less than a year. Roundtables with the provinces and territories and with experts took place from March–July 2005 and by October the goals were approved by the F/T/P ministers of Health (Public Health Agency of Canada, 2005). The goals, under the four headings— basic needs, belonging and engagement, healthy living, and system of health—are deliberately broad and obviously designed to achieve consensus. The idea is for each community, government, and individual to put them into effect, but, without promotion and monitoring, they will be easy to ignore and may never trigger specific objectives and targets given the never-ending complexities of federal-provincial relationships concerning these issues. The PHAC plans to discuss their
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relevance to various sectors with government departments, but this, as has been mentioned before, will take a sophisticated process to avoid being a one-off exercise.
The Future of Health Promotion The federal government has been urged to reclaim its leadership role in health promotion (Law, Kapur, & Collishaw, 2004). “Health promotion” continues to be the term used internationally and the profile has recently been raised again in Canada with both Ontario and Nova Scotia having created ministries of health promotion. As the confusion about population health and health promotion dissipates, the PHAC is poised to begin, once again, to earn a reputation for leadership. One significant step is the change of name of its Centre for Human Development to the Centre for Health Promotion. This is more than a change in name. The intention is to use health promotion as an integrating and unifying concept to organize policies and programs. Internationally, there are opportunities to support health promotion and, at the same time, begin serious work on the determinants of health. The PHAC is funding the Canadian Consortium for Health Promotion Research to organize the 19th International Conference on Health Promotion and Health Education in Vancouver in June 2007. The conference could provide a platform for the federal government to present Canadian health promotion in the context of a renewed public health. Another opportunity is Canada’s participation in the World Health Organization Commission on the Social Determinants of Health. The Canadian representatives, Monique Begin and Stephen Lewis, are being supported by a Canadian Reference Group chaired by Dr. Sylvie Statchenko, deputy chief public health officer
(World Health Organization, 2005). The Canadian representatives to the Commission are also supported by Dr. Ron Labonté, University of Ottawa (globalization), and by Dr. Clyde Hertzman, University of British Columbia (child health). This work could provide a basis for the PHAC to secure its role both nationally and internationally in leading intersectoral action on determinants. In some respects this would be in line with the formation of a federal Social Determinants of Health Task Force proposed in the Toronto Charter for a Healthy Canada (2002) (Raphael, 2005b).
CONCLUSIONS One thing is clear. In the future, terms may come and go, but “the determinants of health” are here to stay. Health promotion laid down the foundation and the population health approach unequivocally put the determinants of health on the agenda. The policy implications remain unclear, but the need to strengthen the social determinants has been widely accepted. At the same time it needs to be said that introducing new policy ideas into government is not too difficult. Gaining acceptance is possible, but taking action is not so easy. Each in its turn—the Lalonde Report (1974), the Epp Report (1986), the Ottawa Charter (1986), and the Strategies for Population Health (1994)—was thought to be the turning point. Proponents promised a great deal, but delivered very little. In fact, there is remarkable similarity in the results achieved by each new wave—changes in language, reorganizations, a host of excellent programs, but little policy. Now there is a new opportunity to move ahead, with population health and health promotion having found their places within a public health framework. With secure and complementary roles, energy will be saved for the real task ahead—sustained and strategic
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effort to pursue the policies that would strengthen the determinants of health. Things may have worked out for the best, but it is still a puzzle why, along the way, the federal government so readily gave up its national and international leadership role in health promotion. Why did thinking people buy the notion that health promotion was simply lifestyles/social marketing? Why was a decision not made to acknowledge some limitations in health promotion’s understanding of the determinants of health and to draw on population health research to
strengthen health promotion? Why was the argument not made that health promotion based on the Ottawa Charter (1986) would be the best way for the federal government to contribute to achieving population health? Yes, there were political and bureaucratic changes, different priorities, diminishing resources—hard times—but the lesson here is simple—“Don’t throw out the baby with the bath water”—particularly when the baby has earned Canada a worldwide reputation. Build and be seen to build.
ACKNOWLEDGEMENTS Thanks to Brian Bell, Tariq Bhatti, Carmen Connolly, Peggy Edwards, Heather Fraser, Lynn Hawkins, Suzanne Jackson, Jim Mintz, Ian Potter, Claude Rocan, Sylvie Statchenko, and Elinor Wilson for providing information and pointing the way to documents and Web sites.
NOTES 1
2
Nutbeam’s (1986) definition is an improvement: “the process of enabling individuals and communities to increase control over the determinants of health and thereby improve their health” (p. 114). The role of social marketing should be clarified. It is not health promotion; it is a health promotion tool representing one of the few ways government can reach Canadians directly. With the exception of the mid-1990s when social marketing budgets virtually disappeared, it has played a vital role in Health Canada strategies and been allocated significant funds.
REFERENCES Canadian Public Health Association. (1996a). Perspectives on health promotion: Final report. Ottawa. Canadian Public Health Association. (1996b). Action statement on health promotion in Canada. Ottawa. Coburn, D., & Poland, B. (1996). The CIAR vision of the determinants of health. Canadian Journal of Public Health, 87(5), 308–310. Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada. Retrieved July 16, 2006, from www.hc-sc.gc.ca/english/pdf/romanow/pdfs/ HCC_Final_Report.pdf. Draper, R. (1989, June 5–9). The WHO strategy for health promotion. Paper presented at the Community Participation Strategies in Health Promotion Workshop, Bielefeld, Germany. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: National Health and Welfare. Evans, R.G., Barer, M.L., & Marmor, T.R. (1994). Why are some people healthy and others not?: The determinants of health of populations. New York: Aldine de Guyter.
CHAPTER 7: The Federal Role in Health Promotion ■ 103 Evans, R.G., & Stoddard, G.L. (1990). Producing health, consuming health care. Social Science and Medicine, 31(12), 1347-1363. Evans, R.G., & Stoddard, G.L. (2003). Consuming research, producing policy? American Journal of Public Health, 93(3), 371–379. Federal, Provincial, & Territorial Advisory Committee on Population Health. (1994). Strategies for population health: Investing in the health of Canadians. Ottawa: Health Canada. Federal, Provincial, & Territorial First Ministers Conference. (2004). The 10-year plan to strengthen health care. Ottawa: Online at www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/ 2004-fmm-rpm/index_e.html. Federal, Provincial, & Territorial Special Task Force on Public Health. (2005). Partners in public health. Ottawa: Public Health Agency of Canada. Online at www.phac-aspc.gc.ca/publicat/healthpartners/ pdf/partnersinhealthmainreport_e.pdf. Frank, J., DiRuggiero, E., & Moloughney, B. (2004). Think tank on the future of public health in Canada. Canadian Journal of Public Health, 95(1), 6–11. Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of health and health promotion. Ottawa: Health Promotion Development Division, Health Canada. Online at www. phac-aspc.gc.ca/ph-sp/phdd/php/php.htm. Hayes, M., & Glouberman, S. (1999). Population health, sustainable development, and policy future. Ottawa: Canadian Policy Research Networks. Health Canada. (1996a). Population health: From rhetoric to action, a discussion paper prepared by the Population health Steering Committee and Working Group. Ottawa. Health Canada. (1996b). Report of the roundtable on population health and health promotion. Ottawa: Health Promotion Development Division, Health Canada. Online at www.phac-aspc/ ph-sp/phdd/roundtable.htm. Health Canada. (1998). Taking action on population health: A position paper for health promotion and programs branch staff. Ottawa: Population Health Development Division, Population Health Directorate, Health Canada. Health Canada. (2000). Realigning Health Canada to better serve Canadians. Ottawa: Minister of Public Works and Government Services. Health Canada. (2001). The population health template: Key elements and actions that define a population health approach. Ottawa: Health Canada, Population and Public Health Branch. Health Canada. (2002). Promoting health in Canada: An overview of recent developments and initiatives. Ottawa: Strategic Policy Directorate, Population and Public Health Branch. Health Canada. (2003). Learning from SARS: Renewal of public health in Canada: A report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada. Health Canada. (2004). Canadian health network: Retrieved January 25, 2006, from www. canadian-health-network.ca/servlet/ContentServer?pagename=CHN-RCS/Page/ ShellCHNRResourcePagetemplate&cid=4266339&lang=E. Health Canada. (2005a). The integrated pan-Canadian healthy living strategy. Cat. no. HP 10-1/2005E, ISBN 0-662-41146-3. Ottawa: Minister of Health. Health Canada. (2005b). Federal Tobacco Control Strategy. Retrieved January 25, 2006, from www.hc.sc.gc.ca/hl-vs/tobac-tabac/about-apropos/role/federal/strateg/index_e.html. Kirby, M., & LeBreton, M. (2002). The health of Canadians—the federal role: Final report. Retrieved July 16, 2006, from www.parl.gc.ca/37/2/parlbus/commbus/senate/com-e/SOCI-E/rep-e/repoct02vol6-e.htm.
104 ■ PART II: National Perspectives Labonté, R. (1995). Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health, 86(3), 165–168. Labonté, R., & Penfold, S. (1981). Canadian perspectives in health promotion: A critique. Health Education, 19(3), 4–9. Lalonde, M. (1974). A New Perspective on the Health of Canadians. Ottawa: Minister of Supply and Services. Law, M., Kapur, A.D., & Collishaw, N. (2004). Health promotion in Canada 1974–2004: Lessons learned. Ottawa: Canadian Medical Association. Legowski, B., & McKay, L. (2000). Health beyond health care: Twenty-five years of federal policy development. Ottawa: Canadian Policy Research Networks. McAmmond, D. (1994). Analytic review towards health goals in Canada. Final report prepared for the Federal, Provincial, and Territorial Advisory Committee on Population Health. Ottawa: Health Canada. National Forum on Health. (1997a). Canada health action: Building on the Legacy: Final report. Ottawa: Minister of Public Works and Government Services. National Forum on Health. (1997b). Canada health action: Building on the Legacy. Vol. 2. Synthesis Reports and Issues Papers. Ottawa: Minister of Public Works and Government Services. Nutbeam, D. (1986). Health promotion glossary. Health Promotion, 1, 113–127. Pinder, L. (1994). The federal role in health promotion: The art of the possible. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada. Toronto: W.B. Saunders. Public Health Agency of Canada. (2004). News release. Retrieved January 30, 2006, from www.phacaspc.gc.ca/media/nr-rp/2004/index.html. Public Health Agency of Canada. (2005). Health Goals for Canada. Retrieved January 30, 2006, from www.healthycanadians.ca/NEW-1-eng.html. Public Health Agency of Canada. (2006). Web site. Retrieved January 15, 2006, from www.phac.gc.ca/about_apropos/index.html. Raphael, D. (2005a). Introduction to the social determinants. In D. Raphael (Ed.), The social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (2005b). Appendix: Strengthening the social determinants of health: The Toronto charter for a healthy Canada. In D. Raphael (Ed.), The social determinants of health. Toronto: Canadian Scholars’ Press Inc. World Health Organization. (1984). Concepts and principles of health promotion. Copenhagen: WHO Regional Office for Europe. World Health Organization. (1986). Ottawa Charter for Health Promotion. Geneva:Author. World Health Organization. (2005). Commission on social determinants of health. Retrieved February 3, 2006 from, www.who.int/social_determinants/en/.
CRITIC AL THINKING QUESTIONS 1. If it is accepted that risk reduction/lifestyle programs are important ways health promotion can contribute to improved health, how can this role be maintained without undermining efforts to influence determinants outside of the health sector? How can these roles be seen as complementary rather than competitive? 2. Governments change frequently. How can progressive policy work be sustained despite the fact that priorities and sometimes values change with new political masters? What is
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the role of bureaucrats? What role can non-governmental organizations play in influencing the maintenance of positive policy change? 3. What are the fundamental building blocks in strengthening the social determinants of health? How can the basic research, tools, mechanisms, etc., be developed and maintained as a natural part of the way the health sector does its business? 4. It is important to have pan-Canadian leadership in health promotion. What role would the federal government ideally play? 5. How important is language clarity to the future of health promotion? What is the impact of terminology on policy, programs, training, and advocacy? Does it matter what an endeavour is called as long as it contributes to the improvement of health?
FURTHER READINGS Savoie, D.J. (2003). Breaking the bargain: Public servants, ministers, and Parliament. Toronto: University of Toronto Press. This book provides historical background on how the federal government works and the traditional roles of public servants and politicians in setting and implementing policies. It goes on to discuss current realities, emergent issues, and thoughts on how they might be resolved.
RELEVANT WEB SITES Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR
The Consortium, with 16 members, aims to enhance health promotion research through collaborative research projects, advocating funding for health promotion research, and acting as a focal point for international activity. Canadian Population Health Initiative (CPHI) www.cihi.ca/cphi
CPHI is a source of research information on the determinants of health. It was established in response to a recommendation from the National Forum on Health to foster better understanding of factors that affect individual and community health and contribute to policy development. Canadian Public Health Association www.cpha.ca/english/
CPHA is a national, independent, not-for-profit, voluntary association representing public health in Canada with links to the international public health community.
CHAPTER 8
A D D R E S S I N G H E A LT H I N E Q UA L I T I E S I N C A N A DA : L I T T L E AT T E N T I O N , I N A D E Q UAT E AC T I O N , L I M I T E D S U C C E S S Dennis Raphael INTRODUCTION ealth promotion is about improving the health of the population by increasing control over the determinants of health (Nutbeam, 1998). An important component of this agenda should be the reduction of inequalities in health and influencing the determinants of these health inequalities (Whitehead, 1998). Health promotion initiatives that fail to consider the source of health inequalities may actually increase inequalities by employing approaches that favour those already enjoying good health at the expense of those whose health is already poor (Graham, 2004).1 Profound health inequalities exist in Canada. These inequalities result from Canadians’ experiencing varying exposures to both health-enhancing and health-threatening living conditions (Raphael, 2002). These differential exposures are related to where Canadians live; the social classes and income groups in which they find themselves; whether they are of Aboriginal, European, or non-European descent; or male or female (Raphael, 2006a,b). These health inequalities are apparent in general health status, life expectancy, and in the incidence of, and mortality from, a wide range of medical conditions. Canada was one of the first jurisdictions to identify addressing health inequalities as important, but Canada now lags far behind many other developed nations in having
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health inequalities on the public health and public policy agendas (Canadian Population Health Initiative, 2002). Not surprisingly, Canada also lags behind other developed nations in researching health inequalities and the sources of such inequalities, and developing and implementing means of reducing these inequalities (Raphael et al., 2005). The past few decades have seen a diminution of health inequalities among Canadians for certain conditions (Wilkins, Berthelot, & Ng, 2002).2 But these declines cannot be attributed to directed action by governments and public health agencies motivated by a health inequalities agenda (Sutcliffe, Deber, & Pasut, 1997; Williamson, 2001; Williamson et al., 2003). Instead, many recent governmental policies have widened known determinants of health inequalities among the population (Dunn, Hargreaves, & Alex, 2002; Raphael, Bryant, & CurryStevens, 2004). And Canadian public health action continues to be focused on issues that play a relatively little role in producing or reducing health inequalities (Raphael, 2003; Raphael & Bryant, 2006). There are troubling implications for the health of Canadians that result from these developments. In this chapter the extent and sources of health inequalities among Canadians is examined. The reason why addressing health inequalities is a marginal issue in Canada is considered by contrasting our situation with developments in other nations. To do so will
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require political and institutional willingness to address key issues related to the societal or social determinants of health.
ADDRESSING HEALTH INEQUALITIES IN C ANADA AND ELSEWHERE Health Inequalities Elsewhere Health inequalities exist in every nation on the planet (Amick, Lavis, & Lopez, 2000). There are two primary discourses that have been applied to explain the existence of these inequalities. The cultural/behavioural explanation is that individuals’ behavioural choices (e.g., tobacco and alcohol use, diet, physical inactivity, etc.) are responsible for their developing and dying from a variety of diseases. The materialist/structuralist explanation emphasizes the material conditions under which people live (Raphael, 2006). These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others. Access to health-enhancing conditions is also related to the way governments behave (Ross et al., 2000). Evidence clearly favours the materialist explanation of the sources of health inequalities (Acheson, 1998; Gordon, Shaw, Dorling, & Davey Smith, 1999; Raphael, 2006a; Shaw, Dorling, Gordon, & Smith, 1999; Townsend, Davidson, & Whitehead, 1992). Jurisdictions differ profoundly to the extent that these inequalities are seen as a cause for concern requiring action to address them (Bryant, 2006). A recent review examined how 13 developed nations are addressing health inequalities. Some, like the UK countries, New Zealand, and Sweden, have undertaken systematic governmental efforts to identify the existence and magnitude of
health inequalities and their sources. In contrast, Canadian efforts are limited to reports on how poverty and income inequality influence health mostly by non-governmental organizations (Canadian Population Health Initiative, 2004; Phipps, 2002; Ross, 2002, 2004). Outside of governmental attention devoted to Aboriginal health, the extent of Canadian activity directed toward the issue of health inequalities is minimal and varies across provinces. Health promotion and population health discourses in Canada, for the most part, do not explicitly focus upon reducing health inequalities. As compared to developments in several European countries, reducing health inequalities in Canada takes a back seat to policy statements about improving social and physical environments (Health Canada, 2001). There has been no defining Canadian “Black Report” (Black & Smith, 1992) or “Independent Inquiry into Health Inequalities” (Acheson, 1998) focused on health inequalities, as was the case in the United Kingdom.
Health Inequalities in Canada: Income and Other Determinants In contrast to other nations where research and policy concern with health inequalities has a long-standing history such as the UK, few Canadian researchers explicitly focus on the extent and source of health inequalities (Raphael et al., 2005). And when these researchers do, many are likely to attribute such differences to behavioural risk factors such as tobacco use, physical inactivity, and diet. As one example, a report from Statistics Canada devoted most of its content to documenting how health behaviours (e.g., smoking, exercise, weight, etc.) and psychosocial variables (e.g., stress and depression) helped explain differences in health status among
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health regions (Shields & Tremblay, 2002). This was done even though data from the same study showed that self-reported income was far and away the best explanation for these regional differences in health outcomes (Tremblay, Ross, & Berthelot, 2002). Such a fixation on individual behaviours and psychosocial risk conditions is surprising as Canada has been seen as a leader in developing health promotion and population health concepts that outline the importance to health of societal factors such as income and its distribution, employment security and working conditions, early childhood, and other social determinants of health (Restrepo, 2000). Nevertheless, there is Canadian research that identifies inequalities in health as being related to Aboriginal status, income and its distribution, geographic location, and gender. Somewhat less work examines how health inequalities result from early life experiences, inadequate housing, food insecurity, lack of access to health services, immigrant status, and social exclusion (Galabuzi, 2004, 2005; Raphael, 2004b; Raphael, Bryant, & Rioux, 2006). And important research focuses on the political economy of health inequalities and how changes in economic structures and processes associated with increasing economic globalization and the adoption of neoliberal public policies drive increasing inequalities in these social determinants of health (Coburn, 2000, 2004; Teeple, 2000). In this chapter, I focus on health inequalities related to income as it is the most studied factor; other chapters cover factors such as gender and Aboriginal status and the literature cited in this chapter provides ample additional information. Income is an especially important determinant of health inequalities as it is a marker of differential experiences with many social determinants of health.3 Income is a determinant of the quality of early life, education, employment,
and working conditions as well as food security (Raphael, 2001). Income also is 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 (Raphael, 2004a). Income level is the best predictor of just about every health indicator experienced by Canadians (Auger, Raynault, Lessard, & Choinière, 2004). The most definitive work in Canada on income and health is done by Wilkins and colleagues at Statistics Canada (Wilkins, Berthelot, & Ng, 2002). Essentially, his analyses are conservative estimates of the relationship between income level and mortality rates. In both 1986 and 1996, those Canadians living within the poorest 20 percent of urban neighbourhoods were much more likely to die from cardiovascular disease, cancer, diabetes, and respiratory diseases—among other diseases—than other Canadians (Wilkins, Berthelot, & Ng, 2002). In 1986, 21 percent of premature years of life lost for all causes prior to age 75 in Canada could be attributed to income differences and this estimate increased to 23 percent by 1996. This figure is obtained by using the mortality rates in the wealthiest quintile of neighbourhoods as a baseline and considering all deaths above that rate to be excess related to income differences. Figure 8.1 shows how excess mortality associated with income manifests itself in premature mortality associated with various diseases. Moreover, as shown in Table 8.1, the burden of ill health is concentrated in the lowest income quintile of neighbourhoods in urban Canada. For just about every cause of death, the richest neighbourhoods fare much better than the others. A recent study reinforces these findings. In this Ontario study, selfreported health status, as well as a functional measure of health, were examined in relation
CHAPTER 8: Addressing Health Inequalities in Canada ■ 109 TABLE 8.1: Age-Standardized Mortality Rates Per 100,000 Population, for Both Sexes, or for Males and Females When Rates Differ by Gender, for Selected Causes of Death by Neighbourhood Income Quintile, Urban Canada, 1996
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to both personal and area variables. Findings indicated that individual level of income was a primary determinant of both self-reported and functional health (see Figures 8.2 and 8.3). Income-related health inequalities are higher than would be expected from income distribution and health data derived from other nations (Humphries & van Doorslaer, 2000).
As mentioned earlier, we could have gone in great detail on many other determinants of health and would have seen reproduced the same patterns of health inequities between males and females, Aboriginal or not, immigrant or not, etc. Let us address now how this problem can be tackled.
FIGURE 8.1: INCOME-RELATED PREMATURE YEARS OF LIFE LOST (0–74 YEARS) ASSOCIATED WITH DISEASE ENTITY, URBAN CANADA, 1996
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FIGURE 8.2: REPORT OF FAIR OR POOR SELF-RATED HEALTH: ODDS RATIOS FOR INDIVIDUAL AND AREA FACTORS, ONTARIO, 1996
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CHAPTER 8: Addressing Health Inequalities in Canada ■ 111 FIGURE 8.3: POOR SCORES (<50TH PERCENTILE) ON THE HEALTH UTILITIES INDEX: ODDS RATIOS FOR INDIVIDUAL AND AREA FACTORS, ONTARIO, 1996
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BOX 8.1: DETERMINANTS OF HEALTH INEQUALITIES IN CANADA
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AN AGENDA FOR ADDRESSING HEALTH INEQUALITIES IN C ANADA Despite the increasing availability of research funding to address “disparities in health” and the “health of vulnerable populations” by the Canadian Institutes of Health Research, there is little evidence that addressing inequalities
in health is high on the agenda of Canadian researchers, policy makers, and the health promotion community. We will look at this first by looking at the common source of health inequities, the social determinants of health. We will then look at how concern for health inequities is absent from the federal and provincial political agenda and then look
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at the UK, which has explicitly decided to tackle the problem.
Identifying the Source of Health Inequalities:The Social Determinants of Health Despite the constant drumbeat of governmental, disease associations, and media messages concerning the role that “lifestyle choices” play in determining health, it is well established that the primary determinants of health concern the living conditions to which Canadians are exposed throughout their lives (Raphael, 2004b). Box 8.2 provides a list of these social determinants of health. The view that living conditions—and governmental actions that shape the quality of these living conditions—are the primary determinants of health is consistent with a raft of statements, conference resolutions (Canadian Public Health Association, 2001), and findings from numerous Canadian research studies quoted in this chapter, many showing that just about every quality indicator of these social determinants of health shows a dete-
rioration in their quality (Raphael, Bryant, & Curry-Stevens, 2004; Raphael & CurryStevens, 2004). The case of poverty is particularly illuminative. Poverty is a particularly important determinant of health inequalities as it represents a situation by which virtually every social determinant of health is compromised (Auger et al., 2004). Canada has some of the highest general and child poverty rates for developed nations (see Figure 8.4) (Campaign 2000, 2004; Innocenti Research Centre, 2005). This is the case despite Canada being wealthier than just about every other nation whose poverty rates are below 10 percent (Organisation for Economic Co-operation and Development, 2003) and despite its signature on the international convention against child poverty (Raphael, 2001). Income and wealth inequality is increasing in Canada (Curry-Stevens, 2004; Frenette, Green, & Picot, 2004; Myles, Picot, & Pyper, 2000). Food insecurity—represented by use of food banks—continues to grow across Canada (Canadian Association of Food Banks, 2005; McIntyre, 2004). Homelessness—and related housing insecurity represented by the propor-
BOX 8.2: THE SOCIAL DETERMINANTS OF HEALTH OF PARTICULAR RELEVANCE TO HEALTH INEQUALITIES IN CANADA
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CHAPTER 8: Addressing Health Inequalities in Canada ■ 113 FIGURE 8.4: HOW CANADA COMPARES TO OTHER RICH NATIONS IN PERCENTAGE OF CHILDREN LIVING IN POVERTY
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tion of families spending either more than 30 percent or more than 50 percent of income on housing is also very high (Shapcott, 2004). The security and quality of work is deteriorating (Jackson, 2004; Tremblay, 2004). Similar trends concerning other social determinants of health, such as early childhood and the social safety net, are observable (Canadian Council on Social Development, 2000; Raphael, 2004b).
Is Canada Addressing Health Inequalities? Is addressing health inequalities on the Canadian public policy agenda? The answer is simply no. Williamson and colleagues examined the degree of implementation of provincial/territorial health goals in Canada (Williamson et al., 2003). Their document
review revealed that only Manitoba, Nova Scotia, and Saskatchewan had explicit goals related to health equity and only British Columbia had a goal related to the health of subgroups. There were many more goals related to the social and economic environment (13 goals in 10 jurisdictions), healthy public policy (7 goals in 7 jurisdictions), and the physical environment (7 goals in 7 jurisdictions). In any event, the researchers found that these health goals had minimal impact on strategic planning within each jurisdiction. Policy makers in BC, Newfoundland, the NWT/Nunavut, and Quebec continued to refer to these goals, but this was not the case in any other jurisdiction. More so, only a minority of local health regions (between 9 percent and 16 percent) reported acting upon goals in provinces where goals related to
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social and economic development, health equity, and the physical environment existed.
Addressing Health Inequalities Elsewhere To consider why addressing health inequalities—with significant exceptions—is a marginal concern in Canada, we need to consider what might be called the political economy of health. Raphael and Bryant recently examined how issues such as health inequalities and the sources of such inequalities become prominent in national health agenda policies (Raphael & Bryant, 2006). Their analysis of the Canadian, US, UK, and Swedish experience concluded that political and economic forces play a strong role in the extent to which policy makers are prepared to view health inequalities as a significant policy concern. More specifically, nations governed by political parties that are guided by principles of equity, democratic participation, and equality of opportunity are more likely to develop public policies that will distribute resources more equitably, provide greater supports for citizens, and work to reduce social inequalities that drive health inequalities (Navarro et al., 2004; Navarro & Shi, 2002). Canada has never had “left party” participation in the federal Cabinet and therefore, with the US, has one of the least developed welfare states among wealthy nations (Alesina & Glaeser, 2004; Rainwater & Smeeding, 2003). In contrast, the case of the UK is particularly illuminative in that a new Labour government was elected upon a commitment to reduce health inequalities. They moved quickly to establish a wide range of cross-cutting initiatives to improve the living conditions of the most vulnerable, thereby reducing health inequalities (Benzeval, 2002; Raphael & Bryant, 2006). The UK has a long-standing intellectual and academic concern with inequalities in
health. In 1980 the Black Report revealed that despite a generation of accessible health care, class-related health inequalities had not only been maintained but in many instances had widened (Black & Smith, 1992). The report appeared at the onset of the conservative Thatcher era and its recommendations for promoting health were ignored for two decades. Instead, during this period, numerous policies widened income and health inequalities. The election of the new Labour government in 1997 saw the ongoing academic and policy concern with health inequalities translated into a governmentwide effort to address this issue through the implementation of public policy initiatives. In 1997, the new Labour government commissioned the Acheson Commission into Inequalities in Health. The commission considered a wide range of evidence and in its synopsis concluded that: The weight of scientific evidence supports a socioeconomic explanation of health inequalities. This traces the roots of ill health to such determinants as income, education and employment as well as to the material environment and lifestyle. (Acheson, 1998, p. iv)
It offered 13 sets of recommendations that spanned a range of determinants of health that include poverty, income, tax, and benefits; education; employment; housing and environment; mobility, transport, and pollution, among others. It emphasized that: (1) all policies likely to have an impact on health should be evaluated in terms of their impact on health inequalities; (2) high priority should be given to the health of families with children; and (3) further steps should be taken to reduce income inequalities and improve the living standards of poor households. Among the major policy initiatives in response to the Inquiry’s findings was
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Reducing Health Inequalities: An Action Report (Department of Health, 1999). This report focuses on raising living standards and tackling low income, improving education and early years, increasing employment, improving transport, building healthy communities, providing housing, and strengthening public health. There is also an important role for the National Health Service to address health inequalities. Key aspects of the government’s agenda and related documents such as Opportunity for All—Tackling Poverty and Social Exclusion (Department for Work and Pensions, 1999), A New Commitment to Neighbourhood Renewal: National Strategy Action Plan (Social Exclusion Unit, 2001), and From Vision to Reality (Department of Health, 2001) contrast with the position of the public health sector in Canada in many ways. The first is the recognition that health inequalities are a cause for serious concern. The second is government authorities’ serious use of available research evidence. The third is the recognition that these areas are cause for concern not only by health ministries and departments but also the entire government. Fourth, there is a commitment to action through the development and implementation of public policy. And fifth, there is a goal for the National Health Service to promote equitable access to services in relation to need and their taking the lead in working with other agencies to tackle the broader determinants of health. In addition, UK goals were set for the elimination of health inequalities. The 2002 Spending Review Public Service Agreement— a kind of business plan—for the Department of Health contained the goal “By 2010 to reduce inequalities in health outcomes by 10% as measured by infant mortality and life expectancy at birth” (UK Government, 2002). To facilitate and support action, the government set up “cross-cutting spending reviews”
focused on health inequalities. These reviews are being used by departments to inform spending plans for the 2003–2006. There is little evidence that Canadian policy makers and public health advocates are close to advancing such an agenda to address health inequalities in Canada. Despite Canada’s impressive reputation as a source of health promotion and population health ideas, there is little evidence of commitment by federal and provincial authorities to follow such an agenda (Raphael & Bryant, 2006; Williamson et al., 2003). Further, public health agencies appear inclined to follow in their neglect of broader issues (Raphael, 2003). The retreat to nonstructural behaviourally oriented approaches to health promotion and population health is strikingly apparent. When there has been public policy moves to strengthen social determinants of health such as housing and early childhood, these have come about in response to a minority government situation in Ottawa.4 It has not resulted from concerned action on the part of public health authorities and health promotion advocates to have governments strengthen the social determinants of health.5
CONCLUSIONS Whitehead outlines an action spectrum on inequalities in health (Whitehead, 1998). The first step is measuring health inequalities followed by recognition that there is a problem that needs to be addressed. Once these occur, movement can be made to raise awareness, and action taken to develop initiatives to reduce these inequalities. There is currently no systematic effort in Canada to measure health inequalities. Indeed, even the United States is further along than Canada in measuring and recognizing that health inequalities are a cause for concern (United Health Foundation, 2004;
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US Department of Health and Human Services, 1998). It has been argued here that reducing health inequalities requires addressing the sources of these health inequalities. The sources of health inequalities are primarily in Canadians’ living conditions, which result in large part by government decision making concerning the allocation of resources among the population. Canada falls way behind other nations in addressing issues of equitable resource allocation, eliminating child and family poverty, and meeting Canadians’ basic needs (Bryant, 2006). This being the case, there are two issues to be faced by health promoters in Canada. The first is to confront the continued dominance of lifestyle and behavioural approaches to health promotion among practitioners and the understandings held by the media and public concerning the sources of health and illness. The second problem is to have those who recognize the importance of the social determinants of health to take an explicitly political approach as a means of moving the health inequalities agenda along.
Such a political approach would recognize that governmental policy making creates the conditions necessary for health. These conditions include equitable distribution of wealth and progressive tax policies that create a large middle class; strong programs that support children, families, and women; and economies that support full employment. Instead, Canadian public policy has been moving more and more toward a neo-liberal US-type model. Nevertheless, reversals are possible. The recent UK experience illustrates how decisions can be made to address health inequalities by improving the quality of citizens’ living conditions. The best means of reducing health inequalities therefore involves Canadians being informed about the political and economic forces that shape the health of a society and the degree of health inequalities within that society. Once so empowered, they can consider political and other means of influencing these forces. To date, the health promotion community has not seen fit to take on a leadership role in this effort. This is rather a daunting task, but one that holds the best hope of improving the health of the Canadian population.
NOTES 1
2
3
This would be the case where health education and behavioural change are emphasized as a health promotion strategy. Individuals with superior economic and social resources—already more likely to be enjoying good health—will be the ones most likely to take up these messages, thereby increasing health inequalities. The best evidence is that inequalities by income have been narrowing in mortality from ischemic heart disease, injuries (except motor vehicles accidents and suicides), cirrhosis of the liver, uterine cancer, prenatal conditions, and pedestrians struck by motor vehicles. Causes of death with mixed results are those of motor vehicle occupants’ deaths, lung cancer and prostate cancer among men, breast cancer for women, and suicide for both sexes. Wider inequalities by income and increased mortality is being seen for lung cancer for females, infectious diseases, ill-defined conditions, mental disorders, and diabetes for both sexes (Wilkins et al., 2002). Many argue that income is a poor proxy for measuring social class, which is a much more profound indicator of socio-economic position. Unlike the situation in the United Kingdom, there are very little data available on the social class position of Canadian study participants. What data are available on social class and health are consistent with the income and health data reported here. See Muntaner and colleagues’
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4
5
recent analysis of the role that social class plays in health in developed nations such as Canada (Muntaner et al., 2006). A minority government situation occurs when the party with the most seats in the House of Commons (Parliament) does not command an absolute majority. In the current case (2004–2005) the governing Liberal Party was dependent upon the support of the New Democratic Party to maintain power. In return for its support, the New Democrats extracted a commitment to increased program spending in the areas of housing, child care, and public transportation. There are a few promising developments. The Health Council of Canada recently called for policy makers to use “strong language” to describe the existence of health inequalities and their sources in Canada (Health Council of Canada, 2005). In Ontario the Association of Local Health Authorities, which represents both the medical officers of health and local health boards, called for the province to incorporate the determinants of health into the mandatory public health practice guidelines in order to reduce health inequalities. A handful of local health units are expanding their focus on the social determinants of health (Raphael, in press).
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[email protected]. Department of Health. (1999). Reducing health inequalities: An action report. London: Department of Health. Retrieved January 30, 2005, from www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/ en?CONTENT_ID=4006054&chk=ZOOf4d. Department of Health. (2001). From vision to reality. London: Department of Health. Retrieved July 23, 2006, from www.dh.gov.uk/assetRoot/04/05/94/59/04059459.pdf. Dunn, J., Hargreaves, S., & Alex, J.S. (2002, March). Are widening income inequalities making Canada less healthy? Retrieved August 2002 from www.opha.on.ca/publications/income_inequalities.pdf. Frenette, M., Green, D.A., & Picot, G. (2004). Rising income inequality amid the economic recovery of the 1990s: An exploration of three data sources. Ottawa: Analytic Studies Branch, Statistics Canada. Galabuzi, G.E. (2004). Social exclusion. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Galabuzi, G.E. (2005). Canada’s economic apartheid: The social exclusion of racialized groups in the new century. Toronto: Canadian Scholars’ Press Inc. Gordon, D., Shaw, M., Dorling, D., & Davey Smith, G. (1999). Inequalities in health: The evidence presented to the Independent Inquiry into Inequalities in Health. Bristol: The Policy Press. Graham, H. (2004). Tackling health inequalities in health in England: Remedying health disadvantages, narrowing health gaps, or reducing health gradients? Journal of Social Policy, 33, 115–131. Health Canada. (2001). The population health template: Key elements and actions that define a population health approach. Strategic Policy Directorate, Population and Public Health Branch, Health Canada. Retrieved June 2002 from www.hc-sc.gc.ca/hppb/phdd/pdf/discussion_paper.pdf. Health Council of Canada. (2005). Health care renewal in Canada: Accelerating change. Ottawa: Health Council of Canada. Humphries, K., & van Doorslaer, E. (2000). Income-related health inequality in Canada. Social Science & Medicine, 50(5), 663–671. Innocenti Research Centre. (2005). Child poverty in rich nations, 2005. Report card no. 6. Florence: Innocenti Research Centre. Jackson, A. (2004). The unhealthy Canadian workplace. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. McIntyre, L. (2004). Food insecurity in Canada. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Muntaner, C., Borrell, C., Kunst, A., Chung, H., Benach, J., & Ibrahim, S. (2006). Social class inequalities in health: Does welfare state regime matter? In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying Alive: Critical perspectives on health, illness, and care. Toronto: Canadian Scholars’ Press Inc. Myles, J., Picot, G., & Pyper, W. (2000). Neighbourhood inequality in Canadian Cities. Statistics Canada, Business and Labour Market Analysis Division. Retrieved July 2002 from www.statcan.ca/english/research/11F0019MIE/11F0019MIE2000160.pdf.
CHAPTER 8: Addressing Health Inequalities in Canada ■ 119 Navarro, V., Borrell, C., Benach, J., Muntaner, C., Quiroga, A., Rodrigues-Sanz, M., et al. (2004). The importance of the political and the social in explaining mortality differentials among the countries of the OECD, 1950–1998. In V. Navarro (Ed.), The political and social contexts of health. Amityville: Baywood Press. Navarro, V., & Shi, L. (2002). The political context of social inequalities and health. In V. Navarro (Ed.), The political economy of social inequalities: Consequences for health and quality of life. Amityville: Baywood. Nutbeam, D. (1998). Health promotion glossary. Geneva: World Health Organization. Organisation for Economic Co-operation and Development. (2003). Health at a glance: OECD indicators 2003. Paris: Author. Phipps, S. (2002). The impact of poverty on health. Ottawa: Canadian Population Health Initiative. Rainwater, L., & Smeeding, T.M. (2003). Poor kids in a rich country: America’s children in comparative perspective. New York: Russell Sage Foundation. Raphael, D. (2001). Canadian policy statements on income and health: Sound and fury—signifying nothing. Canadian Review of Social Policy, 48, 121–127. Raphael, D. (2002). Addressing health inequalities in Canada. Leadership in Health Services, 15(3), 1–8. Raphael, D. (2003). Barriers to addressing the determinants of health: Public health units and poverty in Ontario, Canada. Health Promotion International, 18, 397–405. Raphael, D. (2004a). Introduction to the social determinants of health. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (Ed.). (2004b). Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (2006a). Social determinants of health: An overview of concepts and issues. In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (2006b). Social determinants of health: Present status, unresolved questions, and future directions. International Journal of Health Services, 36, 651-677. Raphael, D., & Bryant, T. (2006). Public health concerns in Canada, USA, UK, and Sweden: Exploring the gaps between knowledge and action in promoting population health. In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. Raphael, D., Bryant, T., & Curry-Stevens, A. (2004). Toronto Charter outlines future health policy directions for Canada and elsewhere. Health Promotion International, 19, 269–273. Raphael, D., Bryant, T., & Rioux, M. (Eds.). (2006). Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. Raphael, D., & Curry-Stevens, A. (2004). Addressing and surmounting the political and social barriers to health. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D., Macdonald, J., Labonte, R., Colman, R., Hayward, K., & Torgerson, R. (2005). Researching income and income distribution as a determinant of health in Canada: Gaps between theoretical knowledge, research practice, and policy implementation. Health Policy, 72, 217–232. Restrepo, H.E. (2000). Health promotion: An anthology. In H.E. Restrepo (Ed.), Health promotion: An Anthology (pp. ix–xi). Washington: Pan-American Health Organization. Ross, D.P. (2002). Policy approaches to address the impact of poverty. Ottawa: Canadian Population Health Initiative.
120 ■ PART II: National Perspectives Ross, N. (2004). What have we learned studying income inequality and population health? Ottawa: Canadian Population Health Initiative. Ross, N., Wolfson, M., Dunn, J., Berthelot, J.M., Kaplan, G., & Lynch, J. (2000). Relation between income inequality and mortality in Canada and in the United States: Cross-sectional assessment using census data and vital statistics. British Medical Journal, 320(7239), 898–902. Shapcott, M. (2004). Housing. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Shaw, M., Dorling, D., Gordon, D., & Smith, G.D. (1999). The widening gap: Health inequalities and policy in Britain. Bristol: The Policy Press. Shields, M., & Tremblay, S. (2002). The health of Canada’s communities. Health reports, 13(Suppl., July), 1-25. Social Exclusion Unit. (2001). A new commitment to neighbourhood renewal. National strategy action plan. London: Social Exclusion Unit, Cabinet Office. Retrieved July 23, 2006, from www.cabinet-office.gov.uk/seu. Sutcliffe, P., Deber, R., & Pasut, G. (1997.). Public health in Canada: A comparative study. Canadian Journal of Public Health, 88, 246–249. Teeple, G. (2000). Globalization and the decline of social reform: Into the twenty-first century. Aurora: Garamond Press. Townsend, P., Davidson, N., & Whitehead, M. (Eds.). (1992). Inequalities in health: The Black Report and the health divide. New York: Penguin. Tremblay, D.G. (2004). Unemployment and the labour market. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Tremblay, S., Ross, N.A., & Berthelot, J.-M. (2002). Regional socio-economic context and health. Health Reports, 13(Suppl.), 1–12. UK Government. (2002). SR 2002: Public service agreements. London: The Treasury Department. United Health Foundation. (2004). America’s health: State health rankings. Minnetonka: United Health Foundation. US Department of Health and Human Services. (1998). Health, United States, 1998: Socioeconomic status and health chartbook. Washington: Author. Whitehead, M. (1998). Diffusion of ideas on social inequalities in health: A European perspective. Millbank Quarterly, 76(3), 469–492. Wilkins, R., Berthelot, J.-M., & Ng, E. (2002). Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports (Stats Can), 13(Suppl.), 1–28. Williamson, D. (2001). The role of the health sector in addressing poverty. Canadian Journal of Public Health, 92, 178–182. Williamson, D., Milligan, C.D., Kwan, B., Frankish, C.J., & Ratner, P.A. (2003). Implementation of provincial/territorial health goals in Canada. Health Policy, 64, 173–191.
CRITIC AL THINKING QUESTIONS 1. Review the health-related stories of your local newspaper over the next few weeks. If you based your understanding of health inequalities on these stories, what would be your views of what makes some people healthy and others ill? 2. What evidence is available concerning the extent of health inequalities in your jurisdiction? What are the current indicators of incidence of poverty, homelessness, and food bank use in your area? Have conditions been improving or declining?
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3. To what extent have other health-related courses you have taken addressed issues of health inequalities? What could be done to increase your discipline’s emphasis on health inequalities? 4. What could be done to improve the public’s understanding of the importance of tackling health inequalities? What should be the role of your local public health unit or health care professionals? 5. To what extent is public policy in your city, region, or nation concerned with reducing health inequalities? Why are some nations more concerned with dealing with this problem than others?
FURTHER READINGS Acheson, D. (1998). Independent inquiry into inequalities in health. London: Stationary Office. This defining work documents how health inequalities result from the experience of people being exposed to differing material conditions of life. Provides the basis for the current UK governmental approaches to reducing health inequalities. Available from www.official-documents.co.uk/document/doh/ih/contents.htm. Davey Smith, G. (2003). Health inequalities: Life-course approaches. Bristol: Policy Press. This book provides an overview of the social and economic factors that are now known to be the most powerful determinants of population health in modern nations. Raphael, D. (2004). Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. This book summarizes how socio-economic factors affect the health of Canadians, surveys the current state of 11 social determinants of health across Canada, and provides an analysis of how these determinants affect Canadians’ health. Raphael, D., Bryant, T., & Rioux, M. (Eds.). (2006). Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. This volume emphasizes the political economy of health and contains chapters on the social determinants of health and health inequalities associated with social class, gender, and race. It has a strong emphasis on how public policy influences health in general and health inequalities in particular. Wilkins, R., Berthelot, J.-M., & Ng, E. (2002). Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports (Stats Can), 13(Suppl.), 1–28. Russell Wilkins and colleagues’ work on income and health inequalities is among the best in Canada. This report summarizes health inequalities as measured by death rates among areas in urban Canada as a function of income.
RELEVANT WEB SITES Canadian Institute of Children’s Health www.cich.ca
The Institute produces biannual reports on the state of health of Canada’s children, highlighting the determinants of health inequalities.
122 ■ PART II: National Perspectives Centre for Social Justice (CSJ) www.socialjustice.org
The CSJ works on narrowing the gap between rich and poor, challenging corporate domination of Canadian politics, and pressing for economic and social justice. It has numerous reports on health inequalities issues. Health Canada Population Health Approach www.phac-aspc.gc.ca/ph-sp/phdd/
This Web site provides details about how the population health aims to improve the health of the entire population by acting upon the broad range of factors and conditions that influence health. Montreal Region Public Health Unit www.santepub-mtl.qc.ca
Medical officer Richard Lessard has been a Canadian leader in monitoring health inequalities and identifying means of reducing these through concerted action. See especially the annual reports Social Inequalities in Health and Urban Health. UK Department of Health www.dh.gov.uk/Home/fs/en
This Web site contains numerous governmental reports on how England is addressing health inequalities.
CHAPTER 9
D E V E L O P I N G K N OW L E D G E F O R H E A LT H P RO M OT I O N Irving Rootman, Suzanne Jackson, and Marcia Hills
INTRODUCTION n the first edition of this book, the chapter on “Developing Knowledge for Health Promotion” (Rootman & O’Neill, 1994) covered the period 1986–1993 in terms of efforts to develop knowledge for health promotion in Canada. Specifically, it described and analyzed the “Knowledge Development” project initiated and carried out with leadership from what was then the Health Services and Promotion Branch of Health and Welfare Canada. Based on reflections about the process, it made some suggestions for the future. Key suggestions were to: • encourage the federal government to invest more resources in knowledge development for health promotion in closer collaboration with other levels of government and the voluntary sector • encourage the six health promotion research centres that were funded in 1993 by the National Health Research Development Program (NHRDP) and the Social Sciences and Humanities Research Council (SSHRC) to play an active role in knowledge development in collaboration with others, including practitioners, communities, voluntary organizations, the private sector, various levels of government, and other members of the research community in health and related fields • expend more resources in supporting interdisciplinary and multi-disciplinary
I
research through sharing examples of successful efforts to do so and providing opportunities to develop the required skills • give more legitimacy to the collection and sharing of practical experience as an acceptable mode of knowledge development in Canada by bringing practitioners into the process of developing knowledge at all stages This chapter explores the extent to which such suggestions have been acted on, as well as how knowledge development has occurred in health promotion in Canada. In doing so, it should be noted, as was done in the first edition, that the term “knowledge development” was retained here as it was chosen then by Health and Welfare Canada because it includes more than scientific research, i.e., the “practical experiences of practitioners and/or lay people” (Rootman & O’Neill, 1994, p. 140). In addition, it includes not just creating knowledge through research and synthesis of information or experience, but also developing capacity to do so through training, information sharing, and other means, as well as developing the infrastructure for both knowledge creation and skill development. Thus, this chapter will consider all three aspects of knowledge development for health promotion in Canada covering the period from 1994–2007. Specifically, the chapter will present and discuss what has happened in Canada to 123
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develop infrastructure for knowledge development in health promotion, to increase capacities of researchers and practitioners, and to improve our knowledge base on health promotion. It will then critically analyze these developments, and discuss their implications for Canada and other countries. Even if it is impossible to cover all of the context and complexity of knowledge development in health promotion in Canada in this chapter, we hope that we will have covered enough to raise the key issues related to that most significant topic.
KNOWLEDGE DEVELOPMENT INFRASTRUCTURE SINCE 1994 Canadian Consortium for Health Promotion Research One of the key components of the infrastructure for health promotion knowledge development that has emerged over the past decade is the Canadian Consortium for Health Promotion Research (CCHPR), which currently consists of 16 university-based centres that conduct health promotion research across Canada, as shown in Table 9.1.
TABLE 9.1: LIST OF MEMBERS OF THE CANADIAN CONSORTIUM FOR HEALTH PROMOTION RESEARCH NETWORK
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The Consortium has developed though six phases (see Table 9.2). The first was the
establishment of the individual centres, which took place mostly between 1990 and
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1993, partly as a result of funding of six centres by NHRDP and SSHRC mentioned above. The second phase, which lasted from 1994–1996, involved meetings and informal collaboration among existing centres facilitated by funding from Health Canada. The third, which lasted from 1996–1998, involved the naming of the participating centres as the Canadian Consortium for Health Promotion Research and informal meetings and activities independent of Health Canada, but associated with meetings sponsored by Health Canada. The fourth, which lasted from 1997–2001, involved direct funding of the activities of the Consortium through a grant from NHRDP, which allowed the Consortium to hire a coordinator and provided some support for formal meetings and activities. When the funding ended in 2001, the Consortium reverted to the previous arrangement of holding meetings supported directly by Health Canada, particularly by one of the regional offices (i.e., fifth phase). The current sixth phase began in 2004 when Health Canada and subsequently the Public Health Agency of Canada awarded a grant to the Consortium to organize the Global Conference of the International Union for Health Promotion and Education (IUHPE) in Vancouver in June 2007. This required the Consortium to establish a corporation involving several members of the Consortium, but also provided some funds to allow the larger Consortium to meet from time to time. Thus, over the period of 1994–2007, the Canadian Consortium for Health Promotion Research took shape, with various kinds of funding arrangements supporting its activities, most of which had to do with capacity development and research and which will be described in the sections that follow. One key issue to note about these phases of development of the Consortium is that infrastructure was very dependent on the
type of funding arrangements. The basic tension has been between the need for basic infrastructure funding and the opportunities arising from specific health promotion research and capacity development projects. The period where basic infrastructure funding dominated was the fourth phase, when there was a coordinator who specifically supported collaborative activities between centres and fostered information sharing and development of an agenda for health promotion activities nationally. In this phase, there was an exchange of tools on evaluation and discussions about how to influence applied research in Canada either via open research competitions or via collaboration with Health Canada. The sixth phase (2004–2007) represents the establishment of the Consortium as a formal non-profit corporation with a board of directors and formal ability to control finances. Signing on to a formal Consortium was difficult for some of the members of the Consortium because of university concerns regarding liability; however, the Consortium Society now has most of the 16 centres as members. The other issue in relation to this phase as far as knowledge development is concerned is that the funding has been tied to very specific (though of broad significance) project outcomes (IUHPE conference and Effectiveness of Community Interventions Project). This intense focus on two major activities has meant the Consortium so far has not been able to engage in many other significant activities at the national level during this current phase. However, it is quite likely that profits realized from the IUPHE Conference, as well as the heightened profile of the Consortium Society, will allow the Consortium to expand its activities significantly.
126 ■ PART II: National Perspectives TABLE 9.2: PHASES OF INFRASTRUCTURE OF CCHPR
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Funding Agencies Since 1994, there were also substantial changes in the funding agencies that have had a significant impact on the infrastructure for health promotion knowledge development in Canada. As indicated in Chapter 7, there were numerous changes at the federal level in the infrastructure for health promotion in general. For one, Health and Welfare Canada was split into two departments in 1993, and the Health Promotion Directorate, which had been the bulwark for the support of national activities in health promotion, including the knowledge development activities described in the first edition of this book (Rootman & O’Neill, 1994), was eliminated in 1995. This substantially weakened the federal government’s support and leadership for knowledge
development activities, although as mentioned, Health Canada continued to provide some support though NHRDP and its national and regional offices. There were also some very substantial changes in the funding agencies for health research, which have had a significant, generally positive effect on the funding of health promotion research in Canada. Probably most important were the elimination of the Medical Research Council of Canada and the establishment of the Canadian Institutes for Health Research (CIHR) in its place in 2000. The latter significantly expanded the funding opportunities for health promotion research through the recognition of “population health” as one of the four pillars of the CIHR program and the establishment of several institutes, such as
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the Institute for Gender and Health, the Institute for Population and Public Health, and the Institute for Aboriginal Peoples Health, all of which were favourable to and supported the expansion of health promotion research in their domain. In particular, the fact that the first director of the Institute of Gender and Health was a former director of two of the university-based centres for health promotion research that made up the Consortium, and that members of the Consortium were appointed to advisory boards and review committees, helped to establish the legitimacy of health promotion research in the CIHR. This key development, a unique experiment in health research funding (and one being looked at closely by other countries as an exemplar), represents a major strategic victory for those (health promotion researchers being among the most prominent) who have long advocated a shift from biomedical dominance in health research. The fact that members of the Consortium were very successful in obtaining peer-reviewed grants through the CIHR also contributed to this legitimacy. On the other hand, as a result of the establishment of CIHR, the budget of NHRDP was reduced and its mandate changed, which eliminated an important source of support for policy-oriented and applied research in health promotion, although at the same time creating opportunities for policy-relevant and intervention research. This has presented major challenges, but also great opportunities for health promotion to continue to establish itself as a legitimate health research field in the broader health research community. Funding for health promotion research in Canada increased substantially over the past decade, not only because of the establishment of CIHR, but also because of the establishment and growth of other national and provincial organizations that have supported such research. These include the Canadian Policy
Research Institute (CPRI), the Canadian Council on Learning (CCL), and the Michael Smith Foundation for Health Research in BC, the Alberta Heritage Foundation for Health Research, as well as the Fonds québécois de la recherche sur la société et la culture and the Fonds de la recherche en santé du Québec in Quebec. All of these organizations have provided funding for health promotion knowledge development projects. In addition, the establishment of the Public Health Agency of Canada (PHAC) will likely have significant implications for health promotion knowledge development. Although it is still a bit early to tell how this will play out in practice, the strong leadership at the top of this new organization has already had an impact, symbolically demonstrated by the resurgence of the language and terminology of health promotion (there is now a Centre for Health Promotion in PHAC), the creation of a health promotion research agenda, and the establishment of collaborating centres, some of which focus on topics related to health promotion. Members of the Consortium have established a working relationship with these collaborating centres, particularly the National Collaborating Centre for Determinants of Health. These relationships are likely to continue along with the development of relationships with the PHAC itself, as the fact that the head of the agency is the co-chair of the IUHPE Conference in 2007 would suggest.
Other Infrastructure Developments: Sharing Knowledge In addition, over the last decade, Canada has successfully established new and productive infrastructures for sharing knowledge about health promotion with colleagues. One of the most successful of these has been Click4HP, the electronic discussion forum presented in Chapter 3. Another vehicle for sharing infor-
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mation is the Ontario Health Promotion email bulletin, which provides information on health promotion weekly to over 4,000 subscribers, with the largest group from Ontario, but now including a significant proportion of people from other parts of Canada (about onethird) and other countries (about one-quarter). Similar electronic portals or bulletins have been developed in most provinces, like Promosanté (www.promosante.org) for instance, which aims at disseminating francophone health promotion information in Québec and across Canada. As also discussed in Chapter 3, in 2004, the Canadian Health Network (CHN), a Webbased health information system funded by the Public Health Agency of Canada for all Canadians, created a health promotion affiliate. The Ontario Prevention Clearinghouse and the Centre for Health Promotion at the University of Toronto formed this affiliate and subsequently provided leadership, not only in creating the resource base on health promotion on the Web but also by coordinating the health promotion components of all affiliates of CHN. As a result of this work, all affiliates have developed a common protocol about how to ensure that their collections include health promotion, and that the marketing and dissemination strategies are consistent across the network. Another important contribution to the Canadian infrastructure for health promotion knowledge development has been the establishment of structures for the support of education and training in health promotion, which are described in more detail in the next section. Thus, overall, since 1993, the infrastructure for supporting knowledge development in health promotion in Canada has improved in terms of support for a national network of centres involved in health promotion (CCHPR), funding for research, electronic information exchange mechanisms, and additional educational opportunities.
DEVELOPMENT OF CAPACITY: HEALTH PROMOTION EDUCATION AND TRAINING Contribution of Canadian Consortium for Health Promotion Research Several centres associated with the Canadian Consortium for Health Promotion Research have played a role in contributing to both formal degree-based university training in health promotion and continuing education for practitioners. Several summer schools on health promotion were established since 1993 and are now offered on a regular basis with a variety of university and continuing education credits (see Table 9.3). Also, in terms of continuing education, the Centre for Health Promotion, in collaboration with the Ontario Prevention Clearinghouse and the Ontario Health Promotion Resource System, developed an interactive online course on health promotion and made it readily available (www.ohprs.ca/hp101/main.htm). In addition, there has been a significant expansion of graduate level academic training opportunities for people interested in health promotion. The Centre for Community Health Promotion Studies at the University of Alberta launched a master’s degree (MSc) program in health promotion studies in 1996 with a distance learning option. As noted in the commentary on Alberta by Wilson and colleagues in Chapter 11, more than two-fifths of the students have been from outside the province. This augments the long-term ongoing MHSc program in health promotion in public health sciences at the University of Toronto, the MA program in health education at Dalhousie University, as well as the graduate training in the domain offered within other public or community health programs as described in Table 9.3. In addition, many more ad hoc opportunities have become available for practitioners,
CHAPTER 9: Developing Knowledge for Health Promotion ■ 129 TABLE 9.3: HEALTH PROMOTION SUMMER SCHOOLS/TRAINING PROGRAMS IN CANADA
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policy makers, researchers, and others to improve their knowledge and skills related to health promotion. These include workshops, seminar series, lectures, interest groups, conference presentations, and publications, many of which are done or provided through the individual member centres of the CCHPR. The Consortium as an organization has also provided support to develop some of these ad hoc information and education opportunities. An example would be the series of national conferences on health promotion research and practice that have been organized by individual centres in partnership with the Consortium as a whole and other Consortium members. Since 1993, there have been five conferences in various parts of the country (Toronto, Calgary, Montreal, Halifax, and Victoria). Each one helped to move the field of practice and research forward as well as provide skill development, networking, and informationexchange opportunities for participants. The Training and Education Committee of the Consortium has played a critical role in capacity development. For example, the committee organized a series of workshops for teachers of health promotion in conjunction with the annual Canadian Public Health Association conference, and initiated a project to allow the organizers of the various health promotion summer schools to work together, share resources, and improve their curricula. In addition, the committee has stimulated opportunities for academic training programs in health promotion to work together. For example, a joint distance-learning course was developed and offered by faculty of the University of Alberta and University of Toronto health promotion programs. The committee also consolidated English and French language resources for teaching health promotion and made them available on the Consortium’s Web site as well
as on an interactive listserv. A national survey was conducted to examine the state of the art in health promotion education in Canada and a book chapter was published based on the results of the survey (Hills & Green, 2001). As indicated by some of the commentaries in the Global Perspectives Section of this book, over the last decade, Canadians have also made a significant contribution to capacity development in health promotion globally. For example, the chairs of the Education and Training Committee of the Consortium organized, edited, and published a special issue on training in health promotion for the official journal of the International Union of Health Promotion and Education (O’Neill & Hills, 2000) in addition to organizing training and education streams during the three last global IUHPE conferences in Puerto Rico, Paris, and Melbourne. Organizing the forthcoming IUHPE Global Conference on Health Promotion in 2007 is also a significant contribution both to global and Canadian capacity in health promotion. Other international contributions of CCHPR members to the development of capacity are noted in chapters 13 and 14. Thus, as was the case with respect to infrastructure development, members of the Canadian Consortium for Health Promotion Research have played a significant role in increasing the number of continuing education opportunities, graduate education specialties, and ad-hoc training and knowledge exchange events both in Canada and throughout the world.
Contributions of Others Others who have contributed to capacity development include the Canadian Institutes for Health Research, which, among other things, introduced a program for supporting research training. Some of the projects supported by
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this program, such as the “Partnering in Community Health Research” project codirected by the Institute of Health Promotion Research at the University of British Columbia, have provided training opportunities for graduate students and community agency members in community-based research, including research with vulnerable populations. As noted in Chapter 6, the recently established Canadian Council on Learning and other organizations have also supported capacity development related to health promotion such as a National Summer Institute on Literacy and Health Research held in 2005. Thus, clearly progress has been made in Canada over the last decade in building skills for better health promotion practice and research across Canada. The limitations are that this progress is somewhat uneven across the country and greatly dependent on the presence of the Consortium, some members of which are somewhat fragile in terms of long-term funding and support.
DEVELOPMENT OF NEW KNOWLEDGE Contribution of Canadian Consortium for Health Promotion Research The Canadian Consortium for Health Promotion Research and its members have been very active in developing new knowledge related to health promotion over the last decade. All of the members have active research programs on a wide range of topics in health promotion, including topics related to the impacts of individual and environmental factors on health (e.g., physical activity, school, or workplace settings), health issues in different population groups (e.g., children, women, older adults), health promotion issues in different types of communities (e.g., rural, Aboriginal), prevention
(e.g., HIV/AIDS, falls), chronic disease management (e.g., self-care, mutual aid), the effectiveness of various kinds of health promotion interventions (e.g., policies, health communication), and outcomes (e.g., quality of life).1 Given the fact that each of these topics involves multiple projects, it is impossible to summarize here the net contribution to new knowledge easily. As an alternative, we will present a couple of examples of projects completed by some member centres of the Consortium working together and of the Consortium as a whole over the last decade. An example of a study involving multiple centres was on quality of life among older adults in Canada, which was led by the Centre for Health Promotion at the University of Toronto and developed out of the Quality of Life Research Program of that Centre. In this particular case, several other centres from across Canada were recruited as collaborators. The project focused particularly on policy decisions affecting the quality of life of older adults. It was a participatory study in which seniors controlled the direction and shape of the project in each city and it used focus groups and individual interviews with older adults and stakeholders, and qualitative methods to see the world through the eyes of participants. Participants highlighted access to information, health care, housing, income security, safety and security, social contacts and networks, and transportation as key issues that affect the quality of life of older adults in Canada. This project showed the value of participatory activities that involve seniors working with other sectors as a productive policy-informing approach. (Bryant et al., 2004) Although there have been many more of these joint ventures involving several Consortium members (the first edition of this book, for instance, was a joint project of the Centre for Health Promotion at the University
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of Toronto and the Groupe de recherche et d’intervention en promotion de la santé de l’Université Laval, which involved several other members of CCHPR), the one briefly described should at least give the reader a sense of the type of collaborative research that has been facilitated by the Consortium. With regard to research projects carried out by the Consortium as a whole, most of them had to do with synthesis and analysis of research and knowledge on particular topics that were of interest to Health Canada or other federal departments (such as the Department of Defense). One such project involved the synthesis of knowledge on the concept of “lifestyle” to be used in the development of the national “Healthy Living Strategy” (Lyons & Languille, 2000). It was suggested that the concept of “lifestyle” should include not only traditional behavioural aspects, but also the roles of social contexts and community views as argued also in Chapter 4. The paper that was produced is now available on both Health Canada’s Web site and the Consortium’s site (see below for URLs). Another project carried out in the context of the government’s “Healthy Living Strategy” was a review of the evidence on the effectiveness and cost effectiveness of active living strategies (Spence, 2000). Another key consortium project, which is still underway in partnership with the Public Health Agency of Canada, involves a series of studies on the effectiveness of health promotion interventions. It began with a study to assess the methods and concepts used to synthesize the evidence of the effectiveness of health promotion by reviewing 17 national and international initiatives (Jackson et al., 2001). This study identified a framework for conducting a synthesis of the evidence in health promotion and some of the particular issues faced by reviewers. Following that, the project moved to identify evaluation strategies that
would help to collect data relevant to the key mechanisms that are at the heart of successful community health promotion initiatives (Hills, Carroll, & O’Neill, 2004). The project is now in its third phase, with a primary focus on indicator development. Thus, it should be clear that a considerable amount of new knowledge relevant to health promotion and various stakeholders has been generated in Canada by members of the CCHPR working individually or together. In addition, a preliminary search for papers published by individual members of the Consortium revealed over 200. However, the question remains whether or not we might have achieved as much as we would have liked. And if not, what might we do better in the future?
CRITIC AL ANALYSIS We now return to the four suggestions that were made in the first edition as stated earlier in this chapter and assess the progress made over the last decade. With regard to the suggestion that the federal government invest more resources in knowledge development for health promotion in closer collaboration with other levels of government and the voluntary sector, it should be apparent that this has, in part, been achieved over the past decade. Most of this investment has come through the establishment of CIHR with a broadened mandate that allows it to support health promotion research on a competitive basis. The support of Health Canada for infrastructure (either for the centres or the Consortium) has waxed and waned over the last decade and certainly has not been coordinated with other federal departments, other levels of government, or the voluntary sector. Part of this was due to the fact that the department was constantly being reorganized over this period, subject
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to pressures to focus on “population health” rather than “health promotion,” forced to reduce expenditures, and ultimately to reduce its size to accommodate the establishment of the Public Health Agency of Canada. Although it is encouraging that the term “health promotion” has come back into vogue at the federal level, it is too early to say whether or not the challenge of investing additional resources to develop knowledge in this domain in collaboration with other levels of government and the voluntary sector will be accepted by the federal government and the Public Health Agency of Canada. With regard to the second suggestion, four of the six health promotion research centres that were funded in 1993 by NHRDP and SSHRC survived after the funding ended. What is more significant is that at least 10 more centres with a focus on health promotion were created in Canada over the last decade. All of these centres play an active role in research, training, and information exchange in collaboration with others, including practitioners, communities, voluntary organizations, the private sector, and various levels of government as well as other members of the research community in health and related fields. It is also significant to note that a lot of non-academic relationships have been developed despite a lack of academic rewards for this kind of work in some universities and the ongoing struggle to find core funding. As for the third suggestion of expending more resources in support of interdisciplinary and multi-disciplinary research through sharing examples of successful efforts to do so and providing opportunities to develop the required skills, it is clear that CIHR has made this one of their priorities and has invested significant resources in doing so. As noted above, at least some of these resources have been awarded to groups
interested in health promotion. There is no reason to believe that this will not continue. Finally, with regard to giving more legitimacy to the collection and sharing of practical experience as an acceptable mode of knowledge development in Canada by bringing practitioners into the process of developing knowledge at all stages, there also have been significant positive changes over the past decade. This was perhaps in part stimulated by the Royal Society of Canada report on participatory research in health promotion produced by the Institute of Health Promotion Research in collaboration with other health promotion centres across the country (Green et al., 1994). Whatever the reason, it is clear that participatory research has become more acceptable as an approach, with virtually all of the centres in Canada adopting it for some projects, as well as other researchers or research units doing so as well. It is especially interesting to note that following up on the work done in Canada, the US Centers for Disease Control have held at least one competition to support participatory research projects in health. The CIHR Institute of Aboriginal People’s Health and Institute for Gender and Health has also held competitions specifically for community-based research, which has become identified in Canada as invariably requiring a participatory methodological approach (Hills & Mullett, 2000a, 2000b). It can be hoped that the latter efforts are only the sign of more to come. In addition to using a participatory research approach, all Consortium members have built up good relationships with their local practitioner communities. These relationships are demonstrated by collaborative research, continuing education opportunities such as health promotion summer schools, and electronic information processes such as those as described earlier in this chapter or in the list of resources below.
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However, although we have reason to be proud of our progress in health promotion knowledge development over the past decade in Canada, we do have some reasons for concern. In addition to the ones that have been noted, some others that we need to pay attention to are the following: • Some of the people who are involved in behavioural research on health feel that they are excluded from participating in health promotion knowledge development efforts, particularly through the CCHPR, which has tended to emphasize the importance of the social determinants of health. • There is some sentiment among those involved in academic training in health promotion in Canada that we are not paying sufficient attention to health promotion in the context of current planning for expanded funding for public health education and training throughout the country. • Some members of the Canadian Consortium for Health Promotion Research feel that the current emphasis on specific projects funded by the PHAC diverted the Consortium from some of its ongoing and long-term work as a body that can support the development of a national, coordinated health promotion knowledge development agenda. None of these or other issues that have been identified in this chapter is irresolvable. However, they need to be addressed in a forthright and honest manner. To this end, we conclude this chapter with several suggestions.
CONCLUSIONS Our suggestions are as follows: The Canadian Consortium for Health Promotion Research should accept a mandate to coordinate and lead knowledge development in health promotion in Canada through the following activities: • expanding its membership to include organizations interested in disease prevention and behavioural research; • coordinating formal and informal training in health promotion to take advantage of current opportunities for expanding public health training in Canada; • developing a long-term plan for the future that highlights priorities for new knowledge development and begin implementing it using the IUHPE Conference in 2007 as a springboard for the future; • discussing with the Public Health Agency of Canada and Health Canada the idea of supporting a knowledge development initiative for health promotion that will actively involve other federal departments, other levels of government, voluntary organizations, and professional organizations. The Public Health Agency of Canada, CIHR, and other funding agencies should make a commitment to support health promotion research infrastructure in Canada through the following activities: • developing a strategic research initiative to support health promotion research; • providing special grants for health promotion research infrastructure If we take these steps, we can be assured that we will build on our strengths and continue to develop the knowledge that is required to promote the health of all Canadians.
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NOTE 1
For listing of research priorities of each of the members of the Consortium, see the Consortium Web site (www.utoronto.ca/chp/CCHPR/index.htm).
REFERENCES Bryant, T., Brown, I., Cogan, T., Dallaire, C., Laforest, S., McGowan, P., et al. (2004). What do Canadian seniors say supports their quality of life? Findings from a national participatory research study. Canadian Journal of Public Health, 95, 299–303. Green, L.W., George, M.A., Daniel, M., Frankish, C.J., Herbert, C.P., Bowie, W.R., et al. (1994). Study of participatory research in health promotion: Review and recommendations for the development of participatory research in health promotion in Canada. Report to the Royal. Society of Canada. Prepared by IHPR and the BC Consortium for Health Promotion Research. Hills, M., Carroll, S., & O’Neill, M. (2004). Vers un modèle d’évaluation de l’efficacité des interventions communautaires en promotion de la santé: compte-rendu de quelques développements nord-américains récents. Promotion and Éducation, 11(Suppl. 1), 17–21. Hills, M., & Green, K. (2001). Health promotion courses and programs in Canadian universities: A survey. In H. Arroyo-Acevedo (Ed.), Formacion de Recursos Humanos en Educacion para la Salud y Promocion de Saude Modelos y Practicas en las Americas. San Juan: Universidad de Puerto Rico. Hills, M. & Mullett, J. (2000a). Collaborative community-based research for social change. Vancouver: British Columbia Health Research Foundation. Hills, M. & Mullett, J. (2000b). Research methods for community-based research. Vancouver: British Columbia Health Research Foundation. Jackson, S.F., Edwards, R.K., Kahan, B., & Goodstadt, M. (2001). An assessment of the methods and concepts used to synthesize the evidence of effectiveness in health promotion: A review of 17 initiatives. From Consortium Web site, noted below. Lyons, R., & Langille, L. (2000). Health lifestyle: Strengthening the effectiveness of lifestyle approaches to improving health. From Consortium Web site, noted below. O’Neill, M., & Hills, M. (2000). Education and training in health promotion and health education: trends, challenges, and critical issues. Promotion and Education, 7, 7–9. Rootman, I., & O’Neill, M. (1994). Developing knowledge for health promotion. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–151). Toronto: W.B. Saunders Canada. Spence, J.C. (2000). Compilation of evidence of effectiveness of active living interventions: A case study approach. From Consortium Web site www.utoronto.ca/chp/CCHPR/.
CRITIC AL THINKING QUESTIONS 1. What is meant by the term “knowledge development”? Do you think it is a useful concept? Why or why not? 2. What are some of the factors that contribute to knowledge development in health promotion or other fields? 3. What is the potential value added to knowledge development of bringing active research centres together into a consortium? Are there any disadvantages?
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4. What do you think is the main thing that should be done to develop knowledge in health promotion? Why? 5. In your opinion, what is the most important priority for knowledge development in health promotion? Why?
FURTHER READINGS Jackson, S.F. (2003). The Canadian Consortium for Health Promotion Research: A network that adds value to governments and universities. Promotion and Education, 10(1), 16–19. An earlier article about the Canadian Consortium for Health Promotion Research. Rootman, I., & O’Neill, M. (1994). Developing knowledge for health promotion. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–151). Toronto: W.B. Saunders Canada. Chapter on knowledge development in health promotion that appeared in first edition of this book. Stewart, M. (1997). Centres for health promotion research in Canada. Canadian Journal of Nursing Research, 29(1), 133–154. An earlier article on the Canadian Consortium for Health Promotion Research. Williamson, D.L., Stewart, M.J., Hayward, K., Letourneau, N., Makwarimba, E., Masuda, J., et al. (2006). Low-income Canadians’ experience with health-related services: Implications for health care reform: Another example of a collaborative study involving more than one member Centre of the Consortium. Health Policy, 76, 106–121. Wilson, D.R., Plotnikoff, R.C., & Shore, C.L. (2000). Research perspectives in workplace health promotion. From Consortium Web site, noted below. A national study of the research perspectives of individuals and organizations with major commitments and experience in the field of workplace health promotion carried out for the Consortium by a working group.
RELEVANT WEB SITES Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR/
This Web site contains information about the Canadian Consortium for Health Promotion Research as well as publications and other resources produced by the Consortium and links to Consortium member sites. Click4HP https://listserv.yorku.ca/archives/click4hp.html
This is a listserv managed by York University that provides an opportunity for people in the field of health promotion to communicate with each other on issues of interest. To subscribe, send mail to
[email protected] with the command (paste it!):
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SUBSCRIBE CLICK4HP. Archives can be obtained at https://listserv.yorku.ca/ archives/click4hp.html. Ontario Health Promotion E-Mail Bulletin
The Ontario Health Promotion e-mail bulletin is a weekly newsletter for people interested in health promotion. It is produced by the Ontario Prevention Clearinghouse and the Health Communication Unit at the Centre for Health Promotion at the University of Toronto. To subscribe, go to www.ohpe.ca/. Promosante www.promosante.org
This is a virtual resource centre that provides health promotion documents in French. Social Determinants of Health https://listserv.yorku.ca/archives/sdoh.html
This listserv on the Social Determinants of Health spun out of the Click4HP listserv in 2004. Also managed by York University, it is an electronic forum for discussion of issues related to the social determinants of health. Archives can be obtained at https://listserv.yorku.ca/archives/sdoh.html.
PA RT I I I
PROVINCIAL PERSPECTIVES
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anada is a federation, with the central government having strong taxation and legislative powers and, in theory, no authority or responsibility over the provision of health services (including public health and health promotion ones) as this belongs to provinces. In practice, however, as seen in the previous section, the federal government has been a major health promotion player on the international and national scenes over the past quarter century, both through the development of an internationally visible discourse as well as through its substantial spending power. Was the decline in the popularity of health promotion on the national scene observed from 1994 onward mirrored in the provinces and territories? If so, was it in a similar or different manner? If not, what has happened? In order to address these questions, we decided to use a different approach than the one we used in the first edition of the book. In that edition, we devoted one chapter to each province or territory, with the exception of the four Atlantic provinces (the authors chose to make a joint presentation). Several comments received about the first edition mentioned that many of these chapters seemed a bit redundant and that no global analysis for the provinces was presented. To address these issues, we chose to reduce the number of chapters in the provincial section to two. In Chapter 10 Bernier presents a comparative analysis of the development of health promotion in three provinces (Alberta, Ontario, and Québec), over the last decade or so. As a political scientist, she then tries to explain why the developments have been so different in these three provinces, offering potential avenues to reflect on the others as well. Under the coordination of one of the editors of the book (Pederson), Chapter 11 addresses the problem from a different angle. For that chapter, we have asked one or more people from
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each province or territory to describe the evolution of health promotion in their jurisdiction since 1994 in a short commentary of a maximum of 1,000 words. None of the authors from the first edition were available or willing to undertake the task again so the analysis is made through fresh eyes. Once more, the Atlantic provinces chose to act jointly, and this time we were fortunate to be able to include material from Nunavut, which was created after the first edition of the book. Out of these commentaries, Pederson offers an analysis of common features of the development of health promotion in Canada’s provinces and territories. At the end of this section, the readers, if they are Canadian, should have a good grasp of how health promotion evolved over the last 12 years in their province or territory, and regardless of where they are from, they should have a sense of the factors that contributed to the variations seen across provinces and territories of Canada.
CHAPTER 10
HEALTH PROMOTION PROGRAM RESILIENCE AND POLICY TRAJECTORIES: A C O M PA R I S O N O F T H R E E P ROV I N C E S Nicole F. Bernier INTRODUCTION t is not uncommon for health professionals to wonder why Canadian health promotion efforts have not fared better than they have so far in governmental agendas. For political scientists, however, the most puzzling questions are raised from the opposite side: Why have public health and health promotion programs survived the austerity period at all, over the past 10–15 years, as the federal and provincial governments were pursuing severe expenditure controls? And also, why do health promotion efforts take divergent orientations when provinces (or nations) are confronted with similar challenges? This chapter focuses on the experiences of Alberta, Ontario, and Quebec from the mid-1990s.1 They have been markedly different from each other and will be referred to as concrete examples to help explore some answers to the questions raised above. As Table 10.1 indicates, Alberta’s policy orientation has been characterized by discontinuity and the dismantlement and rebuilding of its public health infrastructure. It yielded a health promotion provincial framework that focuses heavily on social marketing strategies to promote healthy behaviours among Albertans. Ontario’s policy, which was relatively progressive to start with, has been destabilized by large-scale public sector reforms in all areas of governmental intervention, beginning in 1995. Such reforms induced a retreat of the social determinants of health as a basic prin-
I
ciple of public health policy. Quebec’s policy has been progressively consolidated over the same years, with a better institutionalization of its public health infrastructure at the local, regional, and provincial levels as well as systematic policy efforts at all levels to address the social determinants of health and, in particular, to reduce social health inequities. In a nutshell, policy evolution has taken the form of discontinuity in Alberta, stagnation in Ontario, and consolidation in Quebec. As is argued below, public health programs are at a disadvantage from an electoral calculus standpoint. We will expose the theoretical argument by which we should expect low levels of public commitments and high program vulnerability for public health and health promotion programs. We will also explore some arguments and data that help explain the resilience of public health promotion programs in Ontario and Quebec in the past decade, as well as the diverging orientations pursued by the three provinces. We think that a realistic, macroscopic perspective on the politics of public health policy, as developed here, can help health professionals explore new ways to advance the health promotion agenda in their respective jurisdiction.
FISC AL AUSTERITY AND PROGRAM VULNERABILITY From the inception of Canada’s modern welfare state in the late 1950s, the federal 141
142 ■ PART III: Provincial Perspectives TABLE 10.1: ORIENTATION OF PROVINCIAL PUBLIC HEALTH, 1994–2004
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government has set basic national standards for the provinces’ social assistance and health insurance programs as requirements to qualify for federal transfer payments. Starting in the mid-1970s, the federal government has sought to reduce its health and social transfers to the provinces in an expenditure-control strategy while retaining the leverage necessary to ensure provincial compliance with basic national standards. This withdrawal process was pursued and even intensified in the mid-1990s. Under the banner of deficit reduction, the federal government restructured almost every policy area and accelerated the schedule for reduction of transfer payments to the provinces over time. A new Canada Health and Social Transfer program was created in 1996, replacing both the cost-shared Canada Assistance Plan (for social assistance) as well as the plan for health care and post-secondary education. For instance, the federal government sharply reduced its already eroded transfers to the provinces by 9.4 percent between 1995–1996 and 1996–1997, and by an additional 6.7 percent the following year (Bernier, 2003; Tuohy, 1999), reducing its overall contribution to
these programs from roughly 50 percent when they were created to less than 20 percent a few decades years later. In addition to adjusting to the reduced transfer payments from the federal government, the provinces had to deal with several economic challenges of their own, including the effects of prolonged economic stagnation such as declining taxation revenues and low employment levels. At the same time, reduced eligibility for (federal) unemployment benefits was contributing to sharp increases in (provincial) welfare rolls. In the mid-1990s, increasing deficits and debt accumulation had become “the most pressing political issues at all levels of Canadian governments” (Hanlon & Rosenberg, 1998, p. 561). From a political science theoretical perspective, public health and health promotion programs should have been very vulnerable to cuts. Rational choice theory argues, indeed, that programs that offer immediate tangible benefits to specific groups (such as old age pensions or employment insurance) will fare better than programs (such as environmental protection) that offer diffuse benefits to diffuse groups in an unspecified future
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(Klein, 1976). Province-wide public health programs are among the latter category. Whereas for politicians programs with strong electoral consequences (like the closing of hospitals for instance) are more difficult to reform than others simply because groups and communities can organize and mobilize against them (Pierson, 1994), the political constituencies of the public health sector are generally limited to professionals working in the health sector with a few professional allies in other sectors. In addition, public health programs are generally not visible to the general public so their curtailment does not entail electoral retaliation. Furthermore, public health programs solicit direct budgetary expenditures, which require maintaining taxation or reducing other budgetary items in periods of cost containment. Finally, the traceability of benefits is weak: It is difficult for a voter to link a specific health outcome to a specific preventive public health program over which specific amounts of money have been spent. Indeed, citizens do not tend to reward today’s politicians for setting up programs that will reduce their probability of suffering from Type 2 diabetes and of dying from a given epidemic several years from now. Benefits are thus harvested in a time horizon of several years, while the cost for setting up the program is immediate. Clearly, provincial public health and health promotion programs are associated with a set of conditions that make them very vulnerable to program cuts. The question then becomes: Why did provincial public health and health promotion programs survive the austerity period of the last decade?
UNDERSTANDING PROGRAM RESILIENCE At least three reasons can explain the resilience of public health programs in this
difficult era: state legitimacy, health care resilience, and the need of basic social investments in neo-liberal economies.
State Legitimacy A useful dimension that helps explain the resilience of public health programs is that they fulfill one of the essential welfare state’s functions and represent a basic condition for the state’s legitimacy. Whereas public health programs are normally not visible to the public, they do become visible when not adequately performing their expected roles and when public health problems surface as a result of inadequate government provision. The malfunctioning or inadequacy of public health programs (such as immunization and ensuring basic sanitary conditions) exposes government leaders to potentially strong electoral retaliation, and could even lead to questioning the essence of governmental institutions. In Ontario, the Walkerton E. coli contamination of the water supply and the Toronto-area SARS crisis were dramatic examples that public health does become visible when it cannot provide for basic sanitary conditions to prevent the occurrence of largescale disasters; when it cannot adequately protect the population from epidemics and other public health tragedies; and when it cannot react to threatening events in an efficient, coordinated manner. In many respects, public health programs are similar to social assistance programs, which are often kept to a minimal level of functioning. Pierson pointed out in 1994 that it can be difficult for lean programs to become leaner during budgetary cuts. But after many years of neo-liberal policies, empirical evidence shows that lean social assistance programs can become even leaner. In Canada, provincial governments such as Ontario and British Columbia showed their
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ability and willingness to sharply reduce social assistance benefits, impose stricter conditions for receiving benefits (including for beneficiaries to participate in a workfare program), and even deny benefits to the “undeserving” poor (such as drug or alcohol dependents or beneficiaries who are unable to show they are looking for employment) or after a time limit. For instance, Ontario reduced social assistance benefits by over 21.6 percent in 1996. So based on the experience of social assistance programs, there is no apparent reason why public health and health promotion programs would have been immune to cuts even if they are kept at a minimum to start with. This being said, whereas social assistance programs were shaken by three decades of neo-liberalism, they also proved resilient to it. Resilience can be an indication that political leaders see a strategic advantage for government policy to at least appear to be dealing with the basic needs of the most vulnerable citizens and to be providing a basic social safety net (social assistance) in case things go wrong. In the same train of thought, political leaders may have an interest, from a rational choice perspective, to entertain the idea that their government is doing enough of what is doable to protect the population’s health. Like social assistance programs, the resilience of public health appears, from this perspective, not as much as resulting from strategic considerations to win votes but from fears of the negative costs associated with a public health policy failure. Public health policy thus appears as a prerequisite for government. Within public health, certain types of health promotion programs may entail low financial costs and high political visibility conveying the impression and public image that officials are actively trying to improve the population’s health and welfare. This is especially true of mass media social marketing cam-
paigns. A rational choice perspective helps to understand why such campaigns will be chosen over other health promotion activities, not because of the superior health outcomes they promise to yield, but because of their promise of high electoral visibility at low cost.
Health Care Resilience A second dimension for program resilience is that public health programs are part of the health sector and benefited from the relative structural and institutional stability of the health care system. All national income security programs and federal transfer payments to the provinces underwent fundamental changes as a consequence of the federal government’s restrictive policies in the 1990s, but in spite of some remarkable reform initiatives, the principles of the Canadian medicare model were not directly questioned. As Tuohy (1999) observed, during the period of heavy fiscal austerity, Canada did not attempt to change the policy parameters governing its health institutions and the structural balance of the system between the state, health care professionals, and private financial interests. Provincial governments did not withdraw from health policy, but even asserted their role: With the exception of Ontario, they brought some horizontal and vertical integration in the hospital sector while creating regional authorities for health. They had great latitude to redefine the organization of health care delivery and to rebalance the influence between state actors, the private sector, and the medical profession, but restricted their role to adopting “blunt budget instruments to slow the growth of the health care budget and to reallocate within it” (Tuohy, 1999, p. 245). The relative stability of the Canadian medicare system can be attributed in part to health care being a great national symbol in Canada and, by the mid-1990s, to the fact that
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media attention and polls across the country showed a growing public concern that medicare was in jeopardy (Maioni, 1998; Tuohy, 1999). This was reflected nationally in the revision of the federal–provincial fiscal framework in the mid-1990s: On the one hand, this revision eliminated the obligation for provinces to provide social assistance benefits on a needs basis, which opened the door to conditional benefits and even denial of benefits at the provincial level. On the other hand, and consistent with the Canadian public agenda focused on health care, the five principles of the Canada Health Act were maintained in the new fiscal framework. The amalgamated block funding for social and health transfer program thus entailed that federal requirements and national norms for health care and social assistance contributed to protect health care budgets because the principles were maintained and therefore no flexibility existed, while the federal framework made it permissible for social assistance programs to be fundamentally revised in all Canadian provinces. Public health and health promotion programs have thus benefited from the broader resilience of Canadian health and health care policy relative to Canadian social policy and programs.
Neo-liberalism and Social Investment A third dimension for program resilience is the fact that such programs are consistent with the “social investment” paradigm for social policy design. This paradigm is closely associated with the rise of neo-liberalism and was developed in OECD countries from the early 1980s, but accelerated in the 1990s. It emphasizes the role of government in protecting the public against social risks that private corporations then don’t have to assume (Jenson & Saint-Martin, forthcoming). In the area of income security, the social investment
model seeks not simply to compensate people for lost revenues resulting from risks such as illness or unemployment; it emphasizes the development of specific programs and policies that are focused on reforming individuals and communities, often by targeting the most vulnerable individuals and groups in society. It seeks to control or prevent the occurrence of individual problems where they are most likely to occur, be it in socioeconomic groups, ethnic groups, age groups, or geographical areas. Clearly, public health and health promotion approaches are quite usable in such a social investment model. It is not impossible that the growing influence of social epidemiology as a field of professional investigation and university research has even actively contributed to the flourishing of this paradigm. Illustrations from Ontario and Alberta help to show our point. In Ontario, public health professionals directed their efforts to persuade the conservative Harris government that cutting in certain public health expenditures was detrimental to the population’s health and costly to the province’s finances and health care in the long term. The line of argumentation, supported by epidemiological studies and financial data,2 was largely organized around the idea that public health problems that are not dealt with now would be much more costly to the public purse later. After the election of the Harris government, accessibility to politicians was denied to several groups. However, the public health sector discourse could be articulated in terms that were compatible with the “Common Sense Revolution” of the Harris government and was heard and acted upon (interview data). The Harris government thus chose to emphasize the promotion of healthy lifestyles and chronic disease prevention, as opposed to pursuing a more comprehensive approach.
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In Alberta, the Health Sustainability Initiative (HSI) was set up in the year 2000 as a priority initiative involving 10 ministries and related government agencies, as well as the Premier’s Advisory Council on Health. HSI’s central objective is to reduce the rate of growth for the provincial health care system. “Staying healthier” is the number one governmental effort to curb expenditure growth, which translates in efforts to reduce preventable chronic diseases and injuries. Alberta’s framework for health promotion program is a direct outcome of the HSI. It sets outcomes, objectives, and targets for government action to promote health and prevent disease and injury in different settings: homes, schools, workplaces, and communities. Its insistence on reducing chronic diseases is closely associated with the fact that such diseases represent a great financial burden on health care now and in the future.
UNDERSTANDING POLICY DIVERGENCE Having explored some of the reasons that help explain why programs survived in what appeared a very negative environment, we will now turn to an exploration of arguments and data that will help explain the diverging orientations pursued by the provincial governments in their public health policy. If we are indeed ready to accept the idea that the resilience of public health programs is because they were compatible with the neo-liberal policy orientations pursued by the Alberta and Ontario governments, this challenges us to explain the Quebec experience. Quebec is indeed among Canada’s four largest provinces (along with Ontario, Alberta, and British Columbia), the one where social democratic traditions are stronger (Baer, Grabb, & Johnston, 1993; Bernard & Saint-Arnaud, 2004; Clark, 2002). Quebec’s experience with
fiscal austerity since the mid-1990s has been described as a “deviant case” because while adopting certain economic policies influenced by neo-liberalism, it has largely resisted the neo-liberal model of development espoused by the other provinces, even if it elected in 2003 a liberal government whose legacy is still unclear (Clark, 2002; Vaillancourt et al., 2000). Quebec’s approach to reforming its health sector and its social assistance programs has been less drastic than elsewhere. When other provinces were sharply controlling the growth of program expenditures, Quebec’s social policy went in a significantly different direction. Starting in 1996, a family policy was implemented, which included means-tested family allowances as well as a universal, highly subsidized provincial day care system and modifications to the provincial work legislation to facilitate parental obligations (Jenson, 2002). As already discussed, Quebec’s public health policy also went in a direction markedly different from other provinces. Why is Quebec’s policy so different?
Federal–Provincial Relationships Historically, social policy has been used as an instrument for Quebec’s national affirmation in its relations with Ottawa and the rest of Canada. Typically, in Canada’s post-war history until this day, Quebec would design a social program such as family allowances in 1972 or old age pensions in 1965, and Ottawa would counterreact with an overlapping, equally generous, but national program in a process of competitive nation-building (Bernier, 2003; Jenson, 2002). The growing convergence of public health with Quebec’s social policy during the 1990s and earlier 2000s is one among many other forms of expression of this rivalry between Quebec and Canada for affirming their national identities. This dynamic has also been present
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during the discussions between Quebec and Ottawa representatives in relation to the creation of the Public Health Agency of Canada, with tensions regarding whether the agency would focus on core functions or develop a more comprehensive approach to public health (interview data). In a nutshell, federalprovincial dynamics help us understand public health policy divergence among the three provinces and particularly Quebec’s comprehensive approach. Of course, other macro variables also matter.
led to the election of an NDP government in 1990. Quebec, for its part, has had a strong left presence, which resulted in the formation of three left-oriented (out of a total of six) provincial governments since the beginning of the 1980s (see Table 10.2). The presence of a left-of-centre party in provincial elections thus is a good indicator of the core value base of a population and has been associated with the consistency and comprehensiveness of public health policy in the three provinces studied.
Presence of a Left-Wing Party
Demographics,Wealth, and Prosperity
Political traditions help explain policy divergence. Alberta has traditionally been characterized as a one-party or “quasi-party” system, with a generally weak opposition and a weak presence of the left-wing CCF-NDP party. Ontario has had a stronger tradition of opposition politics with a constant presence of CCF-NDP (Chandler, 1977), which
It is conceivable that wealthier nations or provinces would tend to incorporate a health promotion social determinants of health vision into their health policy simply because they have better resources than others to address them. Similarly, prosperous political entities could be more inclined to adopt progressive policies than less prosperous ones simply
TABLE 10.2: SEAT DISTRIBUTION AMONG MAJOR POLITICAL PARTIES AT GENERAL PROVINCIAL ELECTIONS IN ALBERTA, ONTARIO, AND QUEBEC BETWEEN 1981 AND 2003
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148 ■ PART III: Provincial Perspectives
because of the favourable economic conditions and increased policy leverage they experience. Provinces with a high proportion of seniors may also be expected to invest in alternatives to health care as a cost-reduction device. Provincial results over the period of observation are entirely counterintuitive with respect to such arguments: they show an inverse relationship between economic wealth and prosperity and the magnitude of health promotion efforts. They also show an inverse relationship between the percentage of seniors and the magnitude of health promotion efforts. As Table 10.3 shows, Alberta is by far the richest province in terms of its gross domestic product per capita, while Ontario stands in the middle and Quebec is the poorest of the three provinces. Not only is this a consistent pattern over the years, but the gap in production levels per capita between Alberta and the two other provinces has also widened between 1994 and 2004. Alberta’s wealth has grown at a rate of 80 percent over the period, as compared to 45.3 TABLE 10.3:
percent for Ontario and 49.3 percent for Quebec. Another indicator of wealth and prosperity is the unemployment rate. As Table 10.4 indicates, Alberta has had the lowest rate, Ontario the middle, and Quebec the highest of the three provinces. Similarly, the province with the lowest percentage of seniors over 65 years of age (Alberta, 10.2 percent) is also the one where public health and health promotion programs have been more challenged and more limited. We thus see that the province with the greatest economic leverage (Alberta) has also been less inclined to pursue its public health and health promotion efforts in a consistent and comprehensive manner in the past decade. Inversely, the province with the smallest economic leverage over policy (Quebec) is where the most sustained and comprehensive health promotion efforts are found. These intriguing results lead us to the formulation of a hypothesis for further research: the poorer a political unit (e.g., city, province, nation), the broader the magnitude
GROSS DOMESTIC PRODUCT PER CAPITA ($), BY PROVINCE, SELECTED YEARS
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TABLE 10.4:
UNEMPLOYMENT RATES (PERCENT), BY PROVINCE, SELECTED YEARS
Text not available
CHAPTER 10: Health Promotion Program Resilience and Policy Trajectories ■ 149
of its efforts in public health and health promotion. Similar observations were made, albeit incidentally, by Greer (2004) for the UK, where the poorest country of Wales was also where a population health approach fared best, among the four British countries, into the agenda and outcomes of the health policy adjustments that followed devolution in 1999. The question this raises is: Do rich countries and provinces tend to heavily invest in health care medical services and technologies geared toward individual needs, while poor countries and provinces tend to develop, as a cheaper alternative, low-tech, alternative mass approaches in the form of social and preventative medicine geared toward population groups? If our hypothesis holds, it could imply that health promotion efforts (especially when focusing on the social determinants of health, healthy public policy, and reducing social health inequalities) are part of public endeavours contributing to the polarization of medicine between rich and poor regions. The general assumption that health promotion is more progressive than biomedical approaches to health would then need revision. In its effort to explain the differential behaviour of three of the largest Canadian provinces toward public health and health promotion policies, this section has thus shown that economic leverage over policy does not work the way one would normally expect. It is thus essential to look at how the value base of the population, as it translates into political behaviour, transforms economic
and demographic condition into certain policy directions rather than in others.
CONCLUSIONS This chapter has shown that even if there are good political reasons to expect a low level of public commitment to health promotion and public health policy, they have astonishingly enough been maintained over the last decade, even if differentially, in the three provinces studied. Health promotion policy is not a selfcontained, stand-alone area of governmental intervention. Policy outcomes in public health and health promotion are clearly associated with broader, non-health related, political pursuits by provincial governments, which is why, for instance, a narrow definition of health promotion policy presents the advantage of high visibility at low cost through mass-media campaigns. We have observed that public health policy orientation does not follow a given trajectory characterized by stages according to which we could expect “less” advanced provinces to follow, with a delay, a path similar to the “more” advanced provinces. Rather, each province develops its own solutions for public health and health promotion, which reflect its particular economy, demography, and political traditions. This does not suggest that health professionals seeking to contribute to the advancement of health promotion should consider giving up their endeavours. Instead, as part of the reflexive practitioner attitude this book suggests, they should consider
TABLE 10.5: SENIORS 65 YEARS AND OVER AS A PROPORTION OF TOTAL POPULATION IN 2001
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150 ■ PART III: Provincial Perspectives
exploring the constraints and possibilities for action offered within the parameters of the policy and politics of public health in their own province. Political realism requires us to realize that health promotion, as with every other field of public intervention, is always
inserted in political agendas and part of a macro policy context. The knowledge and pursuit of one’s political interests, and how such interests compete with those of others, is thus essential to push for one’s own values!
NOTES 1
2
A detailed, comparative analysis of the three cases can be found in Bernier (in press). See also Chapter 11 of this book for a description of the evolution of health promotion over the last decade in the three provinces studied. Acknowledgements: The research for this chapter was conducted while holding a CIHR/CHRSF postdoctoral fellowship and has also been supported by the Chaire Approches communautaires et inégalités de santé at the University of Montreal. The author wishes to thank several individuals who agreed to share their time and policy perspective in 2004. In Alberta: B. Hansen, S. Lewis, E. Murphy, P. O’Hara, C. Price, K. Raine, and two anonymous respondents; in Ontario: C. Acker, M. Cushing, M. Herrera, J. Lee, and D. Patychuk; in Quebec: M. Boucher, C. Colin, R. Massé, H. Morais, and J. Rochon. Thanks are extended to Geneviève Guindon for her research assistance and to Rudolf Klein and Louis Imbeau for helpful exchanges.
REFERENCES Baer, D., Grabb, E., & Johnston, W. (1993). National character, regional culture, and the values of Canadians and Americans. Canadian Review of Sociology and Anthropology, 30, 13-36. Bernard, P., & Saint-Arnaud, S. (2004). Du pareil au même? La position des quatre principales provinces canadiennes dans l’univers des régimes providentiels. Canadian Journal of Sociology, 29, 209–239. Bernier, N.F. (2003). Le désengagement de l’État providence. Montréal: Les Presses de l’Université de Montréal. Bernier, N.F. (in press). The scope of the “new public health” in Canada’s provincial agendas. In P. Bourdelais & L. Abreu (Eds.), Welfare systems, social nets, and economic growth. Evora, Portugal: University of Evora Press. Chandler, W.M. (1977). Canadian socialism and policy impact: Contagion from the left? Canadian Journal of Political Science, X, 755–780. Clark, D. (2002). Neoliberalism and public service reform: Canada in comparative perspective. Canadian Journal of Political Science, 35, 771–793. Greer, S.L. (2004). Territorial politics and health policy: UK policy in comparative perspective. Manchester & New York: Manchester University Press. Hanlon, N.T., & Rosenberg, M.W. (1998). Not-so-new public management and the denial of geography: Ontario health-care reform in the 1990s. Environment and Planning, C16, 559–572. Jenson, J. (2002). Against the current: Childcare and family policy in Quebec. In R. Mahon & S. Michel (Eds.), Child Care policy at the crossroads: Gender and welfare state restructuring (pp. 309-332). New York: Routledge. Jenson, J., & Saint-Martin, D. (forthcoming). Building blocks for a new social architecture: The LEGOTM paradigm of an active society: Policy and politics. Klein, R. (1976). The politics of public expenditure: American theory and British practice. British Journal of Political Science, 6(4), 401–432.
CHAPTER 10: Health Promotion Program Resilience and Policy Trajectories ■ 151 Maioni, A. (1998). Parting at the crossroads: The emergence of health insurance in the United States and Canada. Princeton: Princeton University Press. Pierson, P. (1994). Dismantling the welfare state? Reagan, Thatcher, and the politics of retrenchment. Cambridge: Cambridge University Press. Tuohy, C.H. (1999). Accidental logics. New York: Oxford University Press. Vaillancourt, Y., Aubry, F., d’Amour, M., Jetté, C., Thériault, L., & Tremblay, L. (2000). Social economy, health, and welfare: The specificity of the Québec model within the Canadian context. Canadian Review of Social Policy, 45–46, 55–87.
CRITIC AL THINKING QUESTIONS 1. Using a rational choice perspective, give five reasons why political leaders tend to neglect health promotion policy. 2. In the mid-1990s, several public health and health promotion programs were dismantled in Alberta. In Ontario and Quebec such programs were not affected by budgetary cuts as much as could be expected. Describe three elements that help understand program resilience in Quebec and Ontario. 3. Are health professionals in Quebec and Ontario better policy advocates than their Albertan colleagues? What other elements should be considered to understand diverging policy outcomes among provinces? 4. Using a rational choice perspective, discuss the potential and shortcomings of producing evidence as a key strategy for health promotion policy advocacy. 5. Find one idea to help conceive a health promotion policy advocacy strategy that takes the decision makers’ political interests into account.
FURTHER READINGS Boussaguet, L., Jacquot, S., & Ravinet, P. (2004). Dictionnaire des politiques publiques. Paris: Presses de science po. Introduces concepts and references for policy analysis in short but critical texts. Brooks, S., & Miljan, L. (2003). Public policy in Canada: An introduction (4th ed.). Toronto: Oxford University Press. Policy making in the Canadian context, with sectoral examples such as family, Aboriginal, and environmental policy. Howlett, M., & Ramesh, M. (1995). Studying public policy: Policy cycles and policy subsystems. Toronto: Oxford University Press. A synthetic introductory source adapted to Canada suitable for advanced undergraduate students. Lemieux, V. (2002). L’étude des politiques publiques: Les acteurs et le pouvoir (2nd ed.). Montreal: Les Presses de l’Université de Montréal. An introductory reference in French adapted to Quebec. Sabatier, P.A. (Ed.). (1999). Theories of the policy process: Theoretical lenses on public policy. Boulder: Westview Press. Provides an introduction to several analytical frameworks for policy analysis, and is especially useful to students interested in writing a thesis.
152 ■ PART III: Provincial Perspectives Weimer, D.L., & Vining, A.R. (1999). Policy analysis: Concepts and practice (3rd ed.). Upper Saddle River: Prentice-Hall. An advanced text that is considered a classic in public policy with a practical orientation that makes it especially useful to professionals.
RELEVANT WEB SITES Canadian Policy Research Networks/Réseaux canadiens de recherches sur les politiques publiques www.cprn.com/
CPRN’s research is informed, relevant, of high quality and useful to governments at all levels, as well as other stakeholders involved in policy development. See the health section in particular. Canadian Social Research Links www.canadiansocialresearch.net/
Provides a wealth of commented links on Canadian health and social policy; new federal or provincial budgets, official releases, official Web sites, debates, non-governmental organizations, etc. The site is regularly updated and its archives (dating back to 1997) are searchable. The French version is not as well updated. Cric.ca Canada’s Portal/Le portail du Canada www.cric.ca/
This site, managed by the Canadian Unity Council, provides basic official documents that are most useful to policy analysts: main legislations, official agreements, and treaties, etc. Has a special section on health care. Policy.ca http://policy.ca/
A non-partisan resource for public discussion of issues in Canadian public policy. This newer site consists of a growing database of online public policy research publications, as well as information on policy organizations. PolitiquesSociales.net http://politiquessociales.net/
A well-organized, thematic site on Canadian and international social policy in French.
CHAPTER 11
1 2 C A N A D I A N P O RT R A I T S : H E A LT H P RO M OT I O N I N T H E P ROV I N C E S A N D T E R R I TO R I E S , 1 9 9 4 – 2 0 0 6 Ann Pederson INTRODUCTION iven two levels of government with two distinct but connected sets of responsibilities and two official languages, no account of health promotion in Canada is complete without reflection upon the development of health promotion at the provincial and territorial levels. As the activities of the federal government are taken up elsewhere in this book (see Chapter 7), this chapter addresses the question of how health promotion has developed and evolved at the level of the provinces and territories. Accompanying this chapter are 12 case studies, each of which portrays some aspects of the development of health promotion from 1994–2006 within a particular province or territory (the Atlantic provinces are grouped together, but each is discussed).
G
THE FEDERAL/PROVINCIAL/ TERRITORIAL LANDSC APE OF C ANADA Those interested in understanding the development of health promotion in Canada should examine not only the federal government’s very visible activities and policies, but also the programs and policies of the provinces and territories and those of organizations that operate at the provincial and territorial levels. This is because within Canada, authority and responsibility for health is largely a provincial and territorial rather than a federal responsibility. To understand the dynamics of health
policy in Canada, one needs to know that the founding constitutional framework of Canada—the British North America Act of 1867—assigned responsibility for health and welfare to the provinces (except in a few instances) while the federal government was given significant taxation powers. Currently, the provinces provide publicly funded health insurance through individual provincial plans and the federal government provides financial support for health services in exchange for provincial and territorial compliance with the terms of the Canada Health Act (1986) (see Box 11.1). These arrangements mean that health policy making in Canada has come to involve the complexities of federal/provincial/territorial (F/P/T) relations, as well as ideological, professional, and practical battles over what constitutes “health” and “care” and who should pay for it. Indeed a central debate among those working in the health field is what the actual domain of health promotion includes and whether health promotion is—or should be— part of the health care system (see Chapters 2 and 3). Moreover, it means that many of the struggles that relate to the development of health promotion in Canada are played out in Cabinet rooms, at caucus meetings, and in F/P/T meetings, rather than where the Ottawa Charter says that health promotion happens; that is, where people live, love, work, and play (World Health Organization, 1986). Finally, it means that if we want to take the measure of health promotion in Canada we must not 153
154 ■ PART III: Provincial Perspectives
limit our assessment to what happens at the federal level but try instead to develop a more nuanced understanding of the diverse geography, history, language, and culture of the var-
ious regions of the country. As previously noted, this chapter is therefore accompanied by a set of case studies that provide portraits of some of this diversity.
BOX 11.1: THE FIVE CONDITIONS OF MEDICARE
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One additional feature of Canada that is also meaningful with respect to both policy and practice in health promotion is the fact that Canada has two official languages— English and French—which reflect both historic and ongoing geographic, linguistic, and political divides. Although minority language legislation, in principle, provides people with access to federal government services and materials in either official language regardless of where they live, the lived experience of many Canadians is that they function either in English or French rather than both. Much health promotion activity thus becomes invisible, even among Canadians, on either side of this linguistic divide. This is reinforced by relative geographic separation, which means that the majority of French-speaking Canadians are found in Quebec and some Atlantic Canadian provinces, whereas English dominates elsewhere. This chapter and the case studies therefore try to give some visibility both to the question of services for francophone minorities throughout Canada, but also to the differences in approach to health promotion that have arisen in Quebec as compared with the rest of the country.
FINDINGS FROM THE FIRST EDITION In the first edition of this book, we included detailed chapter-length, historical accounts of health promotion in each province and territory except Nunavut, which was established as the eastern portion of the Arctic territory on April 1, 1999. No effort was made to standardize what the authors defined as health promotion, but as most of the authors were either academics or government employees, they were very familiar with the discourses of health promotion and health policy making circulating in official circles—indeed some of them were responsible for its presence—and comfortable setting the boundaries of the discussion for their particular jurisdiction. The chapters typically described government health policy making and prominent provincial programs that fell under the rubric of health promotion. The chapters also described major disease prevention campaigns or demonstration projects, research initiatives, and organizations that were starting to examine the evidence of health promotion’s effectiveness, as well as community or voluntary sector organizations
CHAPTER 11: 12 Canadian Portraits ■ 155
that were leading or supporting health promotion in the jurisdiction. To varying degrees, the authors tried to account for the particular expressions of health promotion that had taken place in their jurisdiction. In keeping with the historical and sociological approach of the book as a whole, most of the authors argued that health promotion in their province reflected the particular mix of party politics, leadership, and political-economic history of the province, as well as demographic issues such as population distribution and epidemiology. All the provinces and territories were said to be engaged in health promotion, but the extent to which it was a function of public health departments, a professional activity, a community-based or a feature of clinical practice varied from jurisdiction to jurisdiction. Taken as a whole, the chapters offered a fairly high degree of consensus that health promotion at the provincial and territorial level struggled for resources in a health care system focused on acute care and, to a lesser but growing extent, chronic disease management. Community development was a feature of health promotion in some jurisdictions—and part of the discourse of most—and many provinces had thriving health promotion research communities. The Healthy Communities movement and its French counterpart, Villes et Villages en Santé, were thriving in many areas of the country and increasing numbers of students were enrolling in programs of health education and health promotion. Most of the authors worried, however, about the capacity of health promotion to live up to its official rhetoric in a climate of growing fiscal constraint and health sector reform.
PREPARING THIS CHAPTER Bearing this loose consensus in mind, we approached the question of learning about
how health promotion has been functioning at the provincial level since the mid-1990s. We again sought contributors in each jurisdiction who were familiar with the development of health promotion and asked them to draft brief responses to a general set of questions: What has happened in health promotion since the first edition of this book in your jurisdiction with respect to policy, research, and practice? Is health promotion still in fashion or has it been displaced by population health or another discourse or practice? Who have been the key actors? Who has been advocating for or against health promotion? How has the concept of health promotion appeared in government discourse (or not)? Are current developments continuing or changing earlier directions from Lalonde (1974) to the mid-1990s? The case studies that accompany this chapter, then, are the set of commentaries on health promotion in Canada at the provincial and territorial levels presented in a west-to-east geographical order. (Regrettably, we are missing specific contributions from the Yukon and Northwest Territories.) To reflect the impact of Canada’s two official languages, we also sought information about how health promotion is available to francophone minorities outside of Quebec and have a brief commentary on this issue as part of the case studies.
REFLECTIONS ON THE C ASE STUDIES A Context of Health Sector Reform In the first edition of this book, Lavada Pinder (1994, p. 94) warned that “health care reform may not only control the health policy agenda for some years to come but could, in doing so, draw health promotion into its orbit—first by taking away scarce resources and secondly by making health promotion a
156 ■ PART III: Provincial Perspectives
function of cost containment.” To varying degrees, and at the risk of overgeneralizing from limited data, it is clear that health care reform has played a significant role in shaping health promotion in the past 15 years. While reform has been an ongoing feature of all health care systems for the past 100 years as successive reforms have altered the organization, financing, and delivery of health care services, including the introduction of national health care systems and health insurance infrastructures such as in Canada (World Health Organization, 2000), contemporary health care reform reflects larger political and social changes in the past two decades. According to the WHO (2000, p. xiv), “These include the transformation from centrally planned to market-oriented economies, reduced state intervention in national economies, fewer government controls, and more decentralization.” Accompanying these changes, the WHO (2000) reports an ideological shift to greater individual responsibility and choice and political efforts to reduce expectations of government. These changes are familiar to those who have been monitoring health care reform in Canada. In what they refer to as a primer on health reform issues in Canada, Fooks and Lewis (2002, pp.1–2) identified nine themes that characterized provincial and national government discussions of health reform: (1) a focus on population health; (2) financing the health care system; (3) primary care reform; (4) regionalization of service delivery; (5) pharmaceutical policy; (6) health human resource planning; (7) quality improvements and infrastructure supports; (8) governance and accountability mechanisms; and (9) home care services. In these reforms, health promotion most often appears as part of population health efforts to prevent disease and enhance wellness and, to a lesser extent, it may appear as one of the
elements of primary care reform (usually defined as reforms related to a person’s first point of contact with the health care system). To contextualize this list of health reform topics, Armstrong and Armstrong (2001) offer a historical, political economic account of health care reform initiatives in Canada. Their account suggests that the reforms noted above have been occurring in a larger context marked by: welfare state restructuring; pressure to reduce or eliminate government deficits and debt; technological change (including drugs, diagnostic imaging, and information technologies); the idea that there were limits to public care (both as a function of a potentially unlimited demand for health care and out of recognition that some determinants of health arise outside of the health care system); and a paradigm shift toward thinking about health care as a business. They thus see many of the specific health reforms being undertaken or contemplated in Canada as consistent with a business-oriented concern with efficiency, effectiveness, and accountability. From this perspective, health promotion becomes a tool for cost containment and a shift in responsibility from the state to provide care and for citizens to reduce their demand for care. One of the most enduring features of health sector reform noted in the case studies is its ongoing and widespread nature. That is, change has become the norm in the health care system and that means that people are required to manage change as part of their everyday lives at work. Taking regionalization as one example, it is clear that in several jurisdictions, regional structures were established and then subsequently recreated following various review processes, sometimes within brief time periods. In British Columbia, for example, regionalization has been a dynamic process, with successive processes of regionalization occurring, beginning in the
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early 1990s. The initial structure proposed would have created a system of 82 community health councils and 20 regional health boards (British Columbia Ministry of Health and Ministry Responsible for Seniors, 1993). Though this vision was never implemented, the first round of regionalization did produce a system that included 34 community health councils, 11 regional health boards, and seven community health services societies—a total of 52 regional health authorities (British Columbia Ministry of Health and Ministry Responsible for Seniors, 1996). Then in 2001, this system was remodelled once again and the current system—comprised of five geographic health authorities, one Aboriginal health authority (the Nisga’a Health Authority), and a new, Provincial Health Services Authority (PHSA)—was created based on a vision articulated in A New Era for Patient-Centred Health Care (British Columbia Ministry of Health Planning, 2001). Managing such changes can challenge an organization’s ability to achieve its goals simply because people are focused upon understanding and adapting to a new system. Further, in the case of regionalization, some of the new structures that have been created are unprecedented in Canada and hence required enormous learning for people across numerous sectors. Again, using BC as the example, the 2001 re-regionalization process included the creation of a Provincial Health Services Authority (PHSA), which is comprised of several formerly autonomous health services agencies, each with a province-wide mandate, which are now linked together in a larger organizational and managerial structure.1 In light of this scale and frequency of change, it is perhaps not surprising to see that the pragmatics of health care delivery have often taken precedence over the longer-term aims of health promotion. It is also clear from the numerous government reports that
accompanied regionalization and decentralization in most provinces and territories that these changes were accompanied by a discourse of individual responsibility for healthful living; increased concern about disease prevention through immunization and monitoring; attention to chronic disease management protocols and mechanisms; and a recognition of the limits of the health care system to foster health—echoes of the 1974 Lalonde Report 32 years ago (Lalonde, 1974)—but in a different political and economic context following years of budget reductions and after two decades of an international discourse about the determinants of health made visible by the Ottawa Charter.2
Current Actions and Future Directions In their case studies, most of the contributors decry the paucity of resources directed to public health and/or health promotion as compared with the expenditures on acute health services, though there is more of a tone of guarded optimism regarding the potential for new funding, particularly since the establishment of the Public Health Agency of Canada in September 2004. Moreover, some areas of activity were reported as receiving more funding than others, namely, activities directed at “healthy living” as opposed to the determinants of health. As is clear throughout this book, the tension between individual action (and responsibility) for healthful living and state-supported action to address the determinants of health remains a feature of health promotion within the provinces and territories. However, some interesting examples of research and legislation point to important actions on the determinants of health, including “smoke-free” legislation, school-based nutrition, and physical activity programs that include limiting access to foods of limited nutritional value, and research into
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the occupational health issues facing those living and working in coastal communities. The case studies illustrate how governments can support or undermine efforts at promoting health without necessarily having institutionalized health promotion per se. That is, the government may have policies on tobacco control legislation, support for social housing, funding for social assistance, and attention to school and workplace opportunities for nutrition and exercise. But it may or may not fund designated health promotion positions, training or research, or have created institutional mechanisms for health promotion within government infrastructure. Notably, several contributors describe eras in which health promotion as any sort of formal entity disappeared within the apparatus of government, but remained strong within community and/or academic organizations. This begs the questions of the ultimate aims of health promotion and whether (and which) institutional mechanisms and professional practitioners (and the supports to educate them) are essential for the survival of health promotion (which is a theme taken up in the conclusion of this book; see Chapter 22). In fact, these contributions make it clear that the universities and academics have played significant roles in sustaining and developing health promotion in Canada. Researchers, including those associated with the Consortium on Health Promotion Research (see www.utoronto.ca/chp/CCHPR/ intro_english.htm), and research-funding organizations have generated mechanisms for health promotion to continue to develop even in times of limited direct funding for designated government health promotion programs and personnel. The enlarged health research infrastructure in Canada since the creation of the Canadian Institutes of Health Research in 2000 and the growth of provincial funding mechanisms have helped
to sustain health promotion efforts and program evaluations through some of the strategic and operating grant initiatives, though research funding is obviously in itself not an adequate mechanism for financing long-term, sustained programming. Currently a wide array of topics from health literacy to mid-life health to school-based nutrition and physical activity programs are underway across the country with the help of research monies to support their development, implementation, and evaluation. Moreover, each region has spawned its own areas of research expertise and concentration, reflective of local conditions, institutional mandates, and research personnel. Unfortunately, health promotion research capacity is not equally distributed across the country: while its absence is especially notable in the North, it is also unevenly resourced in several other provinces and tends to be associated with urban universities with fewer research resources available to rural and remote communities and issues. In addition to noting the value of research infrastructure for strengthening health promotion capacity, the contributors often mentioned growth in the past decade in health promotion training and educational opportunities. These initiatives have included regular health promotion summer schools through many of the health promotion Consortium members as well as new undergraduate and post-graduate degree programs in health promotion and/or public health. These educational opportunities mean increased professional and research capacity for health promotion across the country and the introduction of issues related to accreditation, professionalization, and certification. Ziglio, Hagard, and Griffiths (2000, p. 144) have argued that, “the promotion of health cannot be left to the health sector alone.” Indeed, in Canada’s provinces and territories, partnerships and intersectoral
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action are one hallmark of health promotion evident from these contributions. No sector alone has the resources, skills, or capacity to go it alone when it comes to altering the determinants of health. One manifestation of the emphasis on partnerships has been the creation of infrastructure explicitly for networking, particularly among the research and public health communities, and it is clear that both virtual and more traditional networks have emerged over the past decade. On a related note, the growth of electronic resources for health promotion—as evidenced in part by the list of relevant Web sites at the end of each contribution—is another feature that distinguishes the era reported in this book from that of its predecessor. Some of these are national in scope, such as the Canadian Health Network, but others are local projects that have national and even international connections because of the reach of the worldwide Web, video conferencing, and e-mail, such as Click4HP or the online courses offered by the University of Alberta. This is one area—that of electronic technology and its associated innovations—in which we will expect to see continuing evolution over the next decade as digitized information continues to migrate to smaller, more personalized devices and as wireless networks blanket the world. Despite the many similarities in current health promotion in the provinces and territories, however, there are also differences evident across the country. As noted, each research centre within the Consortium has developed its own research areas and specialization, and most jurisdictions have tailored some of their activities to addressing population-specific needs. As expected, Quebec continues to hold its own as a social policy innovator and its public health institute is likely the envy of the other provinces. It is also clear that national organizations play differ-
ent roles in different parts of the country. For example, the Atlantic region described a lengthy association with the Population and Public Health Branch of the Regional Office of Health Canada (and now the Public Health Agency of Canada Atlantic Regional Office) that was not reported elsewhere in the country. This suggests that federal resources are important in health promotion efforts in the region and suggests a greater potential role for the PHAC in the northern territories and vulnerable areas of various provinces. It also reminds us of the redistributive role of the federal government in allocating resources and supporting programs. To summarize, despite continued limited, dedicated funding, health promotion has regained some ground in recent years. Some of this has been piggybacking on the renewal of support for public health actions following the recent SARS crisis and greater government concern over the potential burdens of diabetes and other chronic illnesses. It therefore remains to be seen how much of the determinants of health discourse is sustained in the face of preparations to fight the next pandemic and clinical efforts focuses on chronic disease prevention and management. Will health promotion become increasingly medicalized under the pressures of an aging population and concerns about health care quality? Will a balance in attention to mental health promotion—an area in which Canada has shown some intellectual and political leadership—accompany the current enthusiasm for physical health concerns? Will the current rhetoric of “upstream” interventions lead to investments in the underlying determinants of health—housing, income, education, working conditions, meaningful social engagement, to name a few—or will that attention stop at the first level of personalized, privatized responsibility for healthful living? Will governments at all levels work
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together to reduce key social and health inequities, particularly among First Nations and Aboriginal peoples? Will linguistically marginalized groups be able to access health resources and care in their first language? It will be interesting to see if, in the next generation of this book, this country’s health promotion researchers, policy makers, and practitioners report significant progress in all these areas as well as actions to improve the other determinants of health. Returning full circle to the discussion of health care reform, one promising area of action and research to watch with respect to health promotion is the area of primary
health care reform. Led in part by the federal government’s Primary Health Care Transition Fund (see Health Canada, 2005), innovative approaches to health care delivery and the recognition of the powerful practical links between primary health care and health promotion are gaining increasing attention (e.g., Ciliska et al., 2005; Donner & Pederson, 2004; Frankish et al., 2006; Moulton et al., 2006). Given their role in delivering health care services, the future of health promotion in the provinces and territories in Canada may lie in establishing close ties with the advocates, innovators, and evaluators of primary health care.
NOTES 1
2
The Provincial Health Services Authority (PHSA) is responsible for managing the quality, coordination, accessibility, and cost of selected province-wide health care programs and services. The agencies that form the Provincial Health Services Authority in British Columbia are: BC Cancer Agency, BC Centre for Disease Control, BC Children’s Hospital and Sunny Hill Health Centre for Children, BC Provincial Renal Agency, BC Transplant Society, BC Women’s Hospital and Health Centre, Forensic Psychiatric Services Commission, PHSA Cardiac Services, and Riverview Hospital. Examples of provincial government reports that discuss health reform and regionalization include • A Framework for Reform by the Premier’s Advisory Council on Health, Province of Alberta, 2000–2001 (The Mazankowski Report) • Caring for Medicare: Sustaining a Quality System by the Commission on Medicare, Province of Saskatchewan, 2000–2001 (The Fyke Report) • Looking Back, Looking Forward: A Legacy Report from the Ontario Health Services Restructuring Commission, Province of Ontario, 1996–2000 • Emerging Solutions by the Commission d’étude sur les services de santé et les services sociaux, Province of Quebec, 2000 (The Clair Commission) • Health Renewal by the Premier’s Health Quality Council, Province of New Brunswick, 2000–2002
REFERENCES Armstrong, P., & Armstrong, H. (2001). The context for health care reform in Canada. In P. Armstrong, C. Amaratunga, J. Bernier, K. Grant, A. Pederson, & K. Willson (Eds.), Exposing privatization: Women and health care reform in Canada (pp. 11–48). Aurora: Garamond. British Columbia Ministry of Health and Ministry Responsible for Seniors. (1993). New directions for a healthy British Columbia. Victoria: Ministry of Health and Ministry Responsible for Seniors. British Columbia Ministry of Health and Ministry Responsible for Seniors. (1996). Better teamwork, better care: Putting services for patients first. Victoria: Ministry of Health and Ministry Responsible for Seniors.
CHAPTER 11: 12 Canadian Portraits ■ 161 British Columbia Ministry of Health Planning. (2001). A new era for patient-centred health care: Building a sustainable, accountable structure for delivery of high quality patient services. Victoria: Ministry of Health Planning. Ciliska, D., Ehrlich, A, & DeGuzman, A. (2005). Public health and primary care: Challenges and strategies for collaboration. Report prepared for the Capacity Review Committee, Ontario. Accessed July 16, 2006, from www.health.gov.on/ca/english/pub/ministry_reports/capacity_review06/ phealth_pcare.pdf. Donner, L., & Pederson, A. (2004). Women and primary health care reform: A discussion paper. Prepared for the National Workshop on Women and Primary Health Care, February 5–7, 2004, Winnipeg, Manitoba. Fooks, C., & Lewis, S. (2002). Romanow and beyond: A primer on health reform issues in Canada. Ottawa: Canadian Policy Research Networks. Frankish, J., Moulton, G., Rootman, I., Cole, C., & Gray, D. (2006). Setting a foundation: Underlying values and structures of health promotion in primary health care settings. Primary Health Care Research and Development, 7, 1–11. Health Canada. (2005). Primary health care transition: Fund summary of initiatives. Ottawa: Author. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Minister of Supply and Services. Moulton, G., Frankish, J., Rootman, I., Cole, C., & Gray, D. (2006). Building on a foundation: Strategies, processes, and outcomes of health promotion in primary health care settings. Primary Health Care Research and Development, 7, 1–9. Pinder, L. (1994). The federal role in health promotion: Art of the possible. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 92–106). Toronto: W.B. Saunders. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. World Health Organization. (WHO). (1999). Glossaire de la promotion de la santé. Division de la Promotion, de l’éducation et de la communication pour la santé. Service éducation sanitaire et promotion de la santé. WHO/HPR/HEP/98.1. 25 pages. World Health Organization. (2000). The world health report 2000. Health Systems: Improving Performance. Geneva: Author. Retrieved April 17, 2006, from http://www.who.int/whr/2000/en/ whr00_en.pdf. Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion developments in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.
Critical Thinking Questions 1. What are the factors that have contributed to the development or decline of health promotion in the provinces and territories of Canada? 2. What are some of the additional factors that might have been overlooked as a result of the process of preparing this chapter? 3. How does primary health care relate to health promotion in Canada? 4. What view of health and health promotion underpins most health promotion activity in the provinces and territories? 5. What do you think are the possible best next steps to improve the health of the minority language groups and other socially excluded groups in Canada?
P ROV I N C I A L A N D T E R R I TO R I A L CASE STUDIES
HEALTH PROMOTION IN BRITISH COLUMBIA: A WALKING CONTRADICTION Jim Frankish and Marcia Hills
Introduction From 1994–2006, health promotion in British Columbia remained a vibrant, growing field that continued to attract practitioners, researchers, and policy makers from many disciplines and backgrounds. Equally, health promotion remained marginalized in many government commitments, academic curricula, and health-services delivery. It was “a walking contradiction—partly truth and partly fiction” (Kristofferson, 1971). The truth lies in the hard work and commitment of the health promotion community. The fiction lies in the notion that BC (or Canada) is a world leader in the actual implementation of health promotion programs or policies and in reducing health disparities or inequities in quality of life among Canadians. BC witnessed major changes through health systems reform, strong growth in health promotion research and training, and the creation of new networks and partnerships in the past decade. There has been growing public and political awareness of the determinants of health. Sadly, however, BC continues to face significant health inequities, particularly between its rural and urban communities. There remain gaps in health status, access to health services, and health promotion/ 162
education resources among First Nations, the poor, and mainstream society. So far, the current BC Liberal government’s commitment to make BC a world leader in health promotion is largely an aspiration; however, this provides a great opportunity to follow this hopeful message with concrete investments in broadly based health promotion strategies and interventions. One recent sign of this renewed commitment is the BC Ministry of Health’s financial support of the Canadian Consortium for Health Promotion Research to host the 19th International Union for Health Promotion and Health Education World Conference in Vancouver in June 2007.
Provincial Health System Reform BC has undergone significant and repeated change with respect to health reform, particularly in terms of regionalization. In the early 1990s, the Seaton Commission (Seaton, 1991) called for the creation of over 100 regional health boards and community health councils, with subsequent transfer of responsibility by 1996. However, several reviews led to the creation of the current system of a province-wide Provincial Health Services Authority, five regional health authorities, and of the as yet unique Nisga’a health authority. Regionalization has been challenging for health promotion in terms of funding, practitioner base, mandate, and leadership.
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In the last reform, the provincial health officer used the Ottawa Charter (1986) as the basis for developing six comprehensive health goals defined as “broad statements of aims for the future” (British Columbia Ministry of Health and Ministry Responsible to Seniors, 1997). These goals were supported by objectives and indicators to measure progress, but implementation presented considerable challenges. It was noted that “moving from a high-level vision of health to concrete action and monitoring of results will require continued effort, coordination, and support” (MacPhail, 1999). Nearly 10 years later, it is still the case that BC’s health goals have been implemented at a philosophical level at best. The presence of designated health promotion practitioners remains highly variable. Large urban regions are more likely to have identifiable health promotion practices and designated staff and resources for health promotion. Smaller rural regions continue to lag in access to services and resources. Roles and responsibilities for undertaking health promotion have been ambiguous. At times, it appears that health promotion belongs to everyone and no one at the same time. Health promotion was caught in the economic doldrums that plagued BC throughout the 1990s and it faced fierce competition for funding. For example, only 2.6 percent of the province’s health budget was targeted toward public health initiatives (British Columbia Ministry of Health and Ministry Responsible to Seniors, 1999). Expenditures were directed toward medically oriented prevention and intervention measures. Few resources were allocated to the social, cultural, environmental, and economic determinants of health. Since the early 2000s, there has been an economic upsurge in BC, which has led to signs of renewed political interest and investment in public health, health promotion, and
population health initiatives. Regionalization has led to research and training at BC universities as well as intersectoral networks and partnerships with communities, schools, and non-governmental organizations. The province is undertaking new work on core services and public health renewal led by people favourable to health promotion, which holds the promise of raising both its profile and implementation over the coming years.
Research to Advance Knowledge and Practice Research in health promotion and population health has remained strong (despite significant challenges) in BC’s universities for two reasons. First are the dedicated efforts of the health promotion community. Second is the improvement in funding from both a federal and a provincial perspective. The Canadian Institutes of Health Research have been a major catalyst for research and training. The Michael Smith Foundation for Health Research (MSFHR), the province’s major health research funding agency established in 2001, has provided substantial funding for health promotion researchers, students, and networks. Representatives of the major universities completed many important initiatives, both collectively and as individual institutions, in the past decade. The BC Coalition for Health Promotion Research, comprised of members from Simon Fraser University (SFU), the University of British Columbia (UBC), the University of Victoria (UVic), and the Canadian Consortium for Health Promotion Research provided an initial foundation for many collaborative efforts. The Community Health Promotion Coalition at UVic experienced growth and change in its evolution to a Senate-approved Centre for Community Health Promotion Research. The centre
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hosted the Canadian Consortium for Health Promotion Research’s national health promotion conference and several summer schools. Researchers (M. Hills, I. Rootman, J. Mullett, and M. MacDonald) and students have focused on primary health care and public health renewal, health promotion effectiveness, Aboriginal peoples’ health, rural and remote health, and international health. The Institute of Health Promotion Research at UBC also experienced change with a new director (A. Yassi), who brought interest and research in workplace health promotion and global health while other researchers (J. Frankish and R. VanWynsberghe) expanded their research (and training) in health literacy, homelessness, and community health/sustainability. At SFU, the Gerontology Research Centre (G. Gutman and A. Wister) continued to provide leadership on health promotion and aging activities. Recent developments at SFU promise to change the face of health promotion in BC. These include the creation of a Faculty of Health Sciences, an Institute of Health Research and Education (2002), and a new Master’s degree in population health (2005). These events appear to have triggered a cascade of similar initiatives at other institutions (e.g., the likely creation of a new School of Public Health at UBC).
Partners in Community Health Research Training Program, which brings together academic and community mentors with academic and community learners. The partners include health authorities, teaching hospitals, and multiple academic institutions. Another example is the Canada–Europe International Health Promotion Advanced Learning Program led by the Centre for Community Health Promotion Research at the University of Victoria. At an organizational level, the capacity for health promotion initiatives has also grown. New universities have contributed to health promotion activities in diverse regions of the province. For example, researchers (A. Michalos, B. Zumbo, and A. Hubley) from the University of Northern BC in Prince George have done significant work on quality of life and health in northern communities. Provincial organizations have provided important leadership. For example, the BC Medical Association regularly provides health promotion awards. Key disease-related voluntary organizations focused on heart disease, arthritis, diabetes, and cancer continue to provide funding for research, training support, and community-based health promotion initiatives. Finally, recent years have witnessed a resurgence of the Public Health Association of BC.
Building Capacity for Health Promotion
Networks and Coalitions for Health Promotion
The capacity for health promotion activities in BC has changed over the past decade. At an individual level, there is strong evidence of a renewed interest in health promotion (and population health) from many quarters. At an interpersonal level, BC has also seen a proliferation of new networks and partnerships, many of which support health promotion initiatives. One training-related example is the
Organizations and individuals working together in networks and coalitions to achieve common goals have been a key feature of advancing health promotion in BC. The BC Health Promotion Coalition provided important initial leadership. In recent years, its members have taken part in multiple provincial networks. Examples include the BC Homelessness & Health Research Network
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and the BC Network for Health & Literacy Research. The Vancouver Foundation has also reconfigured its community research program and developed a stand-alone ethics review process. This process has been paralleled by the creation of similar communitybased, ethics review boards in First Nations across BC. The MSFHR has launched an ambitious program of support for research infrastructure and networks. Many of these efforts remain focused on areas such as biotechnology, human genomics, and the illness care system. Given current dominant funding and research practices, the overall impact of such initiatives on community health promotion remains to be determined, but at least some potential is there.
Political and Policy Processes Health promotion has been both supported and challenged by major political and policy processes. Successive BC governments have launched major efforts toward regionalization, public health renewal, and the creation of community health centres to provide primary health care. While these are positive steps, health promotion initiatives (and practitioners) have not received a significant increase in funding, resources, or training. More work remains to be done to integrate health promotion values and practices into the growing networks of primary care and multidisciplinary teams in the health system (see Chapter 17). Like other provinces and territories, BC has made some progress with respect to
health promotion–related policies. There has been a reduction in smoking based on higher taxes due to the efforts of public health coalitions, and the implementation of legislated smoking prohibitions in most public places. BC’s school system continues to be challenged in many areas, including nutrition and obesity, tobacco and substance use reduction, and physical activity. Recent efforts toward “Action Schools” and the planned legacies of the 2010 Vancouver/Whistler Olympic Games hold promise with respect to creating a more supportive environment and healthful public policies. Much work remains to be done in workplace health promotion, particularly in areas such as mental health promotion. Moreover, despite a four pillars approach (prevention, treatment, harm reduction, law enforcement), BC remains home to many of Canada’s poorest First Nations, and its poorest postal code in Vancouver’s downtown eastside area. Homelessness and health inequities are a growing concern in all areas of the province. In sum, the past decade (and more) of health promotion in British Columbia is perhaps best captured by the famous Dickens’s quote, “It was the best of times, it was the worst of times, it was a Winter of despair.” Given the continuing devotion and hard work of committed practitioners, researchers, and policy makers, however, and the possibilities of renewed resources and improving government and social commitments, there is reason to believe that health promotion in BC may be entering “a spring of hope.”
REFERENCES British Columbia Ministry of Health and Ministry Responsible to Seniors. (1997). Health goals for British Columbia. Victoria: Author. British Columbia Ministry of Health and Ministry Responsible to Seniors. (1999). Medical Services Commission Budget 1999/2000; an overview. Victoria: Author.
166 ■ PART III: Provincial Perspectives Dickens, C. (1962). A tale of two cities. London: Oxford University Press. Kristofferson, K. (1971). The pilgrim in the songs of Kris Kristofferson. Los Angeles: Chappell Music Company. MacPhail, H.J. (1999). Improving health care, helping small business create jobs. (Legislature Assembly, March 30, 1999). Victoria: British Columbia Minister of Finance and Corporate Relations, BC. Seaton, P. (1991). British Columbia Royal Commission on Health Care and Costs. Victoria: The Commission. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Author.
RELEVANT WEB SITES BC Coalition for Health Promotion www.vcn.bc.ca/bchpc
The BC Health Promotion Coalition is a diverse group working toward an enduring source of funding for health promotion activities inspired and implemented by communities in British Columbia. The BC Health Promotion Coalition envisions a fair and equitable process through which people at the grassroots level can more readily access funds to carry out the work that is important to them in improving their health and quality of life. Centre for Community Health Promotion Research web.uvic.ca/calendar2005/CAL/Rese/CfCoHPR.html
The Centre for Community Health Promotion Research at the University of Victoria is engaged in multidisciplinary research to investigate the complex interrelatedness of the broad determinants of health, their impact on health, and systemic changes required to promote health, particularly at the community level. Researchers at the centre direct their efforts at facilitating change within communities and health systems provincially, nationally, and internationally by linking policy, practice, and research. Gerontology Research Centre www.sfu.ca/grc
The Gerontology Research Centre (GRC) was established in 1982. The associated Department of Gerontology was established in 1983. Together, the GRC and the department serve as a focal point for research, education, and information on individual and population aging. The centre conducts research on individual and population aging with a focus on five theme areas: Aging and the Built Environment; Health Promotion/ Population Health and Aging; Changing Demography and Lifestyles; Prevention of Victimization and Exploitation of Older Persons; and Older Adult Education. Institute of Health Promotion Research www.ihpr.ubc.ca
Established within the Faculty of Graduate Studies in 1990, the Institute of Health Promotion Research (IHPR) provides a UBC focus for interdisciplinary collaboration on research, education, and community partnerships in health promotion.
CHAPTER 11: 12 Canadian Portraits ■ 167 Institute for Social Research & Evaluation http://web.unbc.ca/isre
A greater understanding of the social issues of central British Columbia is key to the continued growth and development of the Prince George region. The Institute for Social Research and Evaluation is a research institute located at the University of Northern British Columbia dedicated to examining these issues. Public Health Association of British Columbia www.phabc.org
The mission of the PHABC is to preserve and promote the public’s health through disease and injury prevention, health promotion, health protection, and healthy public policy.
HEALTH PROMOTION IN ALBERTA: MANY MILES TRAVELLED, MANY MILES TO GO Doug Wilson
Introduction Health promotion in Alberta has walked the talk for many miles since 1994, but has many miles to go. The historical context of health promotion in the province was well described previously (Kotani & Goldblatt, 1994). The past decade, however, has seen dramatic changes in the organization of health services, major increases in health promotion research and training, and the development of important provincial networks and coalitions.
Provincial Health System Reform In 1994–1995, Alberta became the first Canadian province to organize the delivery of all health services into geographic regions, each under a single board and budget—socalled regionalization of services. In this process over 100 hospital boards and 27 public health unit boards were abolished and the health system budget was significantly reduced. Today there are 9 health regions in Alberta (there were originally 17, but further
centralization consolidated them into 9), including two of the most populous regional delivery systems in Canada in Edmonton and Calgary, as well as large rural and remote northern regions. Health promotion practitioners and managers were also reorganized in this process and often given different responsibilities in the reformed health system; as a result, the visibility, capacity, and coordination of health promotion and public health across the province were significantly diminished. Nevertheless, certain positive changes have gradually followed from the establishment of integrated regional health delivery systems in Alberta (Casebeer, Scott, & Hannah, 2000). For example, the report of the Premier’s Advisory Council on Health began with the recommendation that “the first reform is to stay healthy” (Premier’s Advisory Council on Health for Alberta, 2001). Health promotion priorities, usually referred to in population health or chronic disease prevention terms, are now discussed at the same regional board table as acute care or continuing care issues (for an example, see Capital Health, 1999). Population-based funding for health regions provides an incentive to consider “upstream” health promotion and disease and injury prevention programs as a means of improving
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health and controlling long-term costs; however, the urgency of acute care issues such as waiting lists often overrides this good intention. The growing awareness in the health regions of gaps in evidence and lack of skilled personnel in health promotion have been associated with exciting initiatives in both research and training at Alberta universities.
Research to Advance Knowledge and Practice Research in health promotion and population health has flourished at Alberta universities, in part because of attractive personnel awards for a wide range of health researchers available through the Alberta Heritage Foundation for Medical Research (AHFMR) and the resulting increased success in securing federal research funds. The Health Promotion Research Group at the University of Calgary was an early contributor to the provincial and national scene, highlighted by their hosting of the Third National Conference on Health Promotion Research in 1994 and the release of a subsequent book of proceedings (Thurston, Sieppert, & Wiebe, 1998). In 2000, Penny Hawe took up a newly created research chair focusing on community-level interventions to promote health. She established a CIHR centre and Alan Markin, the donor of the chair funds, has given a further $15 million to develop an institute. The University of Lethbridge was also significantly involved in the development of health promotion research in Alberta when it was selected as one of six national Centres of Excellence for Health Promotion in 1993. The Regional Centre for Health Promotion and Community Studies was successfully led by Judith Kulig for six years, developed a number of community and academic partnerships, and focused its research on the important concept of community resiliency in rural communities (Walters, 1999).
At the University of Alberta in Edmonton, the six health science faculties shared their expertise and in 1995 launched the interdisciplinary Centre for Health Promotion Studies (CHPS) to provide new programs in research and graduate education (Wilson et al., 2000). Miriam Stewart, the founding director, built a significant research program on social support in vulnerable populations. Research at CHPS, now directed by Kim Raine, has focused on the social, cultural, and behavioural determinants of health in populations and the related policy issues, particularly regarding healthy eating and obesity, physical activity, and tobacco and substance use.
Building Capacity for Health Promotion When the master’s degree (MSc) program in health promotion studies was launched at the University of Alberta in 1996, there were clear indications of interest in the practice community. Time has certainly confirmed this impression; by June 2006 more than 150 students had completed the program. A comprehensive online graduate program is available and, as a result, 33 percent of students are from other Canadian provinces, and 7 percent are international. Graduates have had no difficulty in finding positions in health regions, government agencies, non-governmental organizations, and a wide range of other settings. At the University of Calgary’s Department of Community Health Sciences, some 120 graduate students have undertaken courses and research in health promotion. The new Bachelor of Health Sciences offers a health and society stream that introduces undergraduates to the foundations of health promotion. To build capacity in the health regions, the Swift Efficient Application of Research in Community Health (SEARCH) program was developed by AHFMR, together with the
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universities and regions, as a program and network to train community-based health professionals in applied health research. SEARCH Canada, an Alberta-based public service organization, is continuing to extend its scope, supporting the province-wide network of expertise that has developed and enhancing the use of evidence by health managers, providers, and their organizations.
Networks and Coalitions for Health Promotion Organizations and individuals working together in networks and coalitions to achieve common goals have been a key feature of advancing health promotion in Alberta. Since 1989, the Alberta Centre for Active Living (ACAL) has supported education, research, and networking to promote physical activity by linking practitioners, organizations, and communities. The centre is the Active Living Affiliate of the Canadian Health Network, a Web-based public health information resource for all Canada (see Chapter 3), and provides a dynamic Web site and newsletters for many thousands of individuals. In the mid-1990s there was recognition of the need for more effective collaboration among the organizations involved in health promotion in the province, and out of these discussions the Alberta Consortium for Health Promotion Research and Education was formed with important support from the (then) Health Promotion and Programs Branch (Alberta/NWT Region) of Health Canada. Members included the three university units mentioned previously (RCHPCS, HPRG, CHPS), ACAL, the Alberta Cancer Board, the Nechi Institute for Training, Research and Health Promotion, and two health regions. Although the Consortium has now lapsed, considerable trust and mutual understanding was developed through these
interactions; two more tangible products were an Aboriginal health promotion summer school and an evaluation framework that was used to assess provincial health promotion projects (Thurston et al., 2003). Since 2002, the Alberta Healthy Living Network (AHLN), with support from Alberta Health & Wellness, has emerged as a major provincial initiative aimed at providing leadership for integrated collaborative action to promote health and prevent chronic disease. Over 100 organizations are involved in implementing seven strategies focusing initially on multi-level, integrated actions to support healthy eating, active living, and tobacco reduction. The AHLN has been recognized by WHO as a demonstration project for the Country-wide Noncommunicable Disease Initiative (CINDI). More recently, the Alberta Social and Health Equities Network (ASHEN), supported by the Alberta Public Health Association, has been formed to bring together organizations and community groups to address growing income inequality in Alberta and its effects. The Alberta Coalition for Healthy School Communities (ACHSC) draws together another set of partners focusing on schools as a setting for health promotion. In terms of reorienting the health system, the Alberta Primary Care Initiative is supporting the development of primary care networks, consisting of large groups of family physicians working in multidisciplinary teams with other health providers and utilizing electronic health records to deliver more integrated and comprehensive services that include individual-level health promotion and prevention. At the policy level, progress has been made in tobacco reduction based on higher taxes, the efforts of coalitions, and effective leaders; many municipalities now have regulations prohibiting smoking in all public
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places, although provincial legislation is less stringent. The sustained efforts of the Alberta Centre for Injury Control and Research have been associated with useful policy advances to promote safety. Within the school system, quality daily physical activity has been introduced as a requirement and soft drink machines are being removed in many districts. In summary, health promotion continues to be active in Alberta, as evident from the strong research and training programs, effective networks and coalitions, and successful regulatory efforts. Nevertheless, health pro-
motion remains marginal in the health system itself, and progress in addressing poverty and the social determinants of health has been slow, and in this rich province, more attention at the policy level to health inequities is needed.
Acknowledgements The author wishes to thank colleagues from many of the organizations involved with health promotion in Alberta for their invaluable assistance in the preparation of this manuscript.
REFERENCES Capital Health. (1999). Population health framework for the Capital Health Region. Edmonton: Author. Casebeer, A., Scott, C., & Hannah, K. (2000). Transforming a health care system: Managing change for community gain. Canadian Journal of Public Health, 91(2), 89–93. Kotani, N., & Goldblatt, A. (1994). Alberta: A haven for health promotion. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 166–177). Toronto: W.B. Saunders. Premier’s Advisory Council on Health for Alberta. (2001). A framework for reform report of the Premier’s Advisory Council on Health. Edmonton: Author. Thurston, W.E., Sieppert, J., & Wiebe, V. (1998). Doing health promotion research: The science of action. Calgary: Health Promotion Research Group, University of Calgary. Thurston, W.E., Vollmann, A.R., Wilson, D.R., MacKean, G., Felix, R., & Wright, M.-F. (2003). Development and testing of a framework for assessing the effectiveness of health promotion. Social and Preventive Medicine, 48(5), 301–316. Walters, M. (1999). Six years that made a difference: The Regional Centre for Health Promotion and Community Studies. Lethbridge: University of Lethbridge. Wilson, D., Glassford, R.G., Krupa, E., Masuda, J., Wild, C., Plotnikoff, R., et al. (2000). Health promotion practice, research, and policy: Building capacity through the development of an interdisciplinary study centre and graduate program in Alberta, Canada. Health Promotion & Education, 7(1), 44–47.
RELEVANT WEB SITES Alberta Centre for Active Living www.centre4activeliving.ca
The Alberta Centre for Active Living works with practitioners, organizations, and communities to improve the health and quality of life people living in Alberta through physical activity.
CHAPTER 11: 12 Canadian Portraits ■ 171 Alberta Coalition for Healthy School Communities www.achsc.org
The mission of the Alberta Coalition for Healthy School Communities is to support a comprehensive school health approach that enhances the health of Alberta children and youth. Alberta Healthy Living Network www.ahln.ca
The mission of the Alberta Healthy Living Network is to provide leadership for collaborative action to promote health and prevent chronic disease in Alberta. Alberta Public Health Association www.apha.ab.ca
The Alberta Public Health Association is a provincial not-for-profit association that strengthens the impact of those who promote and protect the health of the public by speaking out for health, advocating on issues that affect health, and facilitating educational and networking opportunities. Centre for Health Promotion Studies www.chps.ualberta.ca
The Centre for Health Promotion Studies offers interdisciplinary graduate education that prepares graduates with the knowledge and skills needed to successfully engage in health promotion activities; conducts and fosters interdisciplinary health promotion research in collaboration with other Alberta and national stakeholders; and participates in communication, networking, and community outreach activities that foster health promotion practice and policy development.
HEALTH PROMOTION IN SASKATCHEWAN: THREE DEVELOPING APPROACHES Lewis Williams
Introduction The advancement of health promotion in Saskatchewan over the past 12 years or so is framed by two major developments: (1) the grounding of policy, practice, and research in a health determinants approach and; (2) the emergence of Aboriginal approaches to health promotion that are distinctly indigenous. The first is predominantly grounded in Western world views and assumptions, is often practised out of biomedically orientated
institutions, and addresses a range of health determinants of which “culture” is one. Emerging Aboriginal approaches, on the other hand, take Aboriginal, identity, culture, and world view as their starting point from which all other thoughts and actions (including those that address underlying health determinants) follow. That these two approaches should frame health promotion developments in this province is hardly surprising given its large and rapidly growing Aboriginal populations, who are increasingly asserting their right to self-determination in ways that are culturally relevant (Government of Saskatchewan, 2001) A further third entity that somewhat bridges both approaches and has a developmental
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trajectory in its own right is the “Northern Way.” This constitutes a set of beliefs, attitudes, and approaches to health promotion adopted by Saskatchewan’s northern, rural, and largely Aboriginal communities in response to resource shortages, their isolation, and perceived marginalization from decisionmaking institutions. While governments may come and go, it is these three entities that continue to give shape and meaning to population health promotion in Saskatchewan, albeit within a legacy of colonial relations.
Changing Focus to the Determinants of Health The landscape of mainstream population health promotion has seen some radical transformations, particularly where policy is concerned. The previous emphasis on behaviour change and healthier lifestyles—which dominated health-related discourse, policy, and practice throughout the 1970s—has largely been replaced, at least at official levels, by socalled upstream approaches focused on addressing underlying health determinants. Federal initiatives playing critical roles in these developments include Hamilton and Bhatti’s integrated model of population health promotion (1996) and the report of the Commission on the Future of Health Care in Canada (Romanow, 2001). Hamilton and Bhatti’s report provided a comprehensive conceptual framework on which to base provincial activities and the Romanow Report endorsed health promotion approaches within primary health care. Key actors partially responsible for actualizing this transformation have included a range of government, university, and community-based organizations. Many of these players galvanized their efforts through the formation of the Saskatchewan Population Health Promotion Partnership (SPHPP) in
1996. This intersectoral and strategic alliance has methodically and persistently introduced a number of successive initiatives that have proved formative for health promotion throughout the province. Quite quickly after its inception, for example, this group coordinated the development of a conceptual framework to guide the population health promotion work of Regional Health Authorities (Saskatchewan Health, 1999), produced a strategic plan of action, and worked to embed the ideas behind such conceptual initiatives in the thinking and practice of the province’s health promotion constituency. Much of this was achieved through Health Promotion Summer schools (Feather, 2003; Prairie Region Health Promotion Research Centre, 1999, 2000; Williams et al., 2005), satellite training events initiated by Saskatchewan Health, and evaluation research aimed at practitioner and organizational health promotion capacity building, through the Saskatchewan Heart Health Project 1998–2003 (Mclean, Feather, & Butler-Jones, 2005). These efforts set the stage for the introduction of the Provincial Population Health Strategy (Saskatchewan Health, 2004), which is proving to be a watershed for the province—never before has health promotion held such authority in official policy, nor have regional health authorities been required to develop population health promotion strategies and embed health promotion approaches into their programs as they are today. This most recent drive by long-time provincial health promotion proponents has been paralleled by movement within the primary care sector to incorporate health promotion-based frameworks and strategies into and alongside its traditional treatment-based programs (Fyke, 2001; Saskatchewan Health, 2001). This has inevitably led to tensions and turf battles as stakeholders at the provincial
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government and regional health authority levels grapple with the concepts and what their articulation within various programs might look like.
Aboriginal Approaches to Health Promotion The second major and far more recent developmental trajectory in Saskatchewan has been the assertion by Aboriginal communities of the value of their traditional knowledge systems and the right to apply these within contemporary contexts, including the domains of primary health care and health promotion. These are very much grassroots-initiated projects in which communities are working with groups such as the Saskatchewan Population Health and Evaluation Research Unit, the Prairie Region Health Promotion Research Centre (PRHPRC), health regions, and the Indigenous Peoples Health Research Centre. One example is work with Sturgeon Lake First Nation to articulate Cree concepts of well-being and to advocate for their inculcation into health policy and practice frameworks (Williams, 2005). Another is research with northern communities to develop culturally specific community indicators (Abonyi & Jeffrey, 2006). At the health region level, the Regina Qu’Appelle Health Region has explored partnership formation among Aboriginal agencies and government departments to improve health outcomes for First Nations and Métis people. The Working Together Towards Excellence (WTTE) project report laid the groundwork for intergovernmental partnerships, proposed collaboration on stakeholder priorities, and addressed challenges that typically occur within such partnerships (Regina Qu’Appelle Health Region, 2002). As a result of WTTE, the organizational capacity and relationships are now developing through the
new First Nations and Métis Health Office in the region. At the community level, the Four Directions Community Health Centre in Regina has promoted disease-risk knowledge and healthy choices by organizing events and projects such as neighbourhood forums, modified round dances, and traditional feasts. These initiatives involved working collaboratively with community volunteers, expert cultural “knowledge keepers,” staff of community-based and government agencies, and elders. The events yield significant multi-level benefits, such as cultural affirmation and learning, ease of and community engagement, co-operation among various agencies, and the potential of social reinforcement for healthy behaviour messages (Kotowich, 2000). A conceptually significant piece of work that has bolstered understanding in indigenous health promotion is the development of the idea of “ethical space” (Ermine, 2000; Ermine, Sinclair, & Jeffery, 2004). This refers to the need for space to be envisioned between indigenous and Western knowledge systems, in which each world view is formed and guided by distinct histories, knowledge traditions, values, interests, and social, economic, and political realities. This work is important as the act of teasing apart these knowledge systems makes apparent the dominance of Western concepts pertaining to health and essentially promises to democratize and make more conscious the practice of health promotion in Saskatchewan. While such developments may not yet have official currency within mainstream health promotion, they promise to be very significant for the field, as has the articulation of indigenous specific models of health promotion proven to be in other countries already.
A Third, Northern Way The tenacious and unique approaches to health promotion adopted by Saskatchewan’s
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northern communities have also played a significant role in advancing and informing its development. As a diverse range of Aboriginal communities with unique needs, they are challengingly positioned in the “in between” space of being the unrecognized “other” where culture, geography, and way of life are concerned. Perhaps two defining characteristics of the “Northern Way” are its historical emphasis on community action and community-defined models of health, and its record of extensive and successful interorganizational collaboration and grappling with the cross-jurisdictional issues that continue to besiege the North (Brown, 2005). A current example is the Northern Healthy Communities Partnership formed between the Northern Regional Health Authorities of Keewatin Yatthe, the Mamawetan Churchill River, and the Athabasca Health Authority to produce a North-wide Population Health Promotion Plan.1 Facing challenges of vast geography, high-needs populations, and prohibitive travel costs, working together across differences is the most feasible way to be successful across these three health authorities.
Conclusion The development of health promotion in Saskatchewan continues to be laced with a number of intersecting cleavages that characterize this era of post-colonial relations. The South has undoubtedly been instrumental in championing and heralding an era of intersectoral action and of addressing underlying structural causes of well-being; these are now, at least in theory, a legitimate part of the health care system’s mandate. We can also expect the “Northern Way” to remain a predominant force in health promotion, both as a response to the area’s unique challenges and in answer to mainstream, southern-initiated policies where the province’s bureaucrats live and work. We will also undoubtedly see the proliferation of Aboriginal-based approaches that will prove to be informative in shaping health promotion discourse, policy, and practice. In particular, in our view, it is these changes that are likely to shape and push the theoretical frontiers of health promotion more generally—both within and beyond Saskatchewan.
NOTE 1
Between them these three regional health authorities cover the northern half of Saskatchewan, while health care services for the southern and more populous half of the province is provided by a further nine regional health authorities.
REFERENCES Abonyi, S., & Jeffery, B. (2006). Developing a community health toolkit with Indigenous health organizations. CIHR-IPPH and CPHI Knowledge Translation Casebook. Ottawa: Canadian Institutes of Health Research. Brown, S. (2005). Evaluating community and organizational transition to enhance the health status of residents of northern Saskatchewan. Interim Evaluation Report to the Northern Health Strategy Working Group. Regina: Saskatchewan Population Health and Evaluation Research Unit, University of Regina. Ermine, W. (2000). A critical examination of the ethics in research involving indigenous peoples. Unpublished Master’s thesis, University of Saskatchewan, Saskatoon, Saskatchewan.
CHAPTER 11: 12 Canadian Portraits ■ 175 Ermine, W., Sinclair, R., & Jeffery, B. (2004). The ethics of research involving indigenous peoples. Report of the Indigenous Peoples’ Health Research Centre to the Interagency Advisory Panel on Research Ethics. Saskatoon: Indigenous Peoples’ Health Research Centre. Feather, J. (2003). Summer school 2002: Working for change in the community and in organizations, Evaluation Report. Saskatoon: Prairie Region Health Promotion Research Centre. Fyke, K. (2001). Caring for medicare: Sustaining a quality system. Regina: Commission on Medicare. Saskatchewan Health. Government of Saskatchewan. (2001). Aboriginal identity: Canada, provinces and territories. Retrieved January 31, 2006, from www.stats.gov.sk.ca/census/aboriginal1.pdf. Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of population health and health promotion. Ottawa: Health Promotion Development Division, Health Canada. Kotowich, R. (2000). Community development coordinator year 2000 fact sheet. Regina: Four Directions Community Health Centre. McLean, S., Feather, J., & Butler-Jones, D. (2005). Building health promotion capacity: Action for learning, learning for action. Vancouver: University of British Columbia Press. Prairie Region Health Promotion Research Centre. (1999). Highlights from summer school 1999. Retrieved January 31, 2006, from www.usask.ca/healthsci/che/prhprc/programs/ss99hilites.html. Prairie Region Health Promotion Research Centre. (2000). Highlights from summer school 2000. Retrieved January 31, 2006, from www.usask.ca/healthsci/che/prhprc/programs/ss00hilites.html. Prairie Region Health Promotion Research Centre. (2003). Summer school 2002: Working for change in the community and in organizations. Evaluation report. Saskatoon: Author. Regina Qu’Appelle Health Region. (2002). Improving First Nations and Métis health outcomes: A call to collaborative action: A report of the “Working Together Towards Excellence Project.” Regina: Author. Romanow, R. (2001). Building on values: The future of health care in Canada (Commission on the Future of Health Care in Canada). Ottawa: Government of Canada. Saskatchewan Health. (1999). A population health promotion framework for Saskatchewan regional health authorities. Regina: Author. Saskatchewan Health. (2001). The action plan for Saskatchewan health care. Regina: Author. Saskatchewan Health. (2004). Healthier places to live, work, and play … a population health promotion strategy for Saskatchewan. Regina: Author. Williams, L. (2005). Healthcare policies, knowledge systems, and approaches to mental well-being in Saskatchewan: A Cree perspective. Funding proposal to the Saskatchewan Health Research foundation. Williams, L., Peterson, T., Graham, N., & Wagner, J. (2005). Evaluation report of summer school 2005: Mental health promotion identity, culture, and power. Saskatoon: Prairie Region Health Promotion Research Centre.
RELEVANT WEB SITES Prairie Region Health Promotion Research Centre www.usask.ca/healthsci/che/prhprc/programs/index.html
The Prairie Region Health Promotion Research Centre was established in 1993 in the College of Medicine, University of Saskatchewan, for the purpose of strengthening population health promotion through fostering research into ways of promoting health. The centre is active in establishing links between organizations, practitioners, researchers, and policy makers; disseminating research findings; and working
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through partnerships to offer training in health promotion practice and research. The centre pays particular attention to northern and Aboriginal health and health promotion issues. Regina Qu’Appelle Health Region www.rqhealth.ca/
The Regina Qu’Appelle Health Region is the largest health care delivery system in southern Saskatchewan. It offers a full range of hospital, rehabilitation, community and public health, long-term care, and home care services to meet the needs of more than 245,000 residents living in 120 cities, towns, villages, rural municipalities, and 18 First Nation communities within the region. Saskatchewan Health, Publications www.health.gov.sk.ca/mc_publications.html
This site includes a series of publications related to the Action Plan for Saskatchewan Health Care, including the Population Health Promotion Strategy for Saskatchewan and action plans on workplace health, mental health and well-being, and substance use/abuse, as well as a plan for people with cognitive disabilities. Saskatchewan Population Health and Evaluation Research Unit www.spheru.ca/www/html/Home/home.htm
SPHERU conducts research into the social and environmental determinants of population health under two broad categories: (1) research on health-determining conditions, the relationships within and between these conditions, and the policy and programmatic implications; and (2) evaluation studies of policy and programmatic interventions to make social and environmental conditions more health-promoting, and more equitable in their allocation of health risks and opportunities across different population groups.
HEALTH PROMOTION IN MANITOB A: PARTNERING FOR ACTION Fran Racher and Robert C.Annis
Introduction Health promotion has advanced in Manitoba since the first edition of this book and English’s (1994) historical overview and discussion. Partners for Health: A New Direction for the Promotion of Health in Manitoba, released by
Manitoba Health in 1989, set the stage for continued development with its focus to develop partnerships between the province and communities (Manitoba Health, 1989). Recent activities now move even further beyond the traditional focus of the health care system and, in keeping with an understanding of the determinants of health, involve many other sectors beyond health that have substantial impact on the health and well-being of individuals, families, and communities.
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Demographics of Manitoba Programs, research, and policy development, whether related to health and health services or the broader determinants of health, are influenced by the distribution of the population across the vast and varied geography of the province. Manitoba, centrally located and the most easterly of the three prairie provinces, is the sixth-largest province in Canada, with the fifth-largest population (1,169,667) in 2004. Winnipeg (650,850), Brandon (43,725), and Thompson (14,215) are the three largest cities (Manitoba Health, 2005). Southern Manitoba is primarily agriculture-based with numerous small communities dispersed across the prairie landscape.
Health System Reform Manitoba Health (1992) claimed that its mission was to promote, preserve, and protect the health of Manitobans and its vision was reflected in a set of goals to achieve this outcome. However, its action was more clearly
identified in the title of the document, Quality of Health for Manitobans, the Action Plan: A Strategy to Assure Manitoba’s Health Services System. In 1997, Manitoba Health (1997) released a new policy document, which indicated a significant shift in priorities and ways of thinking about health, healthy public policy, and community participation. Figure 11.1 illustrates the new framework. Manitoba Health identified the need to: move from a focus on health services to a focus on health and the broad determinants of health; employ an intersectoral approach beyond the health field; change the current illness care system to a health system; transform reliance on government to partnership with community; progress from short-term action to investment in health promotion and disease prevention; and shift from a service provider-driven system to focus on health outcomes using evidence-based research. This philosophy led the way in the development of renewed partnerships across government sectors, and inclusive of organizations and communities.
FIGURE: 11.1: A FRAMEWORK TO PROMOTE, PRESERVE, AND PROTECT THE HEALTH OF ALL MANITOBANS
Image not available
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Health Promotion beyond the Health System Interestingly, the Manitoba government has adopted a community development lens for policy and program development. From the government’s perspective, community development is a community-led process combining social and economic development to foster the economic, social, environmental, and cultural well-being of communities (Manitoba Intergovernmental Affairs and Trade, 2000). As a policy lens, these ideas must come to bear on program development and implementation in any and all sectors of government activity. This lens has, in turn, assisted in the development of several new programs that further facilitate health promotion and community development within and beyond the health system. Healthy Child Manitoba (HCM) is the Manitoba government’s long-term, crossdepartmental strategy to support healthy child and adolescent development. By focusing on a child-centred public policy that places the best interests of children and youth first and using its community development lens, HCM involves seven provincial departments with numerous community organizations that put knowledge into action to achieve “the best possible outcomes for Manitoba’s children” (Healthy Child Committee of Cabinet, 2002). Healthy Baby, Families First, and Healthy Schools are notable components of HCM. Another excellent example of health promotion beyond the health system, Neighbourhoods Alive! (NA!), was launched by the Manitoba government in June 2000. This multi-department initiative, using community development principles to support and encourage community-driven revitalization efforts, focuses on urban neighbourhoods within Brandon, Thompson, and Winnipeg. Through NA! the Manitoba government has committed over $26.5 million
for revitalization activities; $16.6 million to support almost 400 community projects; and $9.9 million to the repair, rehabilitation, or construction of over 1,700 housing units (Manitoba 2000, 2002, 2005). To mark the five-year anniversary of NA! in 2005, Premier Doer announced that core funding would be renewed for an additional five years. A third example of extended partnerships for health promotion can be found in Manitoba’s new Chronic Disease Prevention Initiative (CDPI), which aims to improve the health of Manitobans through a focus on primary prevention of modifiable risk factors for non-communicable chronic diseases using a population health approach (Chronic Disease Prevention Initiative, 2005). The CDPI is a five-year community-focused initiative that builds on a comprehensive, integrated approach emphasizing local community partnerships, citizen engagement and community development, and evidence-based planning to generate supportive environments. Manitoba Health and the Public Health Agency of Canada are funding partners, while regional health authorities of Manitoba, the Northern and Aboriginal Population Health and Wellness Institute, and the Alliance for the Prevention of Chronic Disease are operational partners (Assiniboine Regional Health Authority, 2005; Chronic Disease Prevention Initiative, 2005). These multisectoral, multi-jurisdictional initiatives are also evidenced in Manitoba’s Non-Smokers Health Protection Act, which came into effect October 1, 2004. Following city bylaws in Brandon and Winnipeg, the Manitoba All-Party Task Force on Environmental Tobacco Smoke (2003) recommended legislation that was implemented, calling for a complete ban of smoking in all enclosed public and indoor workplaces where the provincial government had clear jurisdiction.
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Changes, Challenges, and Future Directions Over the past 12 years, cross-sectoral and crossdepartmental work has increased in Manitoba. Communities are becoming more creative, energized, action-focused, and responsible for promoting health at a community level and undertaking community development. Organizations and communities are moving from an education focus to an action focus and action is more often based on evidence designed to support decision making and planning. For example, A Snapshot of Early Child Development in Manitoba (Healthy Child Manitoba, 2003) and Injuries in Manitoba: A 10-Year Review (Manitoba Health, 2004) each offered important information for planning. The Manitoba Centre for Health Policy (2006) has developed many reports that examine patterns of illness in the population, and depict health care utilization. The Rural Development Institute of Brandon University has recently published Rural Community Health and Well-being: A Guide to Action, which outlines a framework, process, and tools to assist rural communities in assessing and taking action regarding community health and sustainability (Annis, Racher, & Beattie, 2005). Regional health authorities are developing positions designed to support planning and decision making, to facilitate knowledge translation and application of existing studies, and to undertake research and generate local data for planning purposes.
Conclusion In summary, the Manitoba government is demonstrating leadership in health promo-
tion at the community level. Manitoba Health and the RHAs are partnering with multiple and varied sectors from across government ministries. All-party task forces, cross-cutting committees of Cabinet, and horizontal departmental planning sculpt new types of partnerships. Although health promotion is seen by many to be the purview of the health ministries, other departments not only partner with health, but also take leadership roles in new community development initiatives. While for Manitobans committed to health promotion there is much to celebrate, much also remains to be done. Manitoba’s health system remains largely a system of illness care with little improvement in the portion of the health budget allocated to public health or health promotion. Moreover, when funding is allocated, it is frequently insufficient to sustain projects and programs over the longer term. Northern Manitoba’s residents in particular continue to face huge difficulties in gaining access not just to health services, but also to education, employment, stable incomes, housing, clean water, and waste management. Distance and geography continue to be a challenge. Neighbourhoods Alive!, with its community development lens, has been effective, but has been restricted to three urban centres. Rural and northern residents, who understand the problems and have much to contribute to developing the solutions, still need to be even more engaged in decision making and planning. Ultimately, all people—whether they reside in urban, rural, or northern regions—must plan and work together to promote, preserve, and protect the health of all Manitobans and the wellbeing of the communities in which they live.
Acknowledgements The authors wish to express their sincere thanks to the many individuals who discussed Manitoba’s progress with us and steered us to many important initiatives across the province,
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often beyond the scope of this chapter. Their commitment to health promotion has helped shape policy and practice in Manitoba, which ultimately benefits the health of its residents and communities.
REFERENCES All Party Task Force on Environmental Tobacco Smoke. (2003). Environmental tobacco smoke: What Manitobans said. Winnipeg: Manitoba Government. Retrieved March 10, 2006, from www.gov.mb.ca/health/documents/tobacco/report.pdf. Annis, R., Racher, F., & Beattie, M. (2005). Rural community health and well-being: A guide to action. Brandon: Rural Development Institute, Brandon University Press. Retrieved March 10, 2006, from www.brandonu.ca/rdi/Publications/guidebook.pdf. Assiniboine Regional Health Authority. (2005). Assiniboine Regional Health Authority chronic disease prevention initiative. Retrieved January 14, 2006, from www.assiniboine-rha.ca/newsletters/ FACT%20SHEET.pdf. Chronic Disease Prevention Initiative. (2005). Chronic Disease Prevention Initiative Project charter. Unpublished final draft document. English, J. (1994). Health promotion in Manitoba. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 195–205). Toronto: W.B. Saunders. Healthy Child Committee of Cabinet. (2002). Healthy Child Manitoba: Programs and services. Winnipeg: Manitoba Government. Retrieved January 14, 2006 from www.gov.mb.ca/healthychild/about/ index.html. Healthy Child Manitoba. (2003). A snapshot of early child development in Manitoba. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/healthychild/ecd/edi2003.pdf. Manitoba. (2000). Neighbourhoods Alive! Program launched by Manitoba Government. Retrieved January 14, 2006, from www.gov.mb.ca/chc/press/top/2000/06/2000-06-28-01.html. Manitoba. (2002). Using CED principles to build strong neighbourhoods. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/ia/programs/neighbourhoods/news/documents/forum2.pdf. Manitoba. (2005). Province celebrates and expands successful Neighbourhoods Alive initiative. Retrieved January 14, 2006, from www.gov.mb.ca/chc/press/top/2005/06/2005-06-08-02.html. Manitoba Centre for Health Policy. (2006). What does the MCHP do? Retrieved January 14, 2006, from www.umanitoba.ca/centres/mchp/whomchp.htm#b. Manitoba Health. (1989). Partners for health: A new direction for the promotion of health in Manitoba. Winnipeg: Author. Manitoba Health. (1992). Quality of health for Manitobans the action plan: A strategy to assure Manitoba’s health services system. Winnipeg: Author. Manitoba Health. (1997). A planning framework to promote, preserve, and protect the health of Manitobans. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/health/rha/planning.pdf. Manitoba Health. (2004). Injuries in Manitoba: A 10-year review. Winnipeg: Author. Retrieved July 21, 2006, from www.gov.mb.ca/healthyliving/injuryreview.html. Manitoba Health. (2005). Manitoba population report, June 1, 2004. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/health/population/2004/pop2004.pdf. Manitoba Intergovernmental Affairs and Trade. (2000). Neighbourhoods Alive! Neighbourhood toolbox:
CHAPTER 11: 12 Canadian Portraits ■ 181 Guide to community economic development. Retrieved January 13, 2006, from www.gov.mb.ca/ia/ programs/neighbourhoods/toolbox/ced.html.
RELEVANT WEB SITES Neighbourhoods Alive! www.gov.mb.ca/ia/programs/neighbourhoods/
Neighbourhoods Alive! is a long-term, community-based social and economic development strategy that recognizes that building healthy neighbourhoods requires more than an investment in bricks and mortar. The Manitoba government created Neighbourhoods Alive! to provide community organizations in designated neighbourhoods with the support they need to rebuild these neighbourhoods. Rural Development Institute, Brandon University www.brandonu.ca/organizations/RDI/index.asp
Rural populations face considerable challenges in today’s rapidly changing society. Restructuring in agriculture and industry, plus fiscal restraint and shifts in rural and northern demographics, are leading to a re-examination of the roles of governments, communities, and individuals. Brandon University’s Rural Development Institute (RDI) is a centre for excellence in rural development helping to strengthen rural and northern communities through research and information on issues unique to rural areas.
HEALTH PROMOTION IN ONTARIO: SURVIVAL THROUGH C APACITY BUILDING Brian Hyndman
Introduction During the years following the release of the Ottawa Charter (1986), the field of health promotion underwent a period of significant growth in Ontario. Key developments included the establishment of a provincial Health Promotion Branch to coordinate health promotion initiatives within the Ontario Ministry of Health; the launch of the Toronto Healthy City Office, which provided the opportunity to apply the principles of community organization and advocacy to community health priorities; and the creation
of the Premier’s Council on Health Strategy (later renamed the Premier’s Council on Health, Well-being, and Social Justice), a progressive health and social policy think tank that advanced health promotion concepts into the mainstream of government policy making. In their summation of the progress achieved during this period, Pederson and Signal (1994, p. 244) identified “a broad view of health and its determinants” as “the major accomplishment of the health promotion movement in Ontario to date.” But by 1994 this “broad view of health and its determinants” faced a number of challenges. The provincial New Democratic government, which had been instrumental in supporting the social change movements that gave rise to a more holistic view of health, was deeply unpopular due to a prolonged
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economic recession and fiscal restraint policies that alienated its core supporters. At the federal level, the shift from health promotion toward population health challenged health promoters to integrate their work into a new paradigm. This was also a period marked by growing cost containment by all levels of government, which placed increased demands on health promotion to demonstrate accountability and prove the “effectiveness” of its initiatives (O’Neill, Pederson, & Rootman, 2000).
Politics and Policy The climate of fiscal restraint hampering the growth of health promotion reached its apex in June 1995 with the election of a Progressive Conservative government that swept into power with the so-called “Common Sense Revolution,” a neo-liberal platform combining steep tax cuts with corresponding decreases in government spending. Somewhat ironically, health promotion’s placement within a larger provincial ministry encompassing the “sickness care” system meant that it did not suffer from the same magnitude of cutbacks that befell other sectors, since health care, along with in-class education and law enforcement, were earmarked as exempt from spending cuts by the new government. However, health promotion was by no means immune to the government’s cost-cutting agenda. In September 1995, the Premier’s Council was disbanded along with the Healthy Community Grants Program, which had provided seed funding for communitybased health promotion projects. The health promotion programs maintained by the province, such as the Ontario Heart Health Program, were more narrowly focused on disease prevention and the promotion of healthy lifestyles. In 1997 the province eliminated the Health Promotion Branch; its
replacement with a “health promotion and wellness” division within the Public Health Branch, the arm of the ministry overseeing the operation of the province’s public health units, signalled a discernable downgrading of health promotion as a vehicle for achieving provincial health priorities.
Networking and Capacity Building Beginning in the 1990s, health promotion in Ontario focused extensively on creating an infrastructure for networking and capacity building. In June 1994, the Centre for Health Promotion at the University of Toronto launched the first Health Promotion Summer School, a continuing education event devoted to sharing and building the health promotion knowledge and skill base. Since that time, the yearly summer school has evolved into the leading educational and training event for health promoters in Ontario. Health promoters in Ontario also capitalized on the increasing use of electronic communication with the introduction of two major networking and capacity-building initiatives. In 1996, York University and the Ontario Prevention Clearinghouse, a health promotion resource centre funded by the province, launched Click4HP, a non-moderated public listserv that provides a venue for international dialogue on the state of health promotion. The following year marked the launch of the Ontario Health Promotion E-Bulletin, a weekly electronic newsletter focusing on health promotion developments in Ontario. The infrastructure for health promotion capacity building in Ontario was further strengthened with the creation of the Ontario Health Promotion Resource System, a network of issue and skill-based resource centres providing training and information to health promotion practitioners in the field.
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The considerable growth in health promotion networking and capacity building at a time when both the political and programmatic base of health promotion in Ontario appeared to be shrinking is a noteworthy phenomenon that has yet to be fully analyzed. One could argue that this trend represented an inward-looking, “preaching to the choir” reaction when health promotion’s core values of equity, social justice, and empowerment were under attack. Conversely, one could argue that the emphasis on capacity building and networking was critical for sustaining health promotion discourse in the absence of a clearly articulated vision for heath promotion by the Ontario and federal governments during much of the 1990s.
Public Health Crises During the opening decade of the 21st century, Ontario was hit with a series of crises that revealed the erosion of public health services following years of cutbacks and underfunding. Events such as the contaminated water crisis in Walkerton in 2000, and the sale of tainted meat in Aylmer, Ontario, in 2003 and outbreak of Severe Acute Respiratory
Syndrome (SARS) in Toronto the same year demonstrated that concerns about the systemic neglect of essential services could not, contrary to prevailing government ideology, be dismissed as self-serving advocacy from so-called “interest groups.” Increased awareness of the inadequacy of public health services was a not insignificant factor contributing to the defeat of the Progressive Conservative government in the 2003 Ontario election.
Conclusion The focus on public health renewal in the wake of these crises offers uncertain implications for the future of health promotion in Ontario. Will developments such as the creation of the federal Public Health Agency of Canada and a new Ministry of Health Promotion by the Ontario government herald an era of new opportunities for health promoters in Ontario? Or will the current preoccupation with pandemic planning result in an erosion of health promotion in an effort to shore up the traditional health protection/communicable disease control functions of public health? The answers to these questions remain to be seen.
REFERENCES O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Pederson, A., & Signal, L. (1994). The health promotion movement in Ontario: Mobilizing to broaden the definition of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and territorial perspectives (pp. 244–261). Toronto: W.B. Saunders.
RELEVANT WEB SITES Centre for Health Promotion, University of Toronto www.utoronto.ca/chp/
The Centre for Health Promotion, established in 1989, is a community–academic partnership. The centre is committed to excellence in education, evaluation, and research. In a multidisciplinary, collaborative context it activates, develops, and
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evaluates innovative health promotion approaches in Canada and abroad. The centre is an active, high-quality, internationally recognized leader in health promotion. Ministry of Health Promotion www.mhp.gov.on.ca/english/about.asp
Created in June 2005, the Ministry of Health Promotion aims to help Ontarians lead healthier lives by delivering programs that promote healthy choices and healthy lifestyles by working closely with partners, stakeholders, and all levels of government. Ontario Health Promotion E-Bulletin www.ohpe.ca/index.php
The Ontario Health Promotion E-mail Bulletin (OHPE) is a weekly newsletter for people interested in health promotion. It is produced by the Ontario Prevention Clearinghouse and the Health Communication Unit of the Centre for Health Promotion, University of Toronto. Ontario Prevention Clearinghouse www.opc.on.ca
The Ontario Prevention Clearinghouse (OPC) is Ontario’s longest-standing health promotion organization. OPC helps individuals, groups, and communities use health promotion strategies to achieve health and well-being.
HEALTH PROMOTION IN QUEBEC: MORE OF THE SAME? Lucie Richard
Three Waves of Change in the Public Health Subsystem Colin (2004) and other analysts (Health Canada, 1996; Nadeau, 1996; Pineault et al., 1993; Pineault & Tousignant, 2000) have observed that the Quebec health care system has undergone three waves of transformation since the early 1990s. These three waves of organizational, programmatic, and legislative change had important implications for health promotion research, policy, and practice. In 1993–1994, the roles and mandates of key institutions and actors in the public health subsystem (e.g., the Ministry of Health and Social Services, Regional Health and Social Services Agencies and their Public Health
Directorates, and Local Community Health Centres) were redefined at the local, regional, and national levels. This period was accompanied by institutional downsizing and increased ambulatory services in the hospital subsystem. Between 1998–2001, additional changes were made to the public health subsystem with the creation of an Institut national de santé publique and the adoption of a new public health law. While the purpose of the first is basically to support the minister and the regional agencies in their public health mission, the second is geared toward “the protection of the health of the population and the establishment of conditions favourable to the maintenance and enhancement of the health and well-being of the general population” (Public Health Act, R.S.Q., Chapter S-2.2, article 1, free translation). Article 3 of the law refers explicitly to health promotion, defining it as “[...] the means of exerting a positive
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influence on major health determinants, in particular through intersectoral coordination” (free translation). The third series of organizational reforms was implemented in 2004 when facilities with different missions (CLSC, CHSLD, and CH)1 were combined within a new type of local structure: the Health and Social Services Centre (CSSS), which formally networked with community groups and physicians in private practice. Accompanying these structural and organizational reforms were changes in orientations and programs. As early as 1992, the Quebec government had adopted a comprehensive policy on health and well-being (Ministère de la santé et des services sociaux, 1992) clearly identifying prevention and health promotion as two key strategies. Following this, national public health priorities for 1997–2002 were announced (Ministère de la santé et des services sociaux, 1997) and, finally, a national public health program was established for 2003–2012 (Ministère de la santé et des services sociaux, 2003). Between 1994 and 2006, health promotion training and research also expanded. This involved the creation or expansion of dedicated research structures, 2 the development of research chairs3 and collaborating centres,4 and the creation of new post-graduate training programs.
resources devoted to these endeavours, especially in CLSCs (Bourdages, Sauvageau, & Lepage, 2003; Ordre des infirmières et infirmiers du Québec, 1999; Poirier, 2000). On the other hand, as noted by O’Neill and Cardinal (1994) a while ago, combining preventive, curative, and health promotion services in Quebec created definite tensions for health promotion, which still struggles to gain attention and resources in an era where cuts in curative services rank high among public concerns. Moreover, the fact that the National Public Health Program of 2003 is organized around health problems rather than around their determinants illustrates the continued dominance of the “prevention” dimension in the “promotion–prevention” duo. The budgetary and organizational context of the last few years has not facilitated greater integration of the health promotion discourse in practice in Quebec. In 1994, O’Neill and Cardinal reminded us of the neo-conservative climate that has been operating since the mid1980s, with a provincial government “concerned mostly with dismantling the welfare state, diminishing the size of the public deficit, decreasing government intervention, and privatizing certain areas of government service” (p. 273). More than 12 years later, we can report that health promotion today finds itself in context of, and experiencing, “more of the same.”
The Status of Health Promotion Given all these changes, how “healthy” is health promotion in Quebec in 2006? While it has been at the centre of the discourse that accompanied changes in the health care system over the last 12 years, has it been able to flourish to the same degree in practice? On the one hand, empirical evidence shows some positive impact of the reforms on the adoption of innovative approaches to prevention-promotion (Richard et al., 2004), whereas other work describes a negative impact on the level of
Conclusion In short, while the rhetoric of the last 12 years of reforms has delighted those who support health promotion, evidence about its financing and its practice should lead them to contain their enthusiasm. Even if the situation is far less gloomy than that presented by O’Neill and Cardinal in 1994, there is still a long way to go to ensure a greater integration of the health promotion discourse in Quebec’s policies and programs.
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NOTES 1
2
3
4
CLSC: Centre local de services communautaires (local community health centre); CHSLD: Centre d’hébergement et de soins de longue durée (long-term care residential centre); CH: Centre hospitalier (hospital). For example, GRIPSUL at Université Laval and the Centre de recherche en promotion de la santé de l’Université de Montréal. For example, the Canada Research Chair on Health Education (J. Otis, UQAM), the Canada Research Chair on Behaviour and Health (G. Godin, Université Laval), and the Chair on Community Approaches and Health Inequalities (L. Potvin, Université de Montréal). For example, the WHO Collaborating Centre on the Development of Healthy Cities and Towns (Université Laval).
REFERENCES Bourdages, J., Sauvageau, L., & Lepage, C. (2003). Factors in creating sustainable intersectoral community mobilization for prevention of heart and lung disease. Health Promotion International, 18(2), 135–144. Colin, C. (2004). La santé publique au Québec à l’aube du XXIe siècle (Public health in Québec at the dawn of the 21st century). Santé publique, 16(2), 185–195. Health Canada. (1996). La réforme des soins de santé au Canada (Health care reform in Canada). Ottawa: Author. Ministère de la santé et des services sociaux. (1992). La politique de la santé et du bien-être (Policy on health and well-being). Quebec: Gouvernement du Québec. Ministère de la santé et des services sociaux. (1997). Priorités nationales de santé publique (National public health priorities). Quebec: Gouvernement du Québec. Ministère de la santé et des services sociaux. (2003). Programme national de santé publique 2003–2012 (National public health program 2003–2012). Quebec: Ministère de la santé et des services sociaux. Nadeau, J. (1996). Reform of the Québec healthcare system. Leadership in Health Services, 5(4), 8–10. O’Neill, M., & Cardinal, L. (1994). Health promotion in Québec: Did it ever catch on? In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 262–283). Toronto: W.B. Saunders. Ordre des infirmières et infirmiers du Québec. (1999). Bilan de la pratique infirmière en milieu scolaire (Current status of nursing practices in school settings). Montréal: OIIQ: Direction de la planification. Pineault, R,. Lamarche, P.A., Champagne, F., Contandriopoulos, A.P., & Denis, J.L. (1993). The reform of the Quebec health care system: Potential for innovation? Journal of Public Health Policy, 14(2), 198–219. Pineault, R., & Tousignant, P. (Eds.). (2000). Transformation of the Montreal network: Impact of health. Research collective. Montréal: RRSSS Montréal-Centre, Direction de la santé publique. Poirier, L.R. (2000). Évaluation de l’efficacité du réseau de services offerts aux personnes ayant des troubles mentaux et vivant dans la communauté (Effectiveness of the network of services offered to noninstitutionalized persons having mental problems). In R. Pineault & P. Tousignant (Eds.), Transformation of the Montreal network: Impact on health. Montréal: RRSSS Montréal-Centre, Direction de la santé publique. Richard, L., Lehoux, P., Breton, E., Denis, J.L., Labrie, L., & Léonard, C. (2004). Implementing the ecological approach in tobacco-control programs: Results of a case study. Evaluation and Program Planning, 27, 409–421.
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RELEVANT WEB SITES Association pour la santé publique du Québec (ASPQ) www.aspq.org
The ASPQ is a multidisciplinary, not-for-profit organization that aims to improve the health of people in Quebec. The association regularly intervenes to promote health, for example, by offering position statements or papers to government. Institut national de la santé publique du Québec www.inspq.qc.ca/
The Web site of l’Institut de la santé publique du Québec (Quebec national public health institute). An English section is available on the site. Centre de recherche Léa-Roback sure les inégalités sociales de santé de Montréal www.centrelearoback.ca
The mission of the Léa-Roback Research Centre is to help reduce social inequalities in health and improve living conditions through facilitating research ; developing alliances among researchers, policy makers, and professionals ; and to enable knowledge transfer. Ministère de la santé et des services sociaux du Québec www.msss.gouv.qc.ca/
The Web site of the Ministère de la santé et des services sociaux du Québec (Quebec health and social services ministry). An English section is available on the site. Réseau francophone international pour la promotion de la santé (REFIPS) www.refips.org
This Web site brings together individuals and organizations involved in health promotion in approximately 30 francophone countries.
THE ATLANTIC PROVINCES: A “HAVE” OR “HAVE-NOT” REGION FOR HEALTH PROMOTION? Renee Lyons, Monique Allain, Sandra Crowell, Stacey Wilson-Forsberg, Marlien MacKay, Rick Manuel, Donna Murnaghan, Laraine Poole, Shirley Solberg, Eleanor Swanson, Patricia L. Williams, Doug Willms, and Fiona Chin-Yee
Introduction Health status and health system indicators suggest that Atlantic Canada is a region of
very high need in terms of prevention and promotion, but low fiscal and human resources to address these needs. There are a number of challenges that face the region. In comparison with other provinces such as British Columbia, Atlantic Canada rates poorly on many key health indicators—rates of cardiovascular disease, asthma, cancer, smoking rates, etc. (Hayward & Colman, 2003). Atlantic Canada also experiences substantial social and economic disparities and a rapidly aging population due to the fact that many young and middle-aged adults have
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left the region for employment (Canadian Rural Partnership, 2004; Statistics Canada, 2002). Illness care costs swallow up such a gigantic portion of provincial budgets that sustained investments in prevention and promotion have been relatively negligible (Mirolla, 2004). Recent reviews of the public health system in the Atlantic provinces, for example, pointed to substantial deficiencies in the basic health systems infrastructure for protection and promotion (Committee on Public Health Capacity, 2004; Jensen & Kisley, 2005; Moloughney, 2006). Despite these challenges, many innovative health promotion initiatives have been launched to improve health status, prevent illness, and mobilize communities to take action on the conditions that impact health. This section of the chapter on health promotion in Canada provides a sampling of health promotion advancements in Atlantic Canada. The health promotion examples we present focus on two themes: governmental policy commitments to the promotion of health and university-based health promotion research projects. The authors offer perspectives on the status of health promotion in Atlantic Canada. Regions and provinces within Canada are often characterized by the media and the federal government as “have or “have not” based on financial disparities. Since health
promotion is, in essence, based on social and cultural change, is there a corresponding health promotion disparity or “poverty” in “have-not” regions such as Atlantic Canada? Is Atlantic Canada a “have” or “have-not” region for health promotion? What are we doing in terms of action to improve health status, prevent illness, and address the determinants of health? Are we seeing progress? Are advancements sufficient to tackle the aging population and the plethora of health issues in the region? What are the conditions that enhance or constrain progress in health promotion in the “far east” of Canada? Health promotion is not an easy theme around which to provide a comprehensive regional analysis. Health promotion is a very broad concept that encompasses a wide range of strategies and content areas. Therefore, instead of claiming to provide a comprehensive overview, we offer a “flavour” of health promotion in the Atlantic region. Several writers were selected from each province to provide examples of policy-based health promotion initiatives and of health promotion research. In addition, two examples of Atlantic-wide health promotion research and action are given. Due to space restrictions we have not included important contributions in research and action made by non-governmental organizations, government agencies, researchers, or the private sector.
REFERENCES Canadian Rural Partnership: Rural Research and Analysis. (2004). Rural repopulation in Atlantic Canada, a discussion paper. Retrieved April 2005, from www.rural.gc.ca/researchreports/popresearch/ repop_e.phtml. Committee on Public Health Capacity. (2004). Investing in health: A report on public health capacity in Newfoundland and Labrador. St. John’s: The Newfoundland and Labrador Department of Health and Community Services. Hayward, K., & Colman, R. (2003). The tides of change: Addressing inequality and chronic disease in Atlantic Canada. Retrieved April 2005, from www.phac-aspc.gc.ca/canada/regions/atlantic/pdf/ Tides_Inequity_and_Chronic_Disease.pdf.
CHAPTER 11: 12 Canadian Portraits ■ 189 Jensen, L., & Kisely, D.S. (2005). Public health in Atlantic Canada. A discussion paper. Halifax: Public Health Agency of Canada, Atlantic Region. Mirolla, M. (2004). The cost of chronic disease in Canada. Retrieved April 2006 from www.gpiatlantic.org/pdf/health/chroniccanada.pdf. Moloughney, B.W. (2006). The renewal of public health in Nova Scotia: Building a public health system to meet the needs of Nova Scotians. Halifax: Nova Scotia Health Promotion and Protection. Statistics Canada. (2002). Profile of the Canadian population by mobility status: Canada: A nation on the move. Retrieved April 2006, from www12.statcan.ca/english/census01/products/analytic/companion/mob/ contents.cfm.
NEW BRUNSWICK: GOVERNMENT POLICY AND ACTION Monique Allain and Marlien MacKay
Since June 1999, the government of New Brunswick has developed and implemented public policy initiatives and programs that promote wellness and healthy living. These initiatives include the Smoke-free Places Act and the Healthier Foods and Nutrition in Public Schools provincial policy. New Brunswick’s recent Provincial Health Plan (2004–2008) (New Brunswick Department of Health, 2004) identified improving population health as its first strategic priority. Within this strategic priority are measures to promote healthy living, to improve the management and control of chronic diseases, to reduce the incidence of cancer, and to prevent sickness and disease through an expanded immunization program. The Wellness Strategy (within the plan) includes approaches to promote personal health practices and to help modify the environments that would support them. The strategy includes initiatives for healthy eating, physical activity, tobacco-free initiatives, and mental health and resiliency, with an emphasis on partnership and collaboration. For
instance, the strategy will assist the New Brunswick Youth Council in building on its consultation process regarding health issues that impact youth. Youth leadership in health promotion and chronic disease prevention is also emphasized. For the past five years, there has been a strong emphasis on using schools to promote health. The Department of Health and Wellness and the Department of Education established the Healthy Learners in School Program in 2000 to improve the health and learning achievement of New Brunswick students (Province of New Brunswick, 2004). The program supports health initiatives that will improve student wellness and learning. The goals are based on three aspects of comprehensive school health frameworks: knowledge, attitudes, and skills to achieve wellness, healthy and safe learning environments (physical and social), and access to services and support. Health committees have been established in each school district and are the mechanism for identifying collective priority and developing and implementing actions with all partners Some information (currently in revision) can be located in the Health section of the government of New Brunswick Web site at www.gnb.ca.
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REFERENCES New Brunswick Department of Health. (2004). Healthy futures: Securing New Brunswick’s health care system. The provincial health plan 2004–2008. Retrieved July 22, 2006, from www.gnb.ca/0051/pdf/ healthplan-2004-2008_e.pdf. Province of New Brunswick. (2004). Healthy Learners in School Program putting health and education together for wellness. Retrieved April 2006, from www.gnb.ca/0053/programs/healthylearners-e.asp.
RESEARCH: HEALTHY CHILDREN Doug Willms and Stacey Wilson-Forsberg
Over the past 10 years, research initiatives of the Canadian Research Institute for Social Policy (CRISP) at the University of New Brunswick (UNB) have contributed to knowledge about the risk and protective factors associated with vulnerability among Canadian children and youth (Willms, 2002) and childhood obesity (Tremblay & Willms, 2000; Willms, Tremblay, & Katzmarzyk, 2003). CRISP’s most ambitious research program to date, Raising and Leveling the Bar, has brought together a multidisciplinary network of 30 committed, enthusiastic researchers from across Canada to pool data and ideas to help
children overcome disadvantages and have an opportunity to succeed. This research program considers how to improve the learning, behaviour, and health outcomes of our children and youth, while reducing inequalities associated with family background. The research program focuses on five key strategies: (1) safeguarding the healthy development of infants; (2) strengthening early childhood education; (3) improving schools and local communities; (4) reducing segregation and the effects associated with poverty; and (5) creating a familyenabling society. This research is being carried out by members of the network across Canada, with support from the core research team at UNB (Canadian Research Institute for Social Policy, 2004).
REFERENCES Canadian Research Institute for Social Policy. (2004). Raising and leveling the bar. Retrieved April 2006 from www.unbcrisp.ca/learningbar/. Tremblay, M.S., & Willms, J.D. (2000). Secular trends in the body mass index of Canadian children. Canadian Medical Association Journal, 163(11), 1429–1433. Willms, J.D. (Ed.). (2002). Vulnerable children: Findings from Canada’s national longitudinal survey of children and youth. Edmonton: University of Alberta Press. Willms, J.D., Tremblay, M.S., & Katzmarzyk, P.T. (2003). Geographic and demographic variation in the prevalence of overweight Canadian children. Obesity Research, 11(5), 668–673.
NOVA SCOTIA: GOVERNMENT POLICY AND ACTION Rick Manuel
Evidence and experience suggests that approximately 40 percent of cases of chronic
heart and lung disease, cancer, diabetes, and mental ill health are preventable (Nova Scotia Health Promotion and Protection, 2004). And up to 95 percent of all injuries are preventable (Atlantic Network for Injury Prevention, 2006). With some of the poorest health statistics in the country, the government of Nova
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Scotia established a separate ministry in 2002 to focus on health promotion and chronic disease and injury prevention. Nova Scotia Health Promotion (NSHP) was created by bringing together the former Sport and Recreation Commission with portions of the Population Health branch of the Department of Health. New resources and responsibilities were added and by 2005, NSHP had a budget of approximately $25 million and a staff of over 70 people. In 2006, the NSHP expanded again to include all public health staff, including the Office of the Chief Medical Officer of Health. With a focus on population health, disparity reduction, healthy public policy, evidence-informed decision making, and community capacity building, Nova Scotia Health Promotion and Protection (NSHPP) is working to address common risk factors for the chronic diseases that take the greatest toll on Nova Scotians and their health care system. Strategic priority areas include: public health and health protection services, physical activity, sport and recreation, healthy eating, tobacco control, injury prevention, addiction prevention, healthy sexuality, chronic disease prevention,
and communications and social marketing. Some recent developments include hiring “school animators” to work in Nova Scotia communities to increase opportunities for students to engage in physical activities before, during, and after school hours; developing and launching a province-wide policy on food and nutrition in Nova Scotia schools; passing the toughest anti-smoking legislation in the country and seeing overall smoking rates drop from about 30 percent to 20 percent over a few short years; working with stakeholders to develop a strategy for preventing falls among seniors; and developing and releasing a comprehensive Alcohol Indicators Report, which provides information on the kinds and severity of harms and problems that result from alcohol abuse. The first of its kind in the country, the report forms the basis for developing strategies to reduce harmful drinking. NSHPP’s strategic plan, annual business plans, accountability reports, policy papers, policy statements, newsletters, monthly updates, and program-specific updates are available on the NSHPP Web site at www.gov.ns.ca/ohp.
REFERENCES Atlantic Network for Injury Prevention. (2006). The economic burden of unintentional injury in Atlantic Canada. Retrieved May 15, 2006, from www.anip.ca/. Nova Scotia Health Promotion and Protection. (2004). Chronic disease prevention. Retrieved April 23, 2006, from www.gov.ns.ca/ohp/chronicDiseasePrevention.html.
RESEARCH: FOOD SECURITY Patricia L.Williams
In 2001, partners representing the Atlantic Health Promotion Research Centre, Nova Scotia Nutrition Council, Mount Saint Vincent University, and individuals from Family
Resource Centres and Projects in Nova Scotia, funded by Health Canada’s Community Action Program for Children (CAPC) and the Canada Prenatal Nutrition Program (CPNP), collaborated to develop a participatory process of “food costing” throughout Nova Scotia. These groups recognized the need to address the problem of growing food insecurity in
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Nova Scotia by finding sustainable solutions for system redesign through capacity building. The participatory food-costing program not only resulted in an analysis of what it costs to eat nutritiously in Nova Scotia, but also a group of “food costers” (participants and staff in CAPC- and CPNP-funded family resource centres and projects) with the skills commitment and interest to continue to build food security. From 2001–2006, the Nova Scotia Participatory Food Security Projects have been at the forefront of provincial and national efforts to address food insecurity through eight related action research projects. These projects have included a wide range of collaborations across Canada, including women who are experiencing food insecurity, communitybased organizations, government, academics, and health and social service professionals. The projects have involved story-sharing workshops as well as community and national dialogues on food security and policy; a national scan of strategies that impact policies
to build food security; the development of a participatory model and tools for ongoing monitoring of the affordability of a nutritious diet; and the development of a food security policy backgrounder and lens for policy makers to assess the impacts of their decisions on food security. Findings from this research show that participatory tools and processes are an effective way to build individual, organizational, community, and systems capacity to address food insecurity and the policies that need changing. The evidence gleaned through this work has influenced both policy and practice within Nova Scotia (Nova Scotia, 2005) and has been used by many other locales working on policy-oriented approaches to food insecurity. In addition, the lessons learned through these projects have contributed to the development of a Web-accessible, plain-language, bilingual workbook, Thought about Food? A Workbook on Food Security & Influencing Policy. See: www.foodthoughtful.ca/ and accompanying DVD.
REFERENCE Nova Scotia Department of Health Promotion and Protection. (2005). Healthy eating. Retrieved February 2007 from www.gov.ns.ca/hpp/healthyeting.html.
PRINCE EDWARD ISLAND: GOVERNMENT AND COMMUNITY ACTION Deborah Bradley and Laraine Poole
The PEI Strategy for Healthy Living was launched in 2003 in response to the growing burden of chronic disease. The strategy was designed to promote collaborative efforts to address several of the most significant behavioural risk factors for chronic diseases: tobacco use, unhealthy diet, and physical inactivity. The PEI Strategy for Healthy Living has
resulted in many improvements in partnerships and collaboration that support health promotion policy and action. For instance, the departments of Health and Social Services, Education, and Community and Cultural Affairs are working together on the strategy at the provincial level. The three departments provide a mechanism for interdepartmental collaboration on planning and joint implementation of common initiatives as related to healthy living. PEI is also fortunate to have three strong and active alliances as partners in the Strategy for Healthy Living: Active Living
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Alliance, Tobacco Reduction Alliance, and Healthy Eating Alliance. Each alliance is composed of member organizations and is involved in a number of initiatives that address specific risk factors. As well, four regional healthy living coordinators were hired in 2004 to help develop partnerships through regional networks, addressing specific needs and priorities at the community level. These “temporary” positions were made available through the Federal Primary Health Care Transition Fund. Some broad-based accomplishments include the development of a Physical Activity Strategy for the Province; development and implementation of School Healthy Eating Policies; implementation of the Smoke-Free Places Act; and development and piloting of the Active Healthy School Communities, an initiative aimed at improving health through school–community partnerships. The Tobacco Reduction Strategy, in place since 1999, has contributed to reduced rates of tobacco use in PEI. Activities such as the Fruit and Vegetable Pilot Project have shown promise in promoting healthy eating
among children and the PEI Stepping Out Program is helping islanders to become more active. Outcome indicators have been developed for all three risk factors, and will be measured over time. Since the Strategy for Healthy Living was launched in 2003, many changes have occurred in the province of PEI. In 2005 the PEI health system was reorganized from a regional system to a central administrative system. Currently, within the Department of Health, a small Health Promotion and Chronic Disease Prevention Unit has been established. However, the risk factor positions were lost and the federal funding for the healthy living coordinators ended in March 2006. Two of the positions remain temporarily funded by the province. However, the department wants to sustain the collaborations that have been developed. Many advances were made by organizations working collectively to maximize impact and to minimize duplication. Detailed information on the PEI Strategy for Healthy Living and related initiatives can be found at www.gov.pe.ca/go/hls.
RESEARCH: HEALTHY SCHOOLS
program that focuses on the school as a major social context for children’s health. The main research objective is to prevent chronic diseases by working directly with school-aged children and youth, providing research support, and disseminating findings to policy makers and other research users. For instance, the team is currently conducting school-based studies that examine student health behaviours related to healthy eating, physical activity, and not smoking; health promotion initiatives in schools across Canada; barriers and facilitators to participating in sports; and the development and testing of innovative programs for student health promotion. Over the past year, CHSRT has created partnerships and collaborations with Canadian and
Donna Murnaghan
The Comprehensive School Health Research Team (CSHRT), led by researchers at the University of Prince Edward Island, is an intersectoral team of academic, government, and community researchers and decision makers working collaboratively toward building new knowledge and infrastructure to support school health research in Atlantic Canada. The primary mandate of this program of research is to develop interventions that promote healthy and active children and youth, important contributors to learning and social/physical development. The CSHRT uses an innovative research and training
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Atlantic research groups that foster research and academic links with universities and health units in New Brunswick, Nova Scotia, Newfoundland, Ontario, and Alberta. Funding for this program of research has been awarded by the Canadian Institutes for Health Research (CIHR), the Canadian Tobacco
Control Research Initiative (CTCRI), the Prince Edward Island Health Research Program (PEI-HRP), Health Canada, the Department of Canadian Heritage, and the Department of Community and Cultural Affairs of Prince Edward Island. More information may be found at www.upei.ca/cshr.
NEWFOUNDLAND AND LABRADOR: GOVERNMENT POLICY AND ACTION
Prevention Coalition will conduct a review of injury prevention data, initiatives, and stakeholders to support a province-wide approach to injury prevention. Wellness initiatives include a “healthy students, healthy schools” program and community-based healthy living programs. A wellness grants program, and a food and nutrition action plan are being developed. A social marketing strategy is being designed to complement the Wellness Plan, and new staff positions to increase capacity for health promotion are being created in each of the regional health authorities. Indicators of effectiveness will be established to evaluate progress (Newfoundland and Labrador Department of Health and Community Services, 2006). See http://gohealthy.ca/en.
Eleanor Swanson
In 2005, the government of Newfoundland and Labrador launched a Provincial Wellness Plan with a $2.4 million commitment, the largest single cash infusion in health promotion in the history of the province. The focus in the first three years is on healthy eating, physical activity, tobacco control, and injury prevention. A second phase will consider other issues such as mental health promotion and environmental health. One aim of the plan is to strengthen partnerships and collaboration such as those developed around tobacco control. For example, a Provincial Injury
REFERENCE Newfoundland and Labrador Department of Health and Community Services. (2006). Achieving health and wellness: Provincial wellness plan for Newfoundland and Labrador. Retrieved April 2006 from www.health.gov.nl.ca/health/publications/2006/wellness-document.pdf.
RESEARCH: COASTAL AND WORKPLACE HEALTH Shirley Solberg
New approaches to research in the form of working with communities and specific groups are changing the ways health promotion research is being done in the province of Newfoundland and Labrador. Two examples of this type of research are SafetyNet, a
Community Alliance for Health Research (CAHR) project funded by the Canadian Institutes for Health Research, and, Coasts under Stress, a project funded jointly by the Social Sciences and Humanities Research Council of Canada and the National Science and Engineering Research Council under the Major Collaborative Research Initiative. In the many research projects being carried out by teams of SafetyNet researchers and
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community partners, the teams are looking for ways to promote health and safety in marine and coastal occupations. Findings from the research on shellfish asthma and work-related musculoskeletal disorders among crab-processing workers is being used as a basis to consult with representatives from the workers, union, industry, and government in single-industry towns to look at communitybased approaches to promoting the health of workers at risk for these occupational health problems (see www.safetynet.mun.ca/). Coasts under Stress also focuses on coastal communities, but has a broader mandate. In this large interdisciplinary project, researchers are examining how fisheries restructuring in
coastal communities has affected human and environmental health and how changes at the policy level may promote the health of individual, families, and communities. In Newfoundland and Labrador the restructuring that has taken place has had a number of negative impacts on the various social determinants of health (e.g., unemployment, outmigration, and gaps in education and health services), creating a great deal of stress and uncertainty in communities. Community feedback by researchers has helped people look at some of the issues facing their communities (Ommer et al., forthcoming; Sinclair & Ommer, in press; www.coastsunderstress.ca/ home.php).
REFERENCES Ommer, R.E., & the Coasts under Stress research project team. (forthcoming). Coasts under stress: Restructuring and social-ecological health. Montreal: McGill-Queen’s University Press. Sinclair, P.R., & Ommer, R.E. (Eds.). (in press). Power and restructuring: Canada’s coastal society and environment. St. John’s: ISER Books.
ATLANTIC-WIDE INITIATIVES: POLICY AND ACTION Fiona Chin-Yee
The Atlantic Regional Office of the Public Health Agency of Canada, through its funding programs, has provided funding for community-based projects that either contribute to the development of healthy public policy or increase community capacity for influencing policy. Since 2001, the agency has funded over 75 community-based organizations in the region that have been working to address health promotion through a policy lens. Project themes have included increasing awareness of the importance of early child development, food security, youth sexual health, youth engagement in social policy,
healthy food policies in schools, and health promotion for adult survivors of abuse, including new immigrants. A strong focus has been health-related policy that affects seniors and an aging society. Community projects are enhanced by development of policy documents that have mined the data specifically about health and its determinants in the Atlantic region. These documents focus on determinants such as poverty, literacy, marginalization, and social exclusion. The work of the Public Health Agency of Canada, Atlantic Regional Office has been important in assisting community organizations within the four Atlantic provinces to develop sophistication and understanding of the importance of healthy public policy. More information is available at www.phacaspc.gc.ca/canada/ regions/atlantic/about/index.html.
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RESEARCH: ATLANTIC HEALTH PROMOTION RESEARCH CENTRE AND ITS ATLANTIC NETWORKS FOR PREVENTION RESEARCH Sandra Crowell
The Atlantic Health Promotion Research Centre (AHPRC) is a vibrant research facility now in its 13th year of operation. The mission is to conduct health promotion research with a special emphasis on the health and well-being of Atlantic Canadians. Over the years, AHPRC has conducted large, collaborative health research projects on a wide range of topics, including seniors’ mental health, indoor air quality in schools, tobacco cessation, community resilience, and helping rural communities to use research to influence policies that affect their health and sustainability. AHPRC’s current research themes include: modification of health systems to prevent stroke and improve health services, food security, oral health of seniors, and healthy mid-life aging. AHPRC’s largest initiative, the Atlantic Networks for Prevention Research (www.anpr.dal.ca) focuses on environmental diagnostics and health—methods to assess settings that impact health. Funded by the Canadian Institutes of Health Research, ANPR focuses on research development in Atlantic Canada by pooling resources and supporting research networks on healthy schools (University of Prince Edward Isalnd), communities (Dalhousie), and workplaces (Memorial University of Newfoundland). University of New Brunswick’s Canadian Research Institute for Social Policy (described above) is engaged in data development on communities, schools, and health. Each of the four research sites also fosters student training and knowledge translation.
The success that AHPRC has achieved is due, in part, to strategic collaborations with researchers and diverse stakeholders from across the region and beyond. AHPRC is also a partner on the Nova Scotia Health Promotion Clearinghouse, a valuable resource for linking people and organizations involved in health promotion to resources and expertise. For more information about AHPRC and its research, visit www.ahprc.dal.ca.
FINAL THOUGHTS The examples given above demonstrate that the Atlantic provinces have shown exciting progress in both policy and research in health promotion. The work on children’s health, occupational health, rural health, and community capacity building is groundbreaking. Researchers and government health promotion/policy staff have been Canadian and international leaders in many aspects of health promotion. Social and economic conditions in this region provide a useful lab for other countries because our circumstances mirror many resource-challenged regions that need models of policy and research development in a less-than-favourable financial climate. The good news is that the governments within the Atlantic provinces are beginning to make investments in illness and injury prevention and public health through departmental restructuring and new funding. In addition, all of the Atlantic provinces have increased their budgets for health research funding over the past five years, including modest to substantial support for health promotion research. There is still considerable dependence on federal government initiatives for programs and research. The most substantial gains in research have resulted from new opportunities provided by the Canadian Institutes for Health Research. Nevertheless, provincial
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grants have been extremely helpful in launching new projects and contributing to retaining research investigators in the region. Over the past decade, Health Canada (Health Canada, 2002) has supported programs and research in health promotion and has played a prominent role in the region in funding population health projects, as well as facilitating Atlantic collaboration. Unfortunately, no funding opportunities provide sustained support for Atlanticwide health promotion research and/or action, and very few truly substantive interventions match the current and anticipated magnitude of preventable health problems in the region. As indicated earlier, a persistent problem for the region is insufficient and short-term funding for health promotion. Health promotion in Atlantic Canada is still highly dependent on initiatives funded by federal tax dollars. Approaches to health promotion and illness prevention can take many forms, each possessing good merit in terms of best practice and evidence of effectiveness, but these initiatives require sustained investments over time to yield major results. They need to be accompanied by solid measures of effectiveness. The constant changes in initiatives, human resources, approaches, and terminology (e.g., healthy living, active living, wellness, population health, vitality, healthy eating, and chronic disease prevention) at the federal level have been particularly unproductive and difficult for this region. The possibilities for pooling resources across the region are considerably underdeveloped. There are still few mechanisms to launch and sustain Atlantic-wide collaboration. Atlantic Canada needs a consistent and focused approach to health with investments over time, with help from the federal government, to become a “have” province for health promotion, and to build a social culture that supports health.
Despite the constraints given above, and the considerable effort that it takes to move innovation forward in a low-resource region such as Atlantic Canada, major accomplishments have been made in both health promotion research and action. Each province has made useful strides forward given the limited resources available to health promotion. Many of the major policy advances have occurred within the past few years, and we will have to test outcomes as these activities are implemented. Atlantic Canada is blessed with skilled, highly motivated, committed, and resourceful people in leadership positions within government, university, and the private and voluntary sectors. These leaders make things happen despite the constraints. We also have our gatekeepers, people in influential positions who resist collaboration, evidence, and change. This situation is very characteristic of locales with limited or no resources for innovation and change. In lowresource health systems where there is little money to stimulate innovation, there are always worries about resource loss with the prospect of change and considerable “unproductive” competition for scarce resources (Alvaro, Lyons, & Warner, forthcoming). So what is the answer to the question: Is Atlantic Canada a “have” or “have-not” region for health promotion? At present we do not have a full set of indicators to provide a clear answer to this important question. If one were to conduct a systematic analysis of progress in health promotion over the last decade within a geographic region such as Atlantic Canada, what indicators would be used? Indicators might include the abundance and impact of health promotion activities, financial and human resource investments by governments, NGOs, and the private sector; a comparative status of programs, services, and policy (Atlantic as compared to other parts of Canada); and progress
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in research and research uptake. We might also examine innovations and learnings that were of value to the rest of Canada and other countries in such areas as the design and testing of interventions, tools and methods development, and health promotion training. These analyses would yield valuable insights into understanding and addressing the current status of health promotion in Atlantic Canada. At this point, we can only speculate via examples. Atlantic Canada has many strengths, but also huge challenges in terms of improving population health status and mobilizing the appropriate intervention “strength” to make a difference. Unless we address many of the root causes of preventable illness both within our region and glob-
ally, advancements to “have” status in Atlantic Canada will continue to elude us (Evans, Barer, & Marmor, 1994). What would it take to address the disparities that contribute to the illness burden in the region? What type of commitment is required in this country to address the basic social, economic, and cultural conditions that would make us a healthier nation, particularly for the groups and regions with the poorest health status? “Consider how the system and the health of our people could be if we actually practised what works” (D. Murnghan, personal communication). A national unity of purpose for improved health and social conditions in Canada is imperative.
REFERENCES Alvaro, C., Lyons, R., & Warner, G. (forthcoming). Conceptualizing resource-related receptor capacity. Halifax: Atlantic Health Promotion Research Centre, Dalhousie University. Evans, R.G., Barer, M.L., & Marmor, T.R. (Eds.). (1994). Why are some people healthy and others not? The determinants of health of populations. New York: Aldine De Gruyter. Health Canada. (2002). Promoting health in Canada: An overview of recent developments & initiatives. Retrieved May 2006 from www.phac-aspc.gc.ca/ph-sp/phdd/promoting.html.
RELEVANT WEB SITES Atlantic Health Promotion Research Centre www.ahprc.dal.ca/welcome/default.asp
The Atlantic Health Promotion Research Centre conducts and facilitates health promotion research that informs policies and practices and contributes to the health and well-being of Atlantic Canadians. Go Healthy Newfoundland Labrador http://gohealthy.ca/en/about
The government of Newfoundland and Labrador has been working to achieve health and wellness for this province for several years and has established a Wellness Plan for this province. The plan and its messages focus on empowering individuals, groups, and communities to take action for health and wellness.
CHAPTER 11: 12 Canadian Portraits ■ 199 Nova Scotia Health Promotion www.gov.ns.ca/ohp
The Department of Health Promotion and Protection was established in February 2006. The new department brings together Nova Scotia Health Promotion, the Public Health branch of the Department of Health, and the Office of the Chief Medical Officer of Health. Prince Edward Island Healthy Living Strategy www.gov.pe.ca/infopei/index.php3?number=1001897
The Healthy Living Strategy encourages and supports residents of Prince Edward Island as they improve their quality of life by reducing risk factors that contribute to chronic disease. The strategy provides support to partners as they develop and implement initiatives in the areas of reducing tobacco consumption, improving eating habits, and increasing activity levels within their communities. Public Health Agency of Canada Atlantic Regional Office www.phac-aspc.gc.ca/canada/regions/atlantic/
PHAC Atlantic undertakes a broad range of activities to improve conditions for everyone in Atlantic Canada, as well as for specific population groups at risk. The mission of the Public Health Agency of Canada is to enable Canadians to take action on their health and the factors that influence it.
HEALTH PROMOTION IN NUNAVUT: INSPIRED BY DESIGN Carol Gregson, Nancy Campbell, Wayne Govereau,Ainiak Korgak,Amy Caughey, Kelly Loubert, and Winnie Banfield
Introduction The history of health promotion by the government of Nunavut is short, since the territory was established only in 1999. Prior to that, the policies, programs, and laws of the government of the Northwest Territories prevailed. Nunavut (the Inuktitut word for “our land”) was created as a result of the Nunavut Land Claims Agreement. For millennia a major Inuit homeland, Nunavut today is a growing society that blends the strength of its deep Inuit roots and traditions with a new spirit of diversity.
Background With a median age of 22.1 years, Nunavut’s population is the youngest in Canada. It is also one of the fastest growing; with a population of 30,245 as of January 2006 (Statistics Canada, 2006), it has grown by more than 8 percent since 1999. Inuit comprise about 85 percent of the population. Government, business, and schooling are shaped by Inuit Qaujimajatuqangit, the traditional knowledge, values, and wisdom that are the foundation of day-to-day life here. Nunavut’s Legislative Assembly has 19 members (MLAs), including a premier and a seven-member Cabinet. It uses a unique consensus approach to decision making: There are no political parties; MLAs do not have a party affiliation. The MLAs select the premier and the Cabinet members, and the premier assigns the Cabinet portfolios. Since
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1999, the government of Nunavut has worked steadily on changes needed to truly reflect the values, culture, and priorities of Nunavummiut. The Legislature has set the mandate for the government through a document called Pinasuaqtavut (Inuktitut for “That what we set out to do”).1 The two priorities and four major goals are supported by a framework of guiding principles, a vision for 2020, and a set of objectives for the government of the day.
Health Promotion Infrastructure Nunavut covers one-fifth of the land mass of Canada, in 25 communities accessible only by air. To fairly distribute services and jobs, the government of Nunavut decentralized its operations. This presents benefits as well as risks to the delivery of health promotion. There are three regions: Qikiqtaaluk (Baffin) in the east, the Kivalliq (Keewatin) on the west side of Hudson’s Bay, and the Kitikmeot in the west, spanning the top of Canada from Alberta to Quebec. Inuktitut and Inuinnaqtun dialects vary significantly by region and somewhat by community. French is also spoken by a significant proportion of the Iqaluit community. Over the long term, the Department of Health & Social Services (H&SS), under Pinasuaqtavut, is to achieve health and social conditions that meet or beat the Canadian average; create caring communities that respond to the needs of individuals and families; keep members of the community well informed, and respect the accumulated wisdom of the elders with decision making combining the best of modern and traditional methods. Health promotion functions are based in the main headquarters in Iqaluit (formerly known as Frobisher Bay), but offered out of every community health centre. (Each community has a health centre.) The
12-member Population Health Division is the leader for developing and coordinating health promotion functions. Health promotion initiatives include improving access to nutritious foods, prenatal and child development programs, and strategies to address communicable diseases such as tuberculosis and sexually transmitted diseases. Health Canada funding supports national programs such as the Aboriginal Diabetes Initiative, Canada Prenatal Nutrition Program (CPNP), Fetal Alcohol Spectrum Disorder, and Tobacco Reduction. Nunavut’s community health centres each have one or more community health representatives (CHR) who carry out health promotion activities under direct supervision of the centre’s supervisor. CHRs usually are fluent in Inuktitut or Inuinnaqtun as well as English, and are an important link between their community and the health care system. There are also health promotion officers in two of the regional headquarters, a territorial CHR coordinator, and two regional nutritionists. There are public health centres in the three regional centres. The department is currently working on a public health strategy and plans to develop a health promotion strategy.
Examples of Programs and Activities The 2004 Nunavut Report on Health Indicators shows that an effort to improve nutrition, increase physical activity, and maintain healthy weights must be a priority (Department of Health and Social Services, 2004). Activities and resources for youth have been developed to support the existing school health curriculum. A popular Drop the Pop campaign began in 2003 and has received national recognition. Unlike southern Canada, Nunavut continues to have the highest rates of smoking in Canada (48 percent c.f. 9 percent for daily
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smokers aged 12–19) and higher rates of lung cancer. Efforts to secure more funding to develop innovative programs to further engage youth not to start smoking, to enforce tobacco control legislation (especially sales to minors), and the development of effective cessation programs is critical. In 2003, the Minister’s Youth Action Team on Tobacco (MYATT) was formed to encourage youth leadership in reducing smoking rates among the youth.
Capacity Building To help enhance health promotion activities by staff or by interested individuals, H&SS holds workshops and training sessions to build on existing skills and knowledge, and to develop confidence in presentation and facilitation skills. Funding for most of these programs come from Health Canada, the First Nations & Inuit Health Branch (FNIHB), with support from the Northern Secretariat office in Ottawa and the Public Health Agency of Canada. Health promotion staff also link with other territorial organizations such as the Qulliit Nunavut Status of Women Council and the Embrace Life Council (suicide prevention). Health promotion activities are delivered in different ways, depending on the audience: one-on-one in health centres; through school presentations; on community radio, in Inuktitut; through interviews with the CHR and/or pre-packaged shows; and
through special events. Print media is very expensive and not effective at reaching the bulk of the population. Posters, give-aways, and television public service announcements are the most effective communications tools.
Health Protection and Primary Care The government of Nunavut’s focus is now shifting so that H&SS devotes more energy and resources to protecting health rather than restoring it. The territory’s partnerships with the federal government and other agencies have enabled H&SS to support communitybased health promotion efforts, but the government must and will do more. The territory’s strong primary health care system, along with the schools and community health committees, will have more health promotion activities to offer in the years to come. For 2006–2007, a new emphasis will be placed on tuberculosis and sexually transmitted illnesses awareness, along with pandemic influenzalinked projects on communicable diseases in general. In sum, health promotion has been a core element of health and social services in Nunavut since its creation in 1999. While many of the challenges facing communities in the South are shared by those in the North, the communities of Nunavut have their own unique challenges, but also their own unique resources for addressing the health concerns facing its communities.
NOTE 1
The full text of Pinasuaqtavut is available online at www.gov.nu.ca/Nunavut/pinasuaqtavut/.
REFERENCES Department of Health and Social Services. (2004). Nunavut report on comparable health indicators. Retrieved July 22, 2006, from www.gov.nu.ca/hsssite/PIRCenglishlow.pdf. Statistics Canada. (2006). The daily: Canada’s population. Retrieved July 22, 2006, from www.statcan.ca/ Daily/English/060629/d060629d.htm.
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RELEVANT WEB SITES Government of Nunavut www.gov.nu.ca
This site provides an overview of the government of Nunavut’s programs and services in four languages, including English and French. Health and Social Services Department of Nunavut www.gov.nu.ca/hsssite/hssmain.shtml
This site describes the programs and services of the Health and Social Services Department of Nunavut; includes resources and publications.
THE SITUATION OF HEALTH PROMOTION IN THE FRANCOPHONE MINORITY COMMUNITIES IN C ANADA Nathalie Boivin
Introduction Health promotion, as defined by the World Health Organization (WHO), is the process of enabling people to increase control over, and to improve, their health (World Health Organization, 1999). For the Acadian and the francophone minority communities in Canada, this means improving access to health care services in French. This section reviews some of the key developments taking place over the last 20 years toward the goal of improving health for the Acadian and francophone minority communities in Canada.
The Minority Situations of Francophones and Anglophones in Canada In 1988, the addition of Article 41 to the law on official languages stipulated that the federal government should support the development and the growth of minority linguistic groups in Canada. Since then, the federal government, through its departments and agencies, has worked at implementing Article 41.
In 1999, the Understanding on Social Union, established between the federal and the provincial and territorial governments, defined a new partnership among these groups to better Canadian social policy focusing on social programs and health care. Along with that understanding came funds ($2.3 billion for health priorities; $800 million being directed to the Fonds pour l’Adaptation des Soins de Santé Primaires-FASSP) to improve health care and access to health care for the two official linguistic minority groups. At the end of the year 2000, at the request of the Fédération des communautés francophones et acadiennes (FCFA), the federal Health minister created a consultative committee to advise him on the best ways for his department to implement Article 41 of the Official Languages Act and better answer the needs of francophone communities living in a minority situation, the situation of the anglophone minority in francophone Quebec being traditionally much less of an issue due to historically less unfavourable conditions for that group than for the francophone minorities. By then, it was clear that people’s access to health care in the language of their choice had a determining impact on their health and their autonomy over their own health; language barriers reducing access to preventive health care; satisfaction for the service provided; and treatment compliance. Linguistic
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barriers are also known to increase consultation time, the number of diagnostic tests done, and the probability of making a mistake. Not being able to speak the language of their choice also influences the quality of the services provided to the clients. In Canada, research established that 55 percent of the francophone communities outside of Quebec had no or limited access to health care in their own language. In Canada, in the fall of 2000, it was estimated that access to health services was three to seven times easier for anglophone than for the francophone minorities (Fédération des communautés francophones et acadiennes, 2001). The research also presented information on the availability of services in French for different types of services (such as first-line services, psychosocial evaluation, and care) for which language is crucial ( Fédération des communautés francophones et acadiennes, 2001). In January 2001, the Throne speech spoke to two of the objectives of the consultative committee: the first one being a commitment to create an inclusive society whereby every family would grow in a safe and strong community, and the second one being that linguistic duality was the essence of the Canadian identity. The consultative committee produced its report in September 2001, recommending a strategy to improve access to health care delivery in their language for all francophones in Canada (Health Canada, 2001, p. 4–5). In order to maximize the impact of the proposed strategy, implementation had to be done in a coherent and integrated way. Three intervention axes were prioritized: networking, service organization, and training. In 2002, a networking initiative was launched to support the creation of Santé en Français provincial, territorial networks whose role is to bring together five partners: health professionals, health managers, political stake-
holders, the health training institutions, and the community. It is in this context that the Société Santé en Français was created in December 2002 to act as a national network.
Mobilizing Communities through Société Santé en Français Buy-in from the community was seen as a crucial component since the community can best identify its own priorities and define the best strategies to meet these priorities. Since the consultative committee felt that the networking and health services organization priorities were to be best achieved by the new group formed in December 2002, the Société Santé en Français was mandated to do so. This organization is made up of 17 regional, provincial, or territorial networks. Each network brings interested partners together to improve access to health services provided in the language of their choice for all francophone minority Canadian communities. The vision of Société Santé en Français is to have francophone and Acadian communities evolve in an environment where they can be innovative and demonstrate initiative within a health system that respects their cultural, social, and linguistic values. It believes that the close work of all five partners—health professionals, health managers, government, training institute, and community—is essential in this endeavour. In July 2003, the first round of funding was announced by the Société through the Fonds pour l’Adaptation des Soins de Santé Primaires (FASSP) of Health Canada. The project promoters selected had to conduct a project aiming at improving access to primary health care for the francophone minority communities. As of November 2005, 70 projects were funded. One of these projects, Préparer le Terrain, aims to help provincial and territorial decision makers elaborate plans
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for the provision and delivery of quality primary health care services to answer the needs of their francophone populations by identifying existing resources and gaps in services and suggesting priorities for improvements.
well-being. The CNFS and Société Santé en Français joined their strengths to conduct consultative commissions on two strategic issues—research and information systems, and human resources.
Training Francophone Professionals
Conclusion
The training component is to be conducted by a new Consortium called the Consortium National de Formation en Santé (CNFS). The CNFS is made up of a group of 10 university- or college-level institutions offering training in French to future health professionals. The objective of the CNFS is to increase the number of health professionals and researchers capable of providing their services in French to the Canadian communities, thus contributing to their health and
The Société Santé en Français and the Consortium National de Formation en Santé constitute two important structures dedicated to helping the Acadian and francophone minority communities improve control over their own health through access to quality health services in the languages of their choice. Hopefully, they will help to redress the situation of less favourable health experienced by francophone minorities of Canada over the last decades and centuries.
REFERENCES Fédération des communautés francophones et acadiennes (FCFA). (2001). Pour un meilleur accès à des services de santé en français. Ottawa: Author. Health Canada. (2001). Rapport au Ministre Fédéral de la Santé. Réalisé par le Bureau d’appui aux communautés de langue officielle pour le compte du Comité consultatif des communautés francophones en situation minoritaire (2nd ed.). Ottawa: Ministre des Travaux Publics et des Services gouvernementaux. World Health Organization (WHO). (1999). Glossaire de la promotion de la santé. Division de la Promotion, de l’éducation et de la communication pour la santé. Service éducation sanitaire et promotion de la santé.
RELEVANT WEB SITES Fédération des communautés francophones et acadienne du Canada www.fcfa.ca/home/index.cfm Le Consortium national de formation en santé www.cnfs.ca La francophonie canadienne www.franco.ca La Société Santé et Mieux-être en français du Nouveau-Brunswick www.ssmefnb.ca Santé en français www.forumsante.ca
PA RT I V
INTERNATIONAL PERSPECTIVES
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n the first edition, we asked people to reflect on the importance of Canada in the practice of health promotion in three areas: the United States (Lawrence Green); Europe, especially the UK (David McQueen); and New Zealand (John Raeburn). This led to quite interesting views and confirmed the international leadership role played in these areas by Canada. However, we were criticized for having chosen a sample representing almost exclusively the English-speaking world; we were also conscious that globalization was a phenomenon that had progressed a lot in the last decade or so and should now be addressed. This section is thus much more important than in the first edition. In Chapter 12, Labonté presents a broad portrait of globalization, its mechanisms, its relationships to health, and examines whether health promoters in Canada or elsewhere can have any effect on it or its consequences. In Chapter 13, Jackson, Ridde, Valentini, and Gierman illustrate how several Canadian academic, governmental, and non-governmental organizations have been active internationally in bilateral or multilateral health promotion projects over the last decade. Providing several examples from their own practice, they discuss some of the issues raised when Canadian health promotion expertise is extended into international settings and contexts in various ways.
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In Chapter 14, colleagues from international non-governmental or governmental agencies address the question of Canada’s influence on the global infrastructure for health promotion, including its organizational base, its evidence base, and its conceptualization. Mittlemark, Lamarre, Cerqueira, and Corbin sketch how Canada has contributed to what they describe as an extensive and flourishing health promotion enterprise. Finally, Chapter 15 provides a fascinating portrait of Canada’s influence on health promotion in many counties. To develop this chapter, we asked people from 23 countries, representing all continents and a wide variety of linguistic, cultural, and economic situations, to provide us with a short (500 words) commentary. In their commentary, we asked them to reflect on the status of health promotion in their country over the last 12 years (if such a thing as health promotion exists there at all ) and to assess if Canadian health promotion had any influence in its development. This leads to an interesting collection of stories, from which Dupéré, the editor of the book who coordinated the process, derives some general analytical comments. At the end of this section, the reader should be able to position Canadian health promotion on the global and international scenes, to have a sense of what health promotion means throughout the world, and to see if Canada still has a role in the global arena.
CHAPTER 12
P RO M OT I N G H E A LT H I N A G L O B A L I Z I N G WO R L D : THE BIGGEST CHALLENGE OF ALL? Ronald Labonté INTRODUCTION uch has changed since the first edition of this book appeared in 1994. Most of us writing about health promotion then were concerned with the persisting tensions in practice: unhealthy lifestyles/living conditions; topdown/bottom-up programming; individual change/collective mobilization; professional knowledge/community wisdom. Our locus for grappling with these tensions was the community, and our major challenge was scaling up to those policy reaches that condition and constrain health opportunities. The limited geography of our terrain was not parochial. It was merely a product of its time. These health promotion tensions and challenge still define the territory for most practitioners— the important “ordinary” of our work that needs to be celebrated, extended, and sustained into the future. But, though necessary, health promotion’s empowering localism—even nationalism—is no longer sufficient. As the 2005 Bangkok Charter for Health Promotion states: “Health promotion must become an integral part of domestic and foreign policy and international relations” (World Health Organization, 2005). What changed?
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FROM THE INTERNATIONAL TO THE GLOB AL The most obvious intrusion into national health complacency was the SARS episode of 2003, which claimed the lives of 774 people world-
wide within a matter of months (World Health Organization, 2004). This figure is dwarfed by the death rates from most other infectious diseases, and is a fraction of the 35,000 estimated heat deaths that afflicted Europe in the summer of 2003 (NewScientist.com, 2003). But SARS warned the sanitized and immunized in rich nations that new and re-emerging infectious diseases were on a global rise and less than 24 hours air travel from almost anywhere. Curbing the incidence of disease in other countries was now as much a matter of self-interest as of international largesse. Working to promote the health of others in distant lands is nothing new. Canadians have long enjoyed a reputation for being internationalists in most things, including health. Our contributions run from the medical heroism of Norman Bethune in pre-Communist China and the (usually anonymous) volunteers with Médecins sans frontières (Doctors without Borders), to public health efforts to prevent the spread of HIV/AIDS or slow down the advancing double burden of chronic disease in poorer countries. This is still the mainstay of what we might call international health promotion, well described in other chapters of this section. But a series of world events over the past three decades require us to consider a global health promotion, one that recognizes that the causes and consequences of disease are no longer confined within national boundaries. A first glimpse of the inherently global reality of our lives came with the lunar landing 207
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of 1969 and its compelling images of a lonely planet adrift in a massive universe. The physicality of being one world (and, by extension, one people) became more prominent, and arguably more powerful, than the cosmopolitan idea. The political significance of this event, which had more to do with altering consciousness than behaviour, was quickly eclipsed by another, less visible force of interconnectedness—the global recession of the early 1970s. This recession was partly caused by two major oil crises (shortages combined with cartels) that saw prices increase sharply. Many developing countries borrowed heavily from wealthier nation lenders to sustain their oil-dependent growth. When the lending countries adopted fiscal policies that quadrupled interest rates, developing world debt escalated to a point where it threatened—through default on loan payments—to collapse the global financial system. Financial markets had become globally entwined. The World Bank and International Monetary Fund (IMF)—originally set up to
rebuild what World War II had destroyed and to prevent economic crises from precipitating a Third—subsequently morphed into “watchdog[s] for developing countries, to keep them on a policy track that would help them repay most of their debts and to open their markets for international investors” (Junne, 2001, p. 206). Their chosen policy track of structural adjustment embodied the neo-liberal economic orthodoxy and conservative politics of the wealthier countries that (still) dominate decisions in both institutions: liberalization, privatization, welfare minimalism, cost recovery, and making the country attractive to foreign investors (Milward, 2000). This orthodoxy became global gospel with the 1989 fall of the Berlin Wall, which created a normative vacuum for countries wishing to experiment with “third way” blends of state centralism and market capitalism. The result was not a fair one: rich countries—the home of foreign investors—became hugely wealthier while poorer nations became stuck in health-debilitating poverty (Figure 12.1).
FIGURE 12.1: GDP/CAPITA US$, 20 RICHEST/POOREST COUNTRIES
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CHAPTER 12: Promoting Health in a Globalizing World ■ 209 BOX 12.1: FROM STRUCTURAL ADJUSTMENT TO AN HIV PANDEMIC
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MAPPING THE NEW TERRITORY: THE DRIVERS OF CONTEMPORARY GLOB ALIZATION The concept that has come to define the political transformation of the past two decades is globalization. Kelley Lee, a UK scholar and one of the early thinkers on the globalization–health linkage, considers it broadly as a function of technology, culture, and economics leading to a compression of time (everything is faster), space (geographic boundaries begin to blur), and cognition (awareness of the world as a whole) (Lee, 2003). This is undoubtedly true, although these have been societal qualities for as long as there have been written records of societies. The qualitative shift lies in the intensity of these changes. Others have argued (convincingly) that, “economic globalization has been the driving force behind the over-
all process of globalization” (Woodward et al., 2001, p. 876). Changes in our global economy are the source of contemporary globalization’s intensification, bringing with it new challenges to health and its promotion. Among these changes are: 1. The scale of international private financial flows resulting from capital market liberalization: Currency transactions worth between $1.8 and $2.2 trillion occur daily (Kahn & Yardley, 2004). These amounts dwarf the total foreign exchange reserves of all governments, reducing their ability to intervene in foreign exchange markets to stabilize their currencies when speculative investors decide to shift their holdings, thereby precipitating a currency crisis. Each country experiencing such a crisis has seen increased poverty and
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inequality, and decreased health and social spending (O’Brien, 2002). 2. The establishment of binding trade rules, primarily through the World Trade Organization (WTO): With the birth of the WTO in 1995, trade agreements became more than simply lowering border barriers. They began to limit the policy flexibilities of national governments in ways that could imperil public health. 3. The reorganization of production across national borders: Multinational enterprises (MNEs) are central to this third and perhaps most significant trend. The emergence of global production or commodity chains allows MNEs to locate labour intensive operations in low-wage countries (often in exclusive export-processing zones that lack health, safety, or labour rights), carry out research and development in countries with high levels of publicly funded education and public investment in research, and declare most of their profits in low-tax countries. Good for business; bad for public health. 4. The crisis of climate change: Climate change is undoubtedly the most urgent global health issue. The scientific consensus is that we will experience some form of profound climatic change over the next two decades—with annual death tolls of 150,000 predicted to double within a matter of years—even assuming we achieve and move well beyond the Kyoto requirements during that time (Plumb, 2003). The apocryphal tale is that of the Easter Islanders, whose ideological enslavement to a belief in the ancients led to the erection of huge stone monuments, whose movement required skids of timber, which, as competition among the families for more and bigger monuments accelerated, denuded
the island of every last tree (Wright, 2004). No trees, no birds, no insects, no mammals, no fresh water, no food. And by the time the Europeans bumped into the island, almost no people. The tragedy is that they likely knew what would happen even as they cut the last tree. Just as we know what will likely happen as we continue to fish our oceans to extinction, eliminate our carbon sinks and biodiversity, contaminate our sources of fresh water, grow our supposedly healthy economies with a continued addiction to toxic fossil fuels, and blind ourselves to the consequences with an ideological enslavement to growth as the only marker of progress.
GLOB ALIZATION AND HEALTH: DISPUTED TERRITORY If our aim is improving global health—with a particular emphasis on the poorer half of humanity facing the greatest burden of disease—we must attend to how contemporary globalization posits its health beneficent effects. These distill to a few key claims and counterclaims: • Rapid diffusion of new health technologies and innovation. This refers back to the impressive role played by several lowcost interventions (such as immunization and antibiotics) in raising life expectancies in many poor countries (World Bank, 1993). The problem is that collapsing health systems in many poor countries can no longer deliver old technologies (immunization coverage globally is declining, and rapidly so in Africa), much less new ones. And those countries that did achieve high health gains in the past did so by also providing potable water, sanitation, women’s education, state subsidization of necessities (such as food), and
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equitable taxation and income redistribution—interventions that are now beyond the fiscal means of many of the world’s poorest nations. • Gender empowerment through increased employment opportunities for women. There is some evidence supporting this, although such work is frequently in unhealthy export-processing zones. Women’s earnings are often channelled back to the control of male family members, and many women’s domestic responsibilities remain unchanged, creating a double burden of work (Durano, 2002). • The growth-health-growth virtuous circle, which is the mainstay globalization-is-good-for-health argument. Its proponents hold that liberalization (the removal of border barriers on the flow of goods and capital) increases trade, which increases growth that decreases poverty; and any decline in poverty is good for people’s health (Dollar, 2001). Economic growth also provides revenue for investments in health care, education, women’s empowerment programs, and so on. Improved health increases economic growth (World Health Organization Commission on Macroeconomics and Health, 2001) and the circle closes virtuously upon itself. But the counterclaims are many. Trade and financial liberalization does not inevitably lead to increased trade or economic growth (Rodriguez & Rodrik, 2000). Those countries where liberalization led to growth (primarily Southeast Asia and China) did so by protecting their domestic industries and financial markets while subsidizing their exports (the same way today’s wealthy nations became so), and not by following the World Bank/IMF conditions and free trade rules (Chang, 2002). While their growth did lift many people out of
poverty at the abject less than $1 per day level (an imperfect measure used by the World Bank), it did not lift them very far. Poverty at the less than $2 per day level increased by almost the same amount over the same period (Wade, 2004). In every other region of the world, poverty rates increased. Economic growth has also given rise to escalating income inequalities within most nations, especially those that have grown the fastest (Cornia & Court, 2001), while trade liberalization has led to the increased marketing and adoption of unhealthy Western lifestyles by larger numbers of people, globalizing new pandemics of tobacco-related diseases, obesity, and diabetes.
HEALTHY GLOB AL PUBLIC POLICY: A MODEST AGENDA The recent global economic changes recounted in this chapter did not just happen. They required policy decisions by governments around the world, decisions from which most affected citizens were often excluded. During the 1990s, the breadth and depth of that exclusion generated a new global social movement that was, if not actively hostile to the present form of globalization, at least profoundly skeptical about the “rising tide lifting all boats” claims made by its cheerleaders. This movement received considerable media attention as a result of protests during meetings of the WTO, the G8,1 the World Bank and IMF, and the World Economic Forum. However, its social justice and environmental sustainability concerns have long shaped grassroots campaigns in low- and middle-income countries, and the quality of its research and advocacy have compelled acceptance of such campaigns’
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legitimacy and even many of their conclusions. These conclusions—the leverage points for change—focus on globalization’s key economic drivers and counterbalances.
Fair Financing As the new millennium dawned, the global community of countries imperfectly constituted as the United Nations consolidated a list of Millennium Development Goals (MDGs) that it thought must be, and could be, achieved by the year 2015 (see Box 12.2). These MDGs—all concerning health or its determinants—were endorsed by all nations, with the wealthiest declaring that the poorest should not lack for the resources necessary to attain them. The rhetoric has not been matched by action. Official development assistance (ODA or simply “aid”) is the principal form of public wealth transfers from rich to poor countries. For over 20 years, most of the world’s wealthier donor nations have pledged to contribute at least 0.7 percent of their GDP to ODA. Very few have. Recent promises to increase ODA are welcome; the European Union countries have pledged to reach the 0.7 percent target by 2015; the US, Japan, and Canada (the only donor country to post consistent budget surpluses in the first five years
of the new millennium) have not. Fulfilling aid commitments is one essential financing plank for global health promotion. But it is insufficient in itself partly because, with the recent exception of subSaharan Africa, developing countries actually send to wealthy nations far more money in debt repayments than they receive in aid (see Figure 12.2). Wealthy countries began a program of debt relief in 1998 for some of the world’s poorest and most indebted countries, which has freed up some funding for health and education services. But the program has been inadequate and, even with more generous debt cancellation announced at the G8 summit in the UK in 2005, will keep most developing countries trapped in a downward spiral of debt. It also requires countries receiving debt cancellation to follow the structural adjustment rules laid out by the IMF and World Bank, essentially placing their economies in the hands (and interests) of the lending nations (Labonté & Schrecker, 2006). Effective cancellation of poor countries’ debts without economic strings attached (though perhaps requiring good public accountability for how the freed-up funds are used to improve health equity within a country’s borders) becomes another key element of fair financing for health.
BOX 12.2: THE MILLENNIUM DEVELOPMENT GOALS
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CHAPTER 12: Promoting Health in a Globalizing World ■ 213 FIGURE 12.2: HOW DEBT SERVICE OBLIGATIONS DWARF DEVELOPMENT ASSISTANCE
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Inherently global health problems, however, demand inherently global solutions. Three solutions have been suggested. The first urges greater funding for global public goods for health, such as cures for disease, control of air and water pollution, new health research, and curbing epidemics. Because such goods directly or indirectly benefit all, funding them should be based on ability to pay. The establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2000 is one example of such a good. As with aid, however, support to the fund by those countries with the ability to pay has never matched estimates of demand for its resources. As of September 2005, commitments amounted to $3.7 billion against minimal requirements of $7.1 billion (Global Fund, online statistics, 2005). The second solution—a more radical one—urges new forms of global taxation to fund health and human development on a global scale. Such taxes include small levies on currency exchange, arms trade, carbon emissions, and international travel/jet fuel,
the latter already being implemented by France. The technically easiest tax (on currency exchange) could raise between $45 billion and $150 billion annually, depending on the amount charged. Wealthier individuals or institutions paying these taxes would scarcely notice the extra charge, while the redistributive impacts on health in poorer countries would be substantial. The third solution calls for closure of taxhaven countries. Many of these tax havens operate under UK or US protectorate status, and increasingly are being used by MNEs and their highly paid executives to hold their wealth exempt from taxation. Between $8 trillion and $13 trillion sit in such tax havens (the low estimate comes from the IMF; the high estimate from the international Tax Justice Network). Using the low estimate and assuming a 5 percent return, taxed at 40 percent, this would raise $160 billion a year (UNRISD, 2000)—about the estimated amount required in extra financing for developing countries to reach the MDG targets.
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Fair Trade
Fair Governance
Economics, while dominating global policy in a particularly selfish form during “the greediest decade in history,” as Nobel Prize winner and former World Bank chief economist Joseph Stiglitz subtitled his recent book The Roaring Nineties (Stiglitz, 2003), is nonetheless important to global health. Trade will remain a key component. At issue are the ecological and equity implications of the current terms of global trade. Developing country mobilizations—particularly among the African nations—together with civil society analyses and campaigns helped to reveal the hypocrisy of the early generation of WTO agreements: the slow removal of rich world subsidies to economic sectors where developing countries might have an advantage (such as agriculture); the introduction of protectionism (in the form of the TRIPS agreement), which runs counter to the notion of free trade; the preponderance of rich world delegates that dominate WTO negotiations (given the ability of wealthier nations to afford to do so); and enforcement rules (trade sanctions) that poorer countries cannot afford to use, even if they win a trade dispute (a form of cash penalty would be of much greater benefit) (Jawara & Kwa, 2003). Fair trade rules require changes in all of these areas. But an even greater requirement is that poorer countries be extended exemptions to trade rules until they are as comparatively developed as the already wealthy players. Equal rules for unequal players only produce unequal results. There are some exemptions to WTO agreements for developing countries, referred to as “special and differential treatment.” Despite repeated promises and commitments to strengthen these in trade agreements, wealthier WTO member nations—including Canada—have not supported actions to do so.
This imbalance demands new forms of global governance. Global governance does not imply global government. The difficulties of even modest reform at the United Nations and the increasing unilateralism of the United States makes global government, for a foreseeable future, an impossible dream (or nightmare, depending on one’s point of view). But global governance, a term describing the occasional confluence of private, public, and civil society interests now shaping collective actions at a global level, is occurring. Some of the structures for this governance already exist in the WTO, the World Bank, and the IMF, but they are not yet fair or transparent. The WTO is nominally the most democratic (one country, one vote) and is becoming more transparent, although in practice the sheer economic weight of the wealthier nations still predominates. The World Bank and IMF are notorious for the secrecy of their decision making and their undemocratic governance, in which the donor nations (those contributing to the institutions’ funding) have voting privileges commensurate to the amount they give. A key reform plank long advocated by developing countries and civil society groups has been to shift the balance of power within these institutions toward developing countries. Other governance efforts are controversial, such as the increase in “global public– private partnerships,” in which large MNEs participate in policy making at the UN or its agencies alongside member nations. The driving force behind these “3-Ps”—which also exist and confound public policy making within national borders—is the simple need for more money to deliver programs, although fairer forms of taxation could also meet this need without ceding increased influence or authority to the private sector (Deacon, 2003). The gradual incursion of peak civil society groups within these global
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policy circles holds some hope for more balanced discussions, though the risk that these groups become another form of elites far removed from the lives of those they claim to better is real, and not unfamiliar to health promoters well versed in the dynamics of local community organizing. There have been some successes in fair global health governance, in which Canadians can take legitimate pride. One of these was the creation of the Framework Convention on Tobacco Control, described as the world’s first global public health treaty. The Convention is now in force, and requires countries to adopt a number of measures on advertising, marketing, warning labels, and smoking restrictions. The idea was instigated by Canadians at the World Health Assembly, and strongly supported by Canadian health activists during its lengthy negotiating phase. It is weaker than activists wanted (the Convention, for example, does not explicitly state that its protocols would trump trade rules)—and there are concerns over how it might be enforced (Fidler, 2002). Whether the experience of the Convention can generalize to other global health governance issues is debatable, but it does show that it is possible. That possibility, in many ways, was created by and fuels the new global social movements for health. I argued in 1994 that health promotion (then) was an embodiment of and response to the knowledge challenges of (then) progressive social movements (Labonté, 1994). The nascent practice of global health promotion is similarly a product of new civil society configurations: • The World Social Forum, the populist and immensely popular alternative to the elite World Economic Forum • A multiplicity of international groups that have long campaigned on specific issues, such as Health Action International and its anti-drug-monopoly work, the Infant
Feeding Action Coalition and its boycott of companies violating an internationally agreed marketing code for infant formula, and MSF’s Access to Essential Medicines Campaign • A new, integrating group, the People’s Health Movement (PHM), a growing global coalition of health activists supporting each other in national and international campaigns. The PHM, in its first five years, has convened two global assemblies, created and lobbied several declarations and charters, worked with the World Health Organization and its 2005–2008 Commission on the Social Determinants of Health, helped to produce Global Health Watch 2005–2006, an equity-oriented and activist-motivated “alternative world health report,” and launched a global “right to health campaign” in 2005 (see Box 12.3). In sum, there is no absence of opportunity for global health promotion activism.
CONCLUSIONS But there are also only so many hours in a day, and a seemingly intractable morass of global health problems. It would be nice to offer a simple prescription for transforming what is toxic in contemporary globalization, allowing its healthful potential (the idealization of the global village) to flourish. But there are no easy remedies, despite the abundance of policy options and entry points. The perennial difficulty is creating that ephemeral beast called “political will.” For better or worse, this “will” remains locked behind borders. A curious irony in creating fairer forms of global governance is that it relies upon the choices of individual nation states. This irony nonetheless opens an opportunity for lobbying and activism by health promoters within
216 ■ PART IV: International Perspectives BOX 12.3: THE RIGHT TO HEALTH
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their own countries, adopting actions or utilizing strategies with which they are not unfamiliar. For instance: • We can align ourselves with the local chapter or organizations of the larger global social movements for health and justice. Just as our advocacy has helped to push local health issues into local political arenas, it can help to prod global health issues into national ones, but not if we attempt it alone. • We can build empowering health promotion partnerships that link poorer nations with wealthier ones. Many of these already exist, partly through the funding mechanism of ODA, or through the new proliferation of international public–private partnerships for health, such as the Global Fund. Many of these new initiatives suffer the same “top-down” problem of early health promotion, with a focus on specific diseases, treatments, or behaviour change without sufficient attention to the social and economic determinants of these dis-
eases. Many health promoters are skilled in good “bottom-up” and more empowering development approaches that can be diffused through these global partnerships. Look for opportunities and seize them. • We can enter the growing debates over how globalization enhances or imperils global health equity. We might do this as individuals, or by joining global social movements, or by ensuring our professional associations take strong, evidencebased positions on how globalization should change to improve health outcomes. Health promotion has developed some useful tools over the past years that can be harnessed to issues central to contemporary globalization, such as applying the techniques of health impact assessment to trade or ODA policies, using capacity-building forms of evaluation to health projects funded through ODA or the new global health partnerships, or working with our national health ministries to promote more international
CHAPTER 12: Promoting Health in a Globalizing World ■ 217 BOX 12.4: CANADA’S GLOBAL HEALTH PROMOTION CONTRIBUTIONS PAST AND FUTURE
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health “laws” like the Framework Convention on Tobacco Control (the obesity pandemic is a good next target). • We need to inject this work with the idealism that made the early days of the healthy cities/healthy communities programs so compelling. Visioning how we want to live is as important as analyzing why we are not yet doing so. We are not living in “the best of all possible worlds.” TINA—There Is No Alternative—is simply disempowering propaganda. It
is not “the end of history” in which Western economic liberalism settles in for an unmovable eternity (which, given its environmental appetite, will not last long, anyway). We need to rekindle an ethical social imaginary. As health promoters in a new millennium, the most disturbing implication of globalization may be that it forces us to confront the fundamental fallacy of our field: promoting the physical and mental health of
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individuals whose well-being rests, in part, on economic practices that are today’s equivalent of logging the last Easter Island tree is
morally unacceptable and, from an intergenerational health vantage, indefensible. What are we to say and to do about that?
NOTE 1
The group of eight leading industrialized nations: Canada, France, Germany, Italy, Japan, Russia, the US, and the UK (with special participation from the European Union). The G8 holds annual summits that formalize economic policies among themselves; by virtue of their combined economic size and dominance in multilateral organizations, these essentially become global economic policies for the rest of the world.
REFERENCES Canada Department of Finance. (2003). The Budget Plan 2003, Table A1.9. Ottawa: Department of Finance. Chang, H.J. (2002). Kicking away the ladder: Development strategy in historical perspective. London: Anthem Press. Cornia, G.A., & Court, J. (2001). Inequality, growth, and poverty in the era of liberalization and globalization. Helsinki: United Nations University World Institute for Development Economics Research (WIDER). Retrieved May 27, 2003, from www.wider.unu.edu/publications/policy-brief.htm. Deacon, B. (2003). Global social governance reform: From institutions and policies to networks, projects, and partnerships. In B. Deacon, E. Ollila, M. Koivusalo, & P. Stubbs (Eds.), Global social governance: Themes and prospects (pp. 11–35). Helsinki: Globalism and Social Policy Programme. Dollar, D. (2001). Globalization, inequality, and poverty since 1980. Washington: World Bank. Retrieved February 1, 2005, from http://econ.worldbank.org/files/2944_globalization-inequality-andpoverty.pdf. Durano, M. (2002). Foreign direct investment and its impact on gender relations: Women in development Europe (WIDE). Retrieved February 1, 2005, from www.eurosur.org/wide/Globalisation/ IS_Durano.htm. Fidler, D. (2002). Global health governance: Overview of the role of international law in protecting and promoting global public health. WHO Global Health Governance Discussion paper no. 3. Geneva: World Health Organization. Global Fund online statistics. Retrieved September 20, 2005, from www.theglobalfund.org/en. Jawara, F., & Kwa, E. (2003). Behind the scenes at the WTO: The real world of international trade negotiations. London: Zed Books. Junne, G.C.A. (2001). International organizations in a period of globalization: New (problems of) legitimacy. In J.M. Coicaud & V. Heiskanen (Eds.), The legitimacy of international organizations (pp. 189–220). Tokyo: United Nations University Press. Kahn, J., & Yardley, J. (2004, August 1). Amid China’s boom, no helping hand for young Qingming. New York Times Late Edition, p. 1. Labonté, R. (1994). Death of program, birth of metaphor: The development of health promotion in Canada. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 72–90). Toronto: W.B. Saunders. Labonté, R., & Schrecker, T. (2006). The G8 and global health: What now? What next? Canadian Journal of Public Health, 97(1), 32–34.
CHAPTER 12: Promoting Health in a Globalizing World ■ 219 Labonté, R., Schrecker, T., & Sen Gupta, A. (2005). Health for some: Death, disease, and disparity in a globalizing era. Toronto: Centre for Social Justice. Lee, K. (2003). Globalization and health: An introduction. London: Palgrave Macmillan. Milward, B. (2000). What is structural adjustment? In G. Mohan, E. Brown, B. Milward, & A.B. ZackWilliams (Eds.), Structural adjustment: Theory, practice, and impacts (pp. 24–38). London & New York: Routledge. NewScientist.com. (2003). European heatwave caused 35,000 deaths. Retrieved March 16, 2006, from www.heatisonline.org/contentserver/objecthandlers/index.cfm?id=4485&method=full. O’Brien, R. (2002). Organizational politics, multilateral economic organizations, and social policy. Global Social Policy, 2, 141–162. OECD Development Assistance Committee. (2005). Development co-operation 2004 report. DAC Journal, 6(1). Plumb, C. (2003). Climate change death toll put at 150,000. December 11, 2003: Reuters. Retrieved June 16, 2005, from www.commondreams.org/headlines03/1211-13.htm. Rodriguez, F., & Rodrik, D. (2000). Trade policy and economic growth: A skeptic’s guide to the crossnational evidence. Discussion paper 2143. London: Centre for Economic Policy Research. Stiglitz, J. (2003). The roaring nineties. New York: Penguin Books. United Nations. (2005). The United Nations Millennium development goals. Retrieved June 27, 2006, from www.un.org/millenniumgoals. UNRISD. (2000). Visible hands: Taking responsibility for social development. Geneva: United Nations Research Institute for Social Development. Wade, R.H. (2004). Is globalization reducing poverty and inequality? World Development, 32(4), 567–589. Woodward, D., Drager, N., Beaglehole, R., & Lipson, D. (2001). Globalization and health: A framework for analysis and action. Bulletin of the World Health Organization, 79, 875–881. World Bank. (1993). World development report 1993: Investing in health. New York: Oxford University Press. World Health Organization. (2004). Summary of probable SARS cases with onset of illness from November 1, 2002 to July 31, 2003. Retrieved February 10, 2006, from www.who.int/csr/sars/country/ table2004_04_21/en/index.html. World Health Organization. (2005). The Bangkok Charter for health promotion. Retrieved March 16, 2006, from www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html. World Health Organization Commission on Macroeconomics and Health. (2001). Macroeconomics and health: Investing in health for economic development. Geneva: World Health Organization. Retrieved February 21, 2005, from www.cid.harvard.edu/cidcmh/CMHReport.pdf. Wright, R. (2004). A short history of progress. Toronto: House of Anansi Press.
CRITIC AL THINKING QUESTIONS 1. What are some of the ways in which contemporary globalization might affect your own health? 2. Is a return to nationalism (a retreat from globalization) something that will be healthier for people? 3. Should we develop global rules for multinational enterprises—and the smaller companies from which they source their materials—to ensure healthier and fairer working conditions? Or are voluntary codes enough? 4. How can we promote the idea of global health equity?
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5. Are there other steps Canadian health promoters can take to reduce global inequalities in health?
FURTHER READINGS Harris, R., & Seid, M. (Eds.). (2004). Globalization and health. Leiden & Boston: Brill Publications. Globalization has many different facets and multiple ways of influencing health. Twelve detailed chapters outline globalization’s health impacts in developed and developing nations, largely from a critical social science perspective. Labonté, R., Schrecker, T., & Sen Gupta, A. (2005). Health for some: Death, disease, and disparity in a globalizing era. Toronto: Centre for Social Justice. This short book, a much expanded version of the authors’ contribution to the Global Health Watch 2005–2006, uses the stories of four people’s lives from around the world to unpack how contemporary globalization creates both health risks and opportunities. It concludes with a discussion of viable policy options for a healthier globalization. Online at www.socialjustice.org. Lee, K. (2003). Globalization and health: An introduction. London: Palgrave Macmillan. As the title suggests, this short text provides an introductory overview of globalization and health. It is particularly useful for its focus on global health policy. People’s Health Movement, Medact, Global Equity Gauge Alliance, UNISA Press, & Zed Books. (2005). Global health watch 2005–2006: An alternative world health report. London: Zed Books. The product of hundreds of health activists and organizations around the world, this book examines health in a globalizing world, with foci on health systems and vulnerable populations. An entire multi-chapter section is devoted to holding countries and multinational institutions accountable for improving global health. Online at www.ghwatch.org. UNDP Human Development Report 2005. (2005). International cooperation at a crossroads: Aid, trade, and security in an unequal world. New York: Oxford University Press. Each year the UNDP issues its annual report, with its landmark Human Development Index. Its 2005 report became another landmark, by focusing on the major economic problems that create barriers to human (and hence health) development and what can be done about them. The report also includes up-to-date global statistics on health and its many determinants.
RELEVANT WEB SITES Canadian Coalition on Global Health Research www.ccghr.ca
Research is only one of many pathways to improving global health, but it is an important one. The Canadian Coalition was formed on the fateful day of 9/11 (quite by chance) and is committed to harnessing global health research evidence to policy action.
CHAPTER 12: Promoting Health in a Globalizing World ■ 221 Canadian Society for International Health www.csih.org
The CSIH is a non-governmental organization that undertakes international health promotion activities and other health development projects around the world. It also hosts an annual international health conference in the fall, one of the best ways for health promoters interested in global health to learn and network. Global Health Watch www.ghwatch.org
This site provides up-to-date information on global health campaigns, solicits inputs for future Global Health Watches, and offers useful advice and materials for global health promoting campaigners. Globalization and Health www.globalizationandhealth.com
This open access journal publishes important, peer-reviewed research and commentary. People’s Health Movement www.phmovement.org
The PHM is an activist group dedicated to the cause of “health for all” through a combination of national actions and international mobilizations. Its People’s Charter for Health is the most widely publicized, translated, and endorsed statement on international health since the Alma-Ata Declaration on Primary Health Care.
CHAPTER 13
C A N A DA ’ S RO L E I N I N T E R N AT I O N A L H E A LT H P RO M OT I O N Suzanne F. Jackson, Valéry Ridde, Helene Valentini, and Natalie Gierman
INTRODUCTION anada plays a significant role at the international level in health promotion. In other chapters, we have already seen how key documents produced by or within the country (such as the Lalonde Report and the Ottawa Charter) have had major impacts on the way the field has developed around the world since 1974 (Lalonde, 2002). We have also seen that, after a period of decreased international leadership since 1994 at the federal level, there seems to be a certain revitalization of interest for health promotion in Canada, as evidenced in part by the fact that the 19th global conference on health promotion will be in June 2007 in Vancouver. In this chapter, we will focus more specifically on what we will call international health promotion activities, as compared to the global perspective covered in the previous chapter. “International” refers to a relationship between nations or with others who are outside the borders of one’s own country. It generally describes an approach within the traditional ethnic, geographic, and political boundaries of nations (Brown, Cueto, & Fee, 2006) in a bilateral (between Canada and another country) or multilateral (between Canada and several other countries) way. In contrast, “global,” as we have seen in the previous chapter, is a more holistic world view that is not limited by traditional national boundaries but uses an interdependent, interconnected, and interrelated approach (Brown,
C
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Cueto, & Fee, 2006; Scriven & Garman, 2005). Given the global interconnectedness of the modern world, almost every individual and/or organization working in health promotion in Canada has international ties. It was thus impossible for us to make an extensive account of all international Canadian ventures since 1994, the period covered by this book. We thus decided to select what seemed to us exemplary cases of international collaboration that give a good idea of what is going on and allow us to raise some of the key dilemmas and issues. We searched for examples keeping a few assumptions in mind. First, as most of us who have been working internationally know, Canada has a good international reputation. This has probably to do with the fact that it has no international colonial past, is not usually seen as having imperialistic ambitions, and employs two widely used international languages. We thus looked for examples of projects located in the two linguistic universes of Canada. Second, in the health promotion world, as reinforced in the rest of this book, Canada is perceived as promoting a more social than individual approach to the field, strongly grounded in a social justice, participatory, and empowerment set of principles (Potvin, 2003). As this reflects the position of the authors of this chapter, there was a tendency to search for projects with that type of orientation and consequently probably underestimates other types of international work
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operating with a different set of assumptions. Finally, we restricted our search to our academic research networks (Canadian Consortium of Health Promotion Research [CCHPR]) as well as certain key governmental and non-governmental organizations, which also affected our choice of projects and examples. Thus, other types of international health promotion ventures led by Canadians, like the ones involving the private sector, are not represented here. This being said, we nevertheless think that the examples chosen here from the set of organizations described in Table 13.1 both provide a good idea of the wide range of international activities and allow us to raise the issues that we will address in the conclusion of this chapter. These examples are organized in two broad categories: (1) training/capacity building, and (2) knowledge development and utilization in the area of evaluation.
INTERNATIONAL PROJECTS IN TRAINING AND C APACITY BUILDING One of the critical issues facing health professionals in all countries is the availability and use of human resources. For developed countries, there are specialized disciplines and university and college training programs for health promotion workers, as well as education modules on health promotion for other health professionals. In developing countries or countries in transition, partly due to the brain drain (in Africa, see Labonté et al., 2004), there are significantly fewer health professional resources and training programs. Most countries have a primary care workforce and some specialists (Labonté, 2003). Given the scope of health promotion practice, which includes policy makers, community developers, and health professionals, there is a need for training programs that
TABLE 13.1: MAJOR CANADIAN PLAYERS IN HEALTH PROMOTION ACTION AT THE INTERNATIONAL LEVEL
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provide the opportunity for people working in government, community, and primary care positions to learn about health promotion. Due to Canada’s leadership role in health promotion and its network of university-affiliated health promotion education and research centres, it is not surprising that Canada has been able to make a significant contribution internationally in training and capacity building. A central focus of Canadian work has been to use a participatory style of education, and train others in how to work with communities and assess community needs; how to plan, design, and evaluate health promotion programs; and how to introduce health promotion concepts into clinical practice and primary care, be it at the local or even in some instances at the national policy making levels. In the following pages, we give examples of Canadian training programs for different audiences: (a) trainers and educators in colleges and universities; (b) community leaders, administrators, and decision makers; (c) primary care and other health professionals; and (d) indigenous peoples. We also (e) give two examples of major integrated capacity-building projects linking professional development to policy adoption and infrastructure implementation.
Training for Educators in Universities and Colleges Training the trainers via direct provision of courses, session programs, etc., is one way Canadians have helped countless countries abroad to develop their own capacity. Here are some examples.
Health, McMaster Research Centre for the Promotion of Women’s Health, and the Ministry of Health in Mozambique. The goal of the project was to strengthen the capacities of education and training institutions to train health workers to create more egalitarian and effective relationships with the communities they serve. The training style was rooted in popular education, health promotion, and community development theories. It included critical inquiry, community participation, empowering, and discovery-based teaching and learning methods, as well as sustainable institutional change approaches. Eleven Mozambicans were trained as core facilitators over 15-month periods in Canada in 2000–2002. This training included a direct link with community agencies in Saskatoon to get a hands-on experience of community health development in Canada. In Mozambique, the facilitators were part of the Centre for Continuing Education in Health at Massinga. The small nearby community of Tevele partnered as a pilot community for demonstrating and implementing the teaching and learning methods used at Massinga to train workers. The community identified health issues using a participatory action research approach. A second term of the Canadian International Development Agency (CIDA) funding is being used to integrate the Massinga Centre into national and provincial health authorities and to strengthen its management capacity. The main lesson of this program was that the facilitative style of working closely together led to enriched learning and experience on both sides of the world. Latin America
Mozambique
The Training for Health Renewal Program was a partnership between the Prairie Region Health Promotion Research Centre at the University of Saskatchewan, Saskatchewan
The creation of networks and coalitions is an important health promotion strategy (De Leeuw, 2001; Pluye, Potvin, & Pelletier, 2004) and some of the key players in the creation of international networks for capacity building
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have been universities, as well illustrated by the Pan-American network described in the Puerto Rico contribution for this book. An additional example was the creation in 2000 of the Inter-American Network of Training on the Social Determinants of Health and the Management of Health Services. At the initiative of faculty at the University of Montreal, and notably because of Quebec’s reputation in relation to the social determinants of health (Ridde, 2004), this network was set up with university partners in Brazil, Peru, Costa Rica, and Nicaragua. Built up over several years through university-based exchanges and visits, the network developed written and video teaching aids to introduce the topic of social determinants of health into university curricula. Seven modules were proposed in 2005, dealing with concepts and theories, social movements, ethics, and situational assessments. The REDET partners described the keys to success as flexible but constant animation, participative processes, engagement of the participants, clear vision that a more community-based approach to teaching would be more effective, and shared social and human development values around social inequalities (Valentini & Albert, 2005). The lessons learned from this five-year project were not to extend the size of the network too quickly at the beginning, and that the creation of such a network takes a long time.
Capacity Building for Community Leaders, Administrators, and Decision Makers Ukraine
A CIDA-funded project led by the Canadian Society for International Health (CSIH) requested the Centre for Health Promotion at the University of Toronto (CHP) to help enhance the Kyiv government’s capacity in
administration and development of health promotion for youth programs through a 30hour certificate program (1998–2001). The project participants commented that they liked the participatory Canadian style of working and teaching, particularly with youth, and participants were enthusiastic about expanding the project to other parts of Ukraine. The second phase of this Youth for Health project (2002–2005) involved working with teachers, municipal leaders, and other administrators in how to work with youth using participatory methods. France
After a triggering event, the Forum on Social Development in April 1998 in Quebec, a set of exchanges were undertaken with the National Federation of Family Benefit Insurance Boards in France (CIF). This organization was already using a social development approach at the local level, helping families deal with daily issues. What interested the French in particular was that Quebec linked social development and health at the governmental policy level, maintaining at the same time a focus on community development and support at the local level (Leroux & Ninacs, 2002). As a result, a threeyear partnership was signed between the Institut national de santé publique du Québec (INSPQ) and the Centre national d’études de la sécurité sociale (France) (CNESSS), the organization responsible for training French leaders in the field of social security; the goal was to facilitate exchanges between networks of teachers, speakers, and lecturers in the fields of social security, public health, and social development. The main lesson in this case is how a provincial government playing a leadership role in healthy public policy can extend that leadership to work with policy makers in another country and transfer skills and lessons learned.
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Developing Health Promotion Capacity in Primary Care Workers and Other Health Professionals China
The Yunan Mother and Child Project in China of the Community Health Research Unit (CHRU) in Ottawa, funded by CIDA and the Chinese government, used a participatory approach for teaching, monitoring, and evaluation in order to improve the quality, accessibility, and timely availability of essential services in ethnic minority counties in Yunan province. The project also supported maternal and child health staff and village doctors in instituting and maintaining dynamic relationships and action with rural women and village midwives and increased the relevance and responsiveness of continuing education regarding the needs of women and children. The project trained over 4,000 nurses, grassroots midwives, and physicians; contributed to a 35 percent drop in maternal/neonatal/infant mortality rate; and the counties involved in the project showed a greater improvement in health status than the provincial average (Roelefs, 2005). These results convinced the provincial health bureau to replicate the model across all 128 counties in Yunan and led the Ministry of Health to incorporate the approach into other national initiatives. As was the case in Ukraine, the Chinese thought that the participatory style of training, which was very different from their usual more authoritarian way, was very useful and adopted the approach across all of Yunan. Due to the results achieved, this project is also an illustration of how education and support of grassroots health professionals can improve health outcomes. Croatia
In 2003, the Centre for Health Promotion at the University of Toronto (CHP) conducted
health promotion planning and evaluation training during a two-week summer school for 11 Croatian physicians from national and regional institutes of public health. Not only did the Croatians develop plans on a variety of health promotion topics, which they then implemented upon their return to Croatia, they also adapted the course modules and materials from the summer school to develop a health promotion course of their own. At a two-day training workshop in the fall of 2003 in Croatia, 70 people from various institutes of public health were then trained and further training took place at two other sites in 2004. This case is a classical illustration of the concrete benefits of training the trainers where the latter build on what they have learned to go beyond what was originally planned.
Capacity Building for Indigenous Peoples Chile
In January 2005, the chair of the Aboriginal Planning Committee for the Ontario Health Promotion Summer School went to Santiago to be part of a week-long workshop on indigenous people’s health. In exchange, four Chileans (including two Mapuche, indigenous people of the Andes) came to Canada to participate and present at the summer school in summer of 2005. The exchange between the indigenous peoples of Chile and Canada was significant and both countries organized tours of indigenous communities and health centres for their visitors. Both countries looked to each other for examples of ways to integrate traditional Aboriginal healing practices into community health centres and ways to ensure Aboriginal participation and control over health issues and organization of health care. The participatory aspects of health promotion and the
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focus on prevention of disease were important components of these exchanges. Mexico
Dr. Consuelo Garcia Andrade, a researcher at the Instituto Nacional de Psiquiatria Ramon de la Fuente Muniz in Mexico City, attended the Ontario Health Promotion Summer School in 2003 and saw the significance of using a health promotion participatory approach and holistic understanding of the role of all aspects of the physical, social, and spiritual environment in working with indigenous communities in Mexico regarding issues of alcoholism. As a result of this connection, people from the Aboriginal Health Services Unit of the Centre for Addiction and Mental Health (CAMH) of Ontario and the University of Toronto Centre for Health Promotion were invited to conduct workshops in mental health promotion and evaluation and talk about Aboriginal health in Mexico City in 2004. Many of the participants in these workshops worked with indigenous peoples in communities outside Mexico City and new ground was broken in using dance, drawing, and other arts to talk with people in these indigenous communities about their heritage, customs, and health. The main lesson we retain from these two examples is the way in which more formal summer schools may lead to a variety of other exchanges and capacitybuilding activities, provided attention is devoted to capitalize on these formal encounters to generate other initiatives.
Integrated Capacity-Building Initiatives To conclude this section, two examples of capacity building on a more ambitious level, involving support to policy makers, professional development, and infrastructure consolidation are presented.
Chile
From 1998–2001, the Centre for Health Promotion at the University of Toronto worked with the Chilean Ministry of Health (Ministerio de Salud de Chile – MINSAL) to support and strengthen (through the transfer of Canadian expertise), the implementation of MINSAL’s National Health Promotion Plan. Specific goals were to contribute to the development and implementation of national and regional health promotion strategies; to support the development and strengthening of infrastructures for health promotion; and to support the development of institutional competencies for the implementation of health promotion programs. The project, funded by CIDA and PAHO, involved partnerships with government bodies, universities, and NGOs in both countries. The main lessons learned were that Canadian teaching tools can be adapted to another country as long as the culturally affected components are modified, that partners need to take ownership of the project in their country, and that multi-level support (national, regional, and local) was a key to success. Brazil
The “Health Promotion in Action” project of the Canadian Public Health Association (CPHA), funded for three years by CIDA, was a partnership with the National School of Public Health (ENSP) and the Brazilian association of graduates in collective health (ABRASCO) The goal was to support the incorporation of health promotion into Brazilian public health policy and programs; to enhance the academic health centre’s capacity to develop, implement, and evaluate health promotion strategies to the Manguinhos community in Rio de Janeiro; and to strengthen health promotion in the graduate program of ENSP. This project illustrates the value of collaboration between
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NGOs and academic institutions as well as the importance of connecting the community, university, and policy levels.
INTERNATIONAL WORK IN EVALUATION THEORY, RESEARCH, AND PRACTICE In addition to training and capacity building, one of the most significant international contributions of Canadians in the field of health promotion has been in the area of evaluation. In order to improve health promotion practice in any country, it is important to have information about best practices, evaluation tools to communicate success and failures in practice, a policy culture that welcomes evidencebased decision making, and lots of concrete evaluation projects. This section describes Canadian international contributions to evaluation work in health promotion in three categories: (1) developing knowledge about health promotion effectiveness; (2) the development of evaluation tools; (3) recommendations for policy makers.
Communicating Internationally Useful Knowledge on Health Promotion Evaluation In 2001, the World Health Organization released a major book called Evaluation in Health Promotion: Principles and Perspectives (Rootman et al., 2001), which is now considered around the world as one of the foundational works in this domain. Of the seven-member editorial team, four were Canadians as were also 12 authors of individual chapters. One of the significant issues in health promotion in all countries is the lack of information about the effectiveness of health promotion programs. Building on expertise about the Canadian situation, the Canadian
Consortium for Health Promotion Research (CCHPR) sponsored a review of reviews to determine whether the existing methods and criteria for synthesizing the literature did justice to health promotion requirements. The review identified some key points where health promotion required a different approach and suggested a model (Jackson et al., 2001). This work drew on English-language literature reviews from around the world; it was of great interest to health promoters in Sweden and Germany and was at the core of francophone debates on this topic in Switzerland (O’Neill, 2003) and France (O’Neill & Arwidson, 2004). Also, in recognition of this lack of information about effectiveness, the International Union for Health Promotion and Education (IUHPE) initiated a Global Health Promotion Effectiveness Project in 2001 where each region of the world was asked to gather information about best practices and effectiveness in health promotion based on literature written by or about people in their region (see www.iuhpe.org). In the North American region of IUHPE, the focus of the work, cochaired by Canadian and American scholars, is on the effectiveness of community interventions. Canadians, via the CCHPR, and with some support of the Canadian government are playing a leading role in developing a model for assessing the impact of community interventions (Hills, Carroll, & O’Neill, 2004). Progress on this project has been shared with the international community at the IUHPE conferences in 2004 and 2007. Canada has thus been at the forefront of international conceptual developments around these issues, and the chapter by Potvin and Goldberg illustrates how they have been utilized in the Canadian context.
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Evaluation Tools In order to increase the number of health promotion programs that are evaluated, work needs to be done to develop user-friendly and culturally sensitive tools. This was identified as a gap by the Latin American region of IUHPE and the Pan-American Health Organization (WHO Regional Office for the Americas) that led to a set of international initiatives where Canada played a prominent role. Several Canadians participated in a PanAmerican Health Organization (PAHO) working group, which also included academics from the US and several countries in Latin America, to develop a Participatory Evaluation Resource Manual for health promoters (Pan-American Health Organization, 2003). Researchers from the University of Victoria, the University of Toronto, Laval University, and the Institut national de santé publique du Québec played major roles in the development and the testing of this tool both in English and French. A second major initiative of PAHO to provide tools to health promoters of the Americas was in the area of economic evaluation. Many decision makers involved in the healthy municipality movement wanted to know the economic effectiveness of adopting a health promotion approach. To address this, the Centre for Health Promotion at the University of Toronto partnered with the University of Valle in Cali, Colombia, with funding from the US Centers for Disease Control, to develop a guide for economic evaluation specifically for health promoters. Starting in 2002, the project involved health economists and health promotion experts from Canada, Colombia, Cuba, and PAHO. Again, Canada played a leading role in the development of this forward-thinking document. A third example of the development of internationally useful evaluation tools relates to empowerment. This initiative was a part-
nership between Quebec academics, two Quebec NGOs, (the Centre de cooperation en santé internationale et en development and Cooperative Tandem), and several francophone West African countries. The project was based on a formulation of theoretical proposals about empowerment by academics (Bernier, Arteau, & Papin, 2005; Bossé et al, 2002; Ninacs, 2001), which were applied to work with sex workers to give them the means and capacity to change their living and working conditions. The same framework and tools were then used in a community nutrition project in Haiti (Ridde & Bailat, 2005). In all of these initiatives to develop tools, the process was collaborative. This took time. It was challenging to adapt them to several linguistic cultures, but in all cases, the Canadian academics and NGOs demonstrated their creativity in developing ways to evaluate at the community level, including evaluation with disenfranchised populations.
Recommendations for Policy Makers When evaluation information is available, it is important that decision makers and policy makers are made aware of it and encouraged to act on evidence of effectiveness. A document called Health Promotion Evaluation: Recommendations to Policymakers was produced by the WHO Europe Working Group on Health Promotion Evaluation in 1995–1996 (World Health Organization, 1998). With less of a culture of evaluation, Latin American policy makers were seen by PAHO as an important target for information, but a different slant was required than that of the European approach. Using that first document, a PAHO-sponsored working group developed a different version for use in Latin America that was published in 2005 in English and Spanish as Healthy
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Municipalities, Cities and Communities: Evaluation Recommendations for Policymakers in the Americas (Pan-American Health Organization, 2005). In these two operations, in Europe and then in Latin America, the successive directors of the Centre of Health Promotion at the University of Toronto (Irving Rootman and Suzanne Jackson) played a major role along with other Canadians. A third policy makers-oriented booklet synthesizing the evidence of health promotion effectiveness for the European Union (International Union for Health Promotion and Education, 1999) was also developed in 1999 with the assistance of Canadians. Once again it is clear that information is not immediately transferable from one cultural context to another and work is required to prepare the adaptations. The European documents were very popular in Canada and it is too soon to know how useful the Latin American documents will be.
CONCLUSIONS In the period from 1994–2005, Canada continued to develop an excellent reputation in its international health promotion ventures. Its leadership role in training, evaluation, and consultation around health promotion actions in other countries is well known. As illustrated by the examples selected for this chapter, the role of Canadian governments (federal, provincial, and regional) has been key to providing credibility to governments in other countries and support to WHO health promotion discussions. At all recent World Health Organization health promotion conferences, for instance, a major Canadian player was the government of Canada. Senior government staff headed the Canadian delegations that attended the Jakarta conference in 1997, the Mexico con-
ference in 2000, the Chile Forum in 2002, and the Bangkok conference in 2005. The Canadian government provided case studies and models showing the successful implementation of health promotion programs in Canada as background documents to these conferences. At the provincial level, Quebec’s National Public Health Program (Programme national de santé publique – PNSP) (2003–2012), (Gouvernement du Quebec, 2003) for instance, set out a health promotion orientation that clearly guided its international work and its significant leadership role in French-speaking countries. And all this is in addition to the international support role that Canadian WHO Collaborating Centres in Health Promotion have played. Other factors that have been critical to the success of Canadians in international health promotion, at least if we look at the sample of projects presented in this chapter, are the presence of two official languages, a facilitation approach, cultural sensitivity, a focus on collaboration and capacity building, and the ability to work with many partners in government, academia, communities, and NGOs. The active work of Quebec academic, NGO, and government sectors has enabled Canada to work in both French- and English-speaking countries and has the potential to lead to cross-cultural fertilization. Unfortunately, this exchange of experiences is still limited within Canada because of the language barriers and has not yet reached its full potential. In the future, ways to increase the opportunity to exchange international experiences more systematically need to be found. Secondly, work with many immigrant cultures at home has also increased Canadians’ sensitivity to, and ability to work with, many other cultures. Even then, Canadians need to maintain a sense of humility in the face of the adaptations
CHAPTER 13: Canada’s Role in International Health Promotion ■ 231 BOX 13.1: ROLE OF WHO COLLABORATING CENTRES IN HEALTH PROMOTION IN CANADA
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required to transform Canadian experiences into other cultural contexts, the risk of cultural imperialism being always present. Thirdly, experience in collaboration between academics, policy makers, and NGOs in Canada and abroad as well as active connections to these networks enrich many projects. This ability to understand equity in partnerships is a well-recognized strength of Canadian health promotion work. It should be noted, however, in line with the Bangkok Charter reflections, that Canadian projects in the future would surely gain in engaging more with private sector partners, while maintaining the social justice and equity foci that characterizes much of their work. Finally, and most significantly, Canadians have used a facilitative approach in their
work that (1) is consistent with the definition of health promotion; (2) has been appreciated and copied by the countries Canadians work with; and (3) has led to reciprocal learning. The Canadian approach to evaluation, for instance, has regularly been to set the stage for better projects by creating an evaluationpositive policy culture and by creating guides and tools for use by practitioners. In our view, it is probably this experience in building healthy public policy; understanding the socio-environmental determinants of health; connecting the individual, the community, and the policy levels; and understanding how partnership and participation in decision making works that has been Canada’s greatest contribution to health promotion on the international stage.
ACKNOWLEDGEMENTS The authors would like to acknowledge the assistance of Blair Johnston and Sharhyar Murshed at the Centre for Health Promotion, University of Toronto, in the preparation of this chapter.
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REFERENCES Bernier, M., Arteau, M., & Papin, C. (2005). Palabres sur le pouvoir d’agir. Outil d’accompagnement sur l’empowerment. Quebec: CCSID. Bossé, Y., Gaudreau, L., Arteau, M., Deschamps, K., & Vandette, L. (2002). L’approche centrée sur le développement du pouvoir d’agir : aperçu de ses fondements et de son application. Canadian Journal of Counseling, 36(3), 180–193. Brown, T., Cueto, M., & Fee, E. (2006). The World Health Organization and the transition from international to global public health. American Journal of Public Health, 96(1), 62–73. De Leeuw, E. (2001). Investigating policy networks for health: Theory and method in a larger organizational perspective. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 185–206). Copenhagen: WHO Regional Publications. Gouvernement du Quéec. (2003). The Québec Public Health Program 2003-2012. Québec: Direction générale de la santé publique de la ministère de la santé et des services sociaux. Hills, M., Carroll, S., & O’Neill, M. (2004). Vers un modèle d’évaluation de l’efficacité des interventions communautaires en promotion de la santé: Compte-rendu de quelques développements nord-américains récents. Promotion & Éducation, 11(Suppl. 1), 17–21. Hope Corbin, J. (2005). Pragmatic health promotion in a globalized world: Reflections on Bangkok from the next generation: Reviews of health promotion and education online. Retrieved February 31, 2006, from www.rhpeo.org/reviews/2005/32/index.htm. International Union for Health Promotion and Education. (1999). The evidence of health promotion effectiveness: Shaping public health in a new Europe. Part Two: Evidence book. Paris: IUHPE. Jackson, S., Edwards, R., Goodstadt, M., & Rootman, I. (1997). Review and evaluation of health promotion: Report of the International Health Promotion Indicators Project. Paper presented at the New Players for a New Era: Leadings Health Promotion into the 21st Century. Fourth International Conference on Health Promotion, Jakarta. Jackson, S., Edwards, R., Kahan, B., & Goodstadt, M. (2001). An assessment of the methods and concepts used to synthesize the evidence of effectiveness in health promotion: A review of 17 initiatives. Retrieved January 31, 2006, from www.utoronto.ca/chp/CCHPR/synthesisfinalreport.pdf. Jackson, S., Perkins, F., Khandor, E., & Cordwell, L. (2005). Integrated health promotion strategies: A contribution to tackling current and future health challenges. Presented at the Bangkok Charter for Health Promotion in a Globalized World: 6th Global conference on Health Promotion, Thailand. Labonté, R. (2003). Dying for trade: How globalization can be bad for our health. Toronto: Centre for Social Justice. Labonté, R., Schrecker, T., Sanders, D., & Meeus, W. (2004). Fatal indifference: The G8 and global health. Cape Town: University of Cape Town Press/IDRC Books. Lalonde, M. (2002). New perspectives on the health of Canadians: 28 years later. Pan-American Journal of Public Health, 12(3), 149–152. Leroux, R., & Ninacs, W.A. (2002). La santé des communautés: Perspectives pour la contribution de la santé publique au développement social et au développement des communautés. Quebec: Institut national de santé publique du Québec. Ninacs, W.A. (2001). Types et processus d’empowerment dans les initiatives de développement économique communautaire au Québec. Unpublished PhD thesis, Université Laval, Quebec. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? SPM International Journal of Public Health, 48(5), 317–326.
CHAPTER 13: Canada’s Role in International Health Promotion ■ 233 O’Neill, M., & Arwidson, P. (2004). L’efficacité de la promotion de la santé. Promotion & Éducation (numéro spécial), 11(Suppl. 1), 55 . Pan-American Health Organization. (2003). Participatory evaluation of healthy municipalities: A practical resource kit for action (Draft). Washington: Author. Pan-American Health Organization. (2005). Healthy municipalities, cities, and communities: Evaluation recommendations for policy makers in the Americas. Washington: Pan-American Health Organization, Area of Sustainable Development and Environmental Health, Healthy Settings Unit. Pluye, P., Potvin, L., & Pelletier, J. (2004). Community coalitions and health promotion: Is it that important to develop an inter-organisational network? Promotion and Education, 11(1), 17–23. Potvin, L. (2003). Implementing participatory intervention and research in communities: Lessons from the Kahnawake Schools Diabetes Prevention Project in Canada. Social Science & Medicine, 56(6), 1295–1305. Ridde, V. (2004). Une analyse comparative entre le Canada, le Québec et la France: L’importance des rapports sociaux et politiques eu égard aux déterminants et aux inégalités de la santé. Recherches Sociographiques, XLV(2), 343–364. Ridde, V., & Bailat, S. (2005). Rapport d’évaluation: Projet de lutte contre la malnutrition infantile dans le département du Sud 2003–2005. Quebec: Fondation Terre des hommes. Roelefs, S. (2005). International projects coordinator. Personal communication in October 2005, Faculty of Nursing, University of Ottawa. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (Eds.). (2001). Evaluation in health promotion: Principles and perspectives. Copenhagen: World Health Organization, Regional Publications, European Series. Scriven, A., & Garman, S. (Eds.). (2005). Promoting health: Global perspectives. London: Palgrave Macmillan. Valentini, H., & Albert, L. (2005). Institutionnaliser la coopération internationale dans le domaine de la santé: Nouveaux modes de partenariats pour une plus grande solidarité internationale. Paper presented at the Conférence luso-francophone de la santé (COLUFRAS). Montréal: USI-UdM, INSPQ. World Health Organization. (1986). The Ottawa Charter for Health Promotion: First international conference on health promotion. Ottawa: Author. World Health Organization. (1997). Jakarta Declaration on Leading Health Promotion into the 21st Century. Jakarta: The 4th International Conference on Health Promotion: New Players for New Era. World Health Organization. (1998). Health promotion evaluation: Recommendations to policy-makers: Report of the WHO European Working Group on Health Promotion Evaluation. World Health Organization, European working group. Retrieved January 31, 2006, from www.who.dk/document/ e60706.pdf. World Health Organization. (2000). Health promotion: Bridging the gap. Mexico City: 5th Global Conference on Health Promotion. World Health Organization. (2005). The Bangkok Charter for Health Promotion in a globalized world: 6th global conference on health promotion. Thailand: Author.
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CRITIC AL THINKING QUESTIONS 1. In what ways has Canada played a role in the development of health promotion internationally? 2. What is the difference between an “international” approach to health promotion as compared with a “global” approach? 3. What are the effects of adopting a capacity-building approach to international health promotion? What are the strengths and weaknesses of such an approach? 4. Why is evaluation a key concern within contemporary health promotion? Are there particular challenges in conducting evaluation in an international context? What is a “culture of evaluation” and why is it important? 5. What are the differences between the Ottawa Charter and the Bangkok Charter? What are the implications of these differences for how Canada might contribute to international health promotion?
FURTHER READINGS Brown, T., Cueto, M., & Fee, E. (2006). The World Health Organization and the transition from international to global public health. American Journal of Public Health, 96(1), 62–73. This article offers critical insights into the changing terminology of “global health” and “international health” as part of larger political and historical processes. Particular attention is paid to the changing role of the World Health Organization, its response to a transformed international political context, and emerging role as a leader of global health initiatives. Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93(3), 383–388. This article outlines the developments of the concept of health promotion from 1980s policies of the World Health Organization. While the European Health for All targets and the settings approach have shifted public health strategies toward both addressing the determinants of health and empowering and supporting the participation of individuals, the focus of health policy still remains focused on expenditure rather than investment. Labonté, R., & Togenson, R. (2003). Frameworks for analyzing the links between globalization and health. Geneva: World Health Organization. This article examines the complex relationship between globalization and health, arguing that research agendas must be expanded beyond a disease-specific focus to one that also examines the complexity of social, environmental, and economic contexts. An exhaustive review and critique of recent frameworks of globalization and health or health-determining contexts concludes that few comprehensive analytical frameworks currently exist. Key points are outlined that may be useful for the future development of analytical frameworks and how such frameworks might be used to improve research into the multiple pathways by which the process of globalization influences health. Lalonde, M. (2002). New perspectives on the health of Canadians: 28 years later. Pan-American Journal of Public Health, 12(3), 149–152. Named one of the “Public Health Heroes of the the Americas” by the Pan-American Health Organization, Marc Lalonde traces both the local and global impacts of the concepts outlined in the
CHAPTER 13: Canada’s Role in International Health Promotion ■ 235 1974 Canadian government publication A new perspective on the health of Canadians and offers his insights into the future of the “health field” concept. World Health Organization. (2005). Summary overview and background to health promotion: Globalization, health challenges, and the Bangkok Charter. Thailand: 6th Global Conference on Health Promotion in Bangkok. This short briefing paper offers an excellent outline of some of the key values, principles, and actions of health promotion since the inception of the Ottawa Charter of 1986, and outlines the challenges for health promotion in a rapidly changing world.
RELEVANT WEB SITES Canadian Consortium for Health Promotion Research—International Projects www.utoronto.ca/chp/CCHPR/international.htm
Individual members of the Canadian Consortium for Health Promotion Research work with academics, organizations and agencies, and communities and governments in many ways. This Web page tracks some of the projects underway and the individual centres that are affiliated with each project. Canadian International Development Agency www.acdi-cida.gc.ca/index-e.htm
The Canadian International Development Agency (CIDA) is Canada’s lead agency for development assistance. Funded by the federal government, it has a mandate to support sustainable development in developing countries in order to reduce poverty and to contribute to a more secure, equitable, and prosperous world. The site is bilingual. Canadian Public Health Association www.cpha.ca/
The Canadian Public Health Association (CPHA) is a national, independent, notfor-profit, voluntary association representing public health in Canada with links to the international public health community. Canadian Society for International Health www.csih.org/
This Web site is available in either English or French. CSIH manages projects funded bilaterally (CIDA), multilaterally (World Bank), and internationally (PanAmerican Health Organization, the Department of Foreign Affairs and International Trade, and Industry Canada) in Latin America, Central and Eastern Europe, Africa, and Asia. Each of these projects contributes directly to an overall program that emphasizes capacity building for health systems reform. CSIH hosts an annual conference and tracks opportunities for internships, research, and advocacy internationally.
236 ■ PART IV: International Perspectives UN Millennium Development Goals www.un.org/millenniumgoals/
The eight Millennium Development Goals (MDGs) form a blueprint agreed to by all the world’s countries and all the world’s leading development institutions. The eight goals are: (1) eradicate extreme poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empower women; (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria, and other diseases; (7) ensure environmental sustainability; (8) develop a global partnership for development.
CHAPTER 14
T H E I M PAC T O F C A N A DA O N T H E G L O B A L I N F R A S T RU C T U R E F O R H E A LT H P RO M OT I O N Maurice B. Mittelmark,1,2 Maria Teresa Cerqueira,3 J. Hope Corbin,4 and MarieClaude Lamarre5 INTRODUCTION he flourishing of any complex collaborative enterprise requires appropriate infrastructure to nourish responsible growth and quality improvement. In the case of health promotion the key features of infrastructure include governmental and non-governmental networks that plan and conduct health promotion work. In the governmental arena, the World Health Organization (WHO) has established a network of health promotion expertise reaching every corner of the globe, and its global conferences on health promotion have been sparkplugs of development. On the non-governmental side, the International Union for Health Promotion and Education has long championed equity in health and the pursuit of quality and effectiveness of health promotion work. Another key feature of infrastructure is the global network of research facilities and collaborations that provide the evidence on which solid health promotion work is founded. Equally important are the training facilities that produce skilled practitioners and researchers to replenish and expand the workforce. The “nerves” that keep all these elements in relative synchrony are the communications facilities provided by conferences, journals, and, more recently, the Internet. Health promotion today is a growing enterprise, and its robust infrastructure has much credit for that. Canadian health promotion has, through its good works at home and abroad, had much
T
to do with the flourishing of international health promotion, not the least through its strengthening of health promotion infrastructure. This chapter aims to illustrate how this has happened, while accepting the hopelessness of doing full justice to Canadian influence. In other words, some Canadian fingerprints are revealed, but most undoubtedly remain to be documented.
INTERNATIONAL GOVERNMENTAL INFRASTRUCTURE Canada has positioned health promotion on political agendas as the leading public health strategy for the improvement of the determinants of health and quality of life. The first international health promotion conference produced the Ottawa Charter of 19866 and marked a major milestone in public health thinking and practice. Canada was a key advocate and partner in the implementation of the strategic areas in the Ottawa Charter. The Canadian experience contributed to strengthening a broad policy focus in the promotion of health, rather than a narrow behaviour change approach, including at the World Health Organization (WHO). The main contributions of WHO at the global level have been twofold. The WHO’s continuation of the conference series started in Ottawa has been vital in keeping health promotion on the agendas of governments. At each of the subsequent 237
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conferences (Adelaide in 1988, Sundsvall in 1991, Jakarta in 1997, Mexico in 2000, and Bangkok in 2005), the Ottawa Charter has been reaffirmed as the defining document in the health promotion arena. The Bangkok Charter for Health Promotion in a Globalized World,7 which was proclaimed at the most recent WHO conference in 2005, states among its purposes to “…[complement and build] upon the values, principles and action strategies of health promotion established by the Ottawa Charter for Health Promotion and the recommendations of the subsequent global health promotion conferences….” The other way in which WHO at the global level has been influenced by Canada, and has in turn used its influence to develop health promotion across the globe, is via debate at the World Health Assembly (WHA). The 51st WHA in 1998 explicitly acknowledged the 1986 Ottawa conference and Charter as sources of inspiration and ideas for health promotion and many other WHA resolutions have included elements urging the adoption of health promotion strategies. As the time of this writing, the WHO Executive Board has recommended that the 59th WHA, scheduled to meet in May 2006, adopt a resolution urging all member states to consider the need to increase investments in health promotion; establish mechanisms for involving all governments; foster the engagement of civil society, monitor policies, programs, and infrastructure; and close the gap between evidence and practice.8 With the legacy of Ottawa now stretching two decades, WHO at the global level has launched, or collaborated in, a series of concrete health promotion initiatives that would hardly exist without the spark ignited in Ottawa. These include the Mega Country Health Promotion Network, the Global School Health Initiative, the co-sponsoring of international conferences of the International
Union for Health Promotion and Education (IUHPE), implementation of the aforementioned 51st WHA Resolution on health promotion, and collaboration in the IUHPE-led Global Programme on Health Promotion Effectiveness. However significant WHO action at the global level has been, “WHO feet on the ground” in the regions have been equally critical to health promotion’s advancement at the country level. The experience in the (PAHO) Region of WHO is of special interest, as several chapters in this book testify (see Chapters 13 and 15).9 Here, just a few major highlights are mentioned. The Caribbean Charter (1993) adopted the Ottawa Charter and called for increased investment in promoting healthy lifestyles. Of considerable significance to the spread of health promotion in the Americas was Canadian support at various stages to the health promotion settings movement. The Quebec Healthy Cities Network supported widespread implementation of the healthy municipality’s initiative, by advocating with mayors for healthy public policies and local plans of action to promote health. The University of Alberta contributed to developing the health promoting schools and universities initiatives, building a strong alliance between the health and education sectors. The Chilean Ministry of Health and the Centre for Health Promotion at the University of Toronto (CHP) with support from PanAmerican Health Organization (PAHO), developed a project to strengthen health promotion capacity in Chile. The Canadian International Development Agency (CIDA) financed the project (1999–2003), facilitating the exchange of knowledge and experiences between Chilean and Canadian institutions, including the Chilean quality of life survey, adapted from the Canadian instrument. As of this writing, Laval University and the Universities of Victoria and Toronto par-
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ticipate in the Working Group on Evaluation convened by PAHO in 1999 to systematize, document, and evaluate the healthy settings initiatives in the region. The Division of International Development at the University of Calgary strengthened healthy communities in the improvement of maternal and infant health in four countries: Bolivia, Honduras, Nicaragua, and Peru. CIDA also funded a local development project in Manguinhos with the school of public health (ENSP-Fio Cruz) in Rio de Janeiro, Brazil. In 2003–2004 a training workshop was developed with the technical expertise from CHP to build and strengthen the capacity of several English-speaking Caribbean countries in health promotion. This overview of Canadian contributions to the work of the WHO illustrates how international governmental infrastructure has benefited from Canadian inspiration, assistance, and collaboration. The Canadian approach has consistently been one of capacity building, with respect for the experience and expertise of health promoters in other parts of the Americas. That Canadian health promotion has operated in other parts of the world solidly within the ethos of participation and empowerment can certainly be no surprise, but its documentation here serves as a tribute to Canada’s long-time dedication to develop health promotion globally in a health promoting way.
IMPACT ON INTERNATIONAL NON-GOVERNMENTAL INFRASTRUCTURE Just as the WHO is the single global intergovernmental organization with the specific mission to safeguard the public’s health, the International Union for Health Promotion and Education (IUHPE) is the only global nongovernmental organization whose mission is
to promote global health and to contribute to the achievement of equity in health between and within countries of the world.10 The influence of Canadian health promotion on the IUHPE is examined here, acknowledging that there is space to mention only a few highlights, and not nearly the full story. At the turn of the 1990s, Canadian health promoters, especially Lavada Pinder, helped lead a transformation through which the IUHPE took on a broader vision of health and a broader concept of health promotion than before, emphasizing the importance of social, economic, and other environmental determinants of health. It was in Canada that the first IUHPE North American Regional Office (NARO) was established, in 1976, immediately following the 9th World Conference of the IUHPE, which took place in Ottawa during that year. As of this writing, Canadian leadership of IUHPE activities in North America continues through the work of the IUHPE regional office at the University of Toronto. Canadian health promoters and organizations have played key roles in IUHPE advocacy work for many years, a recent example of which is the work of Ron Labonté.11 When the IUHPE wished to develop an advocacy position on the effects of global trade on health, Labonté led the effort, ensuring that the IUHPE played an active role in advocating at the World Trade Organization for an approach to globalization and trade that advances human, labour, women’s, and children’s rights; increases environmental protection and ecological sustainability; and allows for democracies to negotiate over how the wealth our economies create can be shared more equitably.12 In fact, Canadian health promoters have taken significant responsibility for key IUHPE work on many occasions. For example, Canadians organized two IUHPE World Conferences on Health Promotion and
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Health Education, the 9th one in Ottawa, in 1976, and the 19th one during June 2007. IUHPE Conferences are open to all health promotion and public health professionals, and aim to advance the scientific and professional development of the field. Considered together with WHO Global Conferences on Health Promotion, they ensure that forums for health promotion dialogue are available at regular intervals for all key partners in health promotion, including the governmental, non-governmental, and business sectors, and policy makers, practitioners, and researchers at all levels from international to local. Hosting the 2007 conference provides an excellent opportunity for Canadian and all other health promoters to commemorate and revisit the 1986 Ottawa Charter. Spanning the critical period of 20 years of health promotion’s development, critical reflection on the steps taken on the path from Ottawa in 1986 to Vancouver in 2007 will undoubtedly be a timely stimulus for creativity as we move into the third decade post-Ottawa.
Besides contributions to IUHPE advocacy and to conferences, Canadian health promoters also play or have played important roles in these core IUHPE activities (see Box 14.1).
IMPACT ON INTERNATIONAL RESEARCH COLLABORATION Literally countless research collaborations involve Canadians with researchers in many parts of the world. The purpose here is to highlight three Canadian activities that have impacted international research infrastructure in significant ways. For many years, Canadian health promoters have trekked regularly across the Atlantic and participated as full partners with Europeans in building capacity for research and evaluation. A prime example comes from the WHO European Working Group on Health Promotion and Evaluation, whose
BOX 14.1: SUMMARY OF CANADIAN IMPACT ON IUHPE ACTIVITIES
Text not available
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work began in 1995. A major product of the Working Group’s effort was the publication in 2001 of a work that has already attained the status of being the international reference work in health promotion evaluation: Evaluation in Health Promotion: Principles and Perspectives (Rootman et al., 2001). Remarkably, four of its editors are Canadians!13 Referred to familiarly simply as “the yellow book,” this volume is today used in training programs and as a desktop reference work across the globe. Through their long collaboration on the European Working Group, Canadian colleagues brought unique strengths and perspectives to this project, helping to set a new standard for appropriateness in the planning and conduct of health promotion evaluation. Related to the work just mentioned, Canadian health promotion researchers have long been linked with one another in ways that have inspired tighter collaboration on other continents. The unique Canadian model that has had perhaps the most influence is the Canadian Consortium for Health Promotion Research, which brings together researchers from all corners of the country in a highly participative network, in which communities play critical roles alongside universities. As Jackson has put it, one of the main benefits of the Consortium is that it serves as a “one-stop shopping” place for all health promoters worldwide who wish to contact Canadian resource people regarding not only research, but also education and training (Jackson, 2003). A third resource for global health promotion has been Canada’s long-term, systematic, and comprehensive approach to doing community-based research on public health problems that have yielded unique dividends for Canadians and non-Canadians alike. Perhaps the most stellar example of this is the Canadian Heart Health Initiative, started in 1989 and ongoing in various forms
even as of this writing. Using resources and expertise from the national level, all 10 provinces, universities and communities, the Initiative showed that a health promotion approach to heart health could engage ordinary people in ways that made lasting differences in a community’s capacity to deal with public health issues. In the period 1994–2000, the dissemination phase of the Initiative in nine provinces demonstrated that there was a contribution not just to heart health, but also to a strengthening of the public health system in general (see Promotion and Education’s Supplement 1, 2001, entirely devoted to this Initiative). Taken in its entirety, the Initiative is a one-of-a-kind demonstration of how policy can inform research that in turn can inform practice in a way that makes a real difference to public health. The publication of the dissemination phase of the Initiative in a special issue of the IUHPE’s journal Promotion and Education in 2001 brought this success story to the rest of the world in an inspiring manner.
IMPACT ON INTERNATIONAL TEACHING COLLABORATION Students of health promotion in every corner of the globe are the future of health promotion, and if the growth in health promotion training programs is any indication, the future is bright. Training programs are not only burgeoning; they are also connecting up in new ways to form international networks for training that truly produce synergy. Canadian influence can be seen at every level, from what goes on in the classroom to how international training networks are organized and operated. Health promotion students are strongly influenced by their teachers and by what they read. An informal survey of 10 influential
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health promotion texts reveals that all highlight Canadian centrality and significance to the field of health promotion. For health promotion students, the Ottawa Charter provides the most commonly cited definition of health promotion (Seedhouse, 1997) and also provides the framework for the delivery of health promotion in a variety of settings (Bunton & Macdonald, 1992). One text uses the Ottawa Charter’s framework to explore success in health promotion since its inception as a way of concluding the book. Another text demonstrates Canadian centrality by devoting an entire chapter to criticizing the Charter (Seedhouse, 1997). Yet another book sees the Charter as so indispensable that it includes the document in its entirety. The building of international infrastructure for health promotion training has been one of the most important developments of the past decade. In this, too, Canadian influence is pervasive. In Europe, for example, European Commission (EC) funding was used to establish the European Union Master’s in Health Promotion Consortium (EUMAHP) in 1998. After its successful conclusion in 2004, it was succeeded by the EC-funded project Public Health Training in the Context of an Enlarging Europe Project (PHETICE). Both EUMAHP and PHETICE provide the infrastructure for joint working among public health trainers and educators across Europe, producing synergy (European added value) in health promotion training (Davies et al., 2000). A main aim has been to agree on a core curriculum to be taught by all European health promotion training programs, and Canadian influence has been noteworthy. The foundation of the core curriculum is the ideology of the Ottawa Charter for Health Promotion and the methods of teaching and working with students emphasize values that are foundational to Canadian health promotion—participation, empowerment, and capacity building. Thus,
both in content and form, European health promotion educational infrastructure has been influenced by Canadian scholarship and practice. Besides these important but indirect influences, Canadian health promoters are helping directly to build European health promotion education infrastructure. As but one example, the University of Toronto Centre for Health Promotion conducted a two-week Croatian Health Promotion Summer School for a group of 11 Croatian physicians from the National and Regional Institutes of Public Health in Toronto in 2003. Following this successful summer school, a two-day training workshop was conducted on health promotion for 70 people from various Institutes of Public Health in Croatia. Further training took place at other sites in 2004.
CONCLUSIONS The recitation in this chapter summarizing some of the ways Canada has influenced global health promotion infrastructure has been uniformly upbeat. However, there have been “downs” as well as “ups,” and it is important and instructive to examine how swings in public policy in Canada have had negative as well as positive outcomes beyond national borders. In 1997, rumours swept the world of health promotion that ill winds of change were aloft in Canada. A new approach to health in Canada was announced, called population health, a strategy meant to unify the entire range of health initiatives from prevention and promotion to treatment and care. The aims of the new approach were laudable: to improve population health by confronting the material and social inequities that fostered health inequities. The strategy called for not only a sustainable and integrated health system, but also for increased national growth, heightened productivity, and
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more citizen engagement in public and private life. All this meant more attention to socalled “upstream” factors, the fundamental determinants of population health. While no health promoter could fault the logic of and the intention for the population health approach, it seemed that with the new emphasis on upstream factors, Canada’s famous community-based approach to health promotion was threatened. The term “population health” quickly replaced health promotion in public pronouncements coming from Canadian authorities. Many observers outside Canada worried that the people-centred spirit of Canadian health promotion was threatened, if not by malignant forces, then by benign neglect. If health promotion was being abandoned in Canada, would not the ill winds spread globally, precisely because Canada—the home of health promotion—must know best? The purpose here is not to comment on what actually happened in Canada in the period since then; there is much disagreement on the facts because complex changes brew confusion from which many truths emerge. What we do know is that from 1997 onward, the conversational agenda of health promoters everywhere was suddenly taken up with the question, “Is health promotion dying out in Canada?” This came at a time when changes in public health in England also seemed to de-emphasize health promotion as a public health strategy, while at the same time health promotion policy, infrastructure, and programs were beginning to flourish in many parts of Latin America, Asia, and Africa. Confusion and concern ensued. O’Neill, Pederson, and Rootman’s (2000) analysis of the state of health promotion in Canada concluded that at the level of national
and state bureaucracies, shrinking health budgets and conservative thinking had indeed contributed to a diminution of health promotion compared to the heydays following the Ottawa Charter. At the same time, they saw evidence of a dynamic health promotion presence in the universities, in Eastern Canada, and in several settings-based initiatives, including the Healthy Communities and Healthy Schools movements. Since the publication of their paper, the tide appears to have changed. Among the signs is the fact that the Public Health Agency of Canada has established health promotion as a competency across the agency, and has established a Health Promotion Centre, which may replace the Health Promotion Directorate of Health Canada that was missed since its elimination in the mid-1990s. Thus, there is little doubt that the near future will see the world look to Canada again for its health promotion inspiration. This is inevitable, since the IUHPE 19th World Conference on Health Promotion and Health Education will take place in Vancouver in June 2007, with the theme “Health Promotion Comes of Age: Research, Policy and Practice for the 21st Century.” A particularly bright spot is the fact that the Public Health Agency of Canada and its top leadership have committed to collaborate with the conference organizers, the inter-university Canadian Consortium for Health Promotion Research, to make the Vancouver conference a success. The many preparations leading to the conference, the conference itself, and the aftermath will provide valuable opportunities to strengthen the interplay of Canadian health promotion at all levels from national to local. This will be most welcome by health promoters everywhere.
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NOTES 1 2 3 4 5 6 7 8 9
10 11
12 13
Department of Education and Health Promotion, University of Bergen, Norway. Authors after the first are listed in alphabetical order. Healthy Settings Unit, Area of Sustainable Development and Environmental Health, PAHO/WHO. Department of Education and Health Promotion, University of Bergen, Norway. International Union for Health Promotion and Education, Paris, France. www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf www.who.int/healthpromotion/conferences/6gchp/hpr_050829_%20BCHP.pdf See www.who.int/nmh/eb117/en/index4.html for the full text of the recommendation. In 1993 PAHO member states adopted Resolution DC 137.R14, a regional health promotion plan of action 1994–1998. See www.iuhpe.org for details. Then at the Saskatchewan Population Health and Evaluation Research Unit, Universities of Regina and Saskastchewan, Canada. See www.ldb.org/iuhpe/Labonté.htm for the detailed report. Irving Rootman, Michael Goodstadt, Brian Hyndman, and Louise Potvin.
REFERENCES Baum, F. (1998). The new public health: An Australian perspective. Melbourne: Oxford University Press. Bunton, R., & Macdonald, G. (1992). Health promotion: Disciplines and diversity. London: Routledge. Davies, J.K., Colmer, C., Lindstrom, B., Hospers, H., Tountas, Y., Modolo, M.A., et al. (2000). The EUMAHP project: The development of a European master’s programme in health promotion. Promotion and Education, VII(1), 15–18. Dines, A., & Cribb, A. (1993). Health promotion concepts and practice. London: Blackwell Science. Gorin, S.S., & Arnold, J. (1998). Health promotion handbook. St. Louis: Mosby. Jackson, S.F. (2003). The Canadian Consortium for Health Promotion Research: A network that adds value to governments and universities. Promotion and Education, 10(1), 16–19. Kemm, J., & Close, A. (1995). Health promotion: Theory and practice. London: Macmillan Press. Naidoo, J., & Wills, J. (1998). Practising health promotion dilemmas and challenges. London: Baillière Tindall. Naidoo, J., & Wills, J. (2000). Health promotion: Foundations for practice. Edinburgh: Harcourt Publishers. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (2001). Evaluation in health promotion: Principles and perspectives. Copenhagen: WHO Regional Office for Europe. Seedhouse, D. (1997). Health promotion, philosophy, prejudice, and practice. Chichester: John Wiley & Sons. Tones, K., & Green, J. (2004). Health promotion: Planning and strategies. London: Sage Publications Ltd. Tones, K., & Tilford, S. (2001). Health promotion: Effectiveness, efficiency, and equity (3rd ed.). Cheltenham: Nelson Thornes. World Health Organization. (2005). Bangkok Charter for Health Promotion in a Globalized World. Retrieved from www.who.int/healthpromotion/conferences/6gchp/hpr_050829_%20BCHP.pdf.
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CRITIC AL THINKING QUESTIONS 1. How might charters and declarations, such as the Ottawa Charter for Health Promotion, influence public health decision making at the national level? State level? Local level? 2. What are the complementary roles of international governmental organizations (e.g., the World Health Organization) and international non-governmental organizations (e.g., the International Union for Health Promotion and Education)? 3. How might Canadian influence on health promotion abroad in turn influence Canadian health promotion?
FURTHER READINGS Jackson, S.F. (2003). The Canadian Consortium for Health Promotion Research: A network that adds value to governments and universities. Promotion and Education, 10(1), 16–19. Mittelmark, M. (2005). Charters, declarations, world conferences: Practical significance for health promotion practitioners “on the ground.” Promotion and Education, 12(1), 6. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141.
RELEVANT WEB SITES Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR/index.htm
The role of the Canadian Consortium for Health Promotion Research is to support the work of its member centres, provide networking opportunities and information exchange, facilitate new opportunities for collaborative research, advocate for and promote health promotion research in Canada, and serve as a conduit to health promotion expertise and knowledge at a national level. Health Promotion at the World Health Organization www.who.int/topics/health_promotion/en/
This page provides links to descriptions of activities, reports, news and events, as well as contacts and co-operating partners in the various WHO programs and offices working on this topic. Health Promotion Links at the Public Health Agency of Canada www.phac-aspc.gc.ca/hp-ps/
This is the link to the main page of the PHAC Web site on health promotion. It contains links to dozens of health promotion topics and programs within Health Canada and the PHAC.
246 ■ PART IV: International Perspectives International Union for Health Promotion and Education www.iuhpe.org
The IUHPE is a leading global network working to promote health worldwide and contribute to the achievement of equity in health among and within countries. It draws its strength and authority from the qualities and commitment of its diverse network of members, and it has an established track record in advancing the knowledge base and improving the quality and effectiveness of health promotion and health education practice. Members range from government bodies, to universities and institutes, to NGOs and individuals across all continents.
CHAPTER 15
V I E W S O N T H E I N T E R N AT I O N A L I N F L U E N C E O F C A N A D I A N H E A LT H P RO M OT I O N Sophie Dupéré INTRODUCTION Intent of the Chapter We are who we are only in the eyes of other people and their looks are what make us come to terms with ourselves as ourselves. —Jean-Paul Sartre, l’Être et le Néant
ur book aims to analyze the Canadian health promotion discourse and practice. Reflection on our practice and discourse necessarily implies reflexivity and self-critique. This has been taken up in the other chapters mostly by “insiders,” Canadians who have examined health promotion in different areas of the field and elicited reflections on what we have learned and how to improve our practice and research. As illustrated in the above quote, Jean-Paul Sartre nevertheless reminds us that the judgment of others is essential to our existence and to the knowledge we have of ourselves. In this spirit and to add to our critical analysis of Canadian health promotion, we thought it would be important to have external observers share their perceptions of Canada’s contribution (or not) to health promotion in their country in order to nourish our reflection and increase our understanding of Canada’s role and influence internationally. In the first edition of the book, Green (1994) and Raeburn (1994) commented on how Canadian health promotion development had an impact on the field in the United
O
States and New Zealand. Two other nonCanadians, Kickbusch (1994) and McQueen (1994), also provided their viewpoints on the influence of Canada globally and in Europe. An important criticism of this approach in the first edition was its narrowness, limited to a Western, Eurocentric, Anglo-Saxon view. We thus wanted to address this issue in the second edition and agreed that rather than having a few long chapters, we would look for shorter contributions, but from a much wider range of countries. We were conscious that this would yield less substantial analyses for each country and more a collection of selected sets of general observations. Nevertheless, because of the diversity and the originality of the format, we believed that it had potential to enrich our reflection and expose the reader to a wider panorama of the influence of Canadian health promotion.
Process We have tried to adopt as much as possible, considering our time and technical constraints, a participatory approach in the writing of this chapter. Every contributor was first asked to send a 500-word commentary on if and how the health promotion movement in Canada had (or did not have) an impact on health promotion as it existed (or not) in their own country, be it in policy, projects, capacity building, research, or otherwise. As editors of the book, we provided feedback 247
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on these first drafts and asked for clarifications when necessary. As a third step, the coordinator of the chapter highlighted some emerging issues/trends from the commentaries, posted them on a dedicated weblog, and invited the authors to react and engage in a dialogue on this first analysis. A first final draft of the chapter, taking into account the comments and suggestions, was sent to the publisher for its external review process and the feedback received was shared with the group of 32 contributors from 22 countries for final reactions. As mentioned in the introduction to this book, for this chapter as for the others, we wanted to include people involved in health promotion from a variety of backgrounds and professional expertise. We also made a special effort to ensure the involvement of the younger generation, being at the same time privileged to count on the participation of some of the most established voices in the field. The commentaries are presented at the end of this chapter by country in alphabetical order (see Table 15.1 for a list of the countries covered). In the next sections general analytical comments about what emerges from these contributions are presented as well as a set of reflections about Canada’s role and contribution on the global scene and a few considerations about the status of health promotion in the 22 countries for which a commentary was provided.
OBSERVATIONS AND REFLECTIONS B ASED ON THE CONTRIBUTIONS The intent here is not to comment in a detailed manner on the state of health promotion (HP) in the different countries nor to make an indepth analysis of the influence of Canada internationally, which is obviously an impossible task given the nature of the material
gathered, but rather to highlight certain general elements that emerge from the contributions. It is important to keep in mind that those commentaries are just snapshots of very rich reflections. We therefore strongly encourage the interested reader to consult the references and additional resources provided by our contributors to learn more about a particular country. Our comments below are divided in three main sections: (1) the perceived influence of Canada on health promotion in other countries; (2) the status of health promotion in the different countries; and (3) the strengths and limits of the analysis.
The Influence of Canada in 22 Countries At least three sets of observations can be derived from the commentaries below: (1) the types of influences; (2) the types of interactions, collaborations, and partnerships developed; and (3) the levels of intensity and impacts. Diverse Types of Influences
We were able to identify seven major types of influences of Canada on health promotion from the commentaries. Some were already signalled in Chapters 13 and 14, but new ones emerged as well. The first, noted by most contributors, is Canada’s influence through its contribution to theoretical and conceptual knowledge in HP. Canada’s historical role in laying out important conceptual bases for the field has been mentioned by many, notably through the Lalonde Report and Canada’s influence on the Ottawa Charter, although, as already mentioned, the fact that the latter is an international rather than a Canadian document usually seems to be omitted. It is important to mention, however, that these documents were not perceived as having the same importance and influence in all countries for
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Text not available
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various reasons such as the lack of participation of developing countries in the meeting that produced the Ottawa Charter (e.g., Latin America, Senegal). Many commentaries have also highlighted the academic contributions of Canadians to HP knowledge. MacDonald, from the UK, especially focused his commentary on this topic and found that Canadians have made a noticeable contribution to academic journals “which compares very favourably with countries of a similar stage in health promotion development” (see Macdonald’s commentary in this chapter). Certain areas of the field have been mentioned by more than one author as areas where Canadians have produced particularly interesting academic contributions: participatory approaches; evaluation and effectiveness in HP; globalization and its impact on population health; multicultural and Aboriginal issues; health disparities and social determinants of health; healthy public policy and health literacy; dissemination and media communication. A second important influence that was highlighted by some authors was Canadians’ practical experience. Canada is perceived by some as having made a difference by providing a distinctive model in certain areas such as: (1) bottom-up experiences/community participatory experience (e.g., Japan); (2) healthy cities (e.g., Brazil, Israel, Latin America); (3) tobacco control (e.g., New Zealand); (4) multi-ethnic society (e.g., Israel); (5) work with indigenous communities (e.g., Australia); (6) evaluation and participatory approaches (e.g., Afghanistan); (7) knowledge dissemination and media communication (e.g., France). A third influence of Canada on health promotion in certain countries was seen through its contribution to capacity building of different sectors (health sector, academic sector,
governmental). Capacity building and training were indeed two of the main contributions and factors in the success of Canada’s work internationally that Jackson and her colleagues identified in Chapter 13 and is certainly an important one to consolidate, considering that lack of human resources was mentioned as a barrier to HP development in certain countries (e.g., Puerto Rico and Romania). A fourth type of influence highlighted by some authors was Canada’s leadership role in guiding healthy public policy, notably by stressing the leadership role of the federal government at home (e.g., Australia), the work of Canada on the health impact of trade agreements (e.g., Mexico; PIC), or the influence of its legislative work (e.g., Switzerland, Israel). Again, this was identified in Chapter 13 as one of the greatest international contributions of Canada in the last decade. A fifth influence that emerged and that was discussed in Chapter 14 is Canada’s contribution to global professional capacity (governmental bodies, IUHPE, forums, chat lines) and to global infrastructure. Canada is seen (see the Nordic countries commentary, for instance) to have produced effective internationalists who have been playing important roles in various international governmental bodies and NGOs. Another element mentioned by a few contributors but nevertheless crucial is Canada’s influence as a donor country (e.g., PIC, Senegal), a role perhaps underestimated and misunderstood in the health promotion community as noted in the PIC commentary. Finally, an influence that was mentioned in the commentary from Australia is Canada’s influence through the Canadian discourse and practice, which is perceived to have distinct values such as equity, social justice, and participation. This was seen as contributing to the reinforcement of value-based HP in a country. Considering the internal debates existing in
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Canada on the role and importance of such a value base, as discussed in other chapters, it is interesting to note the perceived international personality of Canada by some external observers. Contributors were asked to identify, if they wished, Canadian resources that were commonly consulted in their country. Seven out of 22 did so. This low participation was perhaps partly due to the confusion surrounding the request. What is a Canadian resource? Is it defined by the origins of the authors that have developed it? Also, as raised by some authors, many interesting resources or projects are not necessarily 100 percent Canadian but may involve other countries as well. Table 15.2 summarizes the results of this process. No major trend can be identified there, but it is interesting to see that electronic resources seem popular, probably due to the capacity to access them easily even in poorer countries and that Canadian governmental sites offer bilingual information in two important international languages: French and English. A Diversity of Types of Interactions, Collaborations, and Partnerships
Many contributors insisted on mutual influences rather than a one-way influence from Canada (e.g., Brazil, Nordic countries). Pederson, Rootman, and O’Neill (2005), who have recently reflected on Canada’s global contribution to health promotion, have also highlighted this and stated that “Canada’s relationship to health promotion globally is perhaps best understood as a reciprocal one in which all parties benefit” (p. 250). This web of influences seems to take different forms and to be channelled through different mechanisms such as: academic contributions and Canadian Web sites offering accessible bilingual material; virtual exchanges through electronic forums (e.g.,
Click4HP); meetings in international conferences or contacts through international agencies; short-term exchanges like visiting students and professors or visiting governmental officials, professionals, or activists; more intense and organized exchanges such as donor country relationships, or collaborative projects of all kinds (e.g., research, evaluation, training, or capacity building as also shown in Chapters 13 and 14). It is also interesting to note that some contributors in the commentaries below have described how short meetings (international conferences, student and professional exchanges during summer schools, etc.) gave birth to long-term projects. One important issue for the global health promotion community to reflect on is access to these exchanges. Are health promoters from different countries able to access them equally? Do Canadian health promoters have the same probability of meeting people from different countries? Are some countries more present than others? Are some countries absent? Why is that so? Are there measures that could be taken in this respect to enlarge the international dialogue and collaboration in health promotion? Could this situation have an impact on Canada’s health promotion discourse, practice, and contribution internationally? Commentaries also show that collaborations between Canada and other countries range from short-term and superficial contacts to ongoing solid long-term partnerships. Some of the contributors have expressed the desire for more collaborative work with Canadian health promoters (e.g., Israel, Kuwait, Senegal) and suggested increasing opportunities to exchange knowledge and expertise through translating key Canadian health promotion documents in other languages (Spanish, for instance, as mentioned by Mexico). Why has the Canadian health promotion community cultivated strong longterm relationships with some countries and
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less so with others? What guides our choices to establish relationships with some countries (personal affinities and interests; linguistic or cultural affinities; professional affinities; demands from other countries; funding opportunities)? Are there countries that would benefit more from collaboration than others? Should we assign priority to collaboration according to the countries that most need it? Nixon (2006), who has reflected on some of the questions raised above, has recently argued that the conceptual perspectives underpinning projects lead to certain questions and to the exclusion of others, which necessarily lead us to elaborate particular programs and solutions. She suggests that “critical public health ethics,” an emerging field that is concerned with global health equity and power relations between rich and poor countries, becomes a crucial lens to guide international research endeavours. It is noteworthy to mention two recent Canadian initiatives that are concerned with the disparities between the focus of health research investments and the global burden of illnesses as they might be able to nurture reflections on the issues raised in this chapter. The first one is the Global Health Research Initiative, which involves major Canadian federal agencies (CIDA, CIHR, IDRC, HC) and seeks to coordinate Canada’s research response to global health challenges. The second is the Canadian Coalition for Global Health Research (CCGHR), a not-forprofit organization that promotes “better and more equitable health worldwide” notably by encouraging “greater Canadian investment in global health research” and “nurturing productive partnerships among Canadians and people from low and middle income countries” and “translating research into action” (CCGHR, 2006). These initiatives, as well as authors in public health concerned with global health and inequalities, are reflecting on how best
to allocate scarce resources for research, how to establish research priorities, and how to have systemic and meaningful impacts on health (Di Ruggiero et al., 2006; Kickbusch, 2006; Labonté & Spiegel, 2001; Neufeld & Spiegel, 2006). These reflections could inspire and nurture the Canadian health promotion community in its international work. For instance, Neufeld and Spiegel (2006) recommend more coherent resource allocation, aligned with consensually identified priorities in areas in which Canada has shown strengths, which are many, as seen above. Di Ruggiero et al. (2006) argue that Canada can best make research matter globally by orienting the work on the “upstream” determinants of health, a position that many in the Canadian health promotion community will find quite familiar. Finally, Louise Signal, in her commentary about New Zealand, stresses the importance for the HP global community to find more effective ways to work internationally by developing partnerships among nations, working through international organizations, and building alliances with other sectors. Although there has been progress, the inequality under which research has been carried out in the developing countries remains a challenge and models are needed to consolidate partnerships and strengthen research capacity in global health (Forti, 2005). A Diversity of Levels of Intensity and Impacts
The influence of Canada on other countries seems to have different levels of intensity, ranging from no or subtle indirect influence to distinct and significant impact. Influences reported were mainly positive, but ambiguous ones were sometimes pointed out, the most evident example of the latter being found in the commentary about Tunisia. This example reminds us that collaborative ventures and projects often take place in delicate
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social and political contexts and can have unexpected consequences. The Tunisian example reminds us also that international HP work requires as much (if not more than) local work, a lot of reflexivity on one’s practices (see Chapter 16). Elsewhere its author (Marzouki, 1994) illustrated well how HP concepts borrowed from countries of the North are often inappropriate to countries of the South. It prompts us to think about the validity of our assumptions, the universality of our answers, as well as about our role and impact. What are the limits of Canadian HP models? Are they relevant for every other country? What are the necessary adaptations? Indeed, some commentaries below (Brazil and Ukraine notably) indicated that Canadian HP models need adaptation when transposed in other contexts if success is to be attained. Ukraine has also underlined that a key factor of success was the constant evaluation and research, which helped in the monitoring of the project and facilitated effective adaptation of Canadian best practices. This is certainly an example of a successful collaborative project that we can learn from. Canada is generally known for its politics of dialogue and this reaffirms its importance.
THE STATUS OF HEALTH PROMOTION IN 22 COUNTRIES General Observations Given the space the contributors had and the nature of the invitation, which focused on ways in which Canadian influence might be reflected in their country, the information regarding HP in their respective country was necessarily limited. Nevertheless, we have identified four sets of general observations that can be derived from their commentaries. First, whereas most authors seem to sit-
uate the existence of health promotion institutions within the public health system of their country, some spontaneously mention its presence outside the health system and even a few outside the governmental sector (e.g., the contributor from Romania identifies NGOs as key players in HP). Second, health promotion is clearly not operating in the same forms in all the countries. For example, some have mentioned that health education was the dominant approach to HP (e.g., Kuwait, France). Some have also mentioned the existence of health promotion interventions under other labels such as primary health care (e.g., Senegal) or something else (e.g., Brazil, Afghanistan). Thirdly, we can observe many different “health promotion trajectories” for countries. Contemporary mainstream health promotion (as defined by the Ottawa Charter) has not been adopted by certain countries and is just starting to gain currency in others whereas it has been in place for variable periods (ranging from 10 to 20 years), through an established infrastructure, in a number of them. The evolution of health promotion is also influenced by the evolving social, cultural, historic, and political context of each country as clearly seen for Tunisia, Afghanistan, and Brazil. It is interesting to observe in the 22 examples below the variety of experiences as well as the various factors that have triggered the entry of HP in a country, from major social and political movements (as in Brazil) to significant personal encounters of senior politicians (as in Iran). Despite these differences, however, there seem to be common and shared experiences among many countries such as the struggle with the biomedical and curative paradigm dominant in health systems all over the world, as well as the quest for the demonstration of HP effectiveness and credibility (notably for policy makers); this will be discussed further
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in our conclusion to the book. Health promotion is not perceived as a recognized discipline or legitimate field of practice in all countries. Some contributors have underlined the importance of its recognition for the development of public health policies and stronger multisectoral integration, whereas others stress the importance of its legitimization for an increased allocation of resources for research and practice.
Additional Thoughts These observations emerging from the contributions below are quite similar to those formulated by people who have recently looked at health promotion internationally. Scriven and Garman (2005), for instance, who have dedicated a large part of their book on global health promotion to case studies from different regions of the world, have also noted discrepancies in how health promotion is conceived, valued, and approached in different countries. This a particularly interesting element to reflect on as it has consequences for health promotion practices, especially if different labels are used to designate them. An outsider may find that a country has a “low level” of health promotion development based on the formal labelling of it whereas, in reality, there might be more “health promoting interventions” than it might seem; this might have all sorts of repercussions. It may lead us, for example, to miss some important experiences that could be learned from. For instance, health inequalities are emerging as an important concern in several Northern countries, as discussed by Dennis Raphael in Chapter 7 of this book; consequently, many people in these countries are searching for possible interventions to reduce them. Are we looking at all the pertinent experiences in these matters? To take a concrete example voiced in the commentaries, can the
HP community in Canada learn from the mobilization experiences of civil movements such as the Landless Movement in Brazil to tackle increasing social health inequalities here? Hubley (2005), who has reviewed health promotion activities in low- and middleincome countries, highlights the fact that they have received relatively little attention in the field. Some interesting work there remains largely undocumented because of the persistent inequalities under which research is carried out as well as the biases in the publication of knowledge and access to information mentioned by Forti (2005), among others. Additionally, some health promotion initiatives that may be interesting to learn from are excluded and ignored by the global HP community because of insufficient evidence of effectiveness and impact due to lack of resources to assess them (Hubley, 2005) or to different definitions of effectiveness as pointed out by the Global Programme on Health Promotion Effectiveness (International Union for Health Promotion Education, 2006). This initiative, piloted by the IUHPE and WHO, is an important one for the field as it aims to share best practices from around the world and strengthen the capacity to develop evaluation of the effectiveness of health promotion in different parts of the planet. Finally, and more generally, Canada as well as other countries would benefit by looking at initiatives from other sectors that are not labelled health promotion but aim to improve the health of the population. As pointed out by Mittlemark (2005) or Ziglio, Hagard, and Griffiths (2000), intersectoral collaboration with partnerships beyond the traditional disciplines, groups, and professional alliances that define and shape current health promotion (such as social movements, the corporate sector, and less usual academic disciplines) is crucial to address the health challenges of the world. Globally, health
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promotion has tended to remain isolated in its evolution and there is an urgent need to stimulate its development with new energy, alliances, and ideas (Mittlemark, 2005). Along with this quest for other alliances outside of the orthodoxy of health promotion there is a need to reflect on the essence of health promotion, its unique scope, contribution, and benefits. As noted above and elsewhere (Scriven & Garman, 2005), there seem to be common problems—such as the shortage of HP resources and common struggles— notably with the dominant biomedical and curative paradigm, which call for continuing the evaluation of HP effectiveness and efforts to develop its political and scientific credibility (Nutbeam, 1998, 1999; O’Neill, 2003, 2004; Ziglio, Hagard, & Griffiths, 2000).
CONCLUSION Strengths and Weaknesses of the Analysis The analysis presented above, even if it was sent to and is using comments and reactions from the various contributors through the process described in the introduction to this chapter, constitutes the conclusions of the coordinating author of the chapter, which might not be shared by all the contributors below. The idea was not to build a final consensus but to gather a variety of perspectives and see what emerged from the harvest. The range of ways in which the contributors interpreted their task, which was very broad, has its advantages and limits. The main advantage is perhaps the liberty that each took in choosing what she or he wanted to highlight and how to do it. Contributors have taken a particular stance and selected a set of observations about one or more elements of Canada’s contribution to health promotion in their country, a selection that was entirely in
their hands. We have thus obtained, as seen below, a great diversity in terms of styles and content. Although this diversity is undoubtedly a strength of the process, it also limits the conclusions we can draw. The type of material gathered does not permit us to make any generalization; we cannot even pretend that this is a fair or a representative picture of health promotion in the 22 countries, nor of the influence of Canada on them. The selection of authors was made by the editors through their professional and personal networks and has certainly introduced different biases. Although we have certainly gathered a diversity of voices, many important ones are missing. Notably, despite several trials, we were not able to get contributions from China or India, leaving unrepresented a significant part of the world population, nor from Germany, Spain, or the Netherlands, key European players in the global health promotion arena. Furthermore, although we encouraged the authors to adopt a critical position, some may have held back and limited their criticisms because of past or ongoing relationships with us or because of the method we used to gather the information. Finally, many authors have raised the issue of the word count and the almost impossible task of writing a substantial critical reflection in such limited space. This has provoked frustration and important cuts of pertinent material to contextualize their statements or to add important elements. It is therefore important to keep in mind that those commentaries are just snapshots of richer reflections, and we hope that in reading the chapter our contributors will find that their effort was worthwhile. This being said, we believe these short commentaries are very useful in their contribution to our understanding of Canada’s role internationally in the field of health promotion, as well as of the different forms and
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colours health promotion takes in different contexts. They offer a unique patchwork of the situation, allow several clear and significant elements to emerge as well as some important questions and issues to be raised, which, as we have shown, are of the same type as those noted by many global health scholars.
Final Thoughts Many have pointed out the historical leadership of Canada in the field of health promotion notably through the Lalonde Report and the Ottawa Charter, even though the latter as such is not a Canadian document any more than the Kyoto Protocol is a Japanese document. Canada is still perceived today by many as a leader in some areas of the field and there is a remarkably consistent view on Canada’s distinct and international profile as well as on its degree of influence internationally in the 22 contributions.
By reading them we can certainly say that Canada had global influence over the last 10–12 years, but we can wonder about the extent and the nature of its impact since health promotion projects can have both intended and unintended consequences. More evaluation should be conducted on Canadian international and global action. Only through more analysis can we ensure impact and effectiveness when we intervene and create interventions that are sustainable and effective. International work thus requires sustained reflection and informed debate in order to understand what is needed of the Canadian health promotion community to understand Canada’s global responsibilities and accountability in supporting a better integration of the South into the global health promotion community and to promote more equitable North–South relationships in the context of globalization from which both parties can clearly benefit.
REFERENCES Canadian Coalition for Global Health Research (CCGHR). Vision and mission. Retrieved April 12, 2006, from www.ccghr.ca. Di Ruggiero E., Zarowsky, C., Frank, J., Mhatre, S., Aslanyan, G., Perry, A., et al. (2006). Coordinating Canada’s research response to global health challenges: The Global Health Research Initiative. Canadian Journal of Public Health, 97(1), 29–31. Forti, S. (2005). Building a partnership for research in global health: Analytical framework. Ottawa: Task Force on Building partnerships. Canadian Coalition for Global health research (CCGHR). Green, L.W. (1994). Canadian health promotion: An outsider’s view from the inside. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 314–326). Toronto: W.B. Saunders Canada. Hubley, J. (2005). Promoting health in low- and middle-income countries: Achievements and challenges. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 147–166). New York: Palgrave Mcmillan. International Union for Health Promotion and Education (IUHPE). (2006). Global programme on health promotion effectiveness. Retrieved April 12, 2006, from www.iuhpe.org/English/projects_project2. Kickbusch, I. (1994). Introduction: Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 350–374). Toronto: W.B. Saunders. Kickbusch, I. (2006). Mapping the future of public health: Action on global health. Canadian Journal of Public Health, 97(1), 6–8. Labonté, R., & Spiegel, J. (2001). Setting global health priorities for funding Canadian researchers.
258 ■ PART IV: International Perspectives A discussion paper prepared for the Institute on Population and public health. Retrieved April 12, 2006, from www.spheru.ca/PDF%20Files/GHpaper%20-%20PDF.pdf. Lalonde, M. (1974). Nouvelle perspective de la santé des canadiens. Ottawa: Gouvernement du Canada: Ministère des Approvisionnements et Services Canada. Marzouki, M. (1994). Promotion de la santé, une vision du Sud. In R. Bastien, L. Langevin, G. Larocque, & L. Renaud (Eds.), Promouvoir la santé: Réflexions sur les théories et les pratiques (pp. 3–38). Montréal: Partage. McQueen, D. (1994). Health promotion research in Canada: A European/British perspective. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 335–348). Toronto: W.B. Saunders. Mittlemark, M. (2005). Global health promotion: Challenges and opportunities. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 48–57). New York: Palgrave Mcmillan. Neufeld, V.R., & Spiegel, J. (2006). Canada and global health research: 2005 update. Canadian Journal of Public Health, 97(1), 39–41. Nixon, S.A. (2006). Critical public health ethics and Canada’s role in global health. Canadian Journal of Public Health, 97(1), 32–34. Nutbeam, D. (1998). Evaluating health promotion: Progress, problems, and solutions. Health Promotion International, 13(1), 27–44. Nutbeam, D. (1999). The challenge to provide “evidence” in health promotion. Health Promotion International, 14(2), 99–101. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? Sozial- und Praventivmedizin/Social and Preventive Medicine, 48(5), 317–326. O’Neill, M. (2004). Le débat international sur l’efficacité de la promotion de la santé: d’où vient-il et pourquoi est-il si important? Promotion et Education, Hors Série(1), 6–9. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future? In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). New York: Palgrave Mcmillan. Raeburn, J.M. (1994). The view from down under: The impact of Canadian health promotion on development in New Zealand. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 327–334). Toronto: W.B. Saunders. Sartre, J.-P. (1976). L’Être et le Néant. Paris: Gallimard. Scriven, A., & Garman, S. (2005). Promoting health: Global perspectives. New York: Palgrave Mcmillan. World Health Organization (WHO). (1986). Ottawa Charter for Health Promotion. Health Promotion International, 1(4), i–v. Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion development in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.
CRITIC AL THINKING QUESTIONS 1. Describe the kind of influences Canada’s health promotion movement had or has on certain countries by providing concrete examples from five country commentaries below to illustrate your arguments. 2. Identify some factors that might explain Canada’s influence (or lack of) on health promotion in other countries by providing concrete examples from the country commentaries to illustrate your arguments.
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3. How could Canada improve its HP international work and collaborations? 4. Of all the commentaries below, which ones strike you the most? Why? 5. Does the practice of health promotion vary from one country to another? Why?
HEALTH PROMOTION IN AFGHANISTAN Valéry Ridde, Suraya Dalil, Shukrrullah Wahidi, and Linda Bartlett
How Health Promotion Is Embedded in the Recent Health Policies In Afghanistan today, health promotion is largely unrecognized as a public health discipline. However, health programs in Afghanistan include health promotion activities. Afghanistan’s turbulent history has left health care and other infrastructures decimated, and the population’s health indicators are among the worst in the world, signalling a population struggling for survival and development (Bartlett et al., 2005). In 2002, the Afghan Ministry of Public Health established key priorities called the Basic Package of Health Services (BPHS) to address the greatest health problems of the population, including those living in remote areas. The BPHS includes primary prevention and health promotion services for maternal and newborn care, immunization against communicable diseases, nutrition, health education, and supply of essential drugs. Additional health promotion activities, including those related to mental health and disability, are planned. In addition, a settings approach is occasionally utilized, as in the multisectoral Healthy Schools Initiative. Afghanistan is currently in a complex transitional phase, moving from a war and emergency situation toward one of sustainable development. This requires continuation and expansion of multisectoral efforts to address the multiple influences on development identified in the health promotion approach (for instance health, education,
economic, ethnic, and gender disparities), which require long-term and substantial technical and financial resources. Further recognition and emphasis should be given to health promotion activities and policies to optimize Afghanistan’s ability to build a sustainable, secure, and healthy society.
How Health Promotion Programs Are Evaluated Health promotion experts are advocating the use of participatory approaches to evaluate programs on which Canada has had significant influence through concrete tools or more academic contributions (Cousins & Whitmore, 1998; Ridde et al., 2003). In addition to the relevance of this approach to evaluate NGOs health promotion programs, this Canadian participatory way was adopted for the programs implemented by Aide Médicale Internationale. In this context, between 2001 and 2003, three evaluations were conducted. Thanks to the changing context (from conflict and the Taliban to a situation of post-conflict and rebuilding of the state) we were able to use approaches closer to the ideal type of the participatory model. One of the goals was to build capacity among the NGO stakeholders and was best exemplified in a 2003 evaluation, which adapted a method proposed by Aubel (1999). A final one-day workshop was conducted, where a draft action plan regarding the implementation of recommendations was developed, based on the evaluation findings and lessons learned, and an evaluation steering committee was devised to follow up on the action plan and implement it. The Afghanistan case is thus an excellent
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example of a very complex international situation of humanitarian aid where evaluation of health and health promotion ventures is
essential but almost impossible to undertake without through a participatory approach (Ridde, 2003).
REFERENCES Aubel, J. (1999). Participatory program evaluation manual: Involving program stakeholders in the evaluation process. Calverton: Child Survival Technical Support Project and Catholic Relief Services. Bartlett, L.A., Mawji, S., Whitehead, S., Crouse, C., Dalil, S., Ionete, D., et al. (2005). Where giving birth is a forecast of death: Maternal mortality in four districts of Afghanistan, 1999–2002. Lancet, 365(9462), 864–870. Cousins, J.B., & Whitmore, E. (1998). Framing participatory evaluation. In E. Whitmore (Ed.), Understanding and practicing participatory evaluation (pp. 5–23). San Francisco: Jossey-Bass Publishers. Ridde, V. (2003). L’expérience d’une démarche pluraliste dans un pays en guerre: l’Afghanistan. Canadian Journal of Program Evaluation, 18(1), 25–48. Ridde, V., Baillargeon, J., Ouellet, P., & Roy, S. (2003). L’évaluation participative de type empowerment: Une stratégie pour le travail de rue. Service Social, 50, 263–279. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (2001). Evaluation in health promotion: Principles and perspectives. WHO Regional Publications, European Series, no. 92. Copenhagen: World Health Organization.
FURTHER READINGS Islamic Transitional Government of Afghanistan. Ministry of Health. (2003/1382). A basic package of health services for Afghanistan. From www.af/resources/aaca/cg+adf/health_nut_cg/ BPHS%20Final.pdf. In March 2002, the Afghan Ministry of Health began a process to determine its major priorities for rebuilding the national health system, and which health services were so important for addressing the greatest health problems that they should be available to all Afghans. It was decided to call these crucial services a Basic Package of Health Services (BPHS). Ridde, V., & Shakir, S. (2005). Evaluation capacity building and humanitarian organization. Journal of MultiDisciplinary Evaluation, 3, 78–112. From http://evaluation.wmich.edu/jmde/ JMDE_Num003.html. This article documents a process of evaluation capacity building in a humanitarian organization in Afghanistan between 2001 and 2003. The authors carried out an annual evaluation and they undertook evaluation capacity-building activities. Strong, L., Wali, A., & Sondorp, E. (2005). Health policy in Afghanistan: Two years of rapid change: A review of the process from 2001 to 2003. From www.lshtm.ac.uk/hpu/conflict/files/publications/file_33.pdf. This paper outlines policy developments in the reconstruction of Afghanistan’s health system between 2001 and 2003. A brief overview of the current health system and successes to date is presented together with an update on more recent developments.
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RELEVANT WEB SITES Afghanistan Centre at Kabul University www.afghanresources.org/index.asp
Afghanistan Centre at Kabul University (ACKU) provides the most comprehensive collection of materials related to Afghanistan in the region. A variety of Western and Afghan languages are represented. Afghanistan Research and Evaluation Unit www.areu.org.af/
The Afghanistan Research and Evaluation Unit (AREU) is an independent research organization whose mission is to conduct and facilitate action-oriented research and learning that informs and influences policy and practice. AREU also actively promotes a culture of research and learning by strengthening analytical capacity in Afghanistan and creating opportunities for analysis, thought, and debate.
THE EVOLUTION OF HEALTH PROMOTION: CANADA’S CONTRIBUTIONS TO POLICY, THEORY, RESEARCH, AND PRACTICE IN AUSTRALIA Marilyn Wise
Australia invested in health education early in the 20th century and during the 1970s began to undertake community-based health promotion. Since then, the WHO Health for All initiative, the Lalonde Report, the AlmaAta Declaration, and the Ottawa Charter (and the subsequent WHO global documents) have stimulated the development of specialized health promotion capacity within the health sector, in the non-government and private sectors, and in academia. The practice of health promotion evolved to include the application of the comprehensive range of strategies that has been demonstrated to be effective in achieving significant, sustained improvements in the health of populations. The 21st century is seeing persistent inequalities in health and has challenged
health promotion practitioners, researchers, and policy makers to engage in the politics of social decision making to define society’s goals and to pursue social justice, equitable access to health care and health protection, and to enable all citizens to achieve optimal health status. From the time of the Lalonde Report in 1974, characteristics of health promotion discourse and practice emerging from Canada have reinforced the values that underpin health promotion in Australia. Beyond the focus on lifestyle, the Canadian approach has emphasized the significant role of the state in creating policy environments within which individuals, communities, and organizations (including the private sector) can make decisions that promote or maintain health and contribute to equitable population health outcomes. Canadians have helped build the case and have highlighted the need to work both with government and communities, particularly indigenous and poorer communities. Canadians have also contributed to the conceptual and theoretical frameworks that
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underpin health promotion policy, practice, and research in Australia and to building evidence of effectiveness, combining methodological rigour in all aspects of practice, research, and evaluation. Effective health promotion requires strong, well-resourced organizational bases to conduct and disseminate research; to design, deliver, and evaluate local and national practice; and to establish and implement or contribute to public policy. Canada has contributed to the identification of the structural components of such capacity, and to understanding the need for specific investment to ensure that the rights of all citizens to optimal health are included in policy, research, and practice. As a result, Canada has demonstrated the relationship between First Nations, Inuit, and Métis land and political rights and their health, which is an issue of significance in Australia
too. The investment in organizational infrastructure (for instance, the Canadian Population Health Initiative, the appointment of a federal minister of state for public health, university-based research centres in health promotion) has also been inspiring. Finally, Canada has contributed to building evidence of the effects of globalization on the health of populations, and on some practical, evidence-based responses that are helping us to address the issues “at source” and to influence global practice. In all, it is widely acknowledged in Australia that Canada has made significant contributions to building the scientific and political credibility of health promotion as a discipline and field of practice that has proven to be effective in improving the health of populations.
REFERENCES Chandler, M., & Lalonde, C. (1998). Cultural continuity as a hedge against suicide in Canada’s First Nations. Transcultural Psychiatry, 35(2), 193–211. Jackson, S., Cleverly, S., Poland, B., Burman, D., Edwards, R., & Robertson, A. (2003). Working with Toronto neighborhoods toward developing indicators of community capacity. Health Promotion International, 18(4), 339–350. Labonté, R., Schrecker, T., & Amit Sen, G. (2003). Health for some: Death, disease, and disparity in a globalizing era. Toronto: Centre for Social Justice. Raphael, D. (2003). Barriers to addressing the societal determinants of health: Public health units and poverty in Ontario, Canada. Health Promotion International, 18(4), 397–405. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D., Poitvin, L., Springett, J., et al. (Eds.). (2001). Evaluation in health promotion: Principles and perspectives. WHO Regional Publications, European Series, no. 92. Copenhagen: World Health Organization.
FURTHER READINGS Baum, F. (2002). The new public health: An Australian perspective (2nd ed.). Melbourne: Oxford University Press. This is a comprehensive overview of “the new public health” in Australia and includes strong chapters on health promotion or, as this author views it, on health development and empowerment, organizational development, public health policy, and healthy societies and environments. Baum’s work is distinguished by its clear focus on equity and social justice, themes that she develops
CHAPTER 15: Views on the International Influence of Canadian Health Promotion ■ 263 eloquently throughout the book, backed by evidence and guidance on means to bring about positive changes in society, as well as individuals. Duckett, S.J. (2004). The Australian health care system (2nd ed.). Melbourne: Oxford University Press. A lucid overview of the Australian health care system that orients readers to the strengths and weaknesses of a complex health care system that has been described as “a strife of interests.” Duckett uses a systems approach to describe the inputs and processes of the system and the associated outputs and outcomes, including health outcomes. The book provides a context for the policy, design, and delivery of health promotion (and public health) interventions in Australia. Hawe, P., Degeling, D., & Hall, J. (1990). Evaluating health promotion: A health workers’ guide. Sydney: MacLennan and Petty. Although published some time ago, this book has influenced all subsequent health promotion teaching, research, and practice in Australia. It continues to serve the field well, describing and illustrating a logical, evidence-based analytical approach to designing and evaluating programs. Moodie, R., & Hulme A. (Eds.). (2004). Hands-on health promotion. Melbourne: IP Communications. The book focuses on contemporary health promotion practice, drawing together evidence of policy, structures, and processes, and examples of effective practice at local and global levels. It is a wellstructured overview of the field in the early 21st century and offers insights into the “state of the art” in health promotion, with particular focus on priority populations and major public health issues.
THE CONTRIBUTION OF C ANADIAN INITIATIVES TO BRAZILIAN HEALTH PROMOTION Márcia Faria Westphal and Tatiana Pluciennik Dowbor
The Situation of Health Promotion in Brazil In 1998, with the support of the InterAmerican Development Bank, the Brazilian Ministry of Health launched a national health promotion program, but it never allocated the resources to make it work properly. However, without using a health promotion label, the Brazilian federal government implemented diverse initiatives aimed at impacting the social determinants of health. A current example is the Zero Hunger Program. Another major initiative is the Family Health Program;
launched in 1994, health promotion is one of its main components and in 2005, it was covering 43 percent of the Brazilian population, reaching almost 5,000 cities and 76.8 million people. Other examples of local health promotion projects include more than 40 healthy municipality and 19 healthy school initiatives. Moreover, the Brazilian non-governmental sector runs different initiatives aimed at impacting the social determinants of health as is the case of the Landless Movement, a civil society movement aimed at narrowing the huge equity gap through rural reform. On the academic front, Brazil has health promotion research centres (for instance at the University of São Paulo, the Catholic University of Parana, the Federal University of Pernambuco, and the Ceara School of Public Health), and several universities include health promotion in their curricula.
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Influences That Shaped Brazilian Health Promotion Brazil has a history of hard political conflicts and public health reform was part of a political fight that utilized the international public health reform movements since the declaration of Alma-Alta to lead to the current situation; an important part of the Brazilian health promotion agenda was constructed through this internal fight. In this context Canada had its impact on how and how much health promotion would be disseminated in Brazil, but more on the initiatives that are formally labelled health promotion than on the ones that are not so. Canadian influence was also probably more significant on initiatives that are more consensus- and partnership-oriented than on the ones that make social conflicts more explicit, such as the landless movement. There are several examples of the Canadian influence on Brazilian health pro-
motion. The first Brazilian healthy municipality initiative was undertaken in São Paulo in partnership with Toronto as sister cities. The Brazilian Family Health Program is sometimes described as being inspired by several international initiatives, including Canada’s Family Doctors and Community Health Centres programs. Several Brazilian professionals got the opportunity to exchange experiences with Canadian counterparts, Canadian professors regularly come to Brazil, and many Brazilian students go to Canada for graduate studies in health promotion. On coming back to Brazil, many were able to critically recontextualize their knowledge and fruitfully contribute to local and national health promotion developments. Finally, it is worth mentioning that Brazilians thinkers also had an impact on the development of health promotion in Canada, as is the case with Paulo Freire, whose work has been very influential.
REFERENCES Ferraz, S.T. (2000). Cidades Saudáveis: Uma urbanidade para 2000. Brasília: Paralelo 15. Westphal, M., et al. (2004). La Promoción de Salud en Brasil. In H. Arroyo-Acevedo (Ed.), La Promocion de la salud en America Latina: Modelos, estructuras y vision crítica. San Juan, Puerto Rico: División de Impresos Universitarios, Universidad de Puerto Rico.
RELEVANT WEB SITES Brazilian Collective Health Graduate Association www.abrasco.org.br Collective Health Unit OPAS Brazil www.opas.org.br/coletiva Family Health Program http://dtr2004.saude.gov.br/dab/ Health Promotion Center www.cedaps.org.br
Healthy Municipalities Study, Research, and Documentation Center www.cidadessaudaveis.org.br Zero Hunger Program www.fomezero.gov.br
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THE CHILEAN NATIONAL HEALTH PROMOTION PLAN Judith Salinas
local government and encourage them to act in an intersectoral and collaborative way on the social determinants of health.
Health Promotion as a Public Policy The birth of health promotion in Chile began in 1998 with the development of the country’s first National Plan for Health Promotion. This plan created the VIDA CHILE Council, a cross-sectoral coordination body chaired by the Minister of Health and comprising 28 public and private institutions (Salinas, 2000, 2004; Salinas & Vio, 2002; Salinas et al., 2005). The role of this council is to help ministries establish healthy public policies and to support the implementation of local health promotion plans, conducted by all the municipalities throughout the country, with a wide social base and support from the highest government authorities. The council has formulated five specific cross-sectoral targets for 2010. These have become objectives in health reform to reduce smoking, obesity, and sedentary lifestyles as well as for increasing social participation and healthy spaces. In 2005, nearly 18 percent of the population have participated in health promotion activities through social organizations, educational institutions, as well as many workplaces and primary care centres. In addition, the Ministry of Health has hosted three important national events: two Chilean congresses for local and regional participants, and a Forum of the Americas with PAHO/WHO. Health promotion in Chile has faced difficulties in achieving cross-sectoral agreement with other actors and enforcing regulations. VIDA CHILE suggests that participants must consolidate what has been achieved and build on best practices and scientific evidence. The great challenge is to succeed in making health promotion into a state policy that encompasses all sectors and administrations of national and
Canada’s Contribution This process has counted on Canada’s ongoing and important contribution. At the beginning of 1999, representatives of government and national and international organizations of both countries endorsed the Collaboration Agreement for Development of Health Promotion Canada–Chile. This three-year agreement, funded by the Canadian International Development Agency (CIDA), was implemented by the Centre for Health Promotion at the University of Toronto and the Chilean Ministry of Health with the support of CIDA, PAHO/WHO, and the collaboration of other partners in both countries, including universities and governmental and non-governmental agencies. The University of Toronto team led this process, facilitating a tremendous commitment of Canadian people and their experts and institutions who contributed time, resources, consultations, technical assistance, and materials to support health promotion in Chile. This was achieved notably through numerous presentations in international congresses, capacity-building workshops, evaluations, technical publications, workbooks, educational materials, as well as the development and operationalization of two academic resources centres in health promotion. There have also been some other important contributions as different Canadian institutions have implemented collaborative projects of research and support toward the Chilean process of health reform, with new partnerships and important effects and achievements. In conclusion, Canada has played a pivotal role in the development of health promotion concepts, models, and strategies in
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Chile. The contribution since the Ottawa Charter and throughout several collaborative projects is widely recognized. It is an exemplary case of leadership and technical co-
operation among countries leading to the mobilization of necessary resources for evaluation, dissemination, and sharing knowledge for health promotion and equity.
REFERENCES Salinas, J. (2000). Health promotion in Chile: An evaluation of a national plan implementation. Promotion & Education, 4, 13–16. Salinas, J., & Vio, F. (2002). Promoción de la Salud en Chile. Revista Chilena de Nutrición, 29(S1), 164–173. Salinas, J. (2004). Vida Chile 1998–2003: Achievements & challenges of health promotion as a public policy. Health Targets: News & Views, 7(1), 8–9. Salinas, J., Castanedo, I., Harrison, D., & Vu, A.L. (2005). The whole of government approach to promoting health: The case of Chile, Cuba, United Kingdom, and Viet-Nam. Paper presented at the 6th Global Conference on Health Promotion, Bangkok, Thailand.
RELEVANT WEB SITES Institute of Nutrition and Food Technology (INTA), University of Chile www.inta.cl
It describes the health promotion courses that the institute offers, scientific publications, healthy eating and physical activity programs, and educational materials in health promotion. Ministry of Health,Vida Sana Section www.minsal.cl
Description of the National Health Promotion Council Vida’s policies, strategies, technical orientations, handbooks, and educational materials. It also includes the health promotion congresses that have taken place, the annual public accountability report, and the Ministry of Health’s technical regulations regarding health promotion Pontifical Catholic University of Chile, Initiative Healthy University www.puc.cl/ucsaludable
Presentation of the Healthy University Program, news, healthy universities congresses, educational materials, and other resources for healthy universities. Regional Resources Centre in Health Promotion “Promesa,” University of Concepción www2.udec.cl/promesa
Virtual page presenting capacity-building programs, technical assistance, documentation, and educational material centre.
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HEALTH PROMOTION IN FRANCE: TRYING TO GO BEYOND THE BIOMEDIC AL WORLD Laurence Guillaumie
France is known for the efficiency of its health care system, but also for lagging behind in the field of health promotion. In the background stand two opposing conceptions: on the one hand, a biomedical model for which the health care system is a crucial determinant, and on the other hand, a public health system for which social, economic, individual, and collective factors are to be taken into consideration (Joël, 2000). During the past 10 years, with the modernization of France’s health care system, the practice of health promotion (still largely labelled health education) has been transformed. The importance given to prioritizing health actions according to specific objectives, to the health determinants, and to health education laid the foundations for several reforms. In 2002, L’Institut national de prevention et d’éducation pour la santé (National Institute for Health Prevention and Education [the INPES]) was created. Its mission is to set up public health programs for the state, and to develop expertise in the field of health promotion and develop health education. A network of 100 local committees for health education initiated in the 1970s is the main field partner of the INPES. This network, whose work is inspired by the Ottawa Charter,
has acquired significant experience in setting up actions in health education intervention. However, the French system remains centred on a biomedical approach, with funding devoted primarily to curative services (Henrard, 2005). Health promotion structures lack the means, training, and methodology to reach professional excellence (Brodin et al., 2004). The actions set up are jeopardized by unreliable funding, except in a few regions that opted for massive investments to develop a strategic health promotion capacity (Bourgueil, 2003). Canada is recognized as a world leader in health promotion. Since the end of the 1970s, Canadian universities have been seriously involved in research on the health determinants (the social ones notably) and have developed several multidisciplinary academic programs accordingly (Giraud & Lorrain, 2004). This has had an impact on health promotion practices in France, either through the training of French students, researchers, and professionals, or by the way Canadian researchers and professionals get involved in French projects. Another Canadian influence, mostly from French-speaking Canada, is also occurring via Internet through electronic access to a variety of innovative materials (description of programs and pedagogical workshops). In the end, even if interest in health promotion increased in France over the last 10 years, which was greatly influenced by Canada, it remains hindered by a system still very centred on curative care and a lack of political consideration for health determinants.
REFERENCES Bourgueil, Y. (2003). L’hôpital et la promotion de la santé: Un projet paradoxal? Revue hospitalière de France, 492, 17–22. Brodin, M., Chambaud, L., Dab, W., Jourdain, A., Lopez, A., & Mansour, Z. (2004). L’efficacité de la promotion de la santé en France: Commentaires d’une table ronde composée d’experts français. Promotion et Education, numéro spécial 1, 36–40. Giraud, F., & Lorrain, J.-L. (2004). Rapport relatif à la politique de santé publique (2 vols). Paris: Sénat.
268 ■ PART IV: International Perspectives Henrard, J.-C. (2005). Politiques et programmes nationaux de santé. Naissance et histoire des priorités et actions des politiques nationales de santé. Actualité et dossier en santé publique, 50, 18–28. Joël, M.-E. (2000). Des soins à la santé publique. Projet, 263, 35–42.
FURTHER READINGS Loriol, M. (2002). L’impossible politique de santé publique en France. Ramonville Saint-Agne: Eres. The French health care system is centred on curative health care. Therefore, facing economic and social interests, public health often lacks the legitimacy and the means to impose itself and promote long-term programs. The objective of this book is to report on shortcomings and weaknesses using an analysis of health services and relationships between the curative sector and authorities. Sandier, S., Paris, V., & Polton, D. (2004). Health care systems in transition. Retrieved January 1, 2006, from http://euro.who.int/document/e83126.pdf. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. This report provides an analytical description of the French health care system and of reform initiatives in progress or under development. It can be used to learn about the organization, financing, and delivery of health services and the process, content, and implementation of health care reform programs.
RELEVANT WEB SITES Banque de Données en Santé Publique (BDSP) www.bdsp.tm.fr
The Banque de données en santé publique is a free databank that provides online public health information and resources for health and social workers. Haut Comité de la Santé Publique (HCSP) www.hcsp.ensp.fr
The Haut Comité de la Santé Publique, in close partnership with the Secretary of Heath and Human Services, participates in the decision making for the improvement of public health. It keeps track of the population’s health and contributes to set health policy goals. A triennial report, showing prospective indicators and analysis related to public health issues, is published to that effect. Institut National de Prévention et d’Education pour la Santé (INPES) www.inpes.sante.fr/
The Institut National de Prévention et d’Education pour la Santé is a public health force in charge of implementing public health programs for the state and its public institutions. It also provides the development of health education for the whole country.
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HEALTH PROMOTION APPROACH IN IRAN Iraj M. Poureslami
Iran is a middle-income country with a population of approximately 73 million. There has been significant improvement in the health status of the population over the past three decades, primarily as a result of the establishment of a primary health care system targeted to communicable disease control. In recent years, as result of rapid urbanization and pervasive socio-economic and genderbased inequities, Iran has experienced striking changes in its serious health problems, moving from an infectious disease to a chronic disease pattern. In an effort to adapt to this situation, the Ministry of Health of Iran has reorganized its infrastructure and reformed the health care system, notably in beginning to establish a health promotion approach after participation of the minister, deputy minister of health, and general director of health education in the 5th international conference of Health promotion in Mexico City in 2000. During the conference and thereafter there were several meetings and mail exchanges between the general director of health education and the director of the Centre for Health Promotion at the University of Toronto in order to initiate the new approach. Documents received in Mexico as well as from the University of Toronto were later translated to Farsi by the Iranian health education department and turned out to be very influential in the establishment of a new health promotion department in the Ministry.
Since the establishment of this new department, a number of innovative activities and projects in community health promotion have been planned and implemented over the past five years. These include publication of many relevant books, reports, and documents; assembling different workshops and seminars across the country for researchers, health care professionals, policy makers, and community organizations; conducting comprehensive school health promotion project in central provinces; developing participatory smoke-free schools in south-east provinces; addressing non-medical determinants of cardiovascular disease and emerging health issues such as road accidents and cancer in most provinces; performing school health-scouts project in selected districts; establishing health houses in major manufactures across the country; and developing health literacy materials about HIV/AIDS and other STDs among youth. In spite of these efforts, it seems the future improvement of health of people in Iran will depend less on providing access to health services than on economic growth, empowerment, and establishment of health promotion in the largest sense. As elsewhere, it will depend on gradually building a fairer and more equitable society, as the most obvious outcome of health promotion. Therefore, the policy makers in the health ministry, with their mandate to “improve the health of the nation’s people,” need to work on building the political willingness and health officials’ consciousness to gradually establish health promotion in the health care system.
REFERENCES Asadi-Lari, M., Sayyari, A.A., Akbari, M.E., & Gray, D. (2004). Public health improvement in Iran: Lessons from the last 20 years. Public Health, 118(6), 395–402. Eshraghi, E. (2001). Promotion of public health welfare through equity in access to education. Tehran: Payame-Noor University of Iran Press.
270 ■ PART IV: International Perspectives LeBaron, S., & Schultz, S. (2005). Family medicine in Iran: The birth of a new specialty. International Family Medicine, 37(7), 502–505. Shahraz, S., Sherafat, R., & Zalki, M. (2003). The boundaries of health system: A proposed model. Archives of Iranian Medicine, 6(4), 243–250. ShadPour, K. (2000). Primary health care networks in Iran. Eastern Mediterranean Health Journal, 6(4), 822–825.
FURTHER READINGS Hosseinpoor, A.R., Mohammad, K., Majdzadeh, R., Naghavi, M., Abolhassani, F., Sousa, A., et al. (2005). Socio-economic inequality in infant mortality in Iran and across its provinces. Bulletin of the WHO, 83(11), 837–844. United Nations Economic and Social Council. (2005). Economic and Social Commission for Asia and the Pacific: Health and Development: Selected Issues. Addressing emerging health risks: Strengthening health promotion. Retrieved January 2006 from www.unescap.org/esid/committee2005/English/CESI2_7E.pdf. Werner, D. (2002). The changing pattern of health in Iran. From www.healthwrights.org/static/HWNL46.pdf.
C ANADA’S INFLUENCE ON HEALTH PROMOTION IN ISRAEL Diane Levin-Zamir, Milka Donchin, Lilach Melville, and Irit Livne
Health promotion in Israel has evolved over the past two decades from a focus on health education to that of population health, applying the five major areas delineated in the Ottawa Charter for Health Promotion. The settings approach to health promotion has been embraced, with specific investment made in health-promoting cities, primary health care facilities, schools, community centres, and hospitals. An inter-organizational Health Promotion National Council for promoting health promotion policy has also been established under the auspices of the Ministry of Health (Fosse, Mittlemark, & Skogli, 2005). Canada’s influence on health promotion in Israel has been profound. In hosting the meeting that produced the Ottawa Charter for Health Promotion (OC), Canada set the stage
for the aforementioned transformation in Israel. The Israel Ministry of Health translated the Charter into Hebrew and made it available to all health promotion practitioners and students throughout Israel. Over the past decade, the principles of the OC have been applied to policy in Israel, as health promotion practitioners are required to design programs according to its essence. Funding sources are encouraged to adopt the OC as quality criteria in considering the candidates that have applied for support. Canadian policy for health has had very concrete influence on Israel, as the Israeli Knesset passed legislation regarding cigarette package design and hazard labels based on Canadian practice and research. The principles of the OC are taught in courses on health promotion in institutes of higher education. The Healthy Cities movement, born in Canada, has set the stage for the establishment of the Israel Network of Healthy Cities, which currently includes 40 cities and regional councils (World Health Organization, 1997). The original model
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demonstrated the importance of combining viable environment, convivial community, and adequate economy for better health and sustainable development. In Israel, this model is the interface between “Health for All” and “Sustainable Development” principles. Health promotion in multicultural societies and settings has been a challenge in Israel for decades, with recent work in reducing health disparities and promoting equity based on the research of Canadian scholars. The work conducted in Canada that explored the health and social needs of cultures in change contributed to the efforts made in Israel in promoting health among the Arab population as well as among Israel’s diverse immigrant population, particularly among people with chronic illnesses. Health literacy research
and practice from Canada (Shohet, 2002; Rootman & Ronson, 2003) are providing a basis upon which they are being researched and put into practice in health systems, in community settings, and in the health media in Israel. Canadian research on globalization and its influence on health determinants has recently generated discussion in Israel, particularly as it relates to its place in the Bangkok Charter for Health Promotion. In summary, we expect that Canada will continue to invest in the development of theory, practice, and policy related to public health and health promotion, which has already had remarkable influence on these fields in Israel. It is now hoped that more reciprocal collaborative work between the two countries can be established in the future.
REFERENCES Fosse, E., Mittelmark, M., & Skogli, K. (2005). European capacity for health promotion at the national level. Report retrieved from the HP-Source.net. HP-Source. (2005). Country profile (Israel). From www.hp-source.net. Rootman, I., & Ronson, B. (2003). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(2), S62–S77. Shohet, L. (2002). Health and literacy: Perspectives in 2002. From www.staff.vu.edu.au/alnarc/onlineforum/AL_pap_shohet.htm. World Health Organization. (1997). City planning for health and sustainable development. WHO European Sustainable Development and Health Series, no. 2. Cophenhagen: WHO Regional Office for Europe.
FURTHER READING HP-Source. (2005). Country profile (Israel). From www.hp-source.net. Detailed description of health promotion policy, practice, and research in Israel according to settings and topic initiatives, including contact details for a wide range of organizations and professionals.
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THE PUBLIC HEALTH NURSE AS A DRIVING FORCE FOR HEALTH PROMOTION IN JAPAN Masamine Jimba and Yuka Nomura
Japan’s health promotion has been influenced both by the social focus of Canada and European countries and the individual focus of the US (Green, 1994). Integrating elements of both approaches, the Japanese Ministry of Health, Labour, and Welfare launched National Health Promotion in the 21st Century (Healthy Japan 21) in 2000 as a basic national health policy for the coming 10 years. In the guidelines of Healthy Japan 21, the famous health promotion PRECEDE-PROCEED model, which we translated into Japanese, is introduced as one of the recommended health planning models. Healthy Japan 21 emphasizes quality of life, promotion of health throughout the life cycle, and individual choice; it also introduced goal-oriented management strategies (Institute for International Cooperation, Japan International Cooperation Agency, 2005). This policy adopted the concept of health promotion as proposed in the Ottawa Charter in 1986, but its implementation remains controversial. One typical criticism is that there is little community participation in its planning and that the process follows the same top-down approach as other health policies in Japan (Takahashi et al., 2002). In this respect, Canada’s practical experience can serve as a model for bottom-up health promotion. Among different types of health workers, it is public health nurses (PHN) who have the greatest potential to carry out this task in Japan. In 1997, the Japanese Nursing Association (JNA) published a Japanese translation of Community Health—Public Health Nursing in Canada: Preparation and Practice, issued by the
Canadian Public Health Association (CPHA) in 1990. This booklet has been used as a practical guideline for health promotion at the community level (Murashima et al., 1999) in interaction in some cases with nurses from the Registered Nurses Association of British Columbia (BC). An interesting example to illustrate the role of community nursing practice in health promotion in Japan is a case study from Kanagawa Prefecture. While the translation of CPHA’s document was being prepared, JNA members visited Canada and several European countries to seek examples of PHNs playing active roles in health promotion at the community level. After considering various models, they decided to adopt BC’s Community Meeting model and tested it in the city of Miura, Kanagawa Prefecture (Japanese Nursing Association, 1997). In coordination with the city of Miura and its citizens, PHNs held a Community Meeting Workshop in 1996 that was also attended by guests from the Registered Nurses Association of BC. During this event, the participants learned Community Meeting methods and heard about BC’s successes. After this workshop, the PHNs created a manual-style booklet to use in community health promotion and Miura citizens are still to this day using this Community Meeting approach. The next step is to determine how to expand this kind of community-level health promotion activity to the country as a whole. Fortunately, Japan has over 39,000 PHNs who work closely with citizens all over the country. Through their work, Japan will advance toward the kind of health promotion that the Ottawa Charter embraces, though how to bring it up to the national level remains a challenge.
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REFERENCES Green, L.W. (1994). Canadian health promotion: An outsider’s view from the inside. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 314–326). Toronto: W.B. Saunders Canada. Institute for International Cooperation, Japan International Cooperation Agency. (2005). Japan’s experiences in public health and medical systems: Towards improving public health and medical systems in developing countries (pp. 39–40). Tokyo: Research Group, Institute for International Cooperation, Japan International Cooperation Agency. Japanese Nursing Association. (1997). Community meeting (Miura workshop report). Tokyo: Author. (In Japanese.) Murashima, S., Hatono, Y., Whyte, N., & Asahara, K. (1999). Public health nursing in Japan: New opportunities for health promotion. Public Health Nursing, 16, 133–139. Takahashi, T., Baker, R., Sato, K., & Touma, A. (2002). An international comparison study on health promotion and medical care improvement for the aged, and its results. Health Research News, 30, 13–16. (In Japanese.)
FURTHER READINGS Japan Public Health Association. (2004). Public health of Japan. From www.jpha.or.jp/jpha/english/index.html This document shows the current situation of public health in Japan, which includes a brief summary of health promotion in Japan. Yamashita, M., Miyaji, F., & Akimoto, R. (2005). The public health nursing role in rural Japan. Public Health Nursing, 22(2), 156–165. This article gives background information about public health nurses in Japan and addresses their expanded roles in community health.
HEALTH EDUC ATION IN KUWAIT
Evolution and Status of Health Education in Kuwait
Layla Aljasem and Amal Hussain Jassem
During the 1960s and 1970s, health education was practised in Kuwait by only a few physicians until a health education department was eventually established in the 1980s (AlMash’an, 2003), whose main goal was to increase health awareness (Planning and Follow-up Department, 1986). Back then, most health education focused on improving health knowledge through lectures, printed materials, television, and radio. As the majority of health educators were non-Kuwaiti with different accents, culture, and minimum health education experience, the population was not very eager to participate in such activities.
The state of Kuwait lies at the northwest corner of the Arabian Gulf. Due to oil revenues, it has a high standard of living (Ministry of Information, 2001). The total population is 2.5 million people and about one-third are Kuwaitis. Due to its fast-growing economy, Kuwait’s exposure to Western civilization has been inevitable and its type of lifestyles has raced ahead of the attitudes, beliefs, traditions, and culture of the Kuwaiti population; chronic illnesses are now the major causes of death.
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However, in the last 15 years, scholarships to specialize in public health and health education were allocated to Kuwaiti physicians by the Ministry of Health. Currently, there are about 20 Kuwaiti public health physicians; two specialized in health education (Department of Human Development, 2004). Moreover, a Council of Health Education was established in 2002. Its members are physicians working in health education and others working in the preventive medicine departments of the five health areas. The council helps improve the communication and cooperation between health education workers and the rest of the health sector. In the past 10 years the Health Education Department has focused on changing attitudes, beliefs, and behaviours detrimental to health. As in most countries, Kuwait health leaders are more concerned with curative aspects of health rather than preventive ones, and devote most of the health budget to curative services. Getting resources to improve healthy attitudes, beliefs, and behaviours has thus been a constant struggle, though many non-profit organizations contribute financially to health education activities. These include: production of printed materials; lectures for students in schools and the general
public in co-operation with community organizations; organization of workshops, exhibitions, and programs through the media; publication of articles in dailies and magazines; marathons; and days for the public, including consultation, exhibition, promotions, competitions, and gifts. However, there is very little funding for research in the field and lifestyle data are lacking. Consequently, no intervention is based on scientific data.
International Co-operation Currently, there is co-operation between Kuwait and the other Gulf countries through a Health Education Gulf Committee, established in 2001. It meets once a year to discuss issues of common interest, exchange field experiences, share materials, and co-operate in organizing conferences, workshops, and symposiums. Until now there is no direct collaboration with Canada. A visit to Kuwait from a Canadian lecturer at the Women’s Health Workshop in May 2005 may have put the first brick for further collaboration in place, in co-operation with the World Health Organization.
REFERENCES Al-Mash’an, M. (2003). Mediator in Medicine and Law (Arabic). Kuwait City: Author. Department of Human Development, Sub-Department of Manpower Statistics, & Planning Division of Manpower Statistics. (2004). Manpower Statistics 2004. Kuwait: Ministry of Health. Ministry of Information. (2001). Kuwait Facts & Figures (8th ed.). Kuwait City: Author. Planning and Follow-up Department. (1986). Health of Kuwait. Kuwait: Ministry of General Health.
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INFLUENCE OF C ANADA IN IMPLEMENTING HEALTH PROMOTION IN LATIN AMERIC A Helena E. Restrepo
Background The Lalonde Report (1974) was a key document for those interested in the role of public health versus medical care to improve the health of populations. But in Latin America very few recognized its importance and its profound worldwide repercussions in public health policies. Only those working at that time in prevention of non-communicable diseases (NCD) with a comprehensive community-based approach used it to justify actions oriented to lifestyle changes. The participation of Latin American countries in the Ottawa Conference on Health Promotion (HP) in 1986 was almost nil, since only a delegate from Uruguay was present. In spite of that, the Pan-American Health Organization (PAHO) offered technical assistance in HP as of 1988. However, it is only in 1992, after the International Conference on Health Promotion and Equity and its Declaration of Santafe de Bogotá (Ministerio de Salud de Colombia, & Organización Panamericana de la Salud, 1992), that the principles and recommendations of the Ottawa Charter was more accepted by PAHO member countries.
Canada’s Leadership The leadership of Canada in HP is recognized all over the world due notably to the Lalonde Report (1974), the Ottawa Charter (1986), and the Epp Report (1986), as well as projects like Healthy Communities. It is why PAHO looked toward Canada, searching for expertise to acquire and disseminate knowledge and experiences among developing
countries of Latin America and the Caribbean. This was encouraged by the fact that the WHO office in Europe (EURO) was developing HP programs using Canada as a model and with some conceptual and methodological frameworks developed with Canadian consultants. Over the years, Canada became a rich source of consultants and information for technical co-operation: individuals like M. Gómez-Zamudio, L. Gravel, R. Lacombe, T. Hancock, R. Labonté, M. O’Neill, L. Pinder, L. Renaud, or I. Rootman, to name but a few, have given support in many ways and on many topics. This can be exemplified using the Healthy Municipalities movement. At the end of 1980s and the beginning of 1990s the countries of Latin America and the Caribbean were strongly encouraged to reform the structure of the state, following the recommendations of the International Monetary Fund, and to give more importance to local levels through decentralization. In this context, PAHO presented the Healthy Municipalities initiative to member countries in 1992, in order to advance in the application of HP theories and practice at the local level. After the pioneer twinning between Toronto and São Paolo, the Quebec movement, Villes et Villages en Santé, was considered a very useful model to follow in the Latin American region; constant support has been provided over the years by the Quebec group ever since. A few other institutions (notably the University of Toronto and the University of Victoria) were also heavily involved in the evaluative dimension of this venture, at the beginning of the 2000s.
Conclusion Canada is a recognized leader in HP development in Latin America and the Caribbean regions. The understanding and sensitivity
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of Canadians toward the social problems of the people of the region has certainly been an important factor for such an extended collaboration and, hopefully our countries will
continue to receive nurture from Canadians’ knowledge in HP and enjoying their friendship.
REFERENCES Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Minister of Supply and Services. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Information Canada. Ministerio de Salud de Colombia, & Organización Panamericana de la Salud. (1992). Promoción de la Salud y Equidad (Declaración de Santafé de Bogotá). Bogotá, Colombia. Organización Mundial de la Salud, Ministerio de Salud y Bienestar Social de Canadá, & Asociación Canadiense de Salud Pública. (1986). Carta de Ottawa para la Promoción de la Salud (versión en español). Ottawa, Canada.
FURTHER READINGS Arroyo, H.V. (Ed.). (2004). La promoción de la salud en América Latina: Modelos, estructuras y visión crítica. San Juan, Puerto Rico: División de Impresos Universitarios, Universidad de Puerto Rico. The book contains a chapter by country describing the development of health promotion in each one. Interamericano de Universidades y Centros de Formación de Personal en Educación para la Salud y Promoción de la Salud (CIUEPS), Red Caribeña de Promoción de la Salud y Educación para la Salud de la Universidad de Puerto Rico. Proyecto Regional de Latinoamérica de Evaluación de la Efectividad de la Promoción de la Salud:
[email protected]. This Project is a component of the Global Project of Effectiveness of Health Promotion of the International Union of Health Promotion and Education (IUHPE). Available at www.iuhpe.org. Restrepo, E.H., et al. (1996). The PAHO/WHO experience: Healthy municipalities in Latin America. In Price, C., Tsouos, A. (Eds.) Our cities, our future: Policies and action plans for health and sustainable development (pp. 203–215). Madrid: WHO/EURO, Ayuntamiento de Madrid, OECD. It describes some of the projects of Healthy Municipalities in Latin America countries presented in Madrid, Spain, during the world meeting on Healthy Cities in 1995.
HEALTH PROMOTION: THE MEXIC AN C ASE Dora Cardaci
Over the last 30 years, Mexico has undergone a profound transformation in both its demographic and epidemiological profiles, as seen
in changes in birth rate, life expectancy, and migration patterns. The health sector now basically deals with two groups of health problems: (1) infectious diseases and malnutrition; and (2) cardiovascular diseases, cancer, mental disorders, and AIDS (Cardaci & Diaz, 2004).
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Mexico’s health system is composed of three broad segments: First, there are the social security institutions, which include IMSS (Mexican Institute of Social Security), ISSSTE (Institute of Social Security for State Employees), and the medical services provided by Pemex (the National Petroleum Company), as well as the defence and navy ministries. The three types of institutions look after 50–55 percent of the population. Second, there are the health services for the uninsured, provided mainly by the health secretary; and, third, the private health services. Health promotion activities are undertaken by the institutions that attend to the population as a whole as well as by the social security institutions, coordinated with other governmental sectors and a diversified set of social actors, mainly NGOs. The Secretary of Health, through its General Directorate of Health Promotion, used to enact laws concerning the promotion of health and to coordinate programs at national, regional, and local levels. However, following the 5th World Conference on Health Promotion held in Mexico in 2000 (OMS, 2000), greater prominence was given to this field through the creation of an Under-Secretariat for Prevention and Health Promotion that coordinates the participation of all sectors and organizations with a primary commitment to health promotion. Examples of important health promotion initiatives in this context are, for instance, Hospital amigo de la madre y el niño (babyfriendly hospitals), actively promoting breastfeeding and joint mother-and-child hospital accommodation. Special health promotion
programs have also been designed to prevent addictions, accidents, and violence, particularly among teenagers and old people, two age groups with an increasing presence in the overall population. Finally, efforts have concentrated on protecting the health of migrants, creating for their benefit the following programs: Frontera saludable 2010 (Healthy Border 2010) and Vete sano, regresa sano (Go healthy, return healthy). Despite Canada’s diverse influences on Mexican health promotion, there is space here to mention only three. Firstly, even before the 1994 signing of the North American Free Trade Agreement (NAFTA), activists and NGOs in both countries worked to lessen the impact on health foreseen in operating the treaty. Secondly, the Québécois movement, Villes et Villages en santé (Healthy Communities) became an important reference for a network linking almost 1,500 Mexican municipalities working to promote health. Lastly, mention must be made of the role played by Canada’s International Development Research Centre (IDRC) in the dissemination and construction of new approaches in environmental health promotion (Rodríguez, 2004). Links such as these with Canadian health professionals and activists are of the utmost importance to Mexico if we mean to continue strengthening the field of health promotion. Indeed, provision must be made for even greater sharing of expertise in the training of health personnel and for a wider distribution of the valuable publications coming out of Canada, starting by having them translated into Spanish.
REFERENCES Cardaci, D., & Díaz, B. (2004). ¿En un mar de ambigüedades? Políticas, programas y estrategias de formación en promoción y educación en salud en México. In H.V. Arroyo (Ed.), La la promoción de la salud en América Latina: Modelos, estructuras y visión crítica (pp. 343–365). San Juan, Puerto Rico: División de Impresos Universitanos, Universidad de Puerto Rico.
278 ■ PART IV: International Perspectives OMS. (2000, June 5). Declaración ministerial de México para la promoción de la salud. De las ideas a la acción. México City. Rodríguez, M. (2004). Importancia del ecosistema en el diseño de programas de promoción de la salud humana: malaria. México: ILCE.
RELEVANT WEB SITES La Fundación Mexicana para la Salus (FUNSALUD) www.funsalud.org.mx Secretan´a de Salud www.salud.gob.mx Instituto Nacional de Salud Pública www.insp.mx
HEALTH PROMOTION IN NEW ZEALAND: COMING INTO ITS OWN Louise Signal
Health promotion has matured in New Zealand over the past two decades into an accepted public health discipline. New Zealand has adopted international concepts and approaches and added its own perspectives and ways of working (Martin, 2002). There is a small but established health promotion infrastructure of health promotion providers, and an increasingly experienced workforce, training programs, research groups, and provider networks for the development of health promotion practice and advocacy, such as the Health Promotion Forum and Te Reo Marama (Ma¯ ori Smokefree Coalition). Recently, the health promotion mandate of primary care has been strengthened, providing new opportunities if appropriate support and capacity building are forthcoming. New Zealand has demonstrated that comprehensive, sustained interventions can succeed in improving health status in areas such as road safety, heart disease prevention,
and tobacco control (Minister of Health, 2004; Ministry of Transport, 2005). However, New Zealand struggles with significant challenges, common internationally. Eliminating health inequalities poses one of the biggest challenges, particularly inequalities for indigenous Ma¯ ori whose life expectancy at birth is nearly 10 years less than Ma¯ ori (Ajwani et al., 2003). Ongoing commitment to, and honouring of, te Tiriti o Waitangi, a contract between Ma¯ori and the British Crown signed in 1840 in which Ma¯ ori exchanged sovereignty for protection of their interests and the same citizenship rights as other British subjects, is thus necessary. Increasing globalization means that many health-related issues are increasingly influenced from outside New Zealand. Health promotion needs more effective ways to work internationally to address them, including developing partnerships between nations, working through international organizations such as the World Health Organization (WHO) and the International Union for Health Promotion and Education (IUHPE), and building alliances with the many other sectors and interest groups with
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shared values. There have been successes, such as the development of the Framework Convention on Tobacco Control, in which New Zealand played a role. New Zealand draws support for health promotion from a number of quarters, including countries such as Canada, Australia, and Britain. Canada had a significant conceptual influence on the foundations of current health promotion practice in New Zealand. The Ottawa Charter is a cornerstone of New Zealand health promotion. The concepts of healthy public policy and healthy cities emerged from Canada and are key aspects of health promotion practice. New Zealand looks to Canada, as it does to other friends and neighbours, for examples of good practice, e.g.,
in tobacco control (Studlar, 2005). People from both countries study and work together, share learning at international conferences, and utilize resources such as Click4HP. New Zealand’s relationship with Canada is due to many factors, including Canada’s leadership in health promotion, the similar colonial history of both countries, and the links between Commonwealth nations. In recent years New Zealand has “come into its own” in relation to health promotion. However, in today’s global world, no nation can achieve health and equity without the support of others. The challenges facing the health of the peoples of the world require vision, courage, and effective partnerships for action.
REFERENCES Ajwani, S., Blakely, T., Robson, B., Tobias, M., & Bonne, M. (2003). Decades of disparity: Ethnic mortality trends in New Zealand 1980–1999. Wellington: Ministry of Health and University of Otago. Martin, H. (2002). TUHA-NZ a treaty understanding of Hauora in Aotearoa-New Zealand: An understanding about the application of te Tiriti o Waitangi in health promotion practice in Aotearoa-New Zealand. Auckland: Health Promotion Forum of New Zealand. Minister of Health. (2004). Implementing the New Zealand Health Strategy 2004: The minister of health’s fourth report on progress on the New Zealand Health Strategy, and her first report on actions to improve quality. Wellington: Ministry of Health. Ministry of Transport. (2005). Ministry of Transport: Brief to the minister of transport 2005. Wellington: Ministry of Transport. Studlar, D.T. (2005). The political dynamics of tobacco control in Australia and New Zealand: Explaining policy problems, instruments, and patterns of adoption. Australian Journal of Political Science, 40, 255–274.
RELEVANT WEB SITES Health Promotion Forum of Aotearoa–New Zealand (HPF) www.hpforum.org.nz
The Health Promotion Forum is a national umbrella organization for health promotion in Aotearoa–New Zealand working for a healthier society. It provides national leadership and support for good health promotion practice consistent with the principles of Te Tiriti o Waitangi and the Ottawa Charter. More than 200 organizations nationwide are members.
280 ■ PART IV: International Perspectives Health Sponsorship Council www.healthsponsorship.org.nz
The Health Sponsorship Council is an example of a New Zealand-based health promotion agency committed to social change and marketing health messages to New Zealanders. It uses a range of communication tools to promote health messages and its health brands, such as Smokefree/Auahi Kore. Ministry of Health www.moh.govt.nz
The Ministry of Health is the leading national government health agency in New Zealand. It has responsibility for policy development and funding of key health promotion action.
GO, C ANADA, GO! THE INTERPLAY OF C ANADIAN AND NORDIC HEALTH PROMOTION Bengt Lindstrom and Monica Eriksson
To compare the Nordic countries to Canada is an interesting venture because this gives an opportunity to try to match us with one of the international leaders in health promotion. There are some similarities, such as prosperity, population size, and geographic position, that make for an interesting comparison between Canada and the five countries of the Nordic Union as a whole (i.e., Denmark, Iceland, Finland, Norway, and Sweden).
The Context: Some Historic, Political, Socio-economic, and Demographic Facts We believe that, at least in this part of the world, many of the contemporary achievements of health promotion actually are effects of a longer development and of certain kinds of political choices. The Nordic countries have about 25 million inhabitants and historically there have been strong political and socio-economic links among them over the past 1,000
years. All the countries have adopted the Nordic welfare state model, some starting in the 1930s. The aim was to operate from a democratic foundation and universally provide for the basic needs of the populations. The welfare systems are very expensive, financed through high levels of income and general taxes. Sweden and Denmark currently have the highest tax rates in the world. Originally, it was thought to be very difficult to restructure the Nordic welfare systems to meet EU requirements, but they are among the few who actually were able to do so properly, as compared to what has been accomplished in some of the leading European nations. However, it seems that for the time being the states have come out of all of this more prosperous than ever, but it is difficult to know what impact these changes will have on the health of the population in the long run. This long-term Nordic policy approach has led to all kinds of generally very positive outcomes. GNP per capita is high—most of the time, the five countries are among the top 10 globally. Canada held the world’s leading position for several years on the Human Development Index (HDI) (that, in addition to socio-economic and health indicators, also includes human rights issues), but over the past three years Norway has taken over the lead.
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The general health data of the Nordic countries are among the best worldwide even if less than 10 percent of the GNP is put into health. Infant and perinatal mortality rates are the lowest in the world and the highest mean life expectancy belongs to Iceland for men and to Sweden and Iceland, among other countries, for women. Nevertheless, the Nordic countries face the same health problems as the rest of the developed world: unstable family structures, high divorce rates, high levels of alcohol and tobacco use notably among the young, mental health problems (some of the highest suicide rates in the world), workload and everyday stress leading to exhaustion, long-term sick leaves, and early retirements. The obesity epidemic is adding to the already very high incidence of diabetes and cardiovascular disease (NMK, 2001).
At present, all the five countries have national public health policies, including health promotion as a theme. Our general assessment is that among experts and policy makers, health promotion is understood and accepted as an issue. However, many health care and education experts are still mixing up health promotion and prevention and the general population maintains a strong belief in the medical system. Thus we are far from a general understanding of health promotion and perhaps the Finnish initiative to include health literacy as a school subject is the right way to go to achieve long-term transformation of the vision of health in the young generation. Funding of health promotion remains very limited as compared to what is given to the medical care system in general, a situation that does not seem much different than what we read about Canada.
The Canada–Nordic Policy Connection
Nordic Best Practices
The Lalonde Report (Lalonde, 1974) was certainly an eye opener and had a strong impact on the Nordic health policies, first through actions within international and UN bodies and later in the national implementation of such policies. However, most of the time, the Nordic influence on international health policy has also been strong and there have been Canadians on most of the international decision and development bodies, working with Nordic colleagues, all the time since Lalonde. The director general of WHO behind the Health for All Policy was Danish and a few of the WHO EURO directors have been Nordics. Later, the IUHPE president was Norwegian, the WHO-International Health Promotion director was Finnish, and a Finn was leading the EC health promotion program—almost at the same time. If one looks at the Canadian input in such bodies, it is just as impressive.
A main conclusion of the evaluation of the effectiveness of health promotion action after the 2005 Global Health Promotion Conference in Bangkok is that synergy and coherence in action is the main road to success (Kickbusch, 2005). Much of this evidence is based on the evaluation of Canadian programs. As a consequence it would be imperative to find both theory-driven models and practices that bring coherence between actions on the individual and societal levels as well as synergy between programs and sectors. This has been said many times before, but again, frequently not followed through. The Nordic countries can nevertheless be proud of several important health promotion achievements, among which the classic one is the North Karelia project in Finland; started in the early 1970s, it definitely had an impact all over the world (IUHPE, 2000). Another good example is the
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accident-prevention programs of Sweden that have reduced accident rates to one of the lowest in the world. Currently, there is a common Nordic program for disability— Design for All—accepted by the Nordic Council of Ministers in October 2005, which takes coherent action to enable disabled people to function fully in society. Another important achievement is the anti-smoking program of Sweden, presently the only nation in Europe to meet the aims of the WHO/EC program on smoking reduction, despite the integration to EU where business and trade considerations have priority and often go against health promotion policies.
The Future As we have seen, there are many ways in which Canada and the Nordic countries have
been influencing each other and working together in health promotion over the last decades. A topic very dear to our hearts that could be an area of increased joint interest in the future is further developing the salutogenic framework originally proposed by medical sociologist Aaron Antonovsky ( Lindström & Eriksson, 2005). With its orientation on what produces health rather than disease (pathogenic) and its concepts like sense of coherence (SOC) and general resistance resources, it has a lot to offer in terms of a major conceptual advancement in health promotion (Eriksson & Lindström, 2005). So, go, Canada, go! and go, Nordics, go! In this area as in many others, we definitely have a lot in common beyond the snow, the cold, and ice hockey on which we can jointly work in the future!
REFERENCES Eriksson, M., & Lindström, B. (2005a). Antonovsky’s sense of coherence scale and the relationship with health—a systematic review. Journal of Epidemiological Community Health, Accepted 60(5), 376-381. Eriksson, M., & Lindström, B. (2005b). Validity of Antonovsky’s sense of coherence scale—a systematic review. Journal of Epidemiology Community Health, 59, 460–466. IUHPE. (2000). The evidence of health promotion effectiveness. Shaping public health in a new Europe. A report for the European Commission. Brussels: ECSC-EC-EAEC. Kickbusch, I. (2005). Policy for health promotion addressing global health governance challenges. Paper presented at the 6th Global Conference on Health Promotion, Bangkok. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Minister of Supply and Services. Lindström, B., & Eriksson, M. (2005a). Professor Aaron Antonovsky (1923–1994)—the father of the salutogenesis. Journal of Epidemiology Community Health, 59, 506–511. Lindström, B., & Eriksson, M. (2005b). Salutogenesis. Journal of Epidemiology Community Health, 59, 440–442. NMK. (2001). Health statistics in the Nordic Countries 1999. Copenhagen: Nordisk Medicinalstatistisk Komité.
RELEVANT WEB SITE Nordic Medico-Statistical Committee www.nom-nos.dk/
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ON BEING A DONOR COUNTRY: C ANADA’S ROLE IN HEALTH PROMOTION IN PACIFIC ISLAND NATIONS Jan Ritchie
The Pacific Ocean is home to 22 nation-states (often designated as Pacific island countries, or PICs), primarily concentrated in the southwestern quarter of this vast stretch of water. These island countries are home to less than 9 million people overall; however, they have unusual strategic importance both because of their location just east of Asia, and because the United Nations and its agencies give votes to member states on an individual membership basis regardless of population size, thus leading to these Pacific votes being influential politically in international affairs. Although most island countries have thrown off their colonial status, they have gained political autonomy but little in the way of economic independence, and it is here that donor countries, including Canada, have had an influence. As already discussed in an earlier chapter by Labonté, the health promotion community within Canada has taken a forward-looking perspective on the health impacts of global trade agreements, and this influence has recently penetrated the Pacific. Canada has funded a policy document produced by the Secretariat of the Pacific Community (SPC), taking forward the Framework Convention on Tobacco Control, and related issues in alcohol control as recommended by the 2004 World Health Assembly, with the document reporting on the negative aspects of reducing tobacco and alcohol tariffs within the recent regional trade agreements (SPC, 2005). Its recommendations, if implemented, will have a marked impact on the health of Pacific island
children since it is clear that smoking uptake is reduced with higher cigarette costs. Other health promoting support includes that from the Canada Fund, run directly by the Canadian High Commissions in New Zealand and Australia, which provides financial support for PIC’s small-scale local initiatives, including some community health promotion projects (www.dfait-maeci.gc.ca/ newzealand/cdafund-en.asp). In 1995, the World Health Organization hosted a meeting of Pacific island health ministers where the ministers determined not only to improve their countries’ health care but also seek to place equal importance on health promotion for their citizens. The Yanuca Island Declaration arising from this meeting has been the frontrunner of a decade of regional commitments to maintain a focus on health promotion across the Pacific through a settings approach, following the principles of the Healthy Cities movement (Galea, Powis, & Tamplin, 2000). Again, Canada has been instrumental in taking this forward through supporting the work of the SPC in acting as a resource base for Pacific island countries, working in the two official languages of the Pacific, French and English. The bilingual nature of the print and Webbased health promotion resources emanating from Canada has meant these materials are particularly valued by SPC for dissemination across the region, and bilingual Canadians with health promotion expertise have played an important part in conducting workshops for health promotion personnel on Healthy Islands’ policy and practice. It is thus mainly through its donor capacity that Canada has influenced the development of health promotion in PICs, a role often underestimated and misunderstood.
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REFERENCES Galea, G., Powis, B., & Tamplin, S.A. (2000). Healthy islands in the Western Pacific-international settings development. Health Promotion International, 15(2), 169–178. SPC. (2005). Tobacco and alcohol in the Pacific Island Countries Trade Agreement: Impacts on population health. Retrieved December 12, 2005 from www.spc.int/AC/Tobacco/ tobacco_trade_agreement_in_the_region.html.
RELEVANT WEB SITES Fiji School of Medicine (FSM) www.fsm.ac.fj
FSM has a strong health promotion stream in both its undergraduate and post-graduate training relevant to PICs. Secretariat of the Pacific Community (SPC) www.spc.org.nc
SPC has developed many health promotion-related resources relevant to PICs. United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) www.unescap.org
UNESCAP similarly has produced relevant resources for the Pacific region.
THE PUERTO-RICO C ANADA LINKAGE Hiram V.Arroyo
Canadian Influence on Puerto Rican Health Promotion The publication of the Ottawa Charter for Health Promotion in 1986 helped consolidate and legitimize the global movement for health promotion in our country. Since then, the Canadian commitment and hands-on experience have been constant guides and sources of academic, professional, and technical references, helping the development of health promotion ideas and values as well as the development of institutional structures. Still needed, however, is the development of stronger multisectoral integration and institutional policy. If these steps are taken, they may lead to the implementation of stable
health promotion initiatives that can be evaluated to assess their effectiveness. Currently, the Puerto Rican health promotion community strongly values and utilizes Canadian models in public health and health promotion. We see the Canadian public health system as a dynamic policy maker, capable of promoting crucial social and structural system changes. In that sense, Canada has been and continues to be a central reference for Latin American countries.
Canadian Links to Puerto Rico– Driven Pan-American Initiatives The Canadian presence is also strong in the ongoing work of the Latin American academic and professional network. For example, many Canadian organizations and prominent individuals partake in initiatives developed by the
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Latin American Regional Office (Oficina Regional Lation-Americana – ORLA) of the International Union for Health Promotion and Health Education (IUHPE), whose headquarters are in Puerto Rico. We have also collaborated with Canada in the training of human resources in the health promotion field. Various Canadian institutions, including Laval University in Quebec and the University of Toronto, were founding members of the Inter-American Consortium of Universities and Training Centers for the Formation of Public Health Education and Health Promotion Personnel (Consorcio Interamericano de Universidades y Centos de Formación de personal en Educación para la Salud y Promoción de la Salud – CIUEPS) launched in 1996 under the leadership of the Pan-American Health Organization and the University of Puerto Rico (Arroyo, 1996). In addition, the CIUEPS collaborated with the Université de Montréal in the development of a guide for media communication (Renaud & Caron-Bouchard, 1999). Finally, the Canadian experience in the
training of health promotion human resources was included (Hills, 2001) in a Pan-American book published by the CIUEPS on this topic (Arroyo, 2000). In a different area, the Canadian presence has been constant in the planning and development of regional, national, and international public health education and health promotion events held in Puerto Rico during the last decade. Some that deserve a special mention are: the IUHPE 16th World Conference on Health Promotion and Health Education (June 1998), the 2nd Puerto Rican Conference on Public Health (September 2004), and the Health Promotion Effectiveness Projects Synergy Meeting between IUHPE/NARO and IUHPE/ORLA (December 2004). There is no doubt that collaborative partnerships with the Canadian academicprofessional community will continue, notably to partake in the organization and insure a strong Puerto Rican and Latin American participation in the IUHPE 19th World Conference to be held in Vancouver, Canada in 2007.
REFERENCES Arroyo, H.V. (1996, April 17–19). Memorias I Asamblea General del Consorcio Interamericano de Universidades y Centros de Formación de Personal en Educación para la Salud y Promoción de la Salud. San Juan, Puerto Rico. Arroyo, H.V. (2000, June). Memorias III Asamblea General del Consorcio Interamericano de Universidades y Centros de Formación de Personal en Educación para la Salud y Promoción de la Salud, Mexico City, D.F., Mexico. Hills, M. (2001). Health promotion courses and programs in Canadian universities: A survey. In H. Arroyo (Ed.), Formación de Recursos Humanos en Educación para la Salud y Promoción de la Salud. San Juan, Puerto Rico: University Printers, University of Puerto Rico. Renaud, L., & Caron-Bouchard. (1999). Guía Práctica Comunicaciones Mediáticas para la Promoción de la Salud. Edited in Spanish by Mauricio Gómez-Zamudio. Montreal-Centro Public Health Directory. Montreal (Quebec).
FURTHER READINGS Arroyo, H.V. (Ed.). (2001). Formación de Recursos Humanos en Educación para la Salud y Promoción de la Salud: Modelos y Prácticas en las Américas. San Juan: División de Impresos Universitarios, Universidad de Puerto Rico.
286 ■ PART IV: International Perspectives The book describes the contribution of many higher education institutions from the Pan-American region in the topic of human resources development and training in the field of health promotion and health education. Arroyo, H.V. (Ed.). (2004). La Promoción de la Salud en América Latina: Modelos, Estructuras y Visión Crítica. División de Impresos Universitarios. San Juan: Universidad de Puerto Rico. This book offers a collection of articles written by expert contributors representing 12 Latin American countries. The articles presents a profile of the national situation of health promotion in Puerto Rico and the following countries: Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, México, Panamá, Perú, Dominican Republic, and Uruguay. Government of Commonwealth of Puerto Rico. (2005). Final report of the National Commission for the study of health system in Puerto Rico. This official report presents a comprehensive analysis of the situation of public health and health promotion in Puerto Rico. From www.rcm.upr.edu. and www.salud.gov.pr.
RELEVANT WEB SITES Government of Commonwealth of Puerto Rico, Department of Health, Auxiliary Secretary for Health Promotion www.salud.gov.pr
The Auxiliary Secretary for Health Promotion is the structure of the Puerto Rico Health Department responsible for developing and evaluating the island-wide Health Promotion National Plan. Inter-American Consortium of Universities and Training Centres for the Formation of Health Education and Health Promotion Personnel www.rcm.upr.edu.
The consortium is an initiative of the Pan-American Health Organization, the University of Puerto Rico, and others institutions of higher education with the purpose of promoting training, research, and special projects in the fields of health education and health promotion. The Consortium Coordination Office is located in the Department of Social Sciences, School of Public Health, Medical Sciences Campus, University of Puerto Rico. Latin American Regional Office (ORLA) of the International Union on Health Promotion and Education (IUHPE) www.iuhpe.org
The IUHPE headquarters of the Latin American Regional Office (ORLA) are located in the Department of Social Sciences, School of Public Health, University of Puerto Rico. This office provides information, contacts, and relevant reports of the IUHPE/ORLA initiatives.
CHAPTER 15: Views on the International Influence of Canadian Health Promotion ■ 287 School of Public Health, Medical Sciences Campus, University of Puerto Rico www.rcm.upr.edu
The School of Public Health is the academic unit of the Medical Sciences Campus with the responsibility for offering direct training, services, and research in public health and health promotion.
ROMANIA: AN EASTERNEUROPEAN APPROACH TO HEALTH PROMOTION Irina Dinca
Health promotion is a quite new concept in Romania. Before 1990 this concept was generally known as sanitary/ hygiene education. The roots of hygiene education in Romania date back to 1948, and in 1951 a national network was set up, with a national centre based at the Institute of Public Health in Bucharest. Health care in communist Romania was free and universal for the population, but based on very tight measures. Some of these measures, in the maternal and child health sector, led in fact to disastrous consequences in terms of maternal mortality and abandoned children. Consequently, after the political changes in December 1989, the first law that was abolished was the one forbidding abortion. Health reform has since started, with many advances and retreats, and this complex process has not yet ended. The major change impacting all sectors of life was Romania’s new openness to the world. In the public health field, concepts like non-communicable disease prevention, health promotion, advocacy, or empowerment were among the first providing renewal of old-fashioned Soviet-influenced social medicine. The Ottawa Charter became one of the main documents studied during post-graduate training in health promotion that all staff employed at local (district) and national levels in the hygiene network had to go through. International technical assistance and train-
ing for Romanian staff abroad became key elements in insuring the change in theoretical approaches. In 1993, Romania joined the European Network of Health Promoting Schools, and then the European Committee for Health Promotion Development. It also benefited from an Investment for Health audit in 1998. Romania has established partnerships with, among other institutions, the Canadian Public Health Association (which mentored and offered funding to the Romanian Public Health Association, including a component in health promotion) and the Université de Montréal (through the summer schools organized in Switzerland through Swiss Development Cooperation [SDC] funding). In addition to these successes at the government level, the newly emerging sector of non-governmental organizations in civil society, which was non-existent during the communist regime, has become a key player in health promotion; it is able to attract excellent staff (salaries are much higher than in the public sector) and significant funding from international donors, while the public sector didn’t fund such organizations until 1997. However, in spite of all of these profound changes at a theoretical level by an elite of health promotion professionals, few changes occurred in everyday practice and the governmental network is still very fragile. National priorities have been established in health promotion (reproductive and family health, sexually transmitted disease prevention, healthy lifestyle including tobacco control, moderate use of alcohol, drug abuse
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prevention, cancer prevention, and tuberculosis prevention), but local priorities are left to the decisions of district teams (e.g., iodine deficiency, etc.). Funds from the Ministry of Health budget became available, but remain scarce, and have to be complemented by
international donors (USAID, UN agencies, SDC). Thus, although some progress has been made in health promotion in Romania, stimulated in part by Canadian experience, there is still much to be done.
RELEVANT WEB SITES National Institute for Research and Development www.incds.ro Romanian Ministry of Health www.ms.ro United Nations Development Programme: Romania www.undp.ro United Nations Population Fund: Romania www.unfpa.ro
HEALTH PROMOTION IN SENEGAL: SIMILARITIES AND DIFFERENCES WITH PRIMARY HEALTH C ARE Awa Seck
Since the adoption of the Ottawa Charter, the concept of health promotion evolved with strong differences worldwide. They are especially evident between developed and developing countries, as health promotion was initially conceived for the industrialized countries.
Primary Health Care (PHC) and Health Promotion in Senegal After the Alma-Ata Conference (World Health Organization, 1978), the Senegalese government based its health policy on PHC. Among the reforms undertaken were the front-line health services to include activities such as health education, community organization, interpersonal communication, hygiene
and sanitation, intersectoral collaboration, home care, and community staff training (Mbacké, 1997). These are components of PHC, but also belong to what would be later called health promotion. Consequently, there are similarities between PHC and health promotion since the Ottawa Charter was certainly influenced by the Alma-Ata Declaration, but health promotion has a broader perspective than PHC and its application goes beyond the local level of health system. During a Senegalese National Health Conference held in 2000, the participants further recognized that to achieve “health for all,” health promotion offered more possibilities than PHC. Thus, it was decided to integrate it into the national health policy (Ministère de la santé, 2000). However, this integration requires health promotion specialists, who are extremely rare in Senegal. To help fill this gap, a study was conducted (Seck, Morin, & O’ Neill, 2003), but, unfortunately, its recommendations have not yet been applied and the need for qualified personnel is still abysmal.
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Canada’s Contribution to PHC and Health Promotion in Senegal Canada has traditionally been one of Senegal’s main partners in development projects. In PHC and health promotion, it has notably taken the form of strengthening the pedagogical skills of nurse and midwife teachers, of working to reduce maternal and infant mortality, of participating in the fight against HIV/AIDS, of developing community-based health insurance, and, more recently, of taking charge of anti-personnel mines victims in the Ziguinchor area (Gouvernement du Canada, 2005). Moreover, Canada contributes to improving the determinants of health by, among other things, fostering basic education, promoting women’s rights, strengthening grassroots economy in rural areas, as well as stimulating decentralization and community participation in local decisions.
These contributions support the “fight against poverty” strategy whereby Senegal, in line with the spirit of the Millennium Development Goals, aims for a 50 percent reduction by 2015. Canada is considered as a major, if not the, world leader in health promotion. We thus think that it could help Senegal even more in supporting the development of a public health promotion policy and its implementation. Support in health promotion training and education could be another very important contribution. Finally, helping to build capacity in health promotion research would allow for better health service reorientation and utilization. Even if it has done a lot in the past, Canada still has a lot to bring to the Senegalese people!
REFERENCES Gouvernement du Canada. (2005). La coopération canadienne au Sénégal. Sénégal: Bureau d’appui à la coopération canadienne au Sénégal, Agence canadienne de développement international. Retrieved January 2, 2005, from www.dfait-maeci.gc.ca/dakar/devel-fr.asp. Mbacké, M.A. (1997). Historique du poste de santé. Saly Mbour: Document préparatoire de la Conférence Nationale sur le poste de santé au Sénégal. Saly Mbour: Ministère de la santé et de l’action sociale. Ministère de la santé. (2000). Assises nationales sur la santé (travaux des commissions, thèmes des tables rondes et des sous-commissions). Dakar: Le Présidium. Seck, A., Morin, D., & O’Neill, M. (2003). L’étude des besoins de formation continue en promotion de la santé pour les infirmières et infirmiers chefs de postes de santé au Sénégal. International Journal of Health Promotion and Education, X(2), 81–86. World Health Organization (WHO). (1978). Declaration of Alma-Ata. Geneva: International Conference on Primary Health Care. Alma-Ata, USSR.
RELEVANT WEB SITES Health Promotion WHO Afro www.afro.who.int/healthpromotion/index.html
In this Web site, there is information about health promotion for the African area. The mission, functions, and strategies to implement health promotion are described for all the African countries.
290 ■ PART IV: International Perspectives International Union for Health Promotion and Education www.iuhpe.org
This Web site is a WHO reference in health promotion and health education. This resource supports continuing education throughout the world because it publishes several reviews and gives recent information on these two interest fields. Réseau Francophone International Pour la Promotion de la Santé www.refips.org
The REFIPS is an important French network, very utilized by the French African people. It helps health promotion professionals by offering many possibilities to exchange knowledge and experience in relation to health promotion.
PROMOTING HEALTH IN SWITZERLAND: A FEDERAL– C ANTONAL INTERPLAY Jean Simos
It’s only since the middle of the 1990s that the concept of “health promotion” was progressively utilized in Switzerland. The term was introduced in the federal Medicare legislation of 1996, which triggered the creation of an institution whose goal would be “to stimulate, coordinate, and evaluate measures intended to promote health and prevent illnesses.” The financing of Health Promotion Switzerland, which was then created, is assured by an annual subscription collected from each citizen through Medicare, which is mandatory for every person residing in Switzerland. In the Swiss confederation, as in Canada but with a much smaller population of about 7 million, most of the health sector belongs constitutionally to the 26 cantons, which are the states of the federal state of Switzerland. Hence, Switzerland doesn’t have a national health promotion policy. In order to alleviate this situation, inter-canton collaborations, as well as with the Confederation, have been developed, but mostly for the French and Italian parts of the country, which are a minority as compared to the German majority. The absence of a critical mass of professionals with
proper training, notably with respect to theories in health promotion, can also partly explain the relative weakness of health promotion in our country. By its contribution to capacity building in health promotion, Canada has gained great visibility in Switzerland. The numerous interventions of Canadian experts in a variety of contexts (e.g., the summer university in Ascona, which has been running for more than a decade) have influenced several key figures in Switzerland’s health promotion community. The exchanges taking place during seminars organized by universities or some of the cantons were beneficial and the implementation of concrete projects enabled Canadian experts to share their experience with their Swiss colleagues as in the case of Geneva’s plan on injury prevention. The cantons where universities are implemented benefit more directly from these contributions although other cantons can also be innovative. For instance, it is tiny Jura (70,000 pop.) that introduced in Switzerland Quebec’s “Operation Nez Rouge,” designed to prevent drunk driving during the winter holidays. International networks such as VillesSanté OMS and Villes et Villages en Santé for healthy cities, or the Réseau francophone de prévention des traumatismes et de promotion de la sécurité of the RÉFIPS for injury pre-
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vention, have also been very useful especially on the lobbying and advocacy side of things. Finally, Canadian legislative work was a source of inspiration for Switzerland. For instance Article 54 of Quebec’s recent public health law, which requires a health impact assessment for every new legislation, has inspired elements of Geneva’s new health law.
The influences of Canada and specifically of Quebec on Swiss health promotion have thus been numerous and diversified and we are convinced that exchanges will continue in the future between our countries.
FURTHER READINGS Bourdages, J., et al. (2005). L’intégration de la prévention et de la promotion dans les systèmes de santé: Quatre réalités, plusieurs similitudes. Promotion & Education (Suppl. 3), 62–64. Paris: Ed. Union Internationale de Promotion de la Santé et d’Education à la Santé. Synthesis of the work carried out during the forum Dialogue sur les systèmes nationaux de santé that was held in margin of the 2nd international symposium on the local and regional health programs. It also gave place to a compared analysis of four countries (Brazil, France, Switzerland, Canada). Secrétariat du Grand Conseil. (2003). Rapport du Conseil d’Etat au Grand Conseil concernant le bilan de la planification sanitaire qualitative. From www.geneve.ch/grandconseil/data/texte/RD00490.pdf. This report relates the experience of a four-year health promotion pilot program. The program was conducted from 1998–2002 in the Geneva district. It can be consulted at www.geneve.ch/grandconseil/data/texte/RD00490.pdf. Simos, J. (2006). Introducing health impact assessment (HIA) in Switzerland. Social and Preventive Medicine 51(3), 130-132. A forum dedicated to the health impact evaluation problematic and its premises in Switzerland.
RELEVANT WEB SITES Promotion Santé Suisse www.promotionsante.ch/fr/default.asp
This Web site of Promotion Santé Suisse (Swiss Health Promotion) gives access to information and other resources related to health promotion in Switzerland. Réseau Francophone des Villes-Santé de l’O.M.S. www.villes-sante.fr/datas/doc_pdf/presentation_RfVS.pdf.
Presentation of WHO’s francophone network Villes-Santé, hosted on the francophone network’s Web site. Also, there are links to other networks and organizations connected to Villes-Santé, which, on another note, was born during the Ottawa Charter epoch.
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THE C ANADIAN APPROACH AND ITS IMPACT IN TUNISIA Moncef Marzouki
At the beginning of the 1980s, I took over as the first Tunisian director of the Community Medicine Department at the Faculty of Medicine of the University of Sousse, situated in the centre of Tunisia. It was a fact then that ambitious and talented Tunisian physicians were not going into public health, a field mainly occupied by political activists (my case) or individuals who had failed on the clinical front. The job entailed teaching duties but, foremost, preventive medicine activities in dispensaries spread out in the suburbs and countryside of the area. As the team I led was composed of almost all Canadians, it was my first encounter with the know-how and the typical Quebec accent. It was an intense time of discovery and fascination about the techniques, concepts, and ethical approaches conveyed by my new friends, a radical departure from the outdated French public health conception that was previously predominant. The Canadian co-operation program, which had triggered the implementation of the Community Medicine Department in 1978, continued during the 1980s and a good part of the 1990s, which enabled systematic exchanges with our friends and colleagues from Montreal and Quebec City. It facilitated the training of the Tunisians, who would then staff the department, and the organization of three international symposiums at Sousse University. For more than 20 years then, the Tunisian faculty disseminated Canadian knowledge revolving around the analysis of health determinants, health promotion planning, and community participation. Sousse’s progressive department was then influencing, for better or worse, the fac-
ulties of Tunis and Sfax, which were still operating with an outdated public health vision of hygiene and immunization. Unfortunately, the adventure ended somewhat bitterly. Accused of being a communist medicine service, Sousse’s department was dismantled in 1992. I was myself banned from the university in 2000 because of my activities as a human rights activist. Even worse, the dispensaries that we had begun to transform into community health centres fostering community participation quickly reverted to their old function: to give minimum health care at the lowest possible cost so that a dominated population stood quietly in its everyday misery. All decision making became concentrated in the hands of the Party. The limit of the Canadian model then struck me: It was the child of democracy and could not function properly in a dictatorial state. The concepts and techniques originating from the shores of the St. Lawrence River were highly subversive. That is why a step backward took place in the middle of the 1990s; why today I live in exile; and why my old colleagues trained in Montreal re-specialized in other areas while being very careful not to irritate the system. So then, was this a complete failure? Yes and no. The fight for a democratic state, a necessary condition for the establishment of health promotion, carries on slowly but surely. As for the ideas and ideals related to a public-minded health service, chances are that as sturdy seeds, they will emerge out of the arid ground when the proper rainfall, called freedom, comes.
FROM YOUTH HEALTH TO A NATIONAL HEALTH PROMOTION PLAN: C ANADA’S PARTNERSHIP WITH UKRAINE Nadiya Komarova and Maryna Murashova
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From 1998–2005, a model of intersectoral multi-level collaboration was introduced in several regions of Ukraine within the Youth for Health (YFH) Project. The project was managed by the Canadian Society for International Health and funded by the Canadian International Development Agency. The model was developed by the Ukrainian Institute for Social Research, the project’s Ukrainian partner, in collaboration with a number of state and non-governmental Ukrainian and Canadian organizations based on the front-line Canadian experience in health promotion. The goal of the model was to promote healthier lifestyles among Ukrainian children and youth. It was critical to correctly select the ways of achieving the project’s goal and determine the criteria of its success. Evaluation and research have been significant components of all activities, which have helped in monitoring the project’s responsiveness and facilitated the effective adaptation of Canadian best practices to the Ukrainian context and conditions. While the project’s overall management was effectively carried out by the Canadian organization, a large role was played by Ukrainian project participants, who took part in the decision-making process using advice and recommendations provided by a number of project advisory bodies, experts, and consultants from both Ukraine and Canada. The development of an effective mechanism of collaboration between Canada and Ukraine to maintain the exchange of information and effective coordination of partners’ actions was among the most crucial prerequisites of success. Contributions from the Canadian partners were extremely valuable at all stages of the development, piloting, and delivery of the YFH model. The expertise of Canadian consultants was particularly useful in organizing and conducting project training, conferences, and special sessions, as well
as in providing advice to youth and professionals on the development of youth health promotion materials and resources. Study tours organized by the Canadian partners played a special role in the process of development of local capacity and in educating Ukrainian decision makers in the development of healthy public policies. Hands-on and scientific results of the YFH project implementation in Ukraine is an exemplary case of a country (Canada) playing a fundamental role in supporting the development of a specific area of activity (youth health promotion) in another country (Ukraine). The intersectoral multi-level YFH model was presented and discussed at the Verkhovna Rada (the Parliament) of Ukraine during parliamentary hearings in 2003, which gave an impetus to the development of the National Health Promotion Program for the Ukrainian population. The Verkhovna Rada of Ukraine then made a decision to create the National Centre of Youth Health Promotion, originally established within the YFH II Project and later transferred to the State Institute of Family and Youth Problems under the Ministry of Ukraine for Family, Youth, and Sports; it is now a fully operational and effectively working structure that will continue to utilize Canadian expertise to further promote healthy lifestyles among Ukrainian children and youth and to facilitate the policy-development processes at the local and national levels.
REFERENCING C ANADA: A COMMENTARY ON C ANADIAN AC ADEMIC PUBLIC ATIONS FROM THE UK Gordon Macdonald
Internationally, but especially in the UK, the
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world of academic health promotion has come of age in the 21st century. From slow embryonic beginnings in the 1970s, academia began embracing health promotion in the 1980s, supported its mushrooming in the 1990s, and is witnessing its maturation in the first decade of this century (Bunton & Macdonald, 2002). Academic health promotion includes the teaching of the subject at undergraduate and post-graduate levels, research in all its forms, and, of course, publication in books, periodicals, reports, and journals. In the 1970s few universities offered any form of study or award in health promotion; today it is truly an international discipline with teaching and research opportunities worldwide. In the 1970s there were barely a handful of dedicated books available to any student of health promotion; today we have access to well over 100 texts (Mittelmark et al., 2000). In the 1970s very few journals were dedicated to health promotion as an independent discipline. Today we have in excess of 50. This is a truly remarkable story, and Canada’s contribution to these developments has been very noticeable. I know this because of my time over the last 15 years as an editor or member of the editorial board of four academic journals: Journal of Contemporary Health (JCH) (now, sadly, no longer published), The Health Education Journal (HEJ) (the longest-running domestic journal in the UK); Promotion and Education (P&E) (one of the official journals of the International Union for Health Promotion and Education), and, finally, Health Promotion International (HPI) (now published for over 20 years). Together these four journals have published at least 49 articles by Canadian authors since 1995, which compares very favourably with countries of a similar stage in health pro-
motion development and similar population. A paper was considered to be Canadian when at least one (but more normally all) the authors were based in Canada when the article was written. The content ranges from original research (Vahabi & Ferris, 1995 or Vossen et al., 2004 for instance) to editorials (e.g., Labonté, 1996), as well as whole issues dedicated to Canadian heart health (P&E, 2001) or edited by Canadians (e.g., Potvin et al., 2005). HPI has carried an article from Canada in virtually every other issue between 1995 and 2005. Some of these articles have been truly seminal. Discussions on evaluating community health initiatives have been conducted on a worldwide basis, but Canada’s contribution is significant (e.g., Judd et al., 2001); Poland’s (1996) two-part debate on the principles and content to evaluate healthy communities initiatives was also influential. Robertson (1998) kicked off a debate on the shift from health promotion to population health, which was followed by a response from Raphael and Bryant (2002) on the limitations of population health. Raphael, Bryant, and Curry-Steven’s work on poverty reduction and public health policy (2003, 2004) builds on the work by Marmot and others in the UK on the social determinants of ill health and disease and has received worldwide attention. With the Ottawa conference some 20 years ago and Vancouver’s coming up in 2007, Canada’s influence on UK health promotion developments continues to impress, and not only at the academic level. Evidence of the significance of Canada’s contribution to health promotion is to be found in UK policy documents and in the four individual UK country members’ public health policies and strategies for the first decade of the 21st century.
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REFERENCES Canadian Heart Health Dissemination Research. (2001). Promotion & Education, (Suppl. 1). Bunton, R., & Macdonald, G. (Eds.). (2002). Health promotion: Disciplines, diversity and developments (2nd ed.). London: Routledge. Judd, J., Frankish, C.J., & Moulton, G. (2001). Setting standards in the evaluation of community-based health promotion programmes—a unifying approach. Health Promotion International, 16(4), 367–380. Labonté, R. (1996). Community and its health—its power and its problems. Journal of Contemporary Health, 4, 2-3. Mittelmark, M.B., Kvernevik, A.M., Kannas, L., & Davies, J.K. (2000). Health promotion curricula; cross-national comparisons of essential reading. Promotion & Education, 7(1), 27–32. Poland, B.D. (1996). Knowledge development and evaluation in, of, and for healthy community initiatives. Part I: Guiding principles. Health Promotion International, 11(3), 237–247. Poland, B.D. (1996). Knowledge development and evaluation in, of, and for healthy community initiatives. Part II: Potential content foci. Health Promotion International, 11(4), 341–349. Potvin, L., Avargues, M.-C., Berghmans, L., Bilodeau, A., Bourdages, J., Brunelle, Y., et al. (2005). L’intégration de la promotion et de la prévention dans les systèmes de santé. Promotion & Education, 12, Supp. 3, 94. Raphael, D. (2003). Barriers to addressing the societal determinants of health: Public health units and poverty in Ontario, Canada. Health Promotion International, 18(4), 397–405. Raphael, D., & Bryant, T. (2002). The limitations of population health as a model for a new public health. Health Promotion International, 17(2), 189-199. Raphael, D., Bryant, T., & Curry-Stevens, A. (2004). Toronto charter outlines future health policy directions for Canada and elsewhere. Health Promotion International, 19(2), 269–274. Robertson, A. (1998). Shifting discourse on health in Canada: From health promotion to population health. Health Promotion International, 13(2), 155–166. Vahabi, M., & Ferris, L. (1995). Improving written patient education materials: A review of the evidence. Health Education Journal, 54(1), 99–106. Vossen, D., McArel, H., Vossen, J., & Thompson, A. (2004). Physical activity and the common cold in undergraduate university students; implications for health professionals. Health Education Journal, 63(2), 145–157.
FURTHER READINGS Cribb, A., & Duncan, P. (2002). Health promotion and professional ethics. Oxford: Blackwell Publishing. Marmot, M., & Wilkinson, R.G. (Eds.). (1999). Social determinants of health. Oxford: Oxford University Press. Tones, K., & Tilford, S. (2001). Health promotion: Effectiveness, efficiency, and equity (3rd ed.). Cheltenham: Nelson Thornes.
RELEVANT WEB SITES NHS Centre for Reviews and Dissemination www.york.ac.uk/inst/crd.dissem.htm
This is is the well-established academic centre at York University specializing in systematic reviews of evidence.
296 ■ PART IV: International Perspectives UK Government’s Department of Health www.doh.gov.uk
This gives a wealth of information on public health policy. UK’s National Institute for Clinical Excellence www.nice.org.uk
This incorporates the health promotion/public health evidence into practice agenda (NICE now includes the defunct Health Development Agency).
C ANADA’S INFLUENCE ON HEALTH PROMOTION IN THE UNITED STATES OF AMERIC A Lawrence W. Green and Robert A. Hiatt
Canada influences the United States in subtle ways. The influences are real, sometimes profound, but often disavowed. Canada’s universal health insurance, for example, inspired reformers in the US health care system, but they always disclaimed Canadian-style universality and uniformity. The Canadian Task Force on the Periodic Health Examination (1979) influenced the US’s first Guide to Clinical Preventive Services (1989), wherein over half of the 169 interventions recommended were patient counselling for health promotion and self-care. Medicine aside, the US has a very substantial commitment within its public health system to health promotion, thanks, in part, to the Lalonde Report (more so even than the Ottawa Charter), which influenced the priorities on the environment, lifestyle, and health services in the first US Surgeon General’s Report on Health Promotion and Disease Prevention (1979). Bilateral discussions in 1980 contributed to comparable questions in Canada’s first Health Promotion Survey and the first comprehensive set of social and behavioural measures in the US National Health Interview Survey (Green, Wilson, & Bauer, 1983).
These early initiatives predated the Ottawa Charter and aligned the official policies and documents of the two countries. Political resistance, however, too often derails the philosophical commitments of health promotion professionals in both countries. The commitment to more sweeping policies of socio-environmental changes recommended by the Ottawa Charter to “make the healthier choices the easier choices” (Milio, 1986) have been limited in the US largely to tobacco control. A central concept of the Ottawa Charter was participation. Canada led the way again in compiling the North American experience in participatory research, and in supporting, through the Royal Society of Canada, a review of the experience of participatory research in health promotion across Canada to derive a set of guidelines for participatory research (www.lwgreen.net/guidelines.html). Sadly, this has been another good idea having difficulty gaining traction as official policy in Canada, but the guidelines have been widely applied by grant-making organizations in the US. Recent interaction between leadership of the National Cancer Institute of Canada (NCIC) and that of the US NCI has created a dynamic framework for cancer control research. A model developed by Canadians in the mid-1990s (Advisory Committee on Cancer Control, 1994) formulated new strategies for cancer control research adopted in
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the US at the turn of the century (Hiatt & Rimer, 1999). This synergistic interaction continues as health promotion evolves in both countries (Best et al., 2003) toward greater emphasis on dissemination and implementation of research and practice with leadership from the Canadian Institute for Health Services Research, NCIC, and the Canadian Heart Foundation (see Johnson et al., 1996).
In return, these interactions have provided Canadians at least the opportunity to observe American false starts and failures first hand, and then to reshape them in more socially responsible and politically palatable forms up north.
REFERENCES Advisory Committee on Cancer Control. National Cancer Institute of Canada. (1994). Bridging research to action: A framework and decision-making process for cancer control. Canadian Medical Association Journal, 151(8), 1141–1146. Best, A., Stokels, D., Green, L.W., Leischow, S., Holmes, B., & Buckholz, K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion, 18(2), 168–176. Canadian Task Force on the Periodic Health Examination. (1979). The periodic health examination. Canadian Medical Association Journal 121, 1193–1254. Green, L.W., Wilson, R.W., & Bauer, K.G. (1983). Data required to measure progress on the objectives for the nation in disease prevention and health promotion. American Journal of Public Health, 73, 18–24. Hiatt, R.A., & Rimer, B.K. (1999). A new strategy for cancer control research. Cancer Epidemiology Biomarkers and Prevention, 8(11), 957–964. Johnson, J.L., Green, L.W., Frankish, C.J., MacLean, D.R., & Stachenko, S.A. (1996). Dissemination research agenda to strengthen health promotion and disease prevention. Canadian Journal of Public Health, (Suppl. 2), S5–S10. Milio, N. (1986). Promoting health through public policy. Ottawa: Canadian Public Health Association. US Department of Health Education and Welfare. (1979). Healthy people: Surgeon general’s report on health promotion and disease prevention. DHEW-PHS-79-55071. Washington: Public Health Service. US Preventive Services Task Force. (1989). Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Baltimore: William & Wilkens.
FURTHER READINGS Best, A., Stokels, D., Green, L.W., Leischow, S., Holmes, B., & Buckholz, K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion, 18(2), 168–176. Reviews extant and emerging health promotion models, their Canadian and American roots, and ways to integrate them toward a more systems-oriented health promotion practice. Green, L.W., Wilson, R.W., & Bauer, K.G. (1983). Data required to measure progress on the objectives for the nation in disease prevention and health promotion. American Journal of Public Health, 73, 18–24.
298 ■ PART IV: International Perspectives Based partly on bilateral talks between Health Canada, Statistics Canada, and the US Department of Health and Human Services, the first National Health Interview Survey was planned to track health behaviour changes associated with the health promotion objectives in the now three decades of the US Healthy People initiative, with data that could be compared with Canada’s experience. Johnson, J.L., Green, L.W., Frankish, C.J., MacLean, D.R., & Stachenko, S.A. (1996). Dissemination research agenda to strengthen health promotion and disease prevention. Canadian Journal of Public Health, (Suppl. 2), S5–S10. Reviews the initiatives of Health Canada, NCIC, the Canadian Heart Foundation, and others to propose a research agenda for dissemination of research to policy and practice.
RELEVANT WEB SITES A Resource for Instructors, Students, Health Practitioners, and Researchers www.lgreen.net
The banner for this Web site declares, “If we want more evidence-based practice, we need more practice-based evidence.” It contains the Guidelines for Participatory Research in Health Promotion based on a review and consultation across Canada. These guidelines have been widely adopted in US federal and foundation grant making. Published applications are cited in www.lgreen.net/guidelines.html. “From Research to ‘Best Practices’ in Other Settings and Populations” by Lawrence W. Green www.ajhb.org/2001/25-3-2.pdf
A reflection by an American on lessons from eight years of work in Canadian health promotion, and the implications of efforts in Canada and the US to build evidencebased practice from research that is often conducted under circumstances that do not generalize to the conditions of most communities in which they would be applied. Johns Hopkins University Press: Journals www.press.jhu.edu/journals/progress_in_community_health_partnerships/
A new journal founded at Johns Hopkins University, illustrating the extent of influence on participatory research in the US since the publication of Participatory Research in Health Promotion by the Royal Society of Canada.
PA RT V
PRACTICAL PERSPECTIVES
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s we noted at the outset of this book, we believe that a sound conceptual base is the foundation of sound practice. We also think that understanding how the field of health promotion has developed within Canada and abroad has practical relevance because it facilitates practitioners’ understanding of the vagaries of funding, policy, and international action. Most importantly, however, we believe that being or becoming a reflexive practitioner increases the likelihood of one’s work being relevant and useful. Reflexivity is another tool for enhancing practice—whether one’s practice is one’s personal health practices, research, policy making, program planning and implementation, management, consulting, or activism. We have thus introduced themes in this section that we think are significant for the practice of health promotion, beginning with the concept of the reflexive practitioner. Chapter 16 opens this section with a critical analysis of the notion of reflexive practitioner by Boutilier and Mason. Drawing on the literature on the reflexive practitioner from several fields, they derive implications for people working in health promotion in various capacities. In Chapter 17, concrete examples of programs run across Canada in the last decade, in a variety of settings, with various populations and on different issues are presented by Richard and Gauvin. They argue for the use of an ecological approach to develop interventions and derive lessons for others from the programs they analyze. There is often a gap between the clinical practice of various health care professionals (nurses, physicians, etc.) and the discourse of health promotion to the point that many of these professionals do not identify with the health promotion field. In Chapter 18, Hills, Carroll, and Vollman explore how this dilemma has been addressed in Canada over the last decade and the challenges of creating a shared vision of health promotion acceptable to clinicians and other types of health promotion practitioners. Over the past 10 years or so, the evaluation of health promotion programs has generated a substantial international debate, notably over issues of defining and measuring effectiveness and, in an evidence-based era, of the nature of evidence required to properly evaluate
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health promotion interventions. In Chapter 19, the theoretical and practical contribution of Canadian scholars and practitioners to this debate is presented and illustrated through specific examples by Potvin and Goldberg. At the end of this section, the reader will understand the major issues related to the practice of health promotion in Canada and will be able, in a reflexive manner, to analyze and eventually transform his or her practice accordingly.
CHAPTER 16
T H E R E F L E X I V E P R AC T I T I O N E R I N H E A LT H P RO M OT I O N : F RO M R E F L E C T I O N TO R E F L E X I V I T Y
Marie Boutilier and Robin Mason1
reflections shed light on the reflective process for others?
INTRODUCTION hen we were invited to write this chapter on reflective practice in health promotion, we expected to draw heavily upon on our previous experience and writings to distill lessons and guidelines for others. Now, as we finish, we are once again reminded of how risky it is to act on assumptions at a project’s beginnings. Upon reflection, we have found that we brought different disciplines, questions, and writing styles to this project and it has led us to examine reflexivity in health promotion as both a solitary and collaborative process. In this chapter, we thus explore reflective practice in health promotion by examining the concepts and the process of reflexivity and reflective practice with implications for people working in health promotion in a variety of capacities. First, we outline some understandings of health promotion practice and health promoters, and some basic characteristics of professional practice with implications for health promotion professionals. Second, we situate the terms “reflective” and “reflexive” in their philosophical and historical contexts and, third, identify foci of reflections in health promotion. Finally, we look at the “how to” of reflective practice in health promotion, including addressing a question that emerged for us: How might our own
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REFLECTIVE PRACTICE IN HEALTH PROMOTION: CONTEXTUAL ELEMENTS Health Promotion Practice The broadly accepted definition of professional practice is the application of knowledge (theoretical and/or technical) in specialized professional work. Health promotion as practised in Canada, however, is a multidisciplinary endeavour, usually drawing on the values and strategies of the Ottawa Charter rather than a rigorously defined discipline. While health promotion is practised by professionals, it is not a profession per se in that it has no standardized education requirements, and no licensing, professional college, or governing body. So while the individual health promoter may well have another professional identity (e.g., nurse), health promoters as a group bring a multidisciplinary values-based training to their professional role. Canadian training programs expect that “health promoters” will practise in a range of organizations, including governments, private corporations, public health units, hospitals, community-based networks, research organizations, and international aid agencies (University of Toronto, 2004) in the delivery of services, policy, and research. 301
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Professionals and Reflective Health Promotion Practice Our reflective practice literature review (Web of Science, Sociofile, Medline, Google Scholar, Google) revealed that “reflection” is applied to occupations as diverse as coaching (Knowles, Borrie, & Telfer, 2005), social work (Riemann, 2005), software development (Hazzan & Tomaykoz, 2003), and medicine (Mamede & Schmidt, 2004). Reflection is seen as integral to core competencies in specific professions, e.g., nursing, (College of Nurses of Ontario, 2007), and in interprofessional practice (Barker, Bosco, & Oandasan, 2005). Yet little has been written about reflective practice specific to professionals who practise health promotion (Boutilier, Mason, & Rootman, 1997; Health Promotion Resource System, 2006; Labonté & Feather, 1996). Broadly, professions perform knowledge-based services that require specialized training, and professional work is marked by some common features, generally applicable to health promotion. Professionals solve problems for others and are therefore, by definition, agents of change (Schön, 1983); the focus on problem solving in professional work necessitates consideration of risk (Evetts, 2006); professional knowledge is a source of power because it accords the power to frame the problem at hand (Schön, 1983); professional work is underpinned by an “ethic of service” to clients and/or patients (Friedson, 2001), which translates to professionalism, requiring professionals to be worthy of trust (Evetts, 2006). As professionals often practise in large organizations, their work becomes standardized according to institutional policies; in this context, the discipline-based problem solving, knowledge-based power, autonomy, “ethic of service,” and role as change agent can lead to a tension between professionals and their employing institutions, with tensions erupting
into power struggles (Reuschemeyer, 1986). This is an important point for health promotion. First, health promoters may find themselves in a dilemma of accountability and power, especially when projects take community development or capacity-building approaches (Hawe et al., 1998). In examining their own power and status vis-à-vis the partner community, health promoters may be caught in a position of “dual accountability”— accountable to both the community and to their employing organization with multiple, possibly conflicting, goals (Mason, 1997; Poland et al., 2001). When health promoters commit to strategies of community “empowerment,” they can feel torn between their employing organization and the community they serve, under the critical eye of managers and employers (Hawe et al., 1998; Poland et al., 2000). Second, the project-by-project nature of many health promotion initiatives also means that health promotion initiatives may feel tenuous and risky because they often compete for funding with more easily measured, biomedically focused health issues (Raphael, 2000), acute care (Poland et al., 2001), or immunization in public health (Boutilier et al., 2001). In addition, there is a trend to individuals working from their homes as consultants rather than salaried employees (Hughes, 1999), creating professional vulnerability in new ways. Finally, the management of resources, including the time required to build trusted relationships, collaboration, and reflection, can be a source of tension between the professional and his or her employer/manager/funder. All these circumstances make the reflection on health promotion work both relevant and necessary.
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CYCLES AND SPIRALS: THE ORIGINS OF “REFLECTION,” “REFLECTIVE PRACTICE,” AND “REFLEXIVITY” The terms “reflective” and “reflexive” are sometimes used interchangeably, but it is important to outline differences when applying them to professional practice.
“Reflection” Reflection can be thought of as a learning process and was first given attention by educational theorists and researchers such as Dewey, Lewin, Freire, and Schön. Reflection was initially defined as the “active persistent and careful consideration of any belief or supposed form of knowledge in the light of the grounds which support it” (Dewey, 1933, p. 118), emerging from a state of doubt and involving “the kind of thinking that consists in turning a subject over in the mind and giving it serious thought” (Moon, 1999). In this model, reflection was conceptualized as individualistic, goal-directed, and solutionfocused, a cycle that concludes with the testing or evaluation of a determined action and then begins all over again. This was the inspiration for Lewin’s (1946) spiral of action research. Educational theory later took on an explicit values base and a political agenda with Paolo Freire’s vision of education as dialogue with no dichotomy between “true reflection and action” (Freire, 1998, p. 64).
“welfare state,” and post-secondary education following World War II. Schön’s groundbreaking contribution was the recognition that in the action of real-life problem solving, professionals must “reflect in action” when the catalogue of known theories and strategies prove overly simplistic and only marginally relevant. Faced with complex problems, when discipline-based knowledge proves inadequate, thoughtful experimentation becomes part of the process of problem solving—a form of “research”—occurring in an iterative and cyclical process akin to action research. The act of questioning and experimenting with strategies occurs in an ongoing cyclical process until the question is reframed (often in collaboration with others) and change occurs. Not only does reflection expand the professional’s tacit knowledge toolkit for problem solving, it can contribute to theory development, self-development (as a professional and individual), decision making, empowerment, and other outcomes that are unexpected, as new ideas or images can be applied in practice (Moon, 1999). In addition, it serves as a preventive process in being drawn into repetitive and routine thinking and solutions, missed opportunities, and boredom or burnout (Schön, 1983). For health promoters, the challenges for reflection are found in the combination of collaboration, multidisciplinary strategies, and values (which generally include an ethic of service to communities), all practised within the context of their employing organizations.
“Reflective Practice” In the reflective practice literature Donald Schön’s The Reflective Practitioner: How Professionals Think in Action (1983) was pivotal. It was published at a time when professionals were increasingly employed by large organizations, following the growth of multinational corporations, the bureaucracy of the
“Reflexive” and Reflexivity The term “reflexive” is now so widely used that “it has … become a sin to not be reflexive” (Maton, 2003, p. 54; original emphasis). Although the term carries different meanings, it is generally rooted in Bourdieu’s (1990) “epistemic reflexivity” or Giddens’s
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notion of the “reflexive project of the self” in a modern “detraditionalized” “risk society” (Giddens, 1991). Lupton (1997) summarizes reflexivity as: [Drawing] upon the assumption that in … modern Western societies individuals constantly seek to reflect upon the practices constituting the self and the body and to maximize … the benefits for the self.… Life, in this formulation, is carried out as an enterprise, demanding a continual search for knowledge to engage in selfimprovement … continually mak[ing] decisions from a variety of options as part of everyday life.… [I]ndividuals experience the self, the body and the social and physical worlds with a high degree of reflection, questioning, evaluation and uncertainty…. [E]xpert knowledges … are no longer … accepted on face value [but] are now open to skepticism and to challenge on the part of lay people.… (p. 374)
Reflexivity is also said to be “a performance that positions the author in relationship to the field … [and] is demonstrated in the act of writing” (Haggerty, 2003). Reflexivity complements standpoint epistemology (Smith, 1987) and participatory research (Park et al., 1993) in that both hold that the enquiry is shaped by the researcher’s social identity based on gender, race, class, and ability. There is the risk that reflexivity may become too inward-looking, self-absorbed, and over individualized in “hermeneutic narcissism” (Maton, 2003), losing its intent of transformative knowledge development. It can “become a disembodied process because it involves turning ourselves into objects of study” (Cunliffe & Easterby-Smith, 2003, p. 34). Or, “the often lofty theoretical justifications for greater reflexivity can manifest themselves as a license to write about our most beloved topic—ourselves … shad[ing] into personal therapy” (Haggerty, 2003, p. 159). In
plain language, the risk is that our reflexive undertakings will focus on our personal emotions and psyches rather than being accompanied by critical analysis of our practice and its context. Haggerty points out that the assumption of self-awareness requisite to reflexivity sidesteps the truism (following Freud) that we cannot be fully aware of our assumptions and, in reflexivity, we may unwittingly “rationaliz[e] unconscious motivations and prejudices” (2003, p. 159). For this reason, we offer the caveat that reflexivity is meant to focus largely on professional practice, with some boundaries drawn by the individual between personal and professional issues. This is integral to “professionalism” for most people and becomes more or less intuitive, but is a point that bears articulation. To summarize, Canadian health promotion practice, integrating values of empowerment and participation, crosses professional boundaries and disciplines and is inextricably linked to the context within which it occurs. Collaboration and reflection (both individual and collaborative) underlie health promotion practice. As professionals, health promoters are agents of change who focus on solving problems with individuals and communities, but as such, they may experience tensions in dual accountability, and risk vulnerability in their positions. We now turn to foci for reflection in health promotion practice.
FOCI FOR REFLECTION IN HEALTH PROMOTION: POWER AND COLLABORATION In order to avoid narcissistic self-scrutiny in their reflections, health promoters need to remain thoughtful, critical, and focused on the context of practice. Health promotion practice, however, often requires the “messiness”
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of collaboration. Collaboration involves working across differences, whether these are discipline-based, characteristics of diverse communities, or of practice settings. On each side (community and institutional organization) there are power networks, structures, including some formal and informal hierarchies, and different notions of knowledge and expertise. The most readily identified challenges relate to issues of power, expertise, and control (Gondolf, Yllo, & Campbell 1997; Peterson 1993; Rovegno & Bandhauer, 1998). In addition, there are challenges related to differences in work cultures, language of practice or discipline, time constraints, and outcome expectations (Buckeridge et al., 2002). Collaborations are forced to confront and, usually, negotiate issues of power. Power and the perception of who has power may derive from differences in status, knowledge (and kinds of knowledge), resources, skills, and commitment to the collaboration itself (Buckeridge et al., 2002). It can be addressed with different strategies in health promotion initiatives; for example, participants can use others’ power to their own ends, redirect their strategies, withdraw altogether, or (less often) become confrontational (Boutilier, Cleverly, & Labonté, 2000). Communication difficulties in collaboration can stem from differing bases and sources of knowledge, work cultures, and professional practices (Mason & Boutilier, 1996). For example, in one instance where the process of collaboration itself was the focus of a health project, distinct work cultures with attendant differences in expectations, values, outcomes, reward systems, and work styles emerged; early misunderstandings resulting from these issues coloured the collaboration and impacted the development of real understanding (Buckeridge et al., 2002). Added to these perhaps predictable misunderstandings are problems that emerge
when the same words (e.g., time, practice, commitment) signify different things to those in the partnership (Bogo et al., 1992; Boutilier & Mason, 1994; Buckeridge et al., 2002; Gilling, 1994; Gondolf, Yllo, & Campbell, 1997; Nyden & Wiewel, 1992; Peterson, 1993). Collaborations can also shift with discrepancies in resources, both tangible (e.g., funding or personnel) or less visible (e.g., intellectual capacity of partners, time, prior community linkages). Developing effective working collaborations requires significant investments, often in short measure at the start: time, trust, and energy (Bevilacqua, Morris, & Pumariega, 1996; Buckeridge et al., 2002). Individual and collective engagement in the process of reflection can help bring these issues to light, while honest commitment to the process also supports the development of trust in the individuals and organizations participating in the collaboration. In reflective practice, individuals deliberately examine their situations, behaviour, practices, and effectiveness within specific situations after the fact, so they become wiser at working within the complex and dynamic world of practice. Experienced professionals also engage in reflection during action, forming judgments, acting and reacting in the moment on the basis of past experience and learning: Schon’s “reflection-in-action.” When decisions are made on the basis of experience and the aims, means and context are considered against the actual situation and probable outcomes; however, reflection may be considered to have begun before the action (Van Manen, 1991, in Clarke, James, & Kelly, 1996). This kind of reflection also builds on reflections from previous projects, merging with reflection-on-action. Not to be taken lightly are the resources needed for both kinds of reflective practice: the time and space to ask questions and speculate upon the answers.
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MOVING BEYOND PROJECTS: BECOMING A REFLECTIVE HEALTH PROMOTION PRACTITIONER Writing,Writing,Writing … In this section we will explore some of the tools that can assist in becoming a reflexive practitioner. The literature offers some examples of how to begin, including: role playing, video or
audiotaping practice sessions, utilizing client feedback, and working with peer or mentor supervision (Evans, 1997; Ferraro, 2000; Kottkamp, 1990). There are also resources in participatory research evaluations that will also often apply to health promotion. These include group reflections and storytelling (Ellis, Reid, & Barnsley, 1990; Labonté & Feather, 1996). However, the most frequently used and easily accessible tool for health promoters is writing (Health Promotion Resource System, 2006).
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Writing is a powerful tool for learning from and reflecting upon experience. First, the act of writing itself engages both hand and brain, integrating the right and left hemispheres in the action. Second, the physical act of converting thoughts into words upon a page demands the slowing down of thought; it allows for moving back into the past and invites musing about the future. While writing, we can pause the action, go back and revisit a thought, consider options, and reformulate a sentence; in this way writing is itself often a reflective process (Kottkamp, 1990). There are different forms that writing can take, including diaries, case records, or journals. While a diary is a list of daily activities with little space set aside for review of those activities, a case record contains detailed description of specific situations or projects. Kottkamp (1990) describes a case record as being based on a problematic situation that includes responses to basic questions about the nature of the situation, the action taken, alternatives considered, and hoped-for outcomes. Also useful is a document in which a
factual description of an event is written in one column and later reflections in a second column (Moon, 1999), to reflection on action. Journal writing shares features in common with case records, but expands the scope of reflection beyond problematic situations. A journal contains the ongoing consideration of the individual in relation to others, the emotions evoked, values in harmony or collision, and skills possessed or wanting, in addition to questions about specific situations, actions taken, alternatives considered, and hoped-for outcomes. A journal may contain conversations, poetry, drawings, or songs that assist in making thoughts or feelings clear. A journal, therefore, is both an ongoing catalogue of activities plus the repository of a critical appraisal of those activities with associated thoughts and feelings. It is the record of a critical and constructive internal dialogue one holds with oneself and as such, the journal is deeply personal. In addition to the descriptive documentation of situations and events, alternatives considered and possible outcomes had these been followed, the
BOX 16.2: AIDS TO WRITTEN REFLECTION
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journal includes a critical analysis of the political context in which actions unfold, one’s knowledge, skills, expertise, values, and assumptions. It becomes the means by which observing, questioning, critiquing, synthesizing, and acting are integrated into daily practice, or reflection-in-action. From reflecting on the specifics of a project or problematic situation and in the midst of making choices in daily practice, one shifts into reflection as a way of encountering the world. To begin journalling, one should set aside a block of time. Begin the entry with the date, place, and a summary of a specific situation, activity, or focus of reflection. The conversation begins most easily by considering issues and questions such as the “What if” ones noted above. Once the present reality has been documented, consider the emotional reactions to that reality. If reflecting on a specific event or situation, consider the emotions related to entry, during the situation, and now, upon reflection.
Reflections Past and Present: Journals and Diagrams In writing this chapter we have inevitably reflected on our own reflective processes. One of us (RM) is a fairly consistent journal writer while the other (MB) uses journals more selectively and more often engages in diagrams that map out relationships and ideas, leading to decisions and strategies. We offer below examples drawn from our own reflections. Journal Reflections (RM)
My career path has taken me to work in community social service settings, research centres, and a hospital. I have worked collaboratively on projects to address local hunger, youth unemployment, newcomer settlement issues, an organizational policy on intimate partner violence, and curriculum development. I have
frequently found journalling a useful way of organizing my thoughts and experiences. In the excerpts below, taken from some early work on trying to integrate education on intimate partner violence (IPV) into a hospital setting, I consider the “place” and “ownership” of education in the larger hospital environment. At the time, I was the facilitator of a group of front-line practitioners who met monthly to discuss IPV and health care practices. We had collaborated on the development of a curriculum on IPV relevant to hospital practitioners and had begun delivering the training to different programs in the hospital. I represented this ad hoc group at meetings with hospital administrators, department chiefs, and program managers. Our group felt vulnerable within the hospital system—beyond my salary, there was no funding for the group or the education program we had developed, no clear lines for reporting or accountability, and our group did not appear on any organizational chart. One advantage we did have was an organizational policy we had developed, and which had been approved and ratified, that made responding to IPV part of everyone’s practice. In addition, education on the issue was ensconced within this policy. So our group, and especially myself as the group’s facilitator, operated in a grey area both within and outside the traditional professional hierarchies and structures. At one and the same time, there was a mandate to ensure that staff were educated as outlined by the policy, but no clear indication or infrastructure to support our claim that our group should be fulfilling that mandate. In order to preserve the anonymity of those to whom I refer in the journal, names and other identifiers have been removed. The original entries are in Box 16.3. In rereading these two excerpts I am aware now of how vulnerable I felt my
CHAPTER 16: The Reflexive Practitioner in Health Promotion ■ 309 BOX 16.3: CASE STUDY: REFLECTIONS ON A PRACTICAL SITUATION
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position was at that time and in that organization. I felt responsible for ensuring our little group’s collaborative way of working was upheld in the face of a sometimes overwhelming bureaucracy and hierarchy. I also felt an enormous trust had been placed in me to represent and speak out for the group; it was as their representative that I found my power and courage. Representing the group also meant, however, that as an individual I was visible in the hospital organization and thus vulnerable whereas other members of the group were not. I became highly attuned to and preoccupied by the organizational politics; I was continuously jockeying for power where the bulk of
power was held by physicians and hospital administrators. As an insider/outsider (a status achieved by default because the lines of reporting were unclear) I was also afforded a certain power in that I attended the same meetings as those who made key decisions and could contribute to the organization’s strategic goals and priorities. Yet I had no resources or infrastructure to help our group achieve its goals. I recall trying to figure out if it was safer to be silent and overlooked or wiser to be outspoken and noticed so that the project and my position could not “disappear” without comment. Now, I wonder whether my anxieties were accurate reflections of dire possibilities
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within the organization or merely my own personal demons. I remember how the conflicts with my community partners added to my general sense of tension, conflict, and frustration. As the first line of the second excerpt shows, I was exasperated by the politicking that seemed to govern every aspect of my daily work life. In rereading this excerpt now, I recognize how reconciled I have become to the politics surrounding practice. The issue itself (IPV) is a politically sensitive one and those who work on it, particularly in hospital environments, are not usually accorded the support or recognition afforded those who specialize in other health issues. On the community side, the tension between comparatively well-resourced hospitals and poorly resourced community partners has continued, although ways of collaborating and supporting each other’s work have been found and respect for the constraints within which we each practise are better understood. Finally, rereading this entry has allowed me to recognize the continuity between the values that made the work important to me then (helping and providing services to women) and today. Diagrams as Reflection (MB)
Rather than the traditional path of doctorate to academic post, my career has focused solely on research in different capacities and in a range of organizations and working arrangements. My written professional reflections have been somewhat sporadic and I have moved in and out of practice reflections depending on the projects I work on, stages of the projects, whether I am employed or working in a volunteer capacity, and the urgency of other dimensions of my life. My reflections have thus incorporated the logistics and “political economy of research,” i.e., how the structures of the university mesh with research funding models and the division
of labour in research (McQueen, 1994). This contingent nature of formal written reflections may hold for many people—it may be that decision moments trigger the need to reflect rather than when work processes can be more or less routine. The irony of this is that it is at these moments of possible crises that the time needed for reflection is in short supply.
CONCLUSIONS We have examined health promotion practice, collaboration, reflection, reflexivity, how to reflect, and considered how the process of reflection can illuminate relationships, power, hierarchies, and improve practice. Reflection is integral to the repertoire of knowledge and understanding of what it means to promote health in a context of multiple interests. It becomes a key resource for health promoters as they develop expertise over time, becoming a part of one’s professional identity and way of being a reflexive practitioner. On reflection, the writing of this chapter itself has shaped our representation of reflexivity. While emphasizing the principles and values outlined in the Ottawa Charter, we are mindful of the practice of health promotion as lived experience for professionals committed to the health of the communities they serve. Reflection requires resources and facilitators, not the least of which is time. We have focused on reflexivity for health promoters, but the processes of reflective practice described here will apply to professional work in general. In health promotion, the importance of collaboration begs the question of whether processes and foci of reflection and reflexivity may differ across disciplines and professions as influenced by their respective assumptions and values. While we see collaborative reflection as part of the health promotion reflective
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process, each individual and health promotion initiative will be unique according to the
diversity of individuals, interests, organizations, values, personalities, and goals involved.
NOTE 1
The authors acknowledge their equal contributions to this chapter.
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312 ■ PART V: Practical Perspectives Evans, D. (1997). Reflective learning through practice-based assignments. Paper presented at the British Educational Research Association Annual Conference, September 11–14. From www.leeds.ac.uk/educol/documents/000000468.htm. Evetts, J. (2006). Short note: The sociology of professional groups. New Directions Current Sociology, 54(1), 133–143. Ferraro, J. (2000). Reflective practice and professional development. ERIC clearinghouse on teaching and teacher education. ED449120. Retrieved June 30, 2006, from http://eric.ed.gov/ERICDocs/data/ ericdocs2/content_storage_01/0000000b/80/2a/32/84.pdf. Freire, P. (1998). Pedagogy of the oppressed (New revised 20th anniversary ed.). New York: Continuum Publishing Company. Friedson, E. (2001). Professionalism: The Third Logic. London: Polity Press. Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Cambridge: Polity Press. Gilling, D.J. (1994). Multi-agency crime prevention: Some barriers to collaboration. Howard Journal of Criminal Justice, 33(3), 246–257. Gondolf, E.W., Yllo, K., & Campbell, J. (1997). Collaboration between researchers and advocates. In G.K. Kantor & J.L. Jasinski (Eds.), Out of the darkness: Contemporary perspectives on family violence (pp. 255–267). Thousand Oaks: Sage. Haggerty, K. (2003). Ruminations on reflexivity. Current Sociology, 51(2), 153–162. Hawe, P., King, L., Noort, M., Gifford, S., & Lloyd, B. (1998). Working invisibly: Health workers talk about capacity-building in health promotion. Health Promotion International, 13(4), 285–295. Hazzan, I., & Tomaykoz, J. (2003). The reflective practitioner perspective in eXtreme programming. XP/agile universe 2003 lecture notes in computer science, 2753, 51–61. Health Promotion Resource System. HP-101, Health promotion online course. Retrieved March 7, 2006, from www.ohprs.ca/hp101/main.htm. Hughes, K. (1999). Gender and self-employment in Canada: Assessing trends and policy implications: CPRN study no. W|04: Changing employment relationships series. Ottawa: Canadian Policy Research Networks. Knowles, Z., Borrie, A., & Telfer, H. (2005). Towards the reflective sports coach: Issues of context, education, and application. Ergonomics, 48(11–14), 1711–1720. Kottkamp. (1990). Means for facilitating reflection. Education and Urban Society, 22(2), 182–203. Labonté, R., & Feather, J. (1996). Handbook on using stories in health promotion practice. Cat. no. H39378/1996E. Ottawa: Minister of Supply and Services. Lewin, K. (1946). Action research and minority problems. Journal of Social Issues, 2, 34–46. Lupton, D. (1997). Consumerism, reflectivity, and the medical encounter. Social Science and Medicine, 45(3), 373–381. Mamede, S., & Schmidt, H.G. (2004). The structure of reflective practice in medicine. Medical Education, 38(12), 1302–1308. Mason, R. (1997). “Total responsibility and absolutely no control”: Participatory research as a health promotion strategy. Unpublished PhD thesis, OISE, University of Toronto. Mason, R., & Boutilier, M. (1996). The challenge of genuine power sharing in participatory research: The gap between theory and practice. The Canadian Journal of Community Mental Health, 15(2), 145–152. Maton, K. (2003). Reflexivity, relationism, & research: Pierre Bourdieu and the epistemic conditions of social scientific knowledge. Space & Culture, 6(1), 52–65. McQueen, D. (1994, June 16). Visions of health promotion research. Keynote address, 3rd Conference on Health Promotion Research, Calgary, Alberta.
CHAPTER 16: The Reflexive Practitioner in Health Promotion ■ 313 Moon, J. (1999). Reflection in learning & professional development: Theory & practice. London: Kogan Page. Nyden, P., & Wiewel, W. (1992). Collaborative research: Harnessing the tensions between researcher and practitioner. The American Sociologist, 23(4), 43–55. Park, P., Brydon-Miller, M., Hall, B., & Jackson, T. (Eds.). (1993). Voices of change: Participatory research in the United States and Canada. Toronto: OISE Press. Peterson, P.D. (1993). Merging cultures: Challenges and opportunities in public academic liaison. Administration and Policy in Mental Health, 20(6), 411–419. Poland, B., Boutilier, M., Tobin, S., & Badgley, R.F. (2000). The policy context for community development practice in public health: A Canadian case study. Journal of Public Health Policy, 21(1), 5–19. Poland, B., Fell, L., Graham, H., Lum, J., Walsh, E., Williams, A.P., et al. (2001). “We’re hired by the hospital, but we work for the community”: Examining hospital involvement in community action. Hospital Quarterly, 4(3), 52–59. Raphael, D. (2000). The question of evidence in health promotion. Health Promotion International, 15(4), 355–367. Reuschemeyer, D. (1986). Power and the division of labour. Cambridge: Polity Press. Riemann, G. (2005). Ethnographics of practice-practising ethnography: Resources for self-reflective social work. Journal of Social Work Practice, 19(1), 87–101. Roth, R. (1989). Preparing the reflective practitioner: Transforming the apprentice through the dialectic. Journal of Teacher Education, 40(2), 31–35. Rovegno, I., & Bandhauer, D. (1998). A study of the collaborative research process: Shared privilege and shared empowerment. Journal of Teaching in Physical Education, 17, 357–375. Schön, D. (1983). The reflective practitioner: How professionals think in action. Boston: Basic Books. Smith, D. (1987). The everyday world as problematic: A feminist sociology. Toronto: University of Toronto Press. Taggar, R., & Clarke, B. (2001). Reflective practice gets new tool. Retrieved June 29, 2006, from College of Nurses of Ontario, www.cno.org/qa/refprac/rp_rpnewtool.html. University of Toronto. (2004). MHSc health promotion grad whereabouts. Unpublished report. Centre for Health Promotion, University of Toronto.
CRITIC AL THINKING QUESTIONS 1. What are the underlying disciplines that form the bases of the knowledge and theoretical frameworks with which you frame questions and issues in health promotion? 2. What is the difference between reflecting on an issue and becoming a reflexive professional? 3. If you were to organize a collaborative reflection process, who would you involve? How would it happen? What questions would you start with? 4. What values are important to you in your work/professional life? Can you imagine a situation in which these are challenged in your work? What would be your first steps in working it through? 5. If you were designing a Type 2 diabetes educational initiative for an urban hospital setting, which stakeholders representing which interests would you consider as you developed your program? Who would be the target audience for the program? If you were designing a similar program for a low-income housing complex, which stakeholders
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representing which interests would you need to consider? In what ways would the program change depending upon where it was being delivered?
FURTHER READINGS Gould, J., & Nelson, J. (2005). Researchers reflect from the cancer precipice. Reflective Practice, 6(2), 277–284. Nelson, J., & Gould, J. (2005). Hidden in the mirror: A reflective conversation about research with marginalized communities. Reflective Practice, 6(3), 327–339. These two articles present the reflections of two researchers employed at a cancer research unit. They often reflect together about the difficult emotional issues involved in working with cancer patients, power relations, and privilege, as well as facets of identity that come into play in their work, including race, class, gender, cultural capital, and personal life histories. To formalize these conversations, they audiotaped and transcribed four dialogue sessions during which they asked themselves what they were learning about themselves as both social scientists and as individuals through their work. Hernández-Ramos, P. (2004). Web logs and online discussions as tools to promote reflective practice. Retrieved July 3, 2006, from The Journal of Interactive Online Learning, 3(1), Summer 2004 ISSN: 1541-4914. From www.ncolr.org/jiol/issues/PDF/3.1.4.pdf. Blogs are increasingly appearing as a means of reflection for both personal and professional communities; this article cites over 500,000 blogs available on the Internet. They are seen as an accessible tool to promote collaborative reflection and to alter individuals’ perceptions of themselves and their practice in testing their ideas with an audience of peers or other professionals, privately or anonymously, depending on the parameters of the blog. The article describes how a teacher education course required 56 students to blog for weekly reflection. Few students intended to incorporate blogging into their professional practice, but it allowed for an examination of the issues in a format that was challenging to everyday practice. Journal of Reflective Practice This journal focuses on reflective practice as applied to various practices, including nursing, occupational therapy, research, art, and social work. It is an interesting and useful source for readings on reflections and how to develop these into a manuscript. Kahan, B., & Goodstadt, M. (2001). The interactive domain model of best practices in health promotion: Developing and implementing a best practices approach to health promotion. Health Promotion Practice, 2(1), 43–67. This article discusses issues associated with taking a best practices approach to health promotion, including determining factors, implementation, and implications for practitioners and policy makers. The authors suggest that health promotion effectiveness will be increased through adoption of a systematic and critically reflective approach to practice—one that considers all major factors affecting practice and is consciously guided by health promotion values and goals, theories and beliefs, evidence, and understanding of the environment. To help practitioners develop and implement best practices, they outline a model, the Inter-active Domain Model of Best Practices in Health Promotion, and a set of best practices criteria.
CHAPTER 16: The Reflexive Practitioner in Health Promotion ■ 315 Labonté, R., & Feather, J. (1996). Handbook on using stories in health promotion practice. Cat. No. H39378/1996E. Ottawa: Minister of Supply and Services. This booklet is directed at health promotion practitioners and walks the reader through a process that includes individual and collaborative reflection. It provides questions to initiate reflection, tips for problem solving, and synthesis. Moon, J. (1999). Reflection in learning & professional development: Theory & practice. London: Kogan Page. The first part of this book provides an overview of reflection and its application to different disciplines, professions, and practices. The second part is a study of learning, in particular higher level learning and the role of reflection in learning. The last section applies reflection to the improvement of learning and practice. Reynolds, M., & Vince, R. (Eds.). (2004). Organizing reflection. Aldershot: Ashgate Publishing Ltd. This collection is based on the idea that reflection has a utility beyond individual self-improvement, that it can, in fact, be a key factor in organizational development. The individual chapters further both theory and the practice of reflection. They discuss reflection as applied to communities of practice, collective reflection, critical reflection, and reflexivity. Included also are discussions of power and power relations, experience, and the role and place of emotions. Schön, D. (1983). The reflective practitioner: How professionals think in action. Boston: Basic Books. This seminal work in the literature on reflective practice provides a “sociology of knowledge” approach to expertise and expert power. It rests on case studies of how professionals learn and hone their intellectual crafts, with implications for individual professionals, and for mentors and learners. Meticulous in its case study analyses, it is easy to read and provides insights into reflexivity applicable across professions. While the discussion chapter on the move away from technical rationality may be somewhat dated, its historical perspective maintains it as a paradigm-shaping work and a continuing resource for professionals, their teachers, and managers.
RELEVANT WEB SITES Case Study: Partners in Practice Port Colbourne, Ontario www.partnersinpractice.org/orgtale.html
Partners in Practice examines the mentoring relationship and ways to support, enrich, and encourage that relationship in early childhood practice. Includes a workbook approach. College of Education, University of North Texas www.coe.unt.edu/teachertools/research/aboutresearch.htm
Includes a description of collaborative action research for teachers and learners, whatever the setting. Also provides tips on getting started, and a framework for action.
316 ■ PART V: Practical Perspectives Learning and Teaching Unit, Manchester Metropolitan University Adult Education Web Site www.ltu.mmu.ac.uk/ltia/issue11/index.shtml
Aims at widening participation in higher education (HE) through “activities and interventions aimed at creating an HE system that includes all who can benefit from it—people who might not otherwise view learning as an option, or who may be discouraged by social, cultural, economic, or institutional barriers.” International Journal of Education & the Arts, 4(1) January 30, 2003 http://ijea.asu.edu/index.html
I, Me, Mine: Soliloquizing as Reflective Practice Monica Prendergast University of Victoria “Examines soliloquies as forms of reflective practice through an understanding of this dramatic voice applied to qualitative research writing, …[e.g.,] data poems, dialogues of symbolic interactions (between “I” in practice and “Me” in reflection), as autobiography (talking to myself about myself), and autoethnography (talking to the group within which I place myself). Soliloquy writing offers myriad ways to engage in reflective practice and qualitative interpretive inquiry.” ItsLife www.itslifejimbutnotasweknowit.org.uk/RefPractice.htm
UK teacher education site; extensive bibliography on reflective practice. Journal Writing www.journal-writing.com/index.html
This Web site was developed by Gerry Starnes and explores journal writing as a vehicle for personal growth.
CHAPTER 17
BUILDING AND IMPLEMENTING E C O L O G I C A L H E A LT H P RO M OT I O N I N T E RV E N T I O N S
Lucie Richard and Lise Gauvin
some emerging challenges to the design, implementation, and evaluation of such innovative initiatives.
INTRODUCTION he main goal of this chapter is to provide examples of innovative, contemporary health promotion programs that effectively translate social ecological conceptions into tangible health promotion interventions. Given that a full description of the complexity inherent in these programs would exceed what can realistically be accomplished within the purview of a single chapter, we centre the presentation on one key dimension of health promotion intervention: the degree of integration of an ecological approach. The ecological approach is currently generating much enthusiasm among theorists, planners, and practitioners in health promotion and public health. However, despite this high level of interest, proponents continue to lament its poor level of integration into programming efforts. Given this paradox and the potential of the approach, we believe it is a useful exercise to describe programs deemed as exemplary in terms of their degree of integration of such an approach. Accordingly, after having briefly described the ecological approach and the historical context of its emergence in public health, we illustrate some applications by describing three highly ecological health promotion initiatives drawn from the contemporary Canadian context. Finally, we identify
T
THE ECOLOGIC AL APPROACH Derived from ecology, a subfield of biology, the ecological approach offers a research and action framework that emphasizes the complex transactions between people, groups, and their environments. Contrary to traditional ecology, which highlighted the physical features of environment, the ecological approach used in health promotion is more social ecological in nature and focuses more centrally on the social, organizational, and cultural components of the environment. Within such a vision, planners and practitioners are urged to design interventions and programs that will integrate people-focused efforts to modify health behaviours with environmentfocused interventions to enhance physical, social, and cultural surroundings. Such complex intervention packages are touted as having the potential for greater success than traditional single-focused health education interventions (Sallis et al., 2006; Smedley & Syme, 2000; Stokols, 1992).
The Rise of the Ecological Perspective Ecological thinking has a long history in disciplines such as biology and psychology. An 317
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emphasis on socio-environmental determinants of health was also at the root of public health at the turn of the 19th century. However, the ecological discourse re-emerged only very recently in public health. In fact, the World Health Organization European Regional Office (World Health Organization, 1984) presented its new conceptualization of health issues as recently as the mid-1980s. This conceptualization reiterated the importance of environmental determinants of health and of ecological approaches to promote the health of populations. Besides WHO, several Canadian organizations played a leadership role in the emergence of the ecological approach and of the health promotion discourse and practice (Epp, 1986; Kickbusch, 1994, 2003; World Health Organization, Health and Welfare Canada, & the Canadian Public Health Association, 1986). Oddly enough, because of its emphasis on complexity and wide-scale system influences, the ecological approach has often been seen as intimidating and difficult to operationalize (Green, Richard, & Potvin, 1996). One way to address this problem has been to stratify the environment as, for example, psychologists have done: Bronfenbrenner (1979) stratified the environment into micro-, meso, exo-, and macrosystems whereas Moos (1979) proposed a four-strata classification revolving around physical settings, organizational factors, human aggregate factors, and social climate. In public health, similar efforts have been undertaken as demonstrated in the ecological framework of McLeroy and colleagues (McLeroy et al., 1988), the MATCH model (Simons-Morton, et al., 1988), or in Stokols’s (1992) seminal paper. Later, application of the ecological approach for the planning of interventions was undertaken by Green and Kreuter (1999) and Stokols (1996). More recent efforts include those of Bartholomew, Parcel, Kok, and Gottlieb
(2001) and of Canadian authors (Best et al., 2003; Edwards, Mill, & Kothari, 2004). Applications of the approach to a wide variety of health and disease problems have also been published over the years (Gauvin, Lévesque, & Richard, 2001; Glasgow et al., 1999; Richard, 1996; Sallis et al., 2006). Despite all these efforts, a low level of integration of the ecological approach in health promotion practice is still observed overall (Beaglehole & Bonita, 2004; Merzel & D’Afflitti, 2003; Orleans et al., 1999; Richard et al., in review; Smedley & Syme, 2000). Yet, the health promotion literature, reports from the field, and testimonials of dozens of planners and practitioners indicate that descriptions of innovative programs aimed at a variety of health determinants are available as exemplars. In a quest to contribute to a greater integration of the ecological approach into professional practices, our strategy is to describe examples of best practices in this regard by spotlighting selected examples of successful Canadian applications of the ecological approach in health promotion programs. Our selection was strategic, covering a variety of target populations, intervention areas, and geographical regions. We now turn to a description of these three success stories.
THREE EXAMPLES OF PROGRAMS Promoting Healthy Living and Health Supportive Environments: Inception of a “Possibility Framework” through the Promoting Action toward Health (PATH) Project is a five-year federally funded health promotion research project. It has been implemented in a relatively disadvantaged area of a mediumsized city in Western Canada. It involves a partnership between a community centre, a regional health authority, and a university. PATH was initially aimed at preventing
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Type 2 diabetes among the midlife population (35–64 years) of the target area. However, in acknowledging that many medical and non-medical causes of diabetes (e.g., obesity, poverty) are also at the root of several other chronic diseases, the need to include other age groups and to adopt a population health approach were recognized (Chappell et al., 2006). It was also evident at the start of the project that involvement of the broader community would be desirable for the project to facilitate community development and health goals (Carson, Chappell, & Knight, in press). Gradually, a stronger emphasis on reducing inequities related to social determinants of health has become apparent: PATH’s goal is to support healthy living through addressing social determinants; that is, the focus is on barriers and obstacles, and making the healthy choices the easy choices. Recognizing the difficulties if not impossibility of changing root socioeconomic conditions in a time-limited research project, PATH seeks to promote healthy living and health supportive environments via initiatives at multiple levels that identify and respond to resident concerns. (Chappell et al., 2006, p. 4)
In line with the ecological approach that the promoters explicitly adopted as a theoretical underpinning (Chappell et al., 2006), a central criterion guiding the choice of initiatives for the project was the capacity to address one or more determinants of health and to effect change at multiple levels. To help ensure this multi-level focus, a planning tool allowing for the charting of project activities by level of change was used. Labelled the “Possibility Framework” (see Table 17.1), this tool “lists specific initiatives in the project by their current level of focus, and includes ‘possible’ examples of initiatives and activities at other levels of intervention”
(Chappell et al., 2006, p. 11). Obviously, the list of initiatives shown in Table 17.1 is not exhaustive (non-listed initiatives such as health fairs, community gardens, and history and heritage activities are also mentioned in Chappell et al., 2006), but the information illustrates the strong ecological dimension of the PATH Project. As seen in Table 17.1, the set of initiatives implemented has potential for reaching the target population in a variety of settings. In addition, PATH includes a variety of intervention targets and strategies. Good examples of this diversity are the establishment of interorganizational networks and linkages as well as various strategies to develop and reinforce personal competencies. A final strength to be highlighted is certainly the strong emphasis put on capacity building and community participation in the PATH Project (Carson et al., in press; Chappell et al., 2006). For example, consistent with a community activation or community action strategy, community residents and local organizations were involved in the planning, design, and management of activities. Accordingly, it was believed that initiatives ought to emanate from residents rather than professionals and researchers. For this reason, the project started at the individual level; “this strategy […] helped avoid a potential paralysis of action due to multiple simultaneous commitment” (Chappell et al., 2006, p. 4). As discussed below, there is often a tension between the comprehensive focus of an ecological approach and the ideal of participation inherent in health promotion (Chappell et al., 2006; Stokols, 1996). The PATH Project is a good demonstration of how such a large-scale approach can thrive with an agenda permeated by community participation and capacity building.
320 ■ PART V: Practical Perspectives TABLE 17.1: MULTI-LEVEL “POSSIBILITY FRAMEWORK” FOR INITIATIVES
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Getting Kids on the Move and Eating Well: Stunning Impact of the Annapolis Valley Health Promoting Schools Project Another interesting example of the application of the ecological approach is found in the Annapolis Valley Health Promoting Schools Project (AVHPSP, 2004). It is one of the few initiatives that has been evaluated extensively in terms of behaviour and health outcomes (Veugelers & Fitzgerald, 2005). Similarly to the PATH project, the AVHPSP revolved around the theme of making the healthy choice the easy choice, but focused more specifically on promoting healthy eating and daily physical activity to fight overweight and obesity among elementary schoolchildren in Nova Scotia. The program promoters believed that “multiple strategies occurring simultaneously to promote healthy eating and physical activity enhances the acceptance and ability to deliver the programmes at the school, school board, and community level. These strategies include policy, education, awareness, leadership development, programme development, programme implementation, and advocacy” (AVHPSP, 2004). The activities were organized in six sets. First, the project aimed at shifting the focus from a “profit” framework toward a “prophet” framework by mobilizing people around the idea of changing environments and policies to effect change. This was achieved through a number of means: identification of a program champion, creating links with the community, and developing leadership among school staff. The second set of activities involved conducting school surveys. This was done by developing an evaluation framework and developing different data collection activities, including a student preference survey, activity logs, and school physical activity and menu snapshots. A plan was also developed to share school-
specific information with the schools. A third set of activities consisted of developing a business plan for healthy food and physical activity in each participating school that was directly in line with an ecological approach. The fourth aimed at implementing a healthy eating strategy: changes were made in food offerings as well as in presentation of new types of food. The fifth strategy was the implementation of physical activity on a daily basis through non-competitive running, playground games, “kids teaching kids” coaching clinics, equipment loan, etc. The final strategy included creating links between schools and the community through building partnerships with local stakeholders. An effectiveness evaluation of the AVHPSP showed that children attending AVHPSP schools had significantly lower rates of obesity and overweight, had healthier diets, and reported more physical activities (Veugelers & Fitzgerald, 2005). The AVHPSP is an example where successful integration of ecological principles led to measurable changes in indicators of population health.
Moving toward Tobacco Control: Shaping the Web of Environmental Determinants in a Quebec Regional Public Health Department Our third example is the tobacco control program of one regional public health department (Breton et al., 2004). In 1994, the Quebec Ministry of Health and Social Services launched an ambitious action plan to tackle the high prevalence and incidence of smoking in the province (Ministère de la santé et des services sociaux, 1994). Supported by a budget of $20 million, this plan included four components—prevention, health protection, cessation, and surveillance/evaluation—and targeted youth and low-income populations. In addi-
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tion to encouraging collaboration with community partners in the development and implementation of interventions, the plan also called for the adoption of a global, ecological approach to tobacco control, including action on a variety of environmental and personal determinants of smoking initiation and maintenance. The ministry mandated the regional public health departments to implement the plan. In the following paragraphs, we describe how one specific public health department responded to this mandate. In line with the ministerial plan, this particular program included a variety of initiatives (see Box 17.1) covering a variety of intervention settings and targets. As shown in Table 17.2, four types of settings emerged as the most dominant in the
program: schools, health organizations, the community, and the society. A variety of intervention targets were also included. Organizational elements (ORG) were by far the most frequently targeted by the interventions like, for instance, school tobaccocontrol policy or increase of tobacco-control skills of key actors in organizations (e.g., physicians, nurses, teachers, administrators). Organizational targets were also involved in strategies aimed at networking organizations. An example here is the creation and maintenance of a network of CLSCs1 involved in tobacco control in various organizations in their territory. Three other types of targets were also aimed at. For example, one initiative (“La
BOX 17.1: SELECTED EXAMPLES OF INITIATIVES IDENTIFIED IN THE TOBACCO-CONTROL PROGRAMMING OF A REGIONAL PUBLIC HEALTH DIRECTORATE
Text not available
Gang Allumée”—“The Enlightened Gang”) involved networking of various actors interested in tobacco control in high school settings, including student representatives seen as key players in the interpersonal environment (INT) of the target population. A selfhelp cessation guide was distributed in the population through various channels; in this example, the individual is the direct target of
the intervention (IND). Finally, one initiative aimed at a political target. At the same time that these local and regional activities took place, the Quebec tobacco-control community was actively working toward the adoption of a new provincial law (Breton, 2005); thus, many of the regional activists were also provincially involved in a strategic coalition aimed at lobbying elected officials (POL).
CHAPTER 17: Building and Implementing Ecological Health Promotion Interventions ■ 323 TABLE 17.2: FREQUENCY OF INITIATIVES (N = 14) ACCORDING TO DIFFERENT TYPES OF INTERVENTION SETTINGS AND TARGETS
Text not available
This tobacco program for youth is an excellent example of an ecological intervention (Richard et al., 1996). First, it integrated environmental and individual targets across a variety of settings. Second, these targets translated into a diversity of strategies of which at least one was aimed directly toward the target population itself and others at the environment. It is noteworthy to mention that smoking was among the first contemporary public health issues to be redefined in a broader social perspective that extended well beyond personal behaviour (Brownson et al., 1997) thus calling for a comprehensive, ecological response from the public health community. The tobaccocontrol programming described above is a good example of such a response.
WHERE TO FROM HERE? In sum, we view the ecological approach as a contemporary and practicable framework within which to orient health promotion interventions. However, we also note several challenges that threaten the reach it might have for future practice and research. The first challenge is conceptual and pertains to the role of community participation in the development and implementation of programs. Although we highlighted the fact that ecological health promotion programming is founded on a broad conception of health determinants, we also note that less emphasis has been devoted to the role of community participation even though it is seen as pivotal in health promotion and population health (Rootman et al., 2001; Schwab & Syme, 1997). The reasons for this situation
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are likely associated with the inherent challenge of reconciling objectives related to multi-level community outcomes on the one hand, and maximizing community participation, which is often fuelled by more proximal preoccupations, on the other hand. For example, Chappell et al. (2006) indicate that, “residents may be seen to want their kitchens to remain at the individual and group level of intervention, whereas PATH may seek expansion to more macro levels. This demonstrates potential conflicting priorities for PATH facilitators between being responsive to community desires on the one hand while on the other hand seeking changes at broader levels” (p. 13). A second and related challenge pertains to the unwillingness of practitioners to advocate for legislative and policy changes partly because they find themselves in the awkward position of trying to influence the very people who employ them. Similarly, they are in the difficult position of interfering with the daily business of very powerful corporations (e.g., the tobacco or fast-food industries). As a result, existing health promotion programs understandably display timid efforts to influence the political sphere. Nevertheless, in the examples described above actions at the political level were actually undertaken. For example, at the regional public health department, one way of facilitating political action was to support coalitions and other collaborative networks that then acted as leaders in terms of political action and advocacy. Similarly, in the “Possibility Framework” of the PATH Project, activities were aimed at co-operative interorganizational efforts to change policy affecting local residents. Significant results in health promotion programming are likely to be achieved only if practitioners, in addition to working at the individual level, are able to influence political targets (O’Neill, 1989; O’Neill, Gosselin, & Boyer, 1997).
A third challenge pertains to the evaluation of the complex and multi-level health promotion programs that integrate the ecological approach. First, there is a need for appropriate methods to establish the efficacy and effectiveness of interventions. In this regard, we noted that AVHPSP promoters deployed unusual efforts to produce evidence of the impact of the program in preventing obesity and changing eating and activity patterns (Veugelers & Fitzgerald, 2005). As noted by several authors, though, randomized clinical trials, which still represent the gold standard for evidence, are difficult to apply in evaluating complex community programs (Victora, Habicht, & Bryce, 2004). Numerous interesting alternatives have been identified, though: clustered randomized trials, quasiexperimentation, and case studies. Yet, efficacy/effectiveness is not the only focus of evaluation. As noted by Glasgow and his colleagues (Dzewaltowski, Estabrooks, Klesges, Bull, & Glasgow, 2004; Dzewaltowski, Glasgow, Klesges, Estabrooks, & Brock, 2004; Glasgow, Klesges, Dzewaltowski, Bull, & Estabrooks, 2004), evaluations of health promotion efforts must also address reach, adoption, implementation, and maintenance. We note with some concern that these evaluation issues will become even more acute as practitioners get more involved in stimulating community participation and political action.
CONCLUSIONS As demonstrated in the three programs described above, integrating ecological principles in practice is possible. We anticipate that further advances will occur at an accelerated pace if researchers and practitioners devote continued efforts to comprehensive evaluation of ecological programs and to knowledge transfer activities. Research on the identification of factors associated with
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greater levels of integration of the ecological approach in actual programming is also a promising avenue.
NOTE 1
CLSC: Centre local de services communautaires (local community health centres)
REFERENCES AVHPSP. (2004). Annapolis Valley Health Promoting Schools Project: Making the healthy choice the easy choice. Retrieved March 20, 2006, from www.hpclearinghouse.ca/features/AVHPSP.pdf. Bartholomew, K.L., Parcel, G.S., Kok, G., & Gottlieb, N.H. Intervention mapping: Designing theory- and evidence-based health promotion programs. Mountain View: Mayfield Publishing Company. Beaglehole, R., & Bonita, R. (2004). Public health at the crossroads: Achievements and prospects (2nd ed.). Cambridge: Cambridge University Press. Best, A., Stokols, D., Green, L.W., Leischow, S., Holmes, B., & Buchholz, K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion, 18, 168–176. Breton, E. (2005). Promouvoir des mesures législatives en vue de réduire le tabagisme: Une analyse de la contribution du système de santé publique à l’adoption de la loi sur le tabac du Québec [Promoting legislative measures toward tobacco control: An analysis of the contribution of the public health system to the adoption of the Québec tobacco law]. Unpublished doctoral dissertation, Université de Montréal, Montréal, Quebec. Breton, E., Richard, L., Lehoux, P., Labrie, L., & Léonard, C. (2004). Analyser le degré d’intégration de l’approche écologique dans les programmes de promotion de la santé: Le cas des programmations de réduction du tabagisme de deux directions de santé publique québécoises [An analysis of the level of integration of the ecological approach in health promotion programmes: The tobacco control programming of two Québec public health directorates]. Revue canadienne d’évaluation de programme, 19(1), 97–123. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge: Harvard University Press. Brownson, R.C., Eriksen, M.P., Davis, R.M., & Warner, K.A. (1997). Environmental tobacco smoke: Health effects and policies to reduce exposure. Annual Review of Public Health, 18, 163–185. Carson, A., Chappell, N.L., & Knight, C.J. (in press). Promoting health and innovative health promotion practice through a community arts centre. Health Promotion Practice. Chappell, N., Funk, L., Carson, A., MacKenzie, P., & Stanwick, R. (2006). Multilevel community health promotion: How can we make it work? Community Development Journal, 41(3), 352–366. Dzewaltowski, D.A., Estabrooks, P.A., Klesges, L.M., Bull, S.S., & Glasgow, R.E. (2004). Behavior change intervention research in community settings: How generalizable are the results? Health Promotion International, 19, 235–245. Dzewaltowski, D.A., Glasgow, R.E., Klesges, L.M., Estabrooks, P.A., & Brock, E. (2004). Re-aim: Evidence-based standards and a web-resource to improve translation of research into practice. Annals of Behavioral Medicine, 28, 75–80. Edwards, N., Mill, J., & Kothari, A.R. (2004). Multiple intervention research programs in community health. Canadian Journal of Nursing Research, 36, 40–54.
326 ■ PART V: Practical Perspectives Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Health and Welfare Canada. Gauvin, L., Lévesque, L., & Richard, L. (2001). Helping people initiate and maintain a more active lifestyle: A public health framework for studies of physical activity promotion. In R.N. Singer, H. Hausemblas, & C. Janelle (Eds.), Handbook of sport psychology (2nd ed., pp. 718–739). New York: Wiley. Glasgow, R.E., Klesges, L.M., Dzewaltowski, D.A., Bull, S.S., & Estabrooks, P. (2004). The future of health behavior change research: What is needed to improve translation of research into health promotion practice? Annals of Behavioral Medicine, 27, 3–12. Glasgow, R.E., Wagner, E.H., Kaplan, R.M., Vinicor, F., Smith, L., & Norman, J. (1999). If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness. Annals of Behavioral Medicine, 21, 159–170. Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach. Mountain View: Mayfield Publishing Company. Green, L.W., Richard, L., & Potvin, L. (1996). Ecological foundation of health promotion. American Journal of Health Promotion, 10(4), 270–281. Kickbusch, I. (1994). Introduction: Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, & international perspectives. Toronto: W.B. Saunders Canada. Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93(3), 383–387. McLeroy, K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351–377. Merzel, C., & D’Afflitti, J. (2003). Reconsidering community-based health promotion: Promise, performance, and potential. American Journal of Public Health, 93(4), 557–574. Ministère de la santé et des services sociaux. (1994). Plan d’action de lutte au tabagisme [Anti-tobacco action plan]. Quebec: Gouvernement du Québec. Moos, R.H. (1979). Social-ecological perspectives on health. In G. Stone, F. Cohen, & N. Alder (Eds.), Health psychology—a handbook: Theories, applications, and challenges of a psychological approach to the health care system (pp. 523–547). San Francisco: Jossey-Bass. O’Neill, M. (1989). The political dimension of health promotion work. In C. Martin & D.V. McQueen (Eds.), Reading for a new public health (pp. 222–234). Edinburgh: Edinburgh University Press. O’Neill, M., Gosselin, P., & Boyer, M. (1997). La santé politique: Petit manuel d’analyse et d’intervention politique dans le domaine de la santé (Monographie du Centre québécois collaborateur de l’OMS pour le développement de Villes et villages en santé). Beauport: Réseau québécois des villes et villages en santé. Orleans, C.T., Gruman, G., Umer, C., Emont, S.L., & Hollendonner, K.K. (1999). Rating our progress in population health promotion: Report card on six behaviors. American Journal of Health Promotion, 14, 75–81. Richard, L. (1996). Pour une approche écologique en promotion de la santé: Le cas des programmes de lutte contre le tabagisme [For an ecological approach in health promotion intervention: The case of tobacco control programmes]. Ruptures: Revue transdiciplinaire en santé, 3(1), 52–67. Richard, L., Gauvin, L., Gosselin, C., Ducharme, F., Sapinski, J.P., & Trudel, M. (in review). Integration of the ecological approach in health promotion and disease prevention programs for older adults. Richard, L., Lehoux, P., Breton, E., Denis, J.L., Labrie, L., & Léonard, C. (2004). Implementing the ecological approach in tobacco control programs: Results of a case study. Evaluation and Program Planning, 27, 409–421.
CHAPTER 17: Building and Implementing Ecological Health Promotion Interventions ■ 327 Richard, L., Potvin, L., Kishchuk, N., Prlic, H., & Green, L.W. (1996). Assessment of the integration of the ecological approach in health promotion programs. American Journal of Health Promotion, 10(4), 318–328. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). Copenhagen: Organisation mondiale de la santé. Sallis, J.F., Cervero, R.B., Ascher, W., Henderson, K.A., Kraft, M.K., & Kerr, J., K. (2006). An ecological approach to creating active living communities. Annual Review of Public Health, 27, 297–322. Schwab, M., & Syme, S.L. (1997). On paradigms, community participation, and the future of public health. American Journal of Public Health, 87, 2049–2051. Simons-Morton, D.-G., Simons-Morton, B.G., Parcel, G.S., & Bunker, J.F. (1988). Influencing personal and environmental conditions for community health: A multilevel intervention model. Family and Community Health, 11(2), 25–35. Smedley, B.D., & Syme, S.L. (Eds.). (2000). Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press. Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6–22. Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10, 282–298. Veugelers, P.J., & Fitzgerald, A.L. (2005). Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. American Journal of Public Health, 95(3), 432–435. Victora, C.G., Habicht, J.P., & Bryce, J. (2004). Evidence-based public health: Moving beyond randomized trials. American Journal of Public Health, 94, 400–405. World Health Organization. (1984). Health promotion: A discussion document on the concept and principles. Copenhagen: World Health Organization, Regional Office for Europe. World Health Organization, Health and Welfare Canada, & the Canadian Public Health Association. (1986). Ottawa Charter for Health Promotion. Canadian Journal of Public Health, 77, 425–430.
CRITIC AL THINKING QUESTIONS 1. How can the ideal of increased community participation in the health promotion process be reconciled with action on a variety of determinants of health (e.g., the community and the socio-political environment)? 2. How can public health interventionists further integrate advocacy and legislative action into their repertoire of action? 3. What are the most appropriate research designs for evaluating health promotion interventions that are characterized by a high degree of integration of the ecological approach? 4. Why is the ecological approach often qualified as intimidating and difficult to operationalize? What would you suggest in order to facilitate its integration into programs? 5. Could you think of other examples of programs and interventions that have successfully integrated the ecological approach?
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FURTHER READINGS Baker, E.A., Metzler, M.M., & Galeo, S. (2005). Addressing social determinants of health inequalities: Learning from doing. American Journal of Public Health, 95, 553–556. Provides a novel perspective on how to develop interventions aimed at dealing with the challenging issue of health inequalities. Paper has a significant focus on studying activities implemented by actors in the field. Bauman, A. (2005). The physical environment and physical activity: Moving from ecological associations to intervention evidence. Journal of Epidemiology and Community Health, 59, 535–536. This editorial provides a provocative view on how evidence can be translated into interventions. Cohen, D.A., Scribner, R.A., & Farley, T.A. (2000). A structural model of health behavior: A pragmatic approach to explain and influence health behaviors at the population level. Preventive Medicine, 30, 146–154. Provides a conceptual model that describes features of the physical and social environment that could be modified to promote the adoption and maintenance of health behaviours. Smedley, B.D., & Syme, S.L. (Eds.). (2000). Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press. A report from the Institute of Medicine Committee on Capitalizing on Social Science and Behavioural Research to Improve the Public Health. It emphasizes the role of social and behavioural factors in influencing health and disease at different stage of life. Many chapters are devoted to public health intervention, including health promotion. Task Force on Community Preventive Services, Zaza, S., Briss, P.A., & Harris, K.W. (Eds.). (2005). The guide to community preventive services: What works to promote health? Oxford & New York: Oxford University Press. Developed in the United States by the Task Force on Community Preventive Services, the Guide provides recommendations for interventions that promote health and prevent disease in communities and health care systems. It is based on systematic review methods for evaluating population-oriented health.
RELEVANT WEB SITES BC Coalition for Health Promotion www.vcn.bc.ca/bchpc Health in Action: On-line Access to Health Promotion and Injury Prevention Information in Alberta www.health-in-action.org Health Promotion Clearinghouse (Nova Scotia) www.hpclearinghouse.ca Ontario Health Promotion Resource System www.ohprs.ca
CHAPTER 17: Building and Implementing Ecological Health Promotion Interventions ■ 329 Ontario Prevention Clearinghouse www.opc.on.ca
A sample of provincial resource systems generally aimed at supporting health promotion organizations and interventionists with community resources and expertise. Several examples of programs appear on these Web sites. Institut national de santé publique du Québec www.inspq.qc.ca/english
The mandate of the Institut is to support the minister and regional agencies in fulfilling their public health mission. The Institut’s mission includes, among other goals, development, updating, dissemination, and implementation of knowledge. Its Web site provides information and resources related to a variety of health issues and interventions. Public Health Agency of Canada www.phac-aspc.gc.ca
With the mandate of promoting and protecting the health of Canadians, the agency is involved in various activities such as program delivery, research and knowledge development, and public and professional education. Its Web site includes information and resources related to key health issues and interventions in Canada. RE-AIM www.re-aim.org
RE-AIM provides an explanatory framework to systematically evaluate health behaviour interventions. The acronym stands for Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance. The Web site provides links to several resources useful to researchers and interventionists (data sources, reporting guidelines, examples of questions to investigate when evaluating health promotion program and policies, etc.).
CHAPTER 18
H E A LT H P RO M OT I O N A N D H E A LT H P RO F E S S I O N S I N C A N A DA : TOWA R D A S H A R E D V I S I O N Marcia Hills, Simon Carroll, and Ardene Vollman INTRODUCTION efore we begin to discuss the complex relations between the health professions and the field of health promotion, it is necessary to consider the definition of health promotion. In this we are in agreement with O’Neill (1997) in his comment on health promotion and nursing when he says that the “main issue at hand is to agree on a definition of health promotion, as this has a direct impact on related research, funding, teaching and practice” (p. 72). This is particularly true with regard to the role of the two dominant health professions, physicians and nurses. While there has been much progress in health promotion as a field of research and practice, it is still unfortunately true that the “ambiguity of the discourse in health promotion” (p. 73) is pervasive, and, as will be shown, this ambiguity continues to have a direct impact on how physicians and nurses understand their roles in relation to the concept. In this chapter, we will follow the Ottawa Charter definition of health promotion as “the process of enabling people to increase control over, and to improve their health” (World Health Organization, 1986). However, we will also draw upon the expanded definition in the updated 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,
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environmental and economic conditions so as to alleviate their impact on public and individual health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Participation is essential to sustain health promotion action” (Nutbeam, 1998). This definition links the “how” and “why” ideology to the “what” of the determinants of health (World Health Organization, 1998). We believe this is crucial because if health promotion is about anything, it is about action taken across the broad spectrum of health determinants, particularly directed toward the social, environmental, and economic conditions that support health. While this does not in any way denigrate the important work of developing personal skills and capabilities, notably through individual counselling strategies in the clinical setting, it makes the strong point that we cannot consider this type of individually focused, “lifestyles counselling” as constituting health promotion in toto. Thus, an evaluation of whether physicians and nurses are integrating health promotion into their education and practice must consider this broader definition of health promotion.1 It must consider health promotion to be the combination of concerted, integrated strategies of action on the broad determinants of health through the values-based process of enabling and empowering people to have control over these determinants. While we
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are not quite ready to give up the “ideology” dimension of the health promotion concept (as this would entail junking the values and moral substance of health promotion), we agree with O’Neill’s general sentiment, as also voiced in Chapter 3 of this book, that clearer agreement on what health promotion entails would be very helpful as not all people currently practising “health promotion” share this ideology and value base. The chapter will focus exclusively on the roles of physicians and nurses in health promotion. This somewhat narrow focus (there are many other health professionals who are relevant to health promotion—including nutritionists, dentists, physiotherapists, chiropractors, mental health professionals, etc.)— is taken for two reasons. First is the simple matter of space: We wanted to focus critically on some very specific issues rather than produce a more superficial survey of all the relevant professions. Second, and more complex, is the desire to bring into relief the crucial challenge health promotion still faces in confronting the Sisyphean task of reorienting health services or “health systems,” which is the more frequently used term now. This requires going back to health promotion’s roots in the AlmaAta Declaration (World Health Organization, 1978) and linking its prospects for tackling the great mountain of health systems reform through the strategy of primary health care. Physicians and nurses are the key strategic professions to mobilize for health systems change, and primary health care, if implemented in its fullest sense, is the basic fulcrum for leveraging this desperately needed change. The chapter will first look at some of the recent trends in how physicians and nurses have engaged in health promotion, and will critically analyze the barriers to fully incorporating a broad definition of health promotion into their everyday reflective practice, both as educators and as clinical practitioners.
It will use a two-dimensional mapping strategy for locating where on the health promotion spectrum doctors and nurses find themselves when attempting to teach and practise health promotion. Finally, the chapter will offer a theoretical argument for primary health care as the key locus for new efforts in the future, to integrate the Ottawa Charter vision of health promotion into the heart of our health systems.
TRENDS IN HEALTH PROMOTION ENGAGEMENT BY PHYSICIANS AND NURSES Over the past two decades or more, many changes have taken place in Canada within these two health professions regarding their engagement in health promotion activities. Health promotion as a concept (however variously defined) has become a standard reference point in medical and nursing education. However, the particular understanding and working definition (explicit or implicit) that dominates is very different for medicine and nursing. In this section, we will explore some of the reasons for this divergence and some solutions for moving both professions toward a more consistent approach to teaching about health promotion from a broader perspective. In addition, it is also the case that there is a vast diversity of attitudes and practices to health promotion once one ventures to the clinical settings, where health professionals have to implement their educational experience when they start to work in communities or in acute care settings.
Health Promotion in Medical and Nursing Education It is very clear that across the spectrum of medical and nursing undergraduate course
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offerings, health promotion has made a significant imprint, albeit at very different levels and with a very different impact for nurses and doctors respectively. We start our analysis with a brief review of undergraduate curricula in both the nursing and medical schools across Canada. Although there is certainly a diversity of perspectives within each profession, the focus of this analysis will be on the overall contrast between how nursing and medicine have approached integrating health promotion into their core curriculum. Health Promotion within the Medical Curriculum
We conducted a brief review of all 16 of the medical curricula in Canada, with the course contents as available on university Web sites for the current year. The information available on each Web site varied in the amount of detail provided. Despite these variations, we were able to ascertain which programs contained health promotion content. No interviews or other data collection methods were used; thus, the analysis is obviously limited. For the purposes of the broad contrasts we want to make, the course descriptions— wherein the curricula health promotion is situated and the prominence given to health promotion overall—provided the required information we needed to allow us to reach our conclusions. These conclusions are based on the words “health promotion” appearing in specific courses and in the broad learning objectives of the programs. The term “health promotion” appears in almost all (14 out of 16) of the program and course descriptions of the medical curricula across Canada. Some of the medical programs—for example, at the University of Alberta—collaborate closely to offer courses with their respective public health and health promotion programs, which can be located in the same school or in other related schools or faculties; however, our conclusions are
drawn out of the analysis of the core curricula and regular electives offered internally by each medical program. Almost invariably, health promotion is linked with, if not conflated with, disease prevention and epidemiology, and is usually subsumed under the broader labels of “population health” or “community health.” The overall focus is on health promotion as a “function” with a related set of technical intervention strategies. Several programs (e.g., Queen’s University and the University of Toronto) now offer placements for medical students in “community health settings” to apply their learning in community medicine broadly interpreted. Despite the move toward a “community” focus in many of the programs, we could find little or no mention of the values-based orientation of health promotion as outlined in the Ottawa Charter, leaving the concepts of participation, empowerment, and equity noticeably missing. Wherever health promotion is mentioned, it is thus strongly associated with epidemiology, population health, and community medicine. For example, at McGill, health promotion is mentioned as one part of the “Epidemiology, Biostatistics, and Occupational Health” course, and at the University of Manitoba, it fits under “Population Health and Medicine.” This orientation, many health promoters have pointed out, tends to leave the emphasis on values out of the equation (Raphael & Bryant, 2000). This is curious because there are strong movements within family medicine such as “patient-centred medicine” (Stewart et al., 1995), and “relationship-centred care” (PewFetzer Task Force, 1994, 2000) that emphasize many of the values that are compatible with a broader interpretation of health promotion, yet these areas of curriculum development are not usually associated with health promotion. This is probably due, as found in our analysis
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of curricula, to the fact that health promotion has often tried to impact medicine through the back doors of disease prevention or social and preventive medicine and has not well connected health promotion’s value base with the more general value base several medical programs seem to encourage and promote. This represents a major missed opportunity as building alliances with innovations in the core of clinical teaching in family medicine could be a more effective strategy for changing medicine’s view of health promotion. Specifically, health promotion could make the connection between everyday clinical realities and the focus on equity, participation, and empowerment that are foundational to health promotion’s philosophy and quite compatible with family medicine orientations in many universities, with the most notable and long running being the McMaster program, along with University of Western Ontario, Laval, and, more recently, UBC, with its innovative “distributed” medical programs strongly emphasizing family medicine. What we found in our analysis of medical curricula is quite in line with a report by the Steering Committee on Social Accountability of Medical Schools, which recently recommended that medical education should adopt “a philosophy that values health promotion and disease prevention as components of medical care and an assumption that physicians have a responsibility in health promotion and disease prevention” (Health Canada, 2001b). This movement is strongly linked to many of health promotion’s broader goals of community involvement, international health, and addressing health inequities (Parboosingh, 2003). Here we again see the twinning of health promotion with disease prevention, but with a more direct link to some basic ethical premises and a broader social focus. Such statements, which are becoming more frequent, demonstrate that the potential for health
promotion to impact medical education is still largely unfulfilled and the effort to broaden the understanding of health promotion within medicine means paying much more attention to its value base and less to its technical component in connection to epidemiology and disease prevention. Health Promotion within the Nursing Curriculum
There are 138 nursing programs in Canada, with 40 of these offering diplomas only (mostly in Quebec). Of the remaining 98 programs, most are university–college collaborations, resulting in only 32 distinct baccalaureate degree programs. Only two of these are university programs without college partners. One rationale for choosing to focus only on programs offering a baccalaureate degree is because after 2005, baccalaureate education became mandatory for nursing programs in most provinces in Canada. This position is supported by the Canadian Nurses Association (2004). Over the last two decades, there have been major changes in nursing curricula in Canada. The major impetus for these changes was what our American colleagues called “the curriculum revolution” (Bevis & Watson, 1989; National League of Nursing, 1988, 1991). In Canada, this movement had a profound impact by recognizing the connections between health promotion and nurses “lived” domain of practice, based on a philosophy of caring and a focus on people’s experiences of health and healing (Bevis, 1989; Duncan, 1996; Hartrick, Lindsay, & Hills, 1994; Stewart, 1990; Watson, 1988). As these ideas took hold, they were eventually transformed into concrete actions for curriculum change and development (Hills et al., 1994; Rush, 1997; Smillie, 1992). During this period, there was, serendipitously, a national movement, which evolved at a variable speed in the different provinces and territories, to push forward
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baccalaureate degrees for nurses as the basic credential for entry to practise in the profession. Before these changes, nursing education was dominated by a technical orientation to biomedical practice and a strong emphasis on individual patient care in acute care settings. It had neglected to embrace its roots in an ethical orientation to patient empowerment and caring (Benner & Wrubel, 1989; Bevis & Watson, 1989; Watson, 1988). In this context, an important decision was made across Canada to integrate and articulate pre-existing diploma programs with the emerging university-centred baccalaureate degrees. This serendipity provided a unique opportunity for a change in orientation because of the necessity for a total reorganization of nursing programs in Canada (Hills et al., 1994). Even if it remains unclear how this formal inclusion of health promotion rhetoric is translated into actual teaching practices, we can now say that in many nursing programs, health promotion is at least nominally recognized as a core aspect of nursing education. Of the selected nursing programs, we conducted a review of each of the university calendars, supplemented by Internet searches for specific courses, to determine the number of the selected nursing programs that had courses or content within courses that named health promotion as a component. While there are certainly large variations in the orientation and focus that each program gives to health promotion, the fact that the language of health promotion is gaining a strong foothold is a promising development and potential base for expanding the scope and depth of health promotion in nursing in Canada. However, there are still important variations in the definition and conceptualization of health promotion. For example, some programs name health promotion as a component of a particular course, usually under “primary health care” or “community health” (McGill, University of Toronto,
University of Calgary), while in other curricula a health promotion perspective is fully integrated across their entire program (University of Victoria, University of Western Ontario, Laurentian University, and University of Alberta) (Hills & Lindsey, 1994). Unlike medicine, the tension is not between health promotion and disease prevention, but more between a broad ecological approach and one more restricted to traditional health education interventions. In addition, there continues to be a tension between a focus on individual patients and the families and communities they live in and with; this tension complicates and creates barriers for encouraging nurses to intervene on the broader determinants of health (Purkis, 1997; Hartrick, 2000). We can thus conclude this subsection by suggesting, as indicated in Figure 18.1 below, that probably the most important distinction between medicine’s and nursing’s inclusion of health promotion in their respective curricula is that nursing has adopted more readily the value-based aspects of health promotion philosophy, notably because it was already close to its generally dominant value base, whereas medicine has concentrated more on its instrumental aspects. We can see a progressive shift in nursing education toward a broader conceptualization of health promotion with much variation in the extent of this shift. Unfortunately, as we will see, the disjunction between education and practice in nursing has a profound effect on how well this new educational philosophy is transformed into health promotion practice where nurses actually work.
Health Promotion in Health Professional Practice For both physicians and nurses, as well as for most professions, integrating their education with the “reality shock” of entering real world practice is a major issue (Kramer, 1974, 1985;
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Rafferty, Allcock, & Lathlean, 1996). For a difficult and complex area such as health promotion, this can be even more difficult to retain and integrate, especially given the lack of systemic supports for this area of practice. This latter issue is particularly true for acute care settings, such as hospitals. Nevertheless, there are particular issues that distinguish the challenges faced by physicians and nurses based on the settings in which they work. Health Promotion within Physician Clinical Practice
As we have been able to observe in several research projects recently (Hills & Mullett, 2005a, 2005b), for physicians, there are major challenges to integrating health promotion into their clinical practice. In the acute care setting, the obstacles are more obvious. Physicians in hospitals are often restricted to episodic care encounters, dominated by a technical routine of rapid diagnosis and treatment schedules; in fact, “objectifying” the patient is an understandable course of action in many basic situational encounters between doctor and patient in a hospital setting (some surgical procedures offer an extreme example of this) (Moreira, 2004). Without a more sophisticated view of health promotion than what is generally taught in medical curricula, specifically an approach that looks at system level and policy change in hospitals, incorporating health promotion becomes close to impossible. These latter issues have been best addressed by the health-promoting hospitals movement (Haddock & Burrows, 1997; Hancock, 1999; Korn, 1997; Pineault, Baskerville, & Letouze, 1990; World Health Organization, 1997). In most provinces, there have been some important changes in relation to the access family practitioners have had to hospitals in recent years, replacing inpatient care by the patient’s regular doctor with full-time “hospitalists” (Sullivan, 2000; van Walraven et al., 2004; Wilson et al., 2001).
Arguably, this shift toward “hospitalists” is unfavourable to the more natural continuity between the patient, his or her family, and the community they live in that family practitioners often provide and a less favourable environment in which health promotion practices can flourish. In primary care, family practitioners in Canada have typically integrated health promotion on a very superficial level, if at all. Unfortunately, partly due to education and policy developments, family practitioners associate health promotion with the battery of demands on them to provide a series of preventive screening and other measures (Pimlott, 2005). This interpretation is reinforced by the bias toward individual “lifestyles” counselling prevalent in the literature on primary care health promotion (Beaulieu et al., 1999; Gillam, McCartney, & Thorogood, 1996; Guthrie, 2001; Hudon, Beaulieu, & Roberge, 2004; Narayan, Bowman, & Engelgau, 2001). The difficulties involved in shifting family physicians to a focus on health promotion beyond the limited strategy of “lifestyles” and health education strategies are many (Green, Cargo, & Ottoson, 1994; Herbert, 1995), yet there are some good examples of a move toward greater involvement for physicians in a “settings” approach (Mackie & Oickle, 1997). This is complicated by the public perception that physicians deal only with acute, biomedical concerns. This latter phenomenon was emphasized in a study investigating adolescents’ perceptions of family physicians in health promotion and disease prevention (Malik, Oandasan, & Yang, 2002). Paradoxically, the main users of primary care medicine (women, mothers with young children, and seniors) are fully aware that physicians are there for more than acute episodic health issues (Hills & Mullett, 2005a). As clearly observed in our research, the normal situation for the primary care physician is as an isolated individual
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managing an impossible range of needs with little or no support, and even less time or patience for people advocating that they take on more. As health promoters, we need to recognize that there are better ways of engaging family practitioners in the health promotion approach than extending preventive medicine to an enlarged series of technical interventions. A different approach might be to support the basic philosophy of helping physicians empower their patients, the families that support them, and the communities in which they live. This can be done in a variety of ways that are more related to how physicians can engage in a broader social and political engagement in advocacy and leadership on the full spectrum of health determinants affecting their patients health than to very specific and limited, individually focused interventions. Health Promotion within Nursing Clinical Practice
Nursing is in the unenviable position of being largely confined to the relatively impermeable institution of the hospital, with all the trappings associated with its militaristic past and its hierarchical present. In 2003, the percentage of nurses working in the hospital sector was 62.4 percent, compared to 12.9 percent in the community sector (Canadian Nurses Association, 2004). Historically, in acute care settings, nurses have had a long and often unrewarding struggle with basic workplace oppression and a lingering subordinate mentality, reinforced often by the medical profession and systematically backed up by hospital administrators and policy makers (Ashley, 1976; Roberts, 1983). As Robinson (1995) explains: “The extent of our oppression means that we often relate to each other through processes characterised by horizontal violence, where we attack each other in response to our subjugated positioning in the culture of health
care” (p. 66). With the advent of the curriculum revolution there was a glimmer of hope that nurses would finally address the power issues inherent in interprofessional, intra-professional, and structural relationships (Benner, Tanner, & Chesla, 1996; Robinson, 1995). It was assumed that teaching nurses differently could impact and dramatically change nursing practice even in hospital settings. Although there were some gains in the 1990s, the recent literature suggests that this dominant subjugated culture continues to exist in many Canadian hospitals (Daiski, 2004; Fletcher, 2000; Roberts, 2000). Even in situations where hospital administrators have been active in presenting opportunities for health promoting activities, nurses have not always been as active as they could be to support the political will necessary for these changes (Whitehead, 2004). However, nursing practice varies considerably in the acute care setting and some nursing units are able to do more health promotion than others. Nursing students who have been trained with a health promotion curriculum report that although they are able to integrate health promotion into their clinical practice (Hills, 1998, 2000), this is often discouraged by the hegemony of the hospital system and its diagnosetreat-cure triad. The most disappointing to date and yet most promising potential for health promotion practice in nursing lies in the community setting. In Canada, the main categories of nurses working in the community setting are public health nurses (sometimes called community health nurses) and the emerging and growing group of nurse practitioners. For public health nurses, there is a further irony in relation to health promotion. Many of the most dedicated and aware health promotion practitioners in Canada are public health nurses, yet they are often hamstrung by two issues: first, they are quite marginalized and
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on the periphery of the health system; second, they tend to rely heavily on a technical orientation to epidemiological surveys to predict what programs and interventions to offer (Chalmers & Bramadat, 1995). These two issues are connected because the lack of resources available often lead public health nurses to focus on identifying problems at the community level, but their professional control over knowledge of community health needs (Chalmers & Bramadat, 1995) leave them less able to enlist community participation to support health promotion activities. As nurse practitioners are only really starting to become a regular part of everyday community practice, and have a strong connection to the effort at primary health care renewal, we will mention them in the next section of the chapter as probably having the pivotal role in introducing health promotion in primary care clinical professional practices.
Summarizing the Differences between Medicine and Nursing in Relation to Health Promotion
We propose here a two-dimensional matrix, with a continuum on the x-axis running from a “technical” orientation to health promotion to a “values-based” orientation, and a continuum on the y-axis, running from an “individual” focus to a broad “community” focus on health promotion. Using this matrix, we can now situate the two dominant health professions in term of their educational and practice-based foci as well as their orientation to health promotion. This simple representational tool allows us to explore visually how various definitions of health promotion have been incorporated in the everyday education and practice of physicians and nurses in Canada (see Figure 18.1) Physician education has moved significantly toward a broader population focus on health promotion, yet has retained a fairly
FIGURE 18.1: FOCUS AND ORIENTATION ON HEALTH PROMOTION
Image not available
338 ■ PART V: Practical Perspectives
technical orientation toward its type of health promotion intervention strategies. Physician practice is still mainly based on a very narrow use and interpretation of health promotion, limited to individual counselling, and only where feasible, given the wider systemic disincentives (i.e., no remuneration) to implement such limited strategies. Nursing education, though uneven, has made a significant move toward a broader focus on community health and a more explicit valuebased approach, while still having a way to go toward meeting the Ottawa Charter approach. Finally, nursing practice still faces many barriers to converting improved education in health promotion philosophy into a strong focus on community and a more determined orientation to basic health promotion values. While the figure offers only a crude representation of the placement of these four aspects of health professional engagement in health promotion, we argue it can be used profitably as a thinking tool to interrogate the landscape of health promotion as it currently stands for nurses and physicians in Canada.
PRIMARY HEALTH CARE AS THE KEY STRATEGY FOR REORIENTING HEALTH SYSTEMS AND INTRODUCING HEALTH PROMOTION IN PROFESSIONAL PRACTICE The Primary Health Care/ Health Promotion Alliance: A Missed Opportunity The Ottawa Charter outlined five action areas where health promoters should focus their collective energies (Building Healthy Public Policy; Creating Supportive Environments; Strengthening Community Action; Developing Personal Skills; and Reorienting
Health Services). While health promotion in Canada has been attempting to address the first four action areas (whatever the actual concrete successes), until recently, there has been a reluctance to tackle the difficult area of reorienting health services. There have been a variety of reasons for this situation, but the key factor has been the political dominance of curative techno-medicine and health promoters’ fear of squandering its energies and being co-opted by medicine and its prerogatives (Frankish et al., 2000). Over the last decade, some health promotion researchers have started to realize that a renewal of primary health care (PHC), particularly one oriented to the original Alma-Ata Declaration (World Health Organization, 1978) principles (Birse & Rootman,1999; Frankish et al., 2000), presents a unique opportunity for health promotion to fulfill its mandate described in the Ottawa Charter’s claim that health promotion could play a significant role in reorienting health services. What follows is a brief outline of how this opportunity can overcome some of the barriers and challenges identified earlier in the chapter. As the history of health promotion is intimately linked with the Alma-Ata Declaration (see Chapter 1), we can see that many of the challenges that technically oriented, individually focused illness care present are addressed there and supplanted by a strong orientation to participation, empowerment, and equity, and a very radical focus on community as the key setting for implementing primary health care. There is also an important advocacy in PHC for multidisciplinary teams and a shift from a system dominated by the priorities of illness care to one driven by primary health care and public health priorities (MacDonald, 1993; Starfield, 1998). Many of the elements of primary health care are also the key ingredients for successful reorientation of the health system toward
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a health promotion focus. While many of the originators of health promotion would recognize this commonality between the two approaches, this important political alliance has often been ignored, forgotten, or deliberately avoided due to the perceived risk of collaborating with the dominant medical profession (Sindall, 2001). This self-defeating strategy has borne little fruit and, in many ways, has allowed health promotion to be further marginalized and excluded from the core of the health system. While many have advocated for an intersectoral focus and a move away from relying on the health sector to promote health, we believe that the most important allies for health promotion still reside in the health sector.
The Promising Future of Health Promotion in Primary Health Care Now we outline a few concrete strategies for using primary health care renewal, reform, and revitalization as a fulcrum for leveraging change in the health system and advancing the aims and vision of health promotion. We will focus on how primary health care could affect physician and nursing education and practice. However, rather than separate the two professions as was done above, we now present an integrated approach we think is crucial to overcoming the dualisms and counterproductive dichotomies that nursing and medicine have perpetuated as primary defence mechanisms in the interest of professional advancement. The first and most obvious aspect associated with primary health care that would encourage physicians and nurses to work together to provide a more health promoting team approach, along with other disciplines, is the long wished for, but seldom practised, move toward interdisciplinary education. The movement for primary health care has long recognized that supporting community-
focused, participatory health promotion requires a variety of disciplines to work together to help identify with the community what its needs and strengths are, and to develop initiatives aimed at improving health and reducing health inequities. Physicians and nurses just happen to be the more powerful (with nurses’ power based more on pure quantity) disciplines in the health sector. There is a strong argument that if we could get physicians and nurses to work and be educated together, we would be able to make a major shift toward the goal of multiple disciplines practising together as a team. Not only that, we can learn much from the difficulties and challenges posed by the past attempts to get these two professional groups to drop their defensive armour and build true collaboration. In education, we know that there is a growing willingness to integrate significant parts of the health curriculum so that at least physicians and nurses can be taught together (Pringle et al., 2000). Nevertheless, despite these exhortations, this has been an exceedingly difficult program of change to implement. Health promoters must get involved and support this movement as strongly as possible. There are many opportunities for academics involved in health promotion to use their now established positions in academe to advocate for this change in health professionals’ curricula. Arguing that this change is a necessity for primary health care reform and the integration of health promotion can provide additional elements for such advocacy. The second obvious place for enabling the reorientation of health systems through primary health care is the organizational setting of community health care practices. These already come in a variety of shapes and sizes in Canada (Lamarche, Chauvette, & Larouche, 2003; Richard et al., 2005), with Quebec probably having the longest systemic
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experimentation since the beginning of the CLSCs in the early 1970s, but they all share the common goal of bringing many different professions together to provide integrated health and social services, so that the needs of communities are met and individuals and families can navigate the systems seamlessly and be empowered to take control of their own health. Health promoters need to find ways of supporting the move toward these types of models and philosophical approaches. Most importantly, they need to ensure that as the system evolves, it does not slide back into a technical and individual focus on illness care. A final aspect is the emerging role and prominence of nurse practitioners (NPs) in Canada. While some NPs will work as advanced practice nurses in hospital settings, many will be engaged in the community in hopes of enhancing primary health care and health promotion. While this represents a great opportunity, health promotion-minded people have a role in making sure that NPs don’t become “mini doctors.” NPs face a particular challenge as they try to legitimize their expanded scope of practice in a medically dominated sector. If NPs are to be truly effective in advancing their role in PHC, a strong health promotion element must be incorporated into their practice. Although such vicissitudes may seem remote from the day-to-day concerns of many health promoters, this is a key strategic area in the overall struggle to reorient health systems and should be a major focus of advocacy efforts.
CONCLUSIONS As we have suggested in this chapter, health promotion has had a significant impact on the two main health professions in Canada over the last 12 years. Yet, there are still great challenges to overcome if we are to realize, even partially, the vision outlined in the Ottawa
Charter for Health Promotion. The litany of barriers and obstacles, real and imaginary, that prevent the health professions from lifting their eyes above the din of system chaos and crisis is interminable. The rationale for optimism is tenuous at best. However, as Gramsci (1971) recommended, “pessimism of the spirit, optimism of the will.” Thus, the real and awaiting opportunities are also legion, and for health promotion to drop the ball, so to speak, at this crucial time, would be unconscionable. We have outlined some of the problems that health professionals create for themselves, but the real message here is how health promoters can be more strategic and more understanding of the problems and complexities that confront physicians and nurses in their day-to-day realities in education and practice. We have for too long relied on the meek role of being the “etcetera” after preventive medicine, the underling of chronic disease management, and the hopeful face of population health. It is time for health promoters to be proud of their heritage in an unabashed commitment to the values and principles and ethics of health promotion. The next time we talk to physicians or nurses about health promotion who are working at the “coal face” or in “the trenches,” we, as health promoters, need to emphasize participation, empowerment, and equity, linking them to the long-standing value base of nursing and the emerging one in family medicine. In this way, we can create a common vision of the landscape of health promotion, getting behind the technocratic curtain, to the shared core values that cultivate caring, commitment, and collaboration to improve people’s health. The key challenge still remains to develop strategies that enable physicians and nurses to be actively involved in health promotion activities that go beyond individual behavioural interventions to broader community development, advocacy, and intersectoral collabora-
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tions for health, but together, we can imagine and implement them.
NOTE 1
In this chapter we do not focus on health promotion research carried out by health professionals. Although there is a significant level of involvement by many health professionals in such endeavours (especially by nurses), we have chosen to limit our analysis to the basic training and practice elements in order to gain an overall perspective on how most physicians and nurse are educated and carry out their practice.
REFERENCES Ashley, I. (1979). Hospitals, paternalism and the role of the nurse. New York: Teachers College Press, Columbia University. Beaulieu, M.-D., Hudon, E., Roberge, D., Pineault, R., Forte, D., & Legare, J. (1999). Practice guidelines for clinical prevention: Do patients, physicians, and experts share common ground? Canadian Medical Association Journal, 161(5), 519–523. Benner, P., Tanner, C., & Chesla, C. (1996). The nurse-physician relationship: Negotiating clinical knowledge. In P. Benner, C. Tanner, & C. Chesla (Eds.), Expertise in nursing practice: Caring, clinical judgment, and ethics (pp. 280–306). New York: Springer Publishing Co. Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Los Angeles: Addison-Wesley. Bevis, E. (1989). Organizing for and evaluating change. In E.O. Bevis, curriculum building in nursing: A process (3rd ed.). New York: National League for Nursing. Bevis, E.O., & Watson, J. (1989). Toward a caring curriculum: A newpedagogy for nursing. New York: National League for Nursing. Birse, E., & Rootman, I. (1999). Implications of health promotion for integrated health systems. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services, 12(1), i–v. British Medical Journal. (2006). From http://bmj.bmjjournals.com/. Canadian Nurses Association. (2004). Canadian Nurses Association: 2003 annual report. Ottawa: Author. Center for the Health Professions. (2006). Future of the health professions, 2006. From www.futurehealth.ucsf.edu/summaries/challenges.html. Chalmers, K., & Bramadat, I. (1995). Community development: Theoretical and practical issues for community health nursing in Canada. Journal of Advanced Nursing, 24, 719–726. Daiski, I. (2004). Issues and innovations in nursing practice: Changing nurses’ dis-empowering relationship patterns. Journal of Advanced Nursing, 48(1), 43–50. Duncan, S.M. (1996). Empowerment strategies in nursing education: A foundation for populationfocused clinical studies. Public Health Nursing, 13(5), 311–317. Fletcher, M. (2000) Handmaidens no more. Canadian Nurse, 96(5), 18–22. Frankish, C.J., et al. (2000). Health promotion in primary health care settings: A suggested approach to establishing criteria, submitted to Health Canada (pp. 1–79). Prepared by the Institute of Health Promotion Research, UBC. Gillam, S., McCartney, P., & Thorogood, M. (1996). Health promotion in primary care. British Medical Journal, 312, 324–325.
342 ■ PART V: Practical Perspectives Gramsci, A. 1971. Selections from the prison notebooks of Antonio Gramsci. London: Lawrence and Wishart. Green, L.W., Cargo, M., & Ottoson, J.M. (1994). The role of physicians in supporting lifestyle changes. Medicine, Exercise, Nutrition, and Health, 3, 119–130. Also in Proceedings of the twenty-ninth annual meeting of the Society of Prospective Medicine (pp. 89–129), St. Louis, Missouri, April 15–17, 1993. Indianapolis: Society of Prospective Medicine, Publishers. Guthrie, C. (2001). Prevention of type 2 diabetes: Health promotion helps no one. British Medical Journal, 323, 997. Haddock, J., & Burrows, C. (1997). The role of the nurse in health promotion: An evaluation of a smoking cessation programme in surgical pre-admission clinics. Journal of Advanced Nursing, 26(6), 1098–1110. Hancock, T. (1999). Creating health and health promoting hospitals: A worthy challenge for the twentyfirst century. Leadership in Health Services, 12(2), viii–xix. Hartrick G. (2000). Developing health-promoting practice with families: One pedagogical experience. Journal of Advanced Nursing, 31, 27–34. Hartrick, G., Lindsey, A.E., & Hills, M. (1994). Family nursing assessment: Meeting the challenge of health promotion. Journal of Advanced Nursing, 20(1), 85–91. Health Canada. (2001a). Health Canada community action program (CAPC)—national program profile (NPP) Cycle 1 summary report: Final. Available at http://www.phac-aspc.gc.ca/dca-dea/publication/ capc-pace_cycle1_e.html. Health Canada. (2001b). Social Accountability: A Vision for Canadian Medical Schools. Ottawa: Author. Available from http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgbs/pdf/pubs/2001-social-vision-med/ 2001-socila-vision-med_e.pdf. Herbert, C.P. (1995). Clinical health promotion and family physicians: A Canadian perspective. Patient Education and Counseling, 25, 277–282. Hills, M. (1998). Student experiences of nursing health promotion practice in hospital settings. Nursing Inquiry, 5, 164–173. Hills, M. (2000). Perspectives on learning and practicing health promotion in hospitals: Nursing students’ stories. In L. Young & J. Hayes (Eds.), Transforming health promotion practice: Concepts, issues, applications, 229–240. Philadelphia: F.A. Davis. Hills, M.D., & Lindsey, E. (1994). Health promotion: A viable curriculum framework for nursing education. Nursing Outlook, 42(4), 158–162. Hills, M.D., Lindsey, A.E., Chisamore, M., Bassett-Smith, J., Abbott, K., & Fournier-Chalmers, J. (1994). University-college collaboration: Rethinking curriculum development in nursing education. Journal of Nursing Education, 33(5), 220–225. Hills, M., & Mullett, J. (2005a). Primary health care: A preferred service delivery option for women. Health Care for Women International, 26(4), 325–339. Hills, M. & Mullett, J. (2005b). Community-based research: A catalyst for transforming primary health care rhetoric into practice. Primary Health Care Research & Development, 4, 279–290. Hudon, E., Beaulieu, M.-D. & Roberge, D. (2004). Integration of the recommendations of the Canadian Task Force on Preventive Health Care: Obstacles perceived by a group of family physicians. Family Practice, 21(1), 11–17. Korn, D. (1997, April 16–19). Health promoting hospitals in Canada. Paper presented at the Feasibility, Effectiveness, Quality, and Sustainability of Health Promoting Hospital Projects, 5th International Conference on Health Promoting Hospitals, Vienna, Austria.
CHAPTER 18: Health Promotion and Health Professions in Canada ■ 343 Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis: C.V. Mosby. Kramer, M. (1985). Why does reality shock continue? In J.C. McCloskey & H. K. Grace ( Eds.), Current issues in nursing (2nd ed., pp. 891–903). Boston: Blackwell. Lamarche, P., Chauvette, M., & Larouche, D. (2003). Choices for change: The path for restructuring primary healthcare services in Canada. Ottawa: Canadian Health Services Research Foundation. Macdonald, J.J. (1993). Primary health care: Medicine in its place. London: Earthscan Publications Limited. Mackie, J.W., & Oickle, P. (1997). School-based health promotion: The physician as advocate. Canadian Medical Association Journal, 156(9), 1301–1305. Malik, R., & Oandasan, I., & Yang, M. (2002). Health promotion, the family physician, and youth: Improving the connection. Family Practice 19(5), 523–528. Mead, N., & Bower, P. (2000). Patient-centredness: A conceptual framework and review of empirical literature. Social Science & Medicine, 51, 1087–1110. Moreira, T. (2004). Coordination and embodiment in the operating room. Body & Society 10(1), 109–129. Narayan, K.M., Bowman, B.A., & Engelgau, M.M. (2001). Prevention of type 2 diabetes. British Medical Journal 323, 63–64. National League of Nursing. (1988). Curriculum revolution: Mandate for change. New York: National League of Nursing Press. National League of Nursing. (1991). Curriculum revolution: Community building and Activism. New York: National League of Nursing Press. Nursing Standard Journal. (2006). Primary health care. From www.nursing-standard.co.uk/primaryhealthcare/. O’Neill, M. (1997). Health promotion: Issues for the year 2000. Canadian Journal of Nursing Research, 29(1), 63–70. Parboosingh, J., & Association of the Canadian Medical Colleges’ Working Group on Social Accountability. (2003). Medical schools’ social contract: More than just education and research. Canadian Medical Association Journal, 168(7), 852–853. Pew-Fetzer Task Force. (1994). Health professions education and relationship-centred care. (Report of the Pew-Fetzer Task Force on advancing psychosocial education. Reprinted January 2000). San Francisco: Pew Health Profession Commission. Pimlott, Nicholas. (2005). Preventive care: So many recommendations, so little time. Canadian Medical Association Journal, 173(11), 1345–1346. Pineault, R., Baskerville, B., & Letouze, D. (1990). Health promoting activities in Quebec hospitals: A comparison of Dsc and non-Dsc hospitals. Canadian Journal of Public Health, 81, 199–203. Pringle, D., Levitt, C., Horsburgh, M.E., Wilson, R., & Whittaker, M.-K. (2000). Interdisciplinary collaboration and primary health care reform. Canadian Family Physician, 46, 763–765. Purkis, M.E. (1997). The “social determinants” of practice? A critical analysis of the discourse of health promotion. Canadian Journal of Nursing Research, 29(1), 47–62. Rafferty, A.M., Allcock, N., & Lathlean, J. (1996). The theory/practice “gap”: Taking issue with the issue. Journal of Advanced Nursing, 23(4), 426–427. Raphael, D., & Bryant, T. (2000). Putting the population into population health. Canadian Journal of Public Health, 91, 9–12. Richard, L., Pineault, R., D’Amour, d., Brodeur, J.M., Sequin, L., Latour, R., & Labadie, J.F. (2005). The diversity of prevention and health promotion services offered by Quebec Community Health Centres: A study of infant and toddler programmes. Health & Social Care in the Community, 13(5), 399–408.
344 ■ PART V: Practical Perspectives Roberts, S. (1983). Oppressed group behaviour: Implications for nursing. Advances in Nursing Science, 5(4), 21–30. Roberts, S. (2000). Development of a positive professional identity: Liberating oneself from the oppressor within. Advanced Nursing Science, 22(4), 71–82. Robinson, A. (1995). Transformative “cultural shifts” in nursing: Participatory action research and the “project of possibility.” Nursing Inquiry, 2, 65–74. Rush, K.L. (1997). Health promotion ideology and nursing education. Journal of Advanced Nursing, 25, 1292–1298. Sindall, C. (2001). Health promotion and chronic disease: Building on the Ottawa Charter, not betraying it? Health Promotion, 16(3), 215–217. Smillie, C. (1992). Preparing health professionals for a collaborative health promotion role. Canadian Journal of Public Health, 83(4), 279–282. Starfield, B. (1998). Primary care: Balancing health needs, services, and technology. New York & Oxford: Oxford University Press. Stewart, M.J. (1990). From provider to partner: A conceptual framework for nursing education based on primary health care premises. Advances in Nursing Science, 12(2), 9–27. Stewart, M., Brown, J., Weston, W., McWhinney, I., McWilliam, C., & Freeman, T. (1995). Patient-centred medicine: Transforming the clinical method. London: Sage. Sullivan, P. (2000). Enter the hospitalist: New type of patient creating a new type of specialist. Canadian Medical Association Journal, 162(9), 1345–1346. Tresolini, C.P., & Pew-Fetzer Task Force. (1994). Health professions education and relationship-centered care: Report of the Pew-Fetzer Task Force on advancing psychosocial education. Reprinted January 2000. San Francisco: Pew Health Professions Commission. van Walraven, C., Mamdani, M., Fang, J., & Austin, P.C. (2004). Continuity of care and patient outcomes: After hospital discharge. Journal of General Internal Medicine, 19, 624–631. Watson, J. (1988). Nursing: Human science and human: A theory of nursing. New York: National League for Nursing. Whitehead, D. (2004). Health promotion and health education: Advancing the concepts. Journal of Advanced Nursing, 47(3), 311–320. Wilson, S., Ruscoe, W., Chapman, M., & Miller, R. (2001). General practitioner—hospital communications: A review of discharge summaries. Journal of Quality in Clinical Practice, 21(4), 104. World Health Organization. (1978). Primary health care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, September 6–12. Geneva: Author. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Author. World Health Organization. (1997). The Vienna recommendations on health promoting hospitals. Copenhagen: Author. World Health Organization. (1998). Health promotion glossary. Geneva: Author.
CRITIC AL THINKING QUESTIONS 1. What would it take to increase the engagement of the health care professions in health promotion?
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2. In what ways can general practitioners contribute to action on the broader determinants of health, particularly the social, economic, and cultural determinants of population health in their own communities? 3. In what ways can hospital-based nurses challenge the hegemony of individually focused, exclusively curative approaches to patient care and help institutionalize health promotion in hospitals? 4. What are some key changes that could be made to the curricula of physicians and nurses that would strengthen the understanding of health promotion? 5. Is it really possible for primary health care to be the catalyst for radical changes to the health system?
FURTHER READINGS Hills, M., & Mullett, J. (2005). Primary health care: A preferred service delivery option for women. Health Care for Women International, 26(4), 325–339. This article traces the similarities between primary health care and women-centred care from their overlapping philosophical foundations to the similar health, social, and economic benefits of both approaches. It is argued that investments in primary health care positively impact women’s health and, as such, should be a preferred option for the delivery of women’s community health services. Several models of health service delivery that operate in accordance with principles of primary health care and that also address the key tenets of women’s-centred care are examined and their merits are compared. The article also identifies the major impediments to the adoption of both primary health care and women’s-centred care approaches. Malik, R., & Oandasan, I., & Yang, M. (2002). Health promotion, the family physician, and youth: Improving the connection. Family Practice, 19(5), 523–528. This article reports on a qualitative study of young people’s use of family physicians and their readiness to see them as health promotion resources. The full text of this article is available online through the journal’s Web site at http://fampra.oxfordjournals.org/. Pew Health Professions Commission. (1995). Critical challenges: Revitalizing the health professions for the twenty-first century. The Third Report of the Pew Health Commission. Available from the Centre for the Health Professions, University of California, San Francisco at www.futurehealth.ucsf.edu/summaries/challenges.html. This report outlines transformations underway in the American health care system in the mid-1990s. It suggests that the emerging health care system include the following characteristics: orientation toward health; constrained resources; coordination of services; intensive use of information; reconsideration of human values; focus on the consumer; expectations of accountability; knowledge of treatment outcomes; and growing interdependence. It is interesting to consider the implications of this document for health professionals in Canada and whether the vision of the future predicted has been fulfilled.
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RELEVANT WEB SITES British Medical Journal http://bmj.bmjjournals.com/
The British Medical Journal is a leading world authority on medical topics, including health care systems. This site will enable readers to monitor developments in the British medical system as it undergoes health reforms. Canadian Health Services Research Foundation—Primary Health Care Theme www.chsrf.ca/research_themes/ph_e.php
This site is available in both English and French. This particular page addresses a variety of initiatives of CHSRF that relate to primary health care reform and research. Canadian Medical Association Journal www.cmaj.ca/
This is the link to Canada’s foremost medical journal; it links readers to the journal itself as well as offering numerous online editorials and commentaries. Centre for the Health Professions, University of California, San Francisco www.futurehealth.ucsf.edu/home.html
This Web site addresses innovations in health care professions in the context of the American health care system. Specifically, the Center for the Health Professions at the University of California, San Francisco, focuses its efforts on understanding the challenges faced by the health care workforce and developing programs and resources that assist in making successful transitions to the emergent health care systems Primary Health Care—a Nursing Standard Journal www.nursing-standard.co.uk/primaryhealthcare/
This is the Web site for a British journal on primary health care in the context of nursing. Primary Health Care aims to inform and encourage critical reflection among people in the primary care and community health field by publishing articles that have clear implications for practice.
CHAPTER 19
T WO RO L E S O F E VA L UAT I O N I N T R A N S F O R M I N G H E A LT H P RO M OT I O N P R AC T I C E Louise Potvin and Carmelle Goldberg INTRODUCTION his chapter is about the meanings and roles of evaluation in the context of health promotion. More precisely, we argue that an important role for evaluation is to support the transformation of practices in health promotion. To do so, we consider definitions of evaluation, the particularities of evaluation in the context of health promotion interventions, and the importance of evaluation for health promotion practice. Using Canadian examples, we then explore two major reasons why health promotion should be evaluated: (1) to increase the effectiveness of health promotion intervention; and (2) to support innovative practices.
T
WHAT IS EVALUATION? There are many definitions of evaluation. In its simplest form, evaluation is the critical appraisal of human actions in context. It is a value-laden feedback response to action. In its most sophisticated form, evaluation research: (1) spans over several years, if not decades; (2) mobilizes a large amount of human and material resources to design and implement a complex system of activities to define, gather, analyze, and interpret a huge quantity of data; and, finally, (3) produces knowledge about numerous aspects of interventions. The knowledge produced by such evaluations potentially influences the practice of thousands of professionals
and ultimately the health of hundreds of thousands of people. The evaluation of the North Karelia Project provides a good illustration of a complex and successful evaluation research endeavour. The project spans over three decades1: data on several cardiovascular risk factors were collected in three Finnish provinces over two decades. The knowledge produced in the several hundreds of documents it generated2 has been integrated into public health training throughout the world. While there are debates about the validity of certain evaluation conclusions, one thing is certain—if the North Karelia intervention had not been coupled with evaluation research that has produced and disseminated all this knowledge, public health and health promotion practices today would be different. Mark, Henry, and Julnes (2000) provide one of the most encompassing definitions of evaluation: “Evaluation assists sense making about policies and programs through the conduct of systematic inquiry that describes and explains the policies’ and programs’ operations, effects, justifications, and social implications” (p. 3). Compared to most, this definition avoids falling into the trap of pitting against one another various forms of evaluations based on either their object, purpose, or method. Indeed, we think that evaluation typologies or classification systems, whichever criteria they use, are of limited usefulness. Especially in health promotion, 347
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evaluations often deploy a variety of methods to address a number of stakeholders’ issues regarding various program components. Following a similar argument, the WHO-EURO task force on health promotion evaluation also proposed a very broad definition: “evaluation is the systematic examination and assessment of features of a programme or other intervention in order to produce knowledge that different stakeholders can use in a variety of purposes” (Rootman et al., p. 26). Thus, whenever the object of inquiry is an intervention’s feature, whenever the method of enquiry is systematic, and whenever the purpose is to produce information that can be used by a variety of social actors, we think it is proper to identify such activity as evaluation.
WHAT IS EVALUATED IN HEALTH PROMOTION? Evaluation is about interventions. It is thus important to have a clear understanding of what is an intervention in the context of health promotion. The verb “to intervene” contains the Latin verb venire, which means to come, and the prefix inter-, which means “in between.” Literally, to intervene is to come in between, to disturb the natural order of things. An intervention implies an action from external actors who have the power to mobilize and deploy resources in the pursuit of specific results (Couturier, 2005). Interventions are planned actions to achieve projected changes. They form the core of a practice, understood as skills learned, reproduced, and improved by professionals through their actions. “Intervention” is a generic term that encompasses diverse modalities of planned actions.
Health Promotion Interventions: Targeting Individuals or Collectivities? As seen throughout this book, there are many definitions of health promotion and they all, as Rootman et al. (2001) pointed out, “involve a set of actions, focused on the individual or environment, which through increasing control, ultimately leads to improved health or well-being” (p. 13). Clearly at the core of health promotion lays the idea of intervention. As also seen in several chapters of this book, the field of health promotion is characterized by a tension between definitions that emphasize changes in individuals, and those that target environmental changes in social conditions as the main purpose of health promotion. According to Rootman et al. (2001), this tension is the main divider between existing definitions of health promotion. The implications of this divide in terms of approach and forms of interventions are seldom discussed. In the rest of this chapter, we will concentrate our discussion on the evaluation of complex multi-level health promotion interventions that involve actions planned and implemented at a collective level for two reasons. First, the prominent evaluation tradition in the health sector represented by clinical epidemiology is well equipped to address evaluation issues of interventions targeting individual changes, but its usefulness and relevance for evaluating health promotion strategies that call for collective action is much more limited (Potvin & Chabot, 2002). Second, as Potvin, Gendron, Bilodeau, and Chabot (2005) indicate, defining a practice that advocates collective strategies of actions represents a major innovation of the Ottawa Charter for the health sector. This issue has been seldom discussed with regard to evaluation.
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Program as the Core Type of Intervention in Health Promotion Practice At this point it is important to make a distinction between policy development and other forms of collective interventions. Building healthy public policy is one of the five strategies of the Ottawa Charter (World Health Organization, 1986). Broadly defined, “public policy is a guide to government action to alter what would otherwise occur” (Milio, 2001, p. 367). Policy is the intervention modality of a governing body, of an organization entrusted with legitimate power to regulate exchanges in the public domain. Policies are specialized forms of interventions and their evaluation requires different sets of skills, designs, and apparatus (Milio, 2001). For this reason, this chapter will restrict its focus to the most common form of health promotion interventions: programs. Although programs can be designed for a variety of purposes, including developing individual skills, we will focus our attention on those programs that imply a composite and multifaceted package of activities as promoted in three of the Ottawa Charter strategies of action: creating supportive environment, strengthening community actions, and reorienting health systems. What Is a Program?
Although health promotion literature is replete with terms such as “programs,” “projects,” “initiatives,” “activities,” and “interventions,” there have been very few attempts to identify common and unique characteristics of the realities defined by those terms. Very often these labels are used interchangeably or they are used in reference to various levels of organization of actions in composite interventions. One reason for this confusion is that the reality circumscribed by these terms is necessarily complex and its delineation necessarily related to a specific context (Potvin,
Gendron, & Bilodeau, in press). Interventions and programs are not things in themselves, but they are always defined from a specific perspective. Judging whether something or someone belongs to a program greatly depends on the particular viewpoint of the individual making the judgment. In a school program aimed at increasing children’s resilience, for example, a teacher trained and deeply involved in leading classroom resilience enhancement activities may perceive that many elements in her school and her broader environment are parts of the program such as the school social worker who runs teacher’s resilience workshops, the local health centre that provides documentation, and the school physical activity teacher who develops “feel good with your body” activities. This view contrasts with that of children’s parents who know about the program only through their child, and who may include only the teacher and the documents they receive periodically as composing the program. So what is to be considered as being part of a program needs to be defined and agreed upon. The structure of multifaceted projects is another dimension of programs that lends itself to confusion among program stakeholders. Within complex interventions, activities can be grouped according to various dimensions such as specific objectives, actors involved, resources mobilized, context, and so on, leading to various degrees of organization. For example, in their study of the published documents from the North Karelia Project, Levesque et al. (2000) needed as many as five hierarchical levels of organization to account for this program’s complex structure. Their detailed analysis provides a compelling example of the constructed nature of programs and their structure. Programs are not a given; they are the product of social activity. Their structure is defined according to which aspects of the program one wants to
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emphasize. It is only through a representation that programs gain some reality (Potvin, Gendron, & Bilodeau, in press).3 Most often, programs are represented by the problematic situation they address, the objectives pursued, the resources mobilized, the services and activities produced, the expected results, and the chain of events necessary for the program to yield those results (Potvin, Haddad, & Frohlich, 2001). It is very rare that the existing relationships between relevant program actors are represented as part of the program. As in program logic models (Cooksy, Gill, & Kelly, 2001), most representations portray programs as technical procedures, independent of the social identity of people involved. It is as if programs are a kind of transplant creating totally new social entities in an existing environment. If this may be true for some programs that are packaged and encapsulated in ready-to-use solutions that necessitate no local adaptation, this is at odds with most of the innovative practices advocated for by the health promotion rhetoric. The Nature of Programs Implied by the Ottawa Charter of Health Promotion
In addition to a comprehensive definition of health and its determinants and to the five well-known strategies of action, the Ottawa Charter (1986) also identifies key values and principles forming the core of the health promotion agenda (McQueen, 2001). Many of these values and principles of action call for a strong integration of programs into the social reality of the milieu in which they are implemented. Furthermore, values such as participation, empowerment, and intersectoral collaboration at the core of the health promotion rhetoric can only be actualized by positioning programs, program participants, and program context in a network of reciprocal relationships. It is within such networks
that health promotion programs germinate and come to life. Contrary to more technical innovations like new drugs, health promotion programs based on those values involve a strong integration into local context, and therefore can hardly be elaborated outside of this context and then imported and tested.4 Such programs need to evolve within their social context, constantly adapting and negotiating practices imported from effective programs. Through this process it is not only the social context and life trajectories of those who interact with the program that get transformed, but also the program itself (Potvin, Haddad, & Frohlich, 2001). Values underlying health promotion are at odds with a conception of program participants as passive subjects who need to be intervened on through programs that come from elsewhere. On the contrary, these values imply that programs are better conceptualized as reconfigurations of existing contextual elements to adapt to new practices suggested by programs, practices that are themselves adapted to fit better the characteristics of the context. “Documenting the events that marked the evolution of this relational system and constructing a coherent narrative to interpret the system’s dynamism is as crucial for understanding health promotion intervention as is the ‘evidence’ about its efficacy” (Potvin & Chabot, 2002).
WHY EVALUATE HEALTH PROMOTION PROGRAMS? Following Mark, Henry, and Julnes, (2000) above, evaluation is thus about making sense of what happens in programs. Since programs are a defining modality for health promotion practice, it follows that evaluation is central for the transformation of health promotion practice. In this section we discuss two crucial
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roles for evaluation with regard to health promotion practices. One is to increase the effectiveness of interventions; this role has been widely advocated by professional associations in attempts to increase the relevance of health promotion for policy makers (International Union for Health Promotion & Education, 1999; Zaza, Briss, & Harris, 2005). The other role is to support the development and diffusion of innovative practices (Bilodeau, Chamberland, & White, 2002).
Evaluation to Increase the Effectiveness of Health Promotion Interventions To play this role, evaluation tries to attribute a result to an intervention, i.e., establish causal links between program and outcomes. Causal claims are usually achieved by holding everything constant (the famous “ceteris paribus” condition of the experimental method) but the intervention under study in an effort to isolate the causal mechanism of interest (Campbell, 1984). Because this can never be totally achieved outside of the laboratory, evaluation researchers use strategies and methods that emulate laboratory conditions. This experimentalist approach to evaluation found two main traditions in health promotion evaluation: clinical epidemiology and social sciences quasi-experimental designs. Clinical Epidemiology
Strongly anchored in experimental medicine, clinical epidemiology is associated with a strong stream of experimental evaluation research facilitated by the fact that medical clinics and hospitals are highly institutionalized settings where power and decisions are concentrated among clinicians. Because of this, clinicians and evaluators can and do exercise a high level of control over two fundamental aspects of the experimental situation.
The first is the subjects’ assignment to treatment conditions. As experimental treatments are usually available only in the context of evaluation research, patients’ freedom is thus limited to consenting to participate to a study. The more absolute the control of evaluators over the treatment assignment process, the more it is possible to ensure that the observed relationship between treatments and outcomes is not explained by some unique individual features. Having accepted these conditions, study subjects can then be treated as equivalent and interchangeable objects. The second aspect of the experimental situation the clinical setting greatly facilitates is the integrity and fidelity of the intervention. Indeed, in the somewhat closed clinical environment, contextual features not directly relevant to the treatment under study can be controlled or held constant, reducing greatly variations in the implementation conditions. These two features of clinical setting are paramount for evaluation to play its alleged role in providing evidence of a causal relationship “when everything else is held constant” (efficacy trials) or under controlled implementation conditions (effectiveness trials). Because most of the early evaluation studies of prevention interventions were developed in clinical settings, patients’ random assignment and treatment standardization rapidly became customary features for quality evaluation. The limitations of the experimentalist tradition for evaluating prevention interventions, however, were soon experienced. As early as the 1970s the Multiple Risk Factor Intervention Trial (MRFIT) study assigned 12,866 healthy male volunteers to three modalities of clinical preventive services. Randomization worked and study groups ended up being statistically equivalent. The three preventive treatments were successfully implemented in 20 clinics throughout the US.
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Interestingly, though, the power of this trial was greatly diminished by the fact that many subjects who had been randomly assigned to either the low-intensity prevention intervention or to the usual care groups sought and were given high-intensity preventive interventions outside of trial clinics (Ockene et al., 1991). So, even in clinical settings where randomization can be implemented, conclusions from efficacy trials are limited by the availability of interventions obtained through other means. Social Science Quasi-experimental Designs
The quasi-experimentalist stream of evaluation developed by Campbell, Cook, and their students (Shadish, Cook, & Leviton, 1991) has also been very influential for defining a paradigm for the evaluation of health education and health promotion programs. Taking the randomized control trial as the gold standard for establishing causal relations between treatments and observed effects, quasi-experimentalists characterize alternative weaker research designs in terms of their capacity to control for plausible rival hypothesis and advocated for their proper use in evaluation research.5 Unfortunately, very early in the development of the field of evaluation, numerous quasi-experimental evaluation projects failed to produce the expected straightforward results that would fuel rational decisions (Pawson & Tilley, 1997). In the field of public health, quasi-experimental evaluations of very important projects such as the Minnesota Heart Health (Luepker et al., 1994) or the COMMIT Trial produced very disappointing results (COMMIT Research Group, 1995). Although both projects showed significant reductions of risk factor prevalence in exposed populations, those reductions were not significantly different from those observed in non-equivalent control communities. For Campbell (1984, 1987) the problem
lies within the evaluation paradigm itself. People entertain unrealistic expectations given the inherent limitations of evaluation, which has to operate outside of the well-controlled world of laboratories. The complexity of reallife situations in which programs are implemented interferes with the evaluator’s capacity to control the experimental situation, thus threatening studies’ internal validity (capacity to infer a causal link between treatments and observed outcomes). Furthermore, because programs are social products necessarily embedded into their social contexts, external validity (the capacity to generalize results of a single evaluation to other program instantiations) is also greatly reduced. It is thus impossible for any single evaluation study to establish clearly a program causal effect. The Difficulties for Experimentalists to Evaluate Health Promotion Programs
The experimentalist tradition does not accommodate well approximations and uncertainties in evaluating interventions. Because such uncertainties are often inherent in health promotion programs, there is much debate on the appropriateness of the experimental paradigm for evaluating health promotion (McQueen, 2001; Rychetnik et al., 2002). In the rare cases where practices have evolved into well-packaged and well-defined programs, they could be suitable to experimental evaluations. We agree with Hawe, Shiell, and Riley (2004) that it is not so much procedural aspects that should be used to create the intervention and control groups to be compared in experimental evaluations but the functions that are thought to be related to the intended effects. But even in randomized trials of program functions, the complex interactions between programs and contextual factors further complicate the role of experimental evaluation. Because all trials are subjected to such interactions with contextual factors, and
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because as we all learn in introductory statistics, main effects are not interpretable in the presence of interaction effects, it follows that causal interpretations from single experimental trials are dubious. The only solution is to pool and synthesize several experimental evaluations of similar programs (however similarity is defined), and to estimate program effectiveness by taking into account implementation variations as possible interaction effects. This solution obviously requires that a great number of experimental evaluation studies be conducted in a wide variety of implementation conditions. In terms of the transformation of practices, what comes out of existing syntheses is that programs with documented effectiveness are usually simple and not very well integrated within local networks of actors (Zaza, Briss, & Harris., 2005).
Evaluation to Support Innovative Practices This is a much less developed but potentially much more important role for evaluation in health promotion. Why Is Supporting Innovation through Evaluation Important?
There are at least three reasons why it is so. First, well-defined programs form only a small part of health promotion practice, and these well-defined programs are usually not well aligned with the innovative practices advocated for in the Ottawa Charter (Potvin et al., 2005). Second, to go the participatory route advocated for by health promotion, practitioners have to start from the preoccupations and possibilities of the local milieus (Israel et al., 1998). In those cases, at best, welltested programs with a demonstrated effectiveness constitute only a good starting point for designing interventions that can go in totally different directions to accommodate
local circumstances. Unfortunately, very few studies document those partnerships’ roles and contributions to programs’ effectiveness. Third, identifying a problem locally even when its causes are scientifically known does not mean that interventions can be readily available or designed in that context. Indeed, program components are always strongly intertwined into the broader social context through a dense network of partnerships. For many, thus, the social context is thought to be at least as important (if not even more important) than technical aspects of program delivery (Bilodeau, Chamberland, & White, 2002). The case study in Box 19.1 illustrates this. In real-life contexts of health promotion programs, the selection and implementation of program interventions is not simply a byproduct of rational choices informed by scientific knowledge. It is strongly influenced by a continuous negotiation and adjustment process. The aim of such a process is to find convergence between: (1) scientific theoretical and empirical knowledge about the identified problem and about effective interventions; (2) people’s subjective knowledge about the problem, its causes, its impact on their lives, and about their own community and its strengths; and (3) the local values and norms relevant to the situation.6 The outcome of this process is a socially constructed innovation where practices are continuously transformed by a dense network of social interactions constitutive of the program. This, as developed in Chapter 17, clearly requires the evaluation to serve a reflexive function that fosters program stakeholders’ capacity to incorporate and act upon the knowledge provided to them (Potvin et al., 2005). One of the crucial roles of evaluation is thus to systematize and facilitate the reflexive function of programs in order to illuminate the process by which programs become local innovations and support their transformative practices.
354 ■ PART V: Practical Perspectives BOX 19.1: SCIENTIFIC AND CONTEXTUAL ELEMENTS FOR PROGRAM PLANNING: THE CASE OF THE KANAWAKHE SCHOOL DIABETES PREVENTION PROJECT
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The Example of the Canadian Heart Health Initiative
Although there are few reports about evaluations deliberately designed to fulfill this role, we think that in many instances, when evaluation studies were implemented to accompany programs from their developmental stages, they have played exactly this role. This is the case with the Canadian Heart Health Initiative (CHHI), established in 1988 as a national program for cardiovascular disease prevention based on intersectoral partnerships. Although its aim would characterize this initiative as prevention, its main operating principle is consistent with those of the Ottawa Charter. The project was based on a collaborative infrastructure to establish partnerships, which makes the initiative unique as a means of delivering a national health program using a web of networks, coalitions, and opinion leaders that diffuse information and resources through formal and informal channels (Stachenko, 1996). The demonstration phase, initiated from 1990–2000, was comprised of 10 provincial heart health programs. The aim of this phase was to experiment with implementation methods for heart health at provincial and community levels; linking intervention proj-
ects with evaluation studies was a compulsory feature of the project. The evaluation of the CHHI was thus a built-in component of the 10 provincial heart health programs and the 311 local and regional demonstration projects. All were designed to accompany the intervention project rather to than prescribe the content and form of the intervention, as shown in the Ontarian case study in Box 19.2.
CONCLUSIONS In this chapter we proposed that there are mainly two ways in which evaluation can support changes in health promotion practice. The first is to attempt to direct health promotion practice to specific interventions found effective in controlled experiments through evidence-based procedures. It is grounded within the experimentalist tradition, where innovations are derived from scientific knowledge and tested in controlled conditions. The viability of this evaluation approach to inform practice is, however, challenged by the assumptions underlying methodologies that systematically remove context from the evaluation inquiry. The second way evaluation can support changes in health promotion practice is by
CHAPTER 19: Two Roles of Evaluation in Transforming Health Promotion Practice ■ 355 BOX 19.2: EVALUATING THE ONTARIO HEART HEALTH INITIATIVE
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facilitating social innovation. This approach is grounded in social science theory where innovation is created by systematizing and putting in place reflexive processes responsive to local project implementation. This approach engages practitioners in a continuous dialogue on the performance and meaning of program actions, and their interactions with the local context. The dynamic relationship fostered by this approach allows practitioners to consciously reinforce certain actions while reorienting others. This facilitates programs’ adaptation by strengthening its reflexive and innovative capacity. These are two opposite perspectives on evaluation. Both are laden with enormous methodological challenges that somehow impede on their capacity to fulfill these roles, leading many stakeholders toward a narrow accountability perspective on evaluation, one
that limits evaluations to the collection of routine data regarding program operations and resources. We strongly believe that this accountability approach is of limited utility to informing practice and orienting program transformation because no attention is devoted to the actions that are actually performed within the social space of the program. This is so mostly because we are conceptually and methodologically ill equipped to observe and analyze the unfolding of social processes that involve a diversity of actors implicated in dynamic relationships at the heart of health promotion programs. This, we think, constitutes a priority for future evaluation research, in order to better understand how health promotion operates and therefore effectively induce changes in the social determinants of health.
NOTES 1
2 3
4
The first evaluation article was published in 1973 (Puska, 1973) whereas studies of the cohort assembled for this evaluation are still published periodically. Searching for “North Karelia Project” in Google Scholar resulted in 855 entries. For Guba and Lincoln (1989), the main purpose of evaluation is to lead program stakeholders toward a consensual program representation. Although we agree that this is part of program evaluation (Thurston & Potvin, 2003), we think that evaluation can produce much more diverse knowledge. Even “hard” technologies cannot be conceived and evaluated outside of the social web in which they were developed and in relation to which they evolve (Lehoux, 2006).
356 ■ PART V: Practical Perspectives 5
6
The proper use of a weaker research design means that researchers generate and design ways to control for hypotheses, other than the treatment, which could also explain observed outcomes (Cook & Campbell 1979). The sociologist Jurgen Habermas (1987) developed the idea that communicative actions—i.e., actions that involve social actors trying to agree on a common course of action—always put in play arguments from three spheres that composed the experienced world. These arguments come from: (1) the objective world as described by scientific knowledge; (2) the normative world that prescribes legitimate forms of interactions in specific contexts; and (3) the subjective world made of the actors’ desires, emotions, and projects not directly accessible for outsiders. Although the idea that programs could be conceived as a form of communicative action is interesting, it is well beyond the scope of this chapter. We think, however, that the three forms of the experienced world that Habermas reconciled in his theory of communicative action are relevant for modelling health promotion programs.
REFERENCES Bilodeau, A., Chamberland, C., & White, D. (2002). L’innovation sociale, une condition pour accroître la qualité de l’action en partenariat dans le champ de la santé publique. Revue canadienne d’évaluation de programme, 17(2), 59–88. Bisset, S.L., Cargo, M., Delormier, T., Macaulay, A.C., & Potvin, L. (2004). Legitimizing diabetes as a community health issue: A case analysis of the Kahnawake schools diabetes prevention project. Health Promotion International, 19, 317–326. Campbell, D.T. (1984). Can we be scientific in applied social science? Evaluation Studies Review Annual, 9, 26–48. Campbell, D.T. (1987). Guidelines for monitoring the scientific competence of the preventive intervention research centers: An exercise in the sociology of scientific validity. Knowledge—Creation, Diffusion, Utilization, 8, 389–430. Cargo, M., Levesque, L., Macaulay, A.C., McComber, A., Desrosiers, S., Delormier, T., et al. (2003). Kahnawake schools diabetes prevention project (KSDPP) community advisory board. Community governance of the Kahnawake schools diabetes prevention project, Kahnawake Territory, Mohawk Nation, Canada. Health Promotion International, 18, 177–187. COMMIT Research Group. (1995). Community intervention trial for smoking cessation (COMMIT). I. Cohort results from a four-year community intervention. American Journal of Public Health, 85, 183–192. Cook, T.D., & Campbell, D.T. (1979). Quasi experimentation: Design and analysis issues for field settings. Boston: Houghton Mifflin. Cooksy, L.J., Gill, P., & Kelly, A. (2001). The program logic model as an integrative framework for a multimethod evaluation. Program Planning and Evaluation, 24, 119–128. Couturier, Y. (2005). La collaboration entre travailleuses sociales et infirmières. Éléments d’une théorie de l’intervention interdisciplinaire. Paris: l’Harmattan. Elliot, J., Taylor, M., Cameron, R., & Schabas, R. (1998). Assessing public health capacity to support community-based heart health promotion: The Canadian heart health promotion. The Canadian Heart Health Initiative, Ontario project. Health Education Research, 13, 607–622. Guba, E.G., & Lincoln, Y.S. (1989). Fourth generation evaluation. Newbury Park: Sage. Habermas, J. (1987). Théorie de l’agir communicationnel. Tome 1. Rationalité de l’agir et rationalisation de la société. Paris: Fayard. Hawe, P., Shiell, A., & Riley, T. (2004). Complex interventions: How “out of control” can a randomized control trial be? British Medical Journal, 328, 1561–1563.
CHAPTER 19: Two Roles of Evaluation in Transforming Health Promotion Practice ■ 357 International Union for Health Promotion & Education. (1999). The evidence of health promotion effectiveness. Shaping public health in a new Europe. Part two, evidence book. Brussels: ECSC-EC-EAEC. Israel, B.A., Schulz, A.J., Parker, E.A., & Becker, A.B. (1998). Review of community-based research: Assessing partnership approaches to improve public health. Annual Review of Public Health, 19, 173–202. Lehoux, P. (2006). The problem of health technology. London: Routledge. Levesque, L., Richard, L., Duplantie, J., Gauvin, L., Cargo, M., Renaud, L., et al. (2000). Vers une description et une évaluation du caractère écologique des interventions en promotion de la santé: Le cas du Programme de la Carélie du nord. Rupture, revue transdisciplinaire en santé, 7, 114–129. Luepker, R.V., Murray, D.M., Jacobs, D.R. Jr., et al. (1994). Community education for cardiovascular disease prevention: Risk factor changes in the Minnesota Heart Health Program. American Journal of Public Health, 84(9), 1383–1393. Mark, M., Henry, G.T., & Julnes, G. (2000). Evaluation: An integrated framework for understanding, guiding, and improving public and non-profit policies and programs. San Francisco: Jossey Bass. McQueen, D.V. (2001). Strengthening the evidence base for health promotion. Health Promotion International, 11, 261–268. Milio, N. (2001). Evaluation of health promotion policy: Tracking a moving target. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 365–385). European series no. 92. Copenhagen: WHO regional publications. Ockene, J.K., Hymowitz, N., Lagus, J., & Shaten, B.J. (1991). Comparison of smoking behavior change for SI and UC study groups. MRFIT Research Group. Preventive Medicine, 20, 564–573. Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage. Potvin, L., & Chabot, P. (2002). Splendour and misery of epidemiology for evaluation of health promotion. Revista Brasileira de Epidemiologia, 5(Suppl. 1), 91–103. Potvin, L., Gendron, S., & Bilodeau, A. (in press). Três posturas ontológicas concernentes à natureza dos programas de saúde: implicações para a avaliação. In M.L.M. Bosi & F.J. Mercado (Eds.), Avaliação qualitativa de programas de saúde. Enfoques emergentes. Petropolis. Brazil: Vozes Editoria. Potvin, L., Gendron, S., Bilodeau, A., & Chabot, P. (2005). Integrating social science theory into public health practice. American Journal of Public Health, 95, 591–595. Potvin, L., Haddad, S., & Frohlich, K.L. (2001). Beyond process and outcome evaluation: A comprehensive approach for evaluating health promotion programmes. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 45–62). European series, no. 92. Copenhagen: WHO Regional Publications. Puska, P. (1973). The North Karelia project: An attempt at community prevention of cardiovascular disease. WHO Chronicle, 27, 55–58. Riley, B., Taylor, M., & Elliot, S. (2003). Organizational capacity and implementation change: A comparative case study of heart health promotion in Ontario public health agencies. Health Education Research, 18, 754–769. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). European Series, no. 92. Copenhagen: WHO Regional Publications. Rychetnik, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence on public health interventions. Journal of Epidemiology & Community Health, 56, 119–127.
358 ■ PART V: Practical Perspectives Shadish, W.R., Cook, T.D., & Leviton, L.C. (1991). Foundations of program evaluation: Theories of practice. Newbury Park: Sage. Stachenko, S. (1996). The Canadian Heart Health Initiative: A countrywide cardiovascular disease prevention strategy. Journal of Human Hypertension, 10(Suppl. 1), S5–S8. Taylor, M., Elliot, S., & Riley, B. (1998). Heart health promotion: Predisposition, capacity, and implementation in Ontario public health units, 1994–96. Revue Canadienne de Santé Publique, 89, 410–414. Thurston, W.E., & Potvin, L. (2003). Evaluability assessment: A tool for incorporating evaluation in social change programs. Evaluation, 9, 453–469. World Health Organization. (1986). The Ottawa Charter for Health Promotion. Retrieved March 2006 from www.phac-aspc.gc.ca/ph-sp/phdd/pdf/charter.pdf. Zaza, S., Briss, P.A., & Harris, K.W. (2005). The guide to community preventive services: What works to promote health. New York: Oxford University Press.
CRITIC AL THINKING QUESTIONS 1. How are evaluated programs different from non-evaluated programs? 2. Who is implicated in conceptualizing and implementing the evaluation? How are the various actors represented in this process? 3. Whose interests are being served by the evaluation? 4. Who is defining evaluation questions? How are the evaluation questions contributing to social betterment? 5. How are evaluation recommendations translated into practice? Whose interests are or are not being served by this process?
FURTHER READINGS Mark, M.M., & Henry, G.T. (2004). The mechanism and outcomes of evaluation influence. Evaluation, 10(1), 35–57. This article describes a framework designed to capture change mechanisms through which evaluations may affect practice and decisions. By discussing mechanisms underlying evaluation’s influence, they hope to move the field forward in relation to its understanding and facilitation of evaluation’s role in the service of social betterment. Mark, M., Henry, G.T., & Julnes, G. (2000). Evaluation: An integrated framework for understanding, guiding, and improving public and non-profit policies and programs. San Francisco: Jossey Bass. This book offers a new approach to evaluation, one that will encourage organizations or agencies to improve their contribution to social betterment. The authors draw from three decades of evaluation practice and theory to present a framework for conceptualizing evaluation and pragmatically assessing social policies and programs. Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage. The authors present a critique of traditional evaluation practice for its inability to produce straightforward results that would fuel rational decisions. They articulate a new evaluation paradigm that requires a careful blend of theory and method to understand causality in terms of underlying causal
CHAPTER 19: Two Roles of Evaluation in Transforming Health Promotion Practice ■ 359 mechanisms. It is concerned with understanding causal mechanisms and the conditions under which they are activated to produce intended outcomes. Potvin, L., Gendron, S., Bilodeau, A., & Chabot, P. (2005). Integrating social science theory into public health practice. American Journal of Public Health, 95, 591–595. This article discusses the challenges inherent in public health programming and evaluation in light of the Ottawa Charter for Health Promotion. It illustrates the need to formulate program theory that embraces social determinants of health and local actors mobilization, social change, and a theory of evaluation that fosters reflexive understanding of public health programs engaged in social change. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (Eds.). (2001). Evaluation in health promotion: Principles and perspectives. European series, no. 92. Copenhagen: WHO Regional Publications. This book is one product resulting from the five-year work of the WHO-EURO Working Group on Health Promotion Evaluation that was led by Irving Rootman and David McQueen. With contributors from Europe and North America, the book provides a broad overview of the challenges and opportunities for evaluation associated with health promotion.
RELEVANT WEB SITES American Evaluation Association www.eval.org/
The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. They publish the American Journal of Evaluation, New Directions for Evaluation, and Guiding Principles for Evaluators. Their activities include an annual conference, training opportunities, career opportunities, and much more. Canadian Evaluation Society www.evaluationcanada.ca/
The Canadian Evaluation Society is a Canada-wide, non-profit bilingual association dedicated to the advancement of evaluation theory and practice. The society promotes leadership, knowledge, advocacy, and professional development. It does this through diverse activities, including the publication of the Canadian Journal of Program Evaluation, annual conferences, diverse professional development events, notification of employment and contact opportunities, and much more. CDC Evaluation Working Group www.cdc.gov/eval/index.htm
The CDC Evaluation Working Group was charged by the US Centers for Disease Control and Prevention with developing a framework that summarizes and organizes
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the basic elements of program evaluation. The working group develops resources and linkages to evaluation of health programs. Evaluation Center, Western Michigan University www.wmich.edu/evalctr/
The Evaluation Center, Western Michigan University, offers links to evaluation tools and resources, publications, and other important Web sites in the field of evaluation. It is also the site of The Journal of Multi Disciplinary Evaluation, edited by Michael Scriven and E. Jane Davidson, with a mission of providing news and thinking of the profession and discipline of evaluation in the world. Health Communication Unit, Centre for Health Promotion, University of Toronto www.thcu.ca/index.htm
The Health Communication Unit at the Centre for Health Promotion, University of Toronto, is one of 22 members of the Ontario Health Promotion Resource System funded by the Ontario Ministry of Health and Long-Term Care. Their goal is to increase the capacity of community and public health agencies to plan for, conduct, and evaluate a wide range of health programs.
PA RT V I
CONCLUDING THOUGHTS
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he final section of this book offers three perspectives that address the implications of the developments described throughout the book. Chapter 20 opens the section with a commentary prepared by Ilona Kickbusch, originally framed as a foreword, but in the end moved here because it provides an overall assessment of the health promotion field over the past decade and positions many of the outcomes of the Ottawa Charter within the context of international and global health. In her commentary, Kickbusch introduces a pair of alternative analogies for considering the development of health promotion—the rhizome and the tree—and illustrates the continuing development of health promotion worldwide as if the field were a person growing up. The second chapter in this section, Chapter 21, was solicited after most of the manuscript was compiled. In a moment of critical reflection, the editors recognized that overall the book reflected a particular slant on health promotion in Canada that could be called the “social” approach, despite material that clearly tells us that health promotion, as practised, continues to focus primarily on individual risk factors and fostering better health-related behaviours. We therefore asked Gaston Godin to comment on the status of the “individual” approach within health promotion in Canada to remind the reader of the roots of this approach and its important intellectual and practical contributions to health promotion. The final chapter of the book, Chapter 22, provides an overall commentary on the book itself and what it says about the status of health promotion in Canada halfway through the first decade of the 21st century. In addition to providing a summary of the key themes developed throughout the book, such as the continuing marginalization of health promotion in the health field, the call for health promotion to demonstrate its effectiveness, and the challenge of building an appropriate theoretical base for the field, this final chapter describes var-
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ious current tensions in the field. In particular, the chapter debates the ways in which health promotion relates to the intellectual and political currents of modernism and post-modernism, linking these to Kickbusch’s opening imagery of the rhizome and the tree.
CHAPTER 20
H E A LT H P RO M OT I O N : N OT A T R E E B U T A R H I Z O M E Ilona Kickbusch
hen asked to write this chapter I was also asked to refer back to the analogy I had made in the earlier book about the “growing up” of health promotion as a child. Now if one were to take the adoption of the Ottawa Charter in November 1986 as its birth date, she would be 20 this year, but one could also argue that given all the preparatory work, she is more like 25. My own son was born right in the middle of this process—1983— and he was present at many of the global health promotion conferences. When he joined me at the Bangkok Conference in August 2005, now a student of international relations and about 2 metres tall, the most common comment he heard was the usual: “I remember you when you were so small”— and a hand would stop somewhere in his present navel region. It frustrated him no end. We tend to see growing up as growing taller. And the most usual analogy is the tree. In general we have a mind frame that understands power to be reflected in strong visible institutions. Yet I would argue that the power and influence of health promotion have been of another kind that exists in nature and has been adapted as a principle of knowledge organization by the French philosophers Gilles Deleuze and Felix Guttari (1976): a rhizome. It is a system that has many roots, that is connected and heterogenic; it does not respect territory but expands continuously, thus creating its own plateaus. Modern knowledge systems are rhizomes—with the World Wide Web
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being its ultimate expression. Health promotion, I would argue, is a rhizome. Looking back is essential in order to understand the present and look into the future. How big and strong or how widespread is health promotion? Are the World Health Organization and Canada, which were so present at its birth, still around to support and nurture it? Has it overcome its adolescent problems when it was challenged by every new view of health that came along? Are the other kids still more popular, particularly those with medical parents? Has it found its identity as a grown-up? Where will it go next? Every mother, of course, sees her child as very special and I believe the Ottawa Charter was a very unique child. It was the first and so far still is the only document to set the health agenda of the late 20th and 21st centuries. Its key assumptions are continuously being reinforced by research. It framed the third public health revolution with empowerment at its centre and there is no going back. Key health policy documents such as the International Tobacco Framework Convention and many others reflect its strategic premise: focus on policies and environments as much as on people. And “making the healthy choice the easier choice” is now the marketing premise of many a consumer goods company. The Charter set the stage for many of the developments in health policy that are now considered key innovations as, 363
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for example, the “whole government” approach of the Swedish health policy or the new German legislation that wants to put health promotion and prevention on a par with the other components of the health system. And it pre-shadowed the work being done in the World Health Organization Commission on Social Determinants and Health. The rhizome has spread. There were things the child was not really prepared for. The Charter had built on the responsibility of the public sector to take seriously its commitments to health, but fell right into two decades of neo-liberalism and the weakening of the state due to global developments. It was accused—despite the major modernization underway globally— that it was relevant only for the developed countries and therefore had no validity for poor countries. It was considered icing on the cake of health care reform, dispensable in the face of more challenging issues such as financing medical care. It was challenged that it could not provide evidence for its effectiveness—despite decades and libraries full of research on the interface between social factors and health. It was attacked as leftist ideology because it insisted on addressing inequalities and structural health determinants. Not an easy schoolyard to be in. Even worse, the child could not always rely on its parents and guardians. It never became a priority in the work of the World Health Organization, and despite its successes was frequently subject to the “not invented here” syndrome. WHO felt more at home starting a set of new initiatives based on a medical view of chronic diseases, but applying health promotion strategies. Not only does the health sector continue to think “disease” and structure itself accordingly, also in a media-driven world it is easier to get attention for problems and risks. Even as its member states started to build and strengthen
health promotion organizations, WHO dismantled its program. And Canada, from the mid-1990s on, dismissed it for a population health approach. The kid was too bound to a social concept of health, and that was a hard sell in the traditional health world. But due to a wide range of initiatives and settings, the rhizome expanded its territory: for example, thousands of municipalities, workplaces and schools around the world are working to implement health promotion. The kid was headstrong, and started playing with what many considered to be the wrong playmates. In the 1990s it had become clear that better health could be achieved only if there was a willingness by the private sector to show social responsibility for health—and, for example, not produce and market goods harmful to health, particularly to children and the developing countries. The Jakarta Conference in 1997 set out to explore this minefield and became the venue for a major health promotion family row, demanding that health promotion refrain from such contacts. Today WHO has meetings with major fastfood and soft drink manufacturers to discuss the global strategy on obesity, diet, and exercise; the United Nations has developed the Global Compact; and many agencies at country level have developed partnerships with the private sector to promote health. The past 20 years have seen tremendous changes in the context for health promotion, and perhaps the most astounding factor is the extent to which health has become an integral part of modern society. The child was born when many issues that are matter of fact in public health today were not taken seriously or not even thought of. Many of today’s energetic health promotion professionals were children or adolescents when the Charter was written, and yet they were already trained under its influence because it was disseminated with great speed to teaching institutions
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and curricula. Health promotion argued that health was a sound investment and today it is a major social, political, and economic driving force. In developed countries the combined expenditures on health care and personal wellness can be as much as 15 percent of GNP or more. Food and soft drink companies are restructuring, the tobacco companies have been reigned in, marketing for ill health is under attack, wellness is one of the fastest-growing sectors of private enterprise, and health information receives more hits on the Internet than pornography. For me the most important sentence in the Ottawa Charter remains the positioning of health within society: Health is created in the context of everyday life—where people live, love, work, and play. Today one might add where we travel, shop, and Google. This simple sentence in the Ottawa Charter is the expression of the significant social process of the de-territorialization of health out of the health care system into the social arena and the market. Health promotion has both been a response to and has considerably contributed to this changing nature of health in society. The young man (let me this time associate the gender with my own son) now has to move in many different arenas in new kinds of “healthscapes” because we now live in a society where health is present in every dimension of life; indeed, where lifestyles have become health styles. This has significant consequences for how we (re)define each and every action area of the Ottawa Charter and where we assign responsibilities for health in society. For example, the European Commission has proposed combining the public health program with the consumer protection program because the synergies are so critical. If health is everywhere, every place or setting in society can support or endanger health and every decision is potentially also a health decision. This
is different from a process of medicalization; rather, it constitutes a new mix of privatization and commodification, empowerment and participation, social inclusion and exclusion, public and private. The dimensions of personal health, public health, medical health, and the health market interface in new ways in a pattern that I call the health society. At this point there are very few policy mechanisms that allow an adequate response to these new kinds of deterritorialized “healthscapes.” Indeed, I believe that the governance of what is called the “health system” (but rarely deals with health) is due for a revolutionary overhaul. It is time therefore for the young man to seek new qualifications in health promotion— maybe he needs to become a health entrepreneur or a litigation lawyer. Maybe he will head the new line of healthy snacks in a major food company, be an equity funds manager who invests in the health market, or creates a new health portal on the Web. If in the past the original focus of health promotion programs was the individual with the “unhealthy” behaviour and if it evolved toward governmental policy interventions over the environment, today the big health debate is directed at the producers of unhealthy products, at those who market them (particularly to children and young people), and at the arenas of everyday life where they are consumed. The supermarket has become a key “health facility” of the 21st century. Health, it turns out, really is everybody’s business in a symbolic, virtual, and real sense: owners of bars and restaurants, retailers, the management of airports and railway lines, to name but a few, all need to be concerned with health. Settings of everyday life become “healthy” settings through a commitment to norms and standards and patterns of appropriate behaviour, with laws and regulations sometimes promoting, in other cases following, cultural shifts.
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Finally, there will be central ethical questions for the young man to consider. In the health society, personal health returns in a new form: autonomy, individualization, and choice come in tandem with increasing inequalities. Individuals do not only have an increased interest in health, they also have an increased responsibility for their own health. The expansion of rights ensures, for example, the rights of non-smokers, but it also leads to debates about higher premiums for people with unhealthy lifestyles. What extent of exclusion and inequality will be politically accepted in health? What social, political, and financial price are we willing to pay for better health both individually and as a community, both at the local and at the global level? While it seems unfair that some parts of society can buy better health in the marketplace, where are the limits set? While it seems appropriate to strive for more health, should we not also critically consider the limits of this quest? These questions cannot be resolved without
a debate on the values that will ultimately drive the health society. It is the strength of health promotion as codified in the Ottawa Charter that its vision of health under conditions of modernity is deeply democratic and participatory. It is the role of citizens in health that becomes the most critical component of health governance in the 21st century. “I remember you when you were so small.” When the Charter was adopted, we knew we had achieved something important, but we could, of course, not gauge the broad range of impacts it would have. I see health promotion as a network or as a rhizome that has made its way through the health arena and society not by creating massive infrastructures, but by changing minds. Maybe that is all we need to continue to do. Not deplore the fact that there are no great health promotion palaces, but continue to work on the process of spreading out and taking root, a process to which many Canadians have centrally contributed and will no doubt continue to do so.
REFERENCE Deleuze, G., & Guattari, F. (1976). Rhizome. Paris : Les Éditions de Minuit.
CHAPTER 21
HAS THE INDIVIDUAL VANISHED FROM C ANADIAN HEALTH PROMOTION? Gaston Godin
s seen in several chapters of this book, Canadian health promotion since the Ottawa Charter (World Health Organization, 1986) is mainly perceived here and abroad as having put an emphasis on the “social” determinants of health. Given our interest in participating in the debate on crucial issues for health promotion, we wish to draw attention to contradictions emerging as a result of the way in which the Ottawa Charter has been used to determine public health intervention priorities. Most health professionals, researchers, and stakeholders eagerly welcomed the publication of this Charter. Enthusiasm was almost palpable because this document called for a broad and thorough approach to health promotion. However, we believe that the way the Charter has been used by a number of parties in Canada is far removed from the initial declaration of intent. Health promotion as interpreted from 1986 on quickly turned into a reassessment of health education interventions primarily targeting individuals and changes in their behaviour (e.g., unhealthy lifestyles) that were current since the 1950s and, in Canada, even after the Lalonde Report of 1974 had opened up much wider areas of possibilities. To some extent, doubts were raised concerning not only the effectiveness of educational and preventive measures to improve the health of individuals, but also on the pertinence of their use. One argument against the appropriateness of this type of interven-
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tion was that the goals targeting behavioural changes instilled guilty feelings and victim blaming because concerned individuals have only limited control over their lifestyle choices. Indeed, according to this thesis, people fail to eat properly essentially because they do not have access to healthy foods at reasonable cost. Likewise, the primary cause of a sedentary lifestyle is low family income. It was then suggested that in order to intervene more appropriately in health promotion, the emphasis should not be placed on individual decision making in connection with behavioural change, but rather on the role played by the social, cultural, and economic environment—that is, socio-structural factors. There was a progressive swing away from studies and interventions targeting the individual and toward consideration of the social, cultural, and economic environment, with these factors now deemed the most important health determinants. This even led some specialists to suggest defining health promotion as the study of “social” health determinants. The end result of this trend is obvious: the individual was progressively excluded from health promotion activities. Yet contrary to this interpretation of the Ottawa Charter so popular since the 1980s, several meta-analyses have confirmed that education is also an efficient strategy encouraging the adoption of healthy behaviour (Kalichman, Carey, & Johnson, 1996; Kok, Van Den Borne, & Dolan Mullen, 1997). This is even truer 367
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when planned under appropriate conditions of implementation (Bartholomew, Parcel, & Kok, 1998). Among other things, one of the winning conditions in health education involves the development of interventions based on recognized theoretical premises (Bartholomew, Parcel, & Kok, 1998; Rakowski, 1999; Webb & Sheeran, in press). However, despite a demonstration based on solid data, several stakeholders in health promotion continue to refuse to acknowledge the merits of the educational approach and insist on abandoning interventions aimed at changing an individual’s behaviour (e.g., Joffe, 1996). In their opinion, only social and cultural conditions are important. In fact, even if it is true that these factors are important, one notes, unfortunately, that arguments voiced in the debate seem to be based more on ideological conviction rather than on scientific reasoning (Abraham, Sheeran, & Orbell, 1998). The contemporary approach to the obesity epidemic provides a prime example of this approach to health promotion. To fight this important health problem, several public health specialists advocate adopting a narrow view, recommending action that might “directly change living conditions at the root of certain kinds of behaviour. Thus, the focus would be on behaviour without necessarily broaching education. […] since people are exposed passively, they will benefit from preventive measures without having to think about them” (ASPQ, 2003, p. 14; free translation). This is an endorsement of the theory of operant conditioning in which an individual responds to a specific external stimulus without being prompted. According to this theory, X need only be changed in order that Y adopt the correct behaviour. From this standpoint, why worry about the person, since his or her motivation is unimportant? If one is to believe advocates of this approach to health promotion, we are not responsible
for our state; the “system” around us is. We eat badly because of McDonald’s and other fast-food restaurants. Our children are obese because of the soft drink machines in schools. We have become sedentary because of the irrational way the environment around us is mapped out: lack of sidewalks, overdevelopment of the road network, etc. This thesis is compellingly supported in the 2004 movie by Morgan Spurlock entitled Super Size Me. The pervasive societal message in this documentary is clearly the following: “We are victims of the system.” It is up to government and public health agencies to control these “polluters” in our physical, economic, and social environment through appropriate laws and regulations. No one has yet questioned the behaviour or individual responsibility of the actor- author of Super Size Me. The solution resides in the pure and simple eradication of McDonald’s restaurants. Although this way of thinking might seem comforting, it removes all sense of responsibility from the individual, making “It’s not my fault, I have done nothing wrong” the winner here—a somewhat simplistic approach to dealing with the situation! However, one would have to be naïve to surmise that this miracle recipe will unconsciously force us to adopt good behaviour and lead to improved health among the population at large. One should harbour doubt; even in a supportive environment, lack of motivation has harmful repercussions. Motivation is an unavoidable companion along the road to changing a bad habit. Every ex-smoker has begun the long rite of passage to a smokefree existence with the intention to stop smoking. We are, in fact, tributaries not only of the environment and context surrounding us, but also of the decisions we make. It is difficult, even impossible, to contemplate significantly changing the behaviour of a person who is not motivated.
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One of our recent studies reviewed the role of cognition versus that of the immediate social environment in the adoption of a particular behaviour, namely, regular physical activity. A subgroup of 1,749 people, chosen at random from 22,702 respondents to the 1998 Quebec Health and Social Survey, was monitored for three months. There were three measured categories of variables available at the beginning of the study to predict behaviour over the next three months: cognition (i.e., intention, attitude, perception of control); personal variables in the immediate social environment (e.g., family income, job status, perceived social support); and the same socio-structural variables measured at the regional level irrespective of respondent background. The results were rather eloquent (Godin et al., in preparation). A firstlevel analysis showed that no variable of the social environment contributed significantly to behaviour prediction (i.e., regular practice of leisure time physical activity); the best determinants were intention and perception of control. A second-level analysis identified some intention–behaviour relationship moderators, meaning variables affecting the strength of the relationship between intention and behaviour. Among these moderators, some were associated with the personal social environment (e.g., level of education) and others with the regional social environment (e.g., regional family income, regional level of education). However, a third-level analysis showed that social structural variables (personal and regional) exert influence only when the individual has a stable intention of adopting a particular course of action.
Temporal stability might be defined as “the extent to which intention remains unchanged over time regardless of whether or not it is challenged” (Sheeran, Orbell, & Trafimow, 1999, p. 722). Therefore, in this example, in a favourable or unfavourable social environment, when an individual has an unstable intention of engaging in physical activity on a regular basis, the intention–behaviour relationship is not only weak, but null for all intents and purposes. In summary, if a person has an unstable intention, the social environment has no effect. Likewise, the social environment encourages a move from intention to action when the person has a stable intention. Consequently, these results clearly demonstrate the importance in health promotion of attributing similar importance to the individual (i.e., his or her motivation) and the social environment (i.e., its quality). Ignoring one or the other is tantamount to being cut off from a significant part of reality. What does the future hold for us in terms of health promotion activities? It is hard to say, but one thing is certain: We must stop relegating the individual to the sidelines in our approaches and interventions. It is time to reinstate the individual to the place he or she should take in health promotion, a place that many have never forgotten in Canada over the last 10–12 years despite an unfavourable environment. By following the global approach advocated in the Ottawa Charter, individual responsibility in the adoption of healthy behaviour will once again find renewed legitimacy.
REFERENCES Abraham, C., Sheeran, P., &1, Orbell, S. (1998). Can social cognitive models contribute to the effectiveness of HIV-preventive behavioural interventions? A brief review of the literature and a reply to Joffe (1996, 1997) and Five-Schaw (1997). British Journal of Medical Psychology, 71, 297–310.
370 ■ PART VI: Concluding Thoughts ASPQ (Association pour la sante publique du Québec). (2003). Les problèmes reliés au poids au Québec: Un appel à la mobilisation. Rapport du Groupe de travail provincial sur la problématique du poids (GTPPP). Montreal: ASPQ Éditions. Bartholomew, L.W., Parcel, S.G., & Kok, G. (1998). Intervention mapping: A process for developing theory- and evidence-based health education programs. Health Education and Behaviour, 25, 545–563. Godin, G., Gallini, M.C., Conner, M., & Sheeran, P. (in preparation). Individual and socio-structural moderators of the intention-behaviour relationship. Joffe, H. (1996). AIDS research and prevention: A social representation approach. British Journal of Medical Psychology, 69, 169–190. Kalichman, S.C., Carey, M.P., & Johnson, B.T. (1996). Prevention of sexually transmitted HIV infection: A meta-analysis review of the behavioral outcome literature. American Behavioral Medicine, 18, 6–15. Kok, G., Van Den Borne, B., & Dolan Mullen, P. (1997). Effectiveness of health education and health promotion: Meta-analyses of effect studies and determinants of effectiveness. Patient Education and Counseling, 30, 19–27. Rakowski, W. (1999). The potential variances of tailoring in health behavior interventions. Annals of Behavioral Medicine, 21, 284–289. Sheeran, P., Orbell, S., & Trafimow, D. (1999). Does the temporal stability of behavioral intentions moderate intention-behavior and past behavior-future behavior relations? Personality and Social Psychology Bulletin, 25(6), 724–734. Webb, T., & Sheeran, P. (in press). Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association.
CHAPTER 22
CONCLUSION: THE RHIZOME AND THE TREE Sophie Dupéré, Valéry Ridde, Simon Carroll, Michel O’Neill, Irving Rootman, and Ann Pederson INTRODUCTION his book has provided a broad yet detailed scan of developments within health promotion in Canada since the mid1990s. These developments have been documented from both inside and outside of Canada, and from the perspectives of active health promotion practitioners, researchers, advocates, educators, and program evaluators. A range of theoretical perspectives has been put forward and activities have been discussed from macro to micro perspectives, as well as from the perspective of various jurisdictions. Given these many varied contributions, what can we conclude about health promotion in Canada and how has it influenced the field globally from 1994–2006? And given what we have found, what does it intimate for the future? In this chapter we try to answer these questions by reflecting on developments in health promotion that continue earlier trends as well as those that have evolved significantly or emerged during this period. We conclude by referring to the analogy Ilona Kickbusch draws in her commentary about health promotion being a rhizome rather than a tree (see Chapter 20). Linking this metaphor to the distinction made between health promotion and the promotion of health in Chapter 3 and to the arguments we develop throughout this chapter allows us to propose a way to think about the development of health promotion over the years that
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returns to, and critically reflects upon, the modern/post-modern distinction that was made in the conclusion to the first edition. These concluding thoughts thus build upon the different chapters of this book, as well as additional literature and dialogue among the authors, a team put together explicitly for the purpose of writing this final chapter.1 We also refer to the predictions and analytical remarks that were made in the first edition, as we recognize that this new edition is both an update of the first book and a broadening of the perspectives from which we reflect upon the development of health promotion in Canada and its influence abroad. One issue that challenged us as we wrote these final thoughts is an old one, namely, the relationship between science, ideology, and health promotion. After extensive discussion, we concluded that this complex topic warrants a fuller treatment than is possible in the short space available. We therefore intend to return to this particular discussion in a future article, although we recognize that in so doing this ongoing discussion—and our analysis of it—remains one of the possibly unsatisfying elements of the book.
OLD ISSUES REMAIN VALID Health Promotion: Still Marginal But Resilient As clearly shown throughout the book, but 371
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particularly in the chapter about the provincial and territorial situations, health promotion continues to be marginal in the overall Canadian health care system. As is evident throughout the world, health promotion in Canada continues to struggle to locate itself in relation to the biomedical and curative paradigms that still dominate health care, research, and policy. The health care constituencies (professionals, especially physicians, hospital boards, etc.) are well organized as well as very influential and powerful, notably by having the public opinion on their side as we were reminded in Chapter 10. In the last decade we have witnessed the health sector’s increasing focus on reducing costs in an economically driven, neo-liberal context, leaving little funding for public health and/or health promotion, although we note a certain renewed interest and additional funding since the establishment of the Public Health Agency of Canada in September 2004. Even within the public health budget and programs, however, health promotion is still marginal and governmental budgets dedicated to its practice in Canada remain extremely modest. Bujold (2004) described this situation by saying that health promotion has always been—and indeed has remained so over the last 12 years—“l’humble Cendrillon” (the humble Cinderella) in the promotion/prevention/protection triad. As argued by Hancock (1994) in the first edition of this book, and more recently by several scholars (Bengel, Strittmatter, & Willmann, 1999; Frolich & Potvin, 1999; McKinlay, 1998; Ziglio, Hagard, & Griffiths, 2000), public health and health promotion practice remain largely anchored in a pathogenic paradigm, oriented toward illness in its manifestations, both in Canada and around the world. As seen in Chapter 4, public health programs are still primarily developed on the basis of epidemiological models of risk factors (Breslow, 1999), with an emphasis on individual risks as
opposed to the ones pertaining to the social and economic context. Thus, despite a decade in Canada of a discourse of the social determinants of health that recognizes the importance of an ecological approach to interventions, Canadian health promotion in its day-to-day practice remains largely lifestyle-oriented and focused on individual behavioural change. This probably can be explained by a lack of well-articulated and supported social theories to guide practice, in contrast to the array of better-known psychosocial theories of health behaviour (Potvin et al., 2005) that continue to inform the training of practitioners (see Chapter 18). That policy and funding structures remain linked with specific diseases, behavioural risk factors, or at-risk populations also creates barriers to the facilitation of the intersectoral work and the holistic view deemed necessary to act within a broader vision of health promotion (Kickbusch, 2003; Ziglio, Hagard, & Griffiths, 2000). Moreover, as argued by Hills and her colleagues in Chapter 18, Canada continues to be challenged to reorient its health system toward a primary health care focus (and in turn to establish the role of health promotion within primary health care). One of the main reasons they mention for the limited progress on this issue, namely, the resistance of health promotion to building alliances with the medical sector, was identified in the first edition of this book (O’Neill, Pederson, & Rootman, 1994) and likely reflects a fear of giving the powerful constituencies of biomedicine the opportunity to redefine the field of health promotion. Rather than a broad health promotion vision, what has been emerging in the medical sector over the last decade is a discourse on clinical preventive practices. In Quebec, for instance, the Clair Commission (Quebec Ministère de la Santé et des Services sociaux, 2001) observed that public health resources lacked coordination and were
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badly used; it also identified the need to better inform health professionals on the preventive practices that could be employed in their clinical encounters (Lévesque & Bergeron, 2003). As highlighted in Chapter 18, clinical preventive practices tend to focus on lifestyle counselling and individual preventive practices. Broader health promotion continues to be absent or only minimally present in the training and practice of most nurses, physicians, and other clinically oriented health professionals. It is thus interesting to observe that despite very little funding, the current emphasis on downsizing the health care system, the rise of clinical preventive practices, and the predominance of the population health discourse, health promotion has been sufficiently resilient to survive. To adopt once more one of Kickbusch’s analogies, the teenager learned to elbow his way in a difficult schoolyard. This can probably be partly explained by the dedication and motivation of people working in the field. More structurally, in her comparison between three provinces, Bernier argues in Chapter 10 that elements like state legitimacy and a neo-liberal social investment perspective explain this resilience. Finally, the fact that at the international level health promotion never vanished and Canada continued to be singled out as a model to emulate, as all the chapters of the international section of the book have shown, surely helped sustain health promotion in Canada.
very present in a paradoxical way in Canada. As mentioned above, the contributors to this book have made it clear that the practice of health promotion in all jurisdictions has still largely been based on individual lifestyle change related to the main illnesses plaguing the population. On the other hand, as also seen throughout the book, the discourse on the social determinants of health was also heavily emphasized and became, at home and abroad, a trademark of Canadian health promotion. Indeed, many authors now suggest (see Chapters 4 and 7, for instance) that health promotion’s work should be more (if not entirely) devoted to social change. This somewhat contradictory tension between most of the practice and the dominant discourse has created significant discomfort for many practitioners as well as for Canadian researchers who have been working on individual change over the last decade. We have asked one of them, Gaston Godin, who holds a Canadian research chair on health-related behaviour, to comment on this situation and his contribution is included in the concluding section of this book. We support Godin’s position that health promotion practice should be based on sound science and note that research has clearly shown that both individual and social factors are crucial to the adoption and the maintenance of healthy lifestyles and healthy life conditions.
Structural versus Individual Change
Professionals, Bureaucrats, and Academics in the Canadian Health Promotion Movement
As thoroughly discussed in the introduction to this book, the evolution from health education to health promotion in the mid-1980s was largely in reaction to the strong emphasis on individual change that characterized the field from its inception in the 1950s. Between 1994 and 2006, this issue was still
In the conclusion of the first edition (O’Neill, Pederson, & Rootman, 1994), it was observed that the key actors who had influenced the development of the field from 1974–1994 were a group of health professionals, policy makers, and academics. The point made then was that health promotion was not a wide-
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spread social movement but rather a professional movement that had successfully advanced a discourse about health and the production of health. It was also suggested that local communities, notably through the healthy cities movement, could become more important in the future, but that they were not then the leaders in health promotion. What is clear in the national and provincial sections of this second edition is that the key actors have essentially remained the same from 1994–2006. The main difference is that academics might have played a larger role than in the previous period, bureaucrats a less important one, and that practitioners have probably maintained a relatively constant level of involvement. Moreover, as they were struggling as well with structural reorganization, local communities, whether through the healthy communities movement or other mechanisms, have not taken the much more active role that Hancock (1994) and others had envisioned.
Two sets of actors who were involved earlier but which were given little attention in the first edition are the private and the voluntary sectors. The role of the private sector has been pointed out by many in this book, including Kickbusch and Labonté, as one of the key emerging elements of the last decade. We will return to this point later. The other set of actors we did not talk much about in the first edition—and which remains underexplored in this volume as well—is the voluntary sector. Our sense is that this sector has always been important to health promotion, but that perhaps this role has increased in the past 10–12 years. We have therefore asked Elinor Wilson, chief executive officer of one of the key Canadian non-governmental associations in relation to health promotion, the Canadian Public Health Association, to write about this issue (see Box 22.1).
BOX 22.1: THE ROLE OF THE VOLUNTARY SECTOR IN HEALTH PROMOTION IN CANADA
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The International Leadership of Canada In the first edition, the editors predicted that Canada would continue to play an important role in health promotion on the international scene. Indeed, and despite always possible biases in the selection of our contributors, it is obvious from all the chapters of our international section that Canada continues to have a good international reputation and has contributed in many different ways to the global development of the field in the last decade. And this is the case despite the marginalization of health promotion in Canada during this period discussed previously. Although there are definitely reasons to celebrate this reputation and these contributions, much reflection and work remain to be done in order to improve Canada’s effectiveness in its international and global actions. As argued in Chapter 15, many individuals and groups of scholars (such as the Canadian Coalition on Global Health Research) concerned with global health and inequalities in Canada and abroad are reflecting on how best to allocate scarce resources for research in the context of the 10/90 gap (see Box 22.2),
on how to establish research priorities, as well as on how to have systemic and meaningful impact on health (Kickbusch, 2006; Labonté & Spiegel, 2001; Neufeld & Spiegel, 2006). The role of Canada as a donor country or as part of powerful political structures like the G8 alluded to in chapters 12 and 15 should also be recognized.
Not Yet a Worldwide Presence In 1994, the editors predicted that health promotion would continue to be primarily a phenomenon of developed countries and a luxury that few developing countries would be able to afford. After a decade, we can certainly affirm that many countries, be they developed or developing if we use this vocabulary, have not yet adopted the Ottawa Charter version of health promotion discourse. As seen in the various country examples of Chapter 15, health promotion is gaining currency in some countries whereas it has been in place for variable periods for others, even through an established infrastructure in a few of them. The adoption of health promotion is clearly influenced by various social, cultural,
BOX 22.2: THE 10/90 GAP IN GLOBAL HEALTH RESEARCH
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historic, and political factors. For instance, as argued by Ridde and Seck (in press) with respect to francophone African countries, some countries may prefer to adopt the Alma-Alta discourse of primary health care than the discourse of health promotion. This preference can probably be partly explained by the historical relation between those countries and France (e.g., aid, training) where, as also seen in Chapter 15, health promotion has very little currency even today. It is also interesting to note from Chapter 15 that health promotion clearly does not operate in the same forms in all countries and that similar activities may exist but be labelled differently. O’Neill and Cardinal (1994) made the same type of observation in the first edition, but with respect to a provincial jurisdiction: they observed that in Quebec the adoption of the health promotion discourse in the mid-1980s was slow; they argued that there were many practices then, as there probably still are, that were consistent with health promotion, but not labelled as such. This appears to be the case for many countries, particularly those of the South. Consequently, there is a lot of interesting work for the global health promotion community that is largely unknown, notably because of publication biases and persistent inequalities under which research is carried out. This calls for measures to make these practices more visible as the Global Effectiveness Project (Jones, 2004) and the Equity for Publication Project of the International Union for Health Promotion and Health Education try to do (see IUHPE Web site below).
MAIN EMERGING ISSUES Globalization As Labonté suggests in Chapter 12, the earliest and probably most significant issue to
emerge over the last decade has been the speed at which the processes of globalization have been unfolding. Globalization has had an impact on countries from the South (De Leeuw, 2001; Kim, 2000) as well as from the North, including Canada (Romanow, 2002). As Labonté observes, many voices are rising to affirm (Feachem, 2001) or deny (Bezruchka, 2000) a positive link between globalization and health. Yet, the “globalization of health” is less recent than many think (Yach & Bettcher, 1998): it could be argued that it began five centuries ago when Europe’s conquest completed the microbial unification of the world (Berlinguer, 1999). Co-operation among countries on health issues is also an old phenomenon, as the first international healthrelated meeting was held in Paris, France, in 1851 (Walt, 1998). However, despite this history, the magnitude of recent globalizing activities is unprecedented and forces us to reflect anew on its link to health promotion practice and research. First, it is important to differentiate actions in international health from global health issues, as argued by Brown, Cueto, and Fee (2006) and Jackson et al. in Chapter 13. Some have even argued that we are now facing the “globalization of international health” (Walt, 1998). According to Labonté (2006), talking about global instead of international health completely reframes the research agenda, as many local or national health situations can no longer be resolved by local or bilateral action but in fact require global responses. This was the case for SARS and has been true of the HIV/AIDS epidemic, and is currently a feature of diverse issues ranging from avian flu, to BSE, to bioterrorism. Furthermore, local actions and policies undertaken in Canada can have unintended consequences in different corners of the world (e.g., brain drain: see the 2006 annual report of the World Health Organization).
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Second, the economic dimension of globalization has led to global institutional changes. Whereas WHO and its member states were still very important global health actors during the writing of this book’s first edition, in recent years there are those who argue that the leadership of many United Nation’s agencies has been supplanted by the World Bank and other economically driven global institutions such as the World Trade Organization. Indeed, a collection of articles on this subject published at the end of the 1990s in the British Medical Journal led a senior WHO official to say: “The World Bank is the new 800 lb gorilla in world health care” (Abbasi, 1999, p. 3). Through the publication of its famous report on health (Banque mondiale, 1993) and its Health, Nutrition, and Population Strategy (World Bank, 1997), the World Bank has had a dramatic influence with its “investment in health” approach. Although this strategy significantly mobilized new funds toward health, the results of this mobilization were questioned by many as early as 1993 and similar issues have been raised with respect to malaria by a Canadianrun research team (Attaran, et al., 2006). Two additional issues need to be raised here. First, it is well known that for the World Bank, health is not considered a right but rather a means of leveraging economic development, especially in poorer countries (Buse & Walt, 2000; de Beyer, Preker, & Feacham, 2000), though this outcome has never fully materialized, as acknowledged by one of the World Bank’s former directors (Stigliz, 2005). Second, the Bank tends to ignore the importance of countries’ legitimate political preferences (Hibou, 1998). The World Bank concept of governance is associated in their publications and their discourse with a limited (or indeed minimalist) role for the state (Attaran et al., 2006; Hibou, 1998). In this context, many other economically driven inter-
national agencies such as the World Trade Organization have also had major healthrelated effects around the world over recent years, not only among countries of the South. As Labonté notes in Chapter 12, in parallel with the increasing role of these institutions, many debates are emerging with respect to global governance and the “watchdog” role of public health and heath promotion practitioners and organizations. The emergence of initiatives such as the People’s Health Movement (see Web site in the list at the end of this chapter) or the drafting of a counter report to WHO’s by Global Health Watch (see Web site below) are indications that mechanisms are becoming organized for this new global governance to function. It will be interesting to see whether the WHO’s Commission on the Social Determinants of Health (see Web site below) has significant impact and what arises from work on the UN Millennium Development Goals. It remains to be seen if the UN organizations are able to balance the impact of these other emerging organizations or whether we have entered a new world order, as Kickbusch suggests in her commentary.
The Evidence Base of Health Promotion An important development since 1994 has been the need for health promotion to strengthen its scientific evidence base. This has been triggered both from outside the field, by the need to prove to governments and other funding bodies that health promotion interventions are effective during a decade of major downsizing in publicly funded health systems (O’Neill, 2004), and from within through important work to establish and assess the theoretical bases of health promotion activities. Contributors throughout this book have continued this
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trend and have tried to elaborate how theory could enhance health promotion practice and research in particular. The Effectiveness Movement and Realistic Evaluation
Health promotion has been struggling with two important questions when it comes to assessing its evidence base: Which types of evidence are required to assess the effectiveness of health promotion? How should we evaluate health promotion interventions? As Potvin and Goldberg discuss in Chapter 19, a whole area of knowledge development arose in the 1990s around these questions, with fundamental consequences for the evolution of the field. International work has been conducted by IUHPE (1999), WHOEURO (Rootman et al., 2001), and many others (Cloetta et al., 2005; Nutbeam, 1998), within which Canadian scholars have been central. This work has been summarized by Jackson and her colleagues (2001) of the Canadian Consortium on Health Promotion Research, who note the key scientific and political dilemmas involved. Despite the importance of this evolution, a paradigmatic dead end remains. Experts in health promotion evaluation have to come to realize the difficulty—and possible irrelevance—of adopting positivist research methods and experimental designs to evaluate health promotion practice, especially at the community level. They are thus now turning to an important recent theoretical development in program evaluation, the realistic approach (Pawson & Tilley, 1997), and exploring its use within the field of health promotion program evaluation (Hills, Carroll, & O’Neill, 2004; Potvin, Gendron, & Bilodeau, in press). One of the biggest challenges in the years to come will be whether this promising approach to evaluation can actually demonstrate health promotion’s effectiveness. Moreover, scholars
and decision makers might well need to reconsider the very concept of effectiveness, which is not as universal as it might seem, as Jullien (2005) eloquently showed in a recent comparison of European and Chinese perspectives toward effectiveness. The Need for Theory
Despite the still unsolved debates about whether the individual or the social is the most important focus for health promotion interventions, researchers and practitioners in both camps believe that better theory is needed to inform practice. This view has sharpened since 1994. On the individual side, psychosocial models aimed at understanding, predicting, and influencing health-related behaviour have been around for decades since the first formulations of the Health Belief Model in the early 1960s. The centrality of intention as a key predictor of behaviour has been demonstrated repeatedly through generations of theoretical models building on one another by authors such as Azjen, Fishbein, Triandis, Bandura, Prochaska, and di Clemente, to name the best known (Godin, 1991). Several sets of variables have been introduced to understand what makes intention evolve, and in general, even if they remain uncommon because of the complexities involved, interventions based on these theoretical advances are much more successful than those not so informed. An attempt has recently been made by a scholar from Canada to assemble all these developments in one “integrated model” (see Godin, 2002). On the social side, and notwithstanding Kickbusch’s claims in this book about “decades and libraries full of research on the interface between social factors and health,” efforts to explicitly link social theory and health promotion have come later and have been less systematic and well articulated than
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on the individual side. In this respect, two recent undertakings to link social theory and health promotion, one primarily international and one largely Canadian, are worth mentioning. The international effort is the publication by some leading voices in the field of a book, entitled Health and Modernity: The Role of Theory in Health Promotion (McQueen et al., forthcoming). The Canadian one, which has had significant international impact, is the development of the collective lifestyles concept presented in Chapter 4. To date, whether building on the sociology of Weber, Habermas, Bourdieu, or Giddens, these efforts have generally produced less integrated and less robust models of the relationships between social factors and health than the ones on individual change, but there is clearly commitment and capacity to extend this line of theorizing and we should continue to expect important theoretical advances. Moreover, health promotion should expand academic alliances to enrich its theoretical base. For example, the authors of Chapter 6 call for more dialogue with the field of women’s studies and present intersectionality as a relevant theory to guide health promotion research and practice. And we note that Canadians have been involved in efforts to integrate the individual and the social elements in a single framework (see Best et al., 2003). These efforts are still preliminary, but we think that the ecological model discussed in Chapter 17 shows tremendous promise in this regard and appreciate that Richard and Gauvin used it to examine some examples of health promotion programs in Canada. Finally, this book illustrates (through the example of health literacy described in Chapter 5) that the various steps to scientifically define, operationalize, and measure a concept in order to move from theory to program planning are numerous and complex. This process is even
more complex if the construct involved is one as broad and difficult to define as health promotion (see Chapter 3). Clearly, the last decade has demonstrated that for both practical and political reasons, the field of health promotion needs to articulate and refine its scientific base; failure to do so runs the risk of health promotion being discredited as simply one of many competing ideological discourses rather than a sound framework for action.
Addressing Social Health Inequalities Health promotion has always focused on action on health determinants in order to improve the overall health of the whole population. This was relatively new at the time of the Ottawa Charter, but since then much substantive knowledge on the determinants of health has been accumulated. Many analytic frameworks have been developed to describe and analyze the different determinants of health, one of which, published at the same time as the first edition of this book, raised much interest and critique, both from those who identified themselves as part of the health promotion field and those who did not (Coburn et al., 2003; Poland et al., 1998). Over the last decade a double evolution seems to have taken place in discussions on the determinants of health. On the one hand, researchers are beginning to move beyond the description of determinants of health and look into their interactions and social processes over time in order to account for differential exposure and vulnerability over the life course. The conceptual contribution of the “collective lifestyle” concept presented in Chapter 4 or the developments of the “ecological health promotion” discussed by Richard and Gauvin in Chapter 17 are salient examples of the Canadian contribution to knowledge development in this area. More recently, some Canadian researchers
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have suggested thinking of the determinants as “contributors to disease causation, rather than as determining factors” (Lock, Nguyen, & Zarowsky, 2005, p. 58). On the other hand, the problem of social inequalities in health is beginning (albeit still timidly) to interest researchers. A core challenge in this analysis is to not only link social inequalities to population health but, more importantly, to understand the social and political processes that produce them (Coburn et al., 2003; Navarro, 1998)—understanding that can only be realized through an interdisciplinary science of health inequalities (Graham, 2004). In terms of actions to reduce social inequalities in health, Canada is still in its infancy (Mackenbach & Bakker, 2002).Very few countries have implemented global and coordinated policies in this respect, including Canada (see Raphael in Chapter 7) and, in Canada, not even Quebec, which is often a leader in policy reforms, has taken such action. Should health promotion actors become social and political entrepreneurs to put the elimination of health inequalities on the Canadian policy agenda? In contrast to the field of public health, which, according to former WHO Director General Gustaf Mahler, “has lost its original link to social justice, social change and social reform,” health promotion has put the reduction of disparities that have an impact on health at the heart of its dominant value base, included it in the Ottawa Charter, and has espoused the importance of such work over the last decade, even if this concern does not rally all the health promotion community.
The Growth of the Tree If we look at the development of health promotion as a specialized field in Canada, there have been significant developments over the past decade, notably the increase in research funding and infrastructure, renewed federal
interest, and a resurgence of interest in credentialing (see Hyndman, 2006). As the first two have been already abundantly discussed, we will briefly comment on the issue of credentialing because of its implications for the conclusion of this chapter. As we complete the manuscript for this book, credentialing is once more emerging as an issue with the creation of a College of Health Promoters in one province, with possible implications for the rest of the country. This is something that many Canadians working in the field had resisted because of the underlying egalitarianism of health promotion expressed in the Ottawa Charter. But internationally, credentialing has always been a hot topic (O’Neill & Hills, 2000), reflected, for example, by IUHPE’s creation of a new vice-presidency on capacity building, training, and education in 2004. The first vice-president is Alyson Taub, a well-known American scholar who has worked for most of her career on credentialing and certification issues, and key elements of her mandate include addressing credentialing at the global level. Despite this tradition of reluctance in Canada with respect to credentialing, pressure appears to be mounting from two constituencies to move in the direction of formalizing professional recognition of health promoters. The first group includes practitioners working in the field, particularly those employed in public health, who are concerned that they lack credibility and protection from a college or licensing body that others such as nurses and dieticians enjoy. The other constituency encouraging credentialing is the community college sector; those offering diploma programs in health promotion are concerned about the recognition of the training and skills of their graduates. In their view, this would be helped considerably by the development of a recognized professional designation in health promotion.
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As a result of these two constituencies coming together, efforts are underway to obtain government support to develop a College of Health Promotion in Canada. Whether this comes to fruition, and what its implications would be in the various provinces in the next decade remains to be seen, but it is clear that such discussions are now on the table. This is one challenge that the field in Canada will have to address, particularly given the definition of health promotion as a professional enterprise put forward in Chapter 3.
CONCLUSION: THE RHIZOME OF THE PROMOTION OF HEALTH OR THE TREE OF HEALTH PROMOTION? In her commentary, Ilona Kickbusch built on the work of Deleuze and Guattari (1987) by employing the metaphor of the “rhizome”— a typically post-modern image—to signify the way in which the ideology of the new public health as disseminated by health promotion since the mid-1980s has helped to give health a central place in our societies as a sort of heterogeneous network, which has an impact through multiple and often unforeseen connections. We would like to conclude this chapter and this book by seeing how this rhizomatic way of seeing health promotion helps us to reflect on the future of the field in Canada and abroad. Perhaps the future of the field lies in the interaction between the modern and postmodern views of health promotion as a tree and as a rhizome rather than in the displacement of one by the other. We can envision health promotion evolving as a tree, to be a professional enterprise conducted within the subsystem of public health services in the health systems of nation-states, with a recognizable and legitimate infrastructure. But
perhaps it will also continue to advance as a rhizome. This may take the form that O’Neill and Stirling have suggested calling “the promotion of health” (see Chapter 3), in which the ideological dimensions of health promotion expand and extend throughout the world. And it may be this second form of development that has the greatest impact in this increasingly globalized world. According to Deleuze and Guattari (1987), the rhizome is characterized by radical heterogeneity, radical multiplicity, and radical rupture. Its productivity lies precisely in its slipperiness and its endless deferral of meaning, its unwillingness to be pinned down, its promiscuity, and even ability to “betray” without regret. This sense of the possibility of betrayal is hinted strongly at by Kickbusch’s oblique reference, in her reflections, to the Jakarta Conference’s acrimony over the involvement of the private sector, an acrimony that was even more obvious in the recent debates over the Bangkok Charter (RHPEO, 2006). There is a great unspoken tension in health promotion surrounding the issue of the “private sector” and reference to “neo-liberalism” and other such global bogeymen. What is noticeably missing from the discussion of these issues is any sense of global capitalism as a dynamic system; that is, one in which the “private sector” does not sit neatly in its place, playing its appropriate role, as a kind of long-neglected dinner guest we suddenly discover we can include in the conversation. “Neo-liberalism” was and is not just a collection of unfortunate ideas dreamt up by mistaken academics at the International Monetary Fund and the World Bank; it is a hegemonic accumulation strategy that has served an important purpose for global capital and will continue to do so. There is an interesting and continuing tension, albeit often not explicit, in the theoretical trajectories that health promotion
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finds itself following and in the hoped-for solutions that are tied up with these differing trajectories. On the one hand, there is a sense of alliance with many of post-modernism’s preoccupations and critiques (e.g., diversity, discourses, networks) and certainly health promotion’s birth coincided with the cultural ascendancy of post-modernism and the alleged shift to post-modernity (Harvey, 1989; Jameson, 1991; Lash & Urry, 1994). And, if we agree with Kickbusch’s argument, the main success of health promotion to date in Canada and globally has been its postmodern rhizomatic way of partaking in the transformation of the place of health in contemporary societies. Yet, arguably, the flavour of most of the thinking, as reflected in the contributions to this book, remains decidedly modern in the classic sense (Bauman, 1987; Habermas, 1987). Take, for example, the early pieces of Chapter
2 on the concept of health, the material in Chapter 3 pursuing a better and more precise definition of the concept of health promotion, or the effort in Chapter 4 to introduce the thinking of Bourdieu and Giddens (the ultimate “late modernist” sociologists) to help theorize the notion of collective lifestyles. Many of the real preoccupations of the book lament, not the over-rationalization and structural sluggishness of modern institutionalization, but the lack of progress health promotion has made in developing, as a tree, a stronger ecological theoretical base with clearer programmatic strategies to implement and institutionalize its agenda for revolutionizing the societal approach to health, particularly within the context of the modern state—still the primary funding body. Time and again, we see the appeal to broaden the use of available theoretical tools, whether they be social theory (Chapter 4), political analysis
BOX 22.3: POSTMODERNISM
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(Chapter 10), or political economy (chapters 7 and 12) to help explain, clarify, and guide health promotion in the future. So what to make of this tension between a successful rhizomatic capacity to promote the growing importance of health in societies, generated, ironically, by health promotion’s inability to lodge itself institutionally to grow as a tree or to build “palaces,” so to speak? In a sense, it is not as if there is a “choice” to be made between what could be perceived as two very different trajectories. Rhizomatic progress is certainly progress of a sort, and may be a more “realistic” notion than the more ambitious one of fostering massive institutional change. Yet, in the very strong appeals of Labonté for struggle on a global scale and Raphael’s uncompromising demand that health promotion push for serious shifts in public policy to address health inequalities, there is a distinct tone of commitment to some very modernist principles of political action. Furthermore, on the level of knowledge development, we detect an engagement in helping to advance a very young field and a willingness to explore many different approaches to build a cumulative and collective knowledge base: another classically modern preoccupation. The reflection offered here is certainly not meant to discourage an engagement with some of the key currents in post-modern thought; many of these ideas are provocative and stimulating, and bring important lessons about modern approaches to theory and practice. It is more to ask that some of the issues generated by the more general debate surrounding the concepts of modernity and post-modernity be considered as part of the great health promotion dialogue. In particular, in addition to establishing scientific
proof of its effectiveness, health promotion increasingly finds itself having to decide on which side of the global political fence it sits or, to put it in oversimplified terms, the World Economic Forum at Davos or the World Social Forum at Porto Allegre. It will have to make those choices, or the choice not to choose—neutrality as Freire (1970) rightly points out, generally resulting in supporting the powerful against the powerless. And these choices will have to be made in the context of how health promotion conceptualizes possible futures if the potential for collective and counter-hegemonic struggles and the development of equitable societies in a mutually supportive world really seems to be possible or if the hegemony of global capital has already taken us past a point of no return. We live in a diverse world of markets, hierarchies, and networks, all organizational forms that health promotion must confront in its day-to-day work. As much as one can be enamoured by rhizomatic networks and appreciate their potential, markets and hierarchies are still the dominant forms in which our world is structured and are the primary social processes through which health is determined. What kind of politics, then, should health promoters practise? And what kind of implications follow from an attachment to such notions as “equity,” “participation,” and “empowerment”? The latter are all concepts derived from classically modern premises concerning autonomy, authenticity, and emancipation: whither do these concepts go in a post-modern world? It is not clear that health promotion has yet come to grips with these fundamental questions, but we definitely think they should be debated in the years to come.
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NOTE 1
Given our intent to give room to new and younger voices, the editorial team decided to engage in an intergenerational dialogue in preparing the conclusion by adding Valéry Ridde, from Quebec, and Simon Carroll, from British Columbia, to our group. This group made for an interesting mix in terms of age, gender, language, professional background, and geography. Our original idea was to engage in a sustained dialogue to reach if not consensual, at least well-debated conclusions. In the end, it was the younger generation that took up the challenge to draft the first set of conclusions, which we then debated as a group. This leadership is reflected in the order of authors of this chapter.
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388 ■ PART VI: Concluding Thoughts Yach, D., & Bettcher, D. (1998). The globalization of public health, I: Threats and opportunities. American Journal of Public Health, 88(5), 735–738. Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion development in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.
RELEVANT WEB SITES Global Forum for Health Research www.globalforumhealth.org
The Global Forum for Health Research was established in 1998 to promote health research devoted to improving the health of people in developing counties. Global Health Watch www.ghwatch.org
The Global Health Watch is a broad collaboration of public health experts, nongovernmental organizations, civil society activists, community groups, health workers, and academics. The Global Health Watch produces an alternative World Health Report. People’s Health Movement (PHM) www.phmovement.org
The People’s Health Movement has its roots in grassroots organizing. It is calling for a revitalization of the principles of the Alma-Ata Declaration of healthy for all by the year 2000. World Health Organization Commission on Social Determinants of Health (CSDM) www.who.int/social_determinants/en/
The Commission on Social Determinants of Health supports countries and global partners to address the social factors leading to ill health and health inequities.
C O P Y R I G H T AC K N OW L E D G E M E N T S
Statistics Canada information is used with the permission of Statistics Canada. Users are forbidden to copy the data and redisseminate them, in an original or modified form, for commercial purposes, without permission from Statistics Canada. Information on the availability of the wide range of data from Statistics Canada can be obtained from Statistics Canada’s Regional Offices, its World Wide Web site at http://www.statcan.ca, and its tollfree access number 1-800-263-1136.
BOXES B OX 1 . 2 : World Health Organization, “WHO Global Strategy for Health for All by the
Year 2000,” from 64th Plenary Meeting, Resolution 36/43 (Geneva: WHO, 1981) http:// daccessdds.un.org/doc/RESOLUTION/GEN/NR0/406/69/IMG/NR040669.pdf?OpenElement BOX 12.1: Ronald Labonte, Ted Schrecker, Amit Sen Gupta, “From Structural Adjustment
to an HIV Pandemic,” from Health for Some: Death, Disease, and Disparity in a Globalizing Era (Toronto: Centre for Social Justice, 2005). Reprinted by permission of Centre for Social Justice.
FIGURES F I G U R E 2 . 1 : N. Joubert & J.M Raeburn, from Mental Health Promotion: People Power and Passion. International Journal of Mental Health Promotion, 1 (1998): 15-22. F I G U R E 2 . 2 : “Centre for Health Promotion Quality of Life Model,” from Quality of Life Research Unit, http://www.utoronto.ca/qol/concepts.htm. Reprinted by permission of Quality of Life Research Unit. F I G U R E 4 . 1 : G. A. Kaplan, S.A. Everson, & J.W. Lynch, “Multilevel Approach to Epidemiology.” In: B.D. Smedley & S.L. Syme, (Eds.), Promoting Health. Intervention Strategies from Social and Behavioural Research (Washington, D.C.: National Academy Press, 2000): 43. F I G U R E 4 . 2 : A. Jetté, “Paradigmatic Obstacles in Improving the Health of Populations,”
from Designing and Evaluating Psychosocial Interventions for Promoting Self-cure Behaviours Among Older Adults. National Invitational Conference on Research Issues Related to SelfCare Aging. Unpublished paper, 1994. 389
390 ■ Copyright Acknowledgements F I G U R E 8 . 2 : Guoliang Xi, I. McDowell, R. Nair, R. Spasoff, “Report of Fair or Poor SelfRated Health: Odds Ratios for Individual and Area Factors, Ontario, 1996,” from Canadian Journal of Public Health, 96 (3) (2005): 209. F I G U R E 8 . 3 : Guoliang Xi, I. McDowell, R. Nair, R. Spasoff, “ Poor Scores (<50th percentile) on the Health Utilities Index: Odds Ratios for Individual and Area Factors, Ontario, 1996,” from Canadian Journal of Public Health, 96 (3) (2005): 210. F I G U R E 8 . 4 : “Child Poverty in Wealthy Nations, Late 1990s,” from UNICEF, Child Poverty in Perspective: An Overview of Child Well-Being in Rich Countries Innocenti Report Card 7, 2007 (Florence, Italy: UNICEF Innocenti Research Centre, 2007): 6. Reprinted by permission of UNICEF Innocenti Research Centre. FIGURE 11.1: Government of Manitoba, “A framework to promote, preserve, and protect
the health of all Manitobans,” from Manitoba Health. www.gov.mb.ca/health/rha/planning.pdf. F I G U R E 1 2 . 2 : Ronald Labonte, Ted Schrecker, Amit Sen Gupta, “How Debt Service Obligations Dwarf Development Assistance,” from Health for Some: Death, Disease, and Disparity in a Globalizing Era (Toronto: Centre for Social Justice, 2005). Reprinted by permission of Centre for Social Justice.
TABLES TA B L E 8 . 1 : “Age-Standardized Mortality Rates per 100,000 Population, for Both Sexes, or for Males and Females when Rates Differ by Gender, for Selected Causes of Death by Neighbourhood Income Quintile, Urban Canada, 1996,” adapted from Statistics Canada publication Health Reports Supplement, Catalogue 82-003-SIE, 13 (2002): 1-28. Reprinted by permission of Statistics Canada. TA B L E 1 0 . 3 : “Gross Domestic Product Per Capita ($), by Province, Selected Years,” adapted from Statistics Canada CANSIM Database http://cansim2.statcan.ca, Series V691994, V691925 and V691902. Reprinted by permission of Statistics Canada. TA B L E 1 0 . 4 : “Unemployment Rates (Percent), by Province, Selected Years,” adapted
from Statistics Canada CANSIM Database http://cansim2.statcan.ca, Series V692006, V691937 and V691914. Reprinted by permission of Statistics Canada. TA B L E 1 0 . 5 : “Seniors 65 Years and Over as a Proportion of Total in 2001,” adapted from Statistics Canada CANSIM Database http://cansim2.statcan.ca, Series V27572635, V27572974, V27572776 and V27572719. Reprinted by permission of Statistics Canada. TA B L E 1 6 . 1 : Robert Roth, “Aids to Written Reflection,” from Preparing the Reflective Practitioner: Transforming the Apprentice Through the Dialectic Journal of Teacher Education, 40(2), March (1989): 31-35. Reprinted by Sage Publications Inc.
Copyright Acknowledgements ■ 391
PHOTOGRAPHS PA RT I O P E N E R : “Phrenology Head Stock x 249050,” by Mark Preston. From
Stock.XCHNG. PA RT I I O P E N E R : “0008 (Friends Smiling for Camera).” From Health Canada Website and Media Photo Gallery, Health Canada, http://www.hc-sc.gc.ca. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006. PA RT I I I O P E N E R : “Flags_Canada_Provincial 219117,” by Zennie. From
www.istockphoto.com. PA RT I V O P E N E R : By Valéry Ridde. Reprinted by permission of the photographer. PART V OPENER: “0084 (First Nations, Nursing Infant).” From Health Canada Website and Media Photo Gallery, Health Canada, http://www.hc-sc.gc.ca Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006. PA RT V I O P E N E R : “0024 (Cyclists).” From Health Canada Website and Media Photo
Gallery, Health Canada, http://www.hc-sc.gc.ca Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006.
INDEX
A Aboriginal peoples approaches to health promotion, 173 “at-risk” population, 48 and victim blaming, 48 Aboriginal Planning Committee, 226 academics, 373–374 Access to Essential Medicines Campaign, 215 Achieving Health for All. See Epp Report Afghanistan, 259–260 Afghanistan Centre at Kabul University, 261 Afghanistan Research and Evaluation Unit, 261 agency, 54, 55 AIDS programs, 83 Alberta capacity building for health promotion, 168–169 gross domestic product per capita, 148 Health Sustainability Initiative (HSI), 146 networks and coalitions, 169–170 political traditions, 147 provincial health system reform, 167–168 research to advance knowledge and practice, 168 Alberta Centre for Active Living, 170 Alberta Coalition for Healthy School Communities, 171 Alberta Healthy Living Network, 171 Alberta Heritage Foundation for Health Research, 127 Alberta Public Health Association, 171 Alijasem, Layla, 273–274 Allain, Monique, 187–189, 189–190 Alma-Ata conference, 1, 4, 5t American Evaluation Association, 359 American Medical Association, 62 anglophones, 202–203 Annapolis Valley Health Promoting Schools Project (AVHPSP), 321 Annis, Robert C., 176–181 Arroyo, Hiram V., 284–285 Association for the Care of Children’s Health, 99 Association pour la santé publique du Québec (ASPQ), 187
392
“at-risk” populations critique of approach, 51–52 as point of intervention, 48 social context, 51–52 Atlantic Health Promotion Research Centre (AHPRC), 196, 198 Atlantic provinces Atlantic Health Promotion Research Centre (AHPRC), 196 Atlantic-wide initiatives, 195 coastal and workplace health, 194–195 final thoughts, 196–198 food security, 191–192 healthy children, 190 healthy schools, 193–194 introduction, 187–189 New Brunswick, 189–190 Newfoundland and Labrador, 194 Nova Scotia, 190–191 Prince Edward Island, 192–193 Australia, 261–262
B Banfield, Winnie, 199–201 Bangkok Charter for Health Promotion, 26–27, 78, 238 Bangkok conference, 11 Banque de Données en Santé Publique (BDSP), 268 Bartlett, Linda, 259–260 BC Coalition for Health Promotion, 166, 328 behaviour modification techniques, 51–52 behavioural change, 49 Bernier, Nicole F., 141–150 binding trade rules, 210 blame the victim, 48 Bourdieu, Pierre, 54 Boutilier, Marie, 301–311 Bradley, Deborah, 192–193 brain drain, 223 Brazil, 227–228, 263–264 Brazilian Collective Health Graduate Association, 264
Index ■ 393 British Columbia capacity for health promotion, 164 health promotion in, 162–167 networks and coalitions for health promotion, 164–165 political and policy processes, 165 provincial health system reform, 162–163 research to advance knowledge and practice, 163–164 social assistance, reduction of, 143–144 British Columbia Health Literacy Research Team, 69 British Medical Journal, 346 broad health promotion approach, 39–40 Building on Values: The Future of Health Care in Canada, 99 Bureau of Women’s Health and Gender Analysis, 88–89 bureaucrats, 373–374
C Campbell, Nancy, 199–201 Canada anglophones, 202–203 children in poverty, 113f contributions to health literacy, 65–68 definition of health promotion in, 34 discourse and practice, 250–251 federal/provincial/territorial landscape, 153–154 federal role in health promotion. See federal government francophone minority communities, 202–204 global health promotion contributions, 217 global infrastructure, impact on, 237–243 health inequalities. See health inequalities health literacy concept, 63–65 health promotion, lack of professional status, 32–33 health promotion practice in, 301 health research infrastructure, 158 influences on WHO, 237–239 international governmental infrastructure, influence on, 239 and international health promotion. See international health promotion (Canadian influence) international leadership of, 375 international non-governmental infrastructure, influence on, 239–240 international research collaboration, impact on, 240–241 medicare system, 144–145, 154 official languages, 154, 155 public agenda, 145 women’s health, 76–77 Canada Health Act, 145
Canada Health and Social Transfer, 142 Canadian academic publications, 293–294 Canadian Coalition for Public Health in the 21st Century, 99 Canadian Coalition on Global Health Research, 220 Canadian Consortium for Health Promotion Research, 101, 105, 124–125, 126t, 128–131, 132–133, 135, 137, 158, 223, 235, 245 Canadian Council on Learning (CCL), 127, 132 Canadian Diabetes Strategy, 97 Canadian-European connection, 5–8 Canadian Evaluation Society, 359 Canadian Health Network (CHN), 45, 97, 128 Canadian Health Network classification scheme, 39–40 Canadian Health Services Research Foundation, 346 Canadian Heart Health Initiative, 93, 354, 356 Canadian Index on Adult Literacy Research in French, 73 Canadian Institute for Health Information, 98 Canadian Institute of Advanced Research, 38, 94 Canadian Institute of Children’s Health, 121 Canadian Institutes of Health Research (CIHR), 65, 98, 111, 126, 131–132, 163 Canadian International Development Agency (CIDA), 235 Canadian Journal of Public Health, 65 Canadian Medical Association Journal, 346 Canadian Policy Research Institute (CPRI), 127 Canadian Policy Research Networks/Réseaux canadiens de recherches sur les politiques publiques, 152 Canadian Population Health Initiative (CPHI), 105 Canadian Public Health Association (CPHA), 64, 96, 99, 105, 227, 235 Canadian Social Research Links, 152 Canadian Society for International Health, 221, 225, 235 capacity, 23–25 capacity building Alberta, 168–169 Brazil, 227–228 British Columbia, 164 Canada’s contributions to international health promotion, 250 Chile, 226–227, 227 China, 226 for community leaders, administrators and decision makers, 225 concepts of health, 23–25 Croatia, 226 France, 225 for indigenous peoples, 226–227 integrated initiatives, 227–228 international health promotion, 225–228
394 ■ Index Mexico, 227 Nunavut, 201 Ontario, 182–183 primary care workers and other health professionals, 226 Ukraine, 225 capacity development, 128–132 Cardaci, Dora, 276–277 Caribbean Charter, 238 Carroll, Simon, 330–341, 371–383 case studies Alberta, 167–171 Atlantic provinces, 187–198 British Columbia, 162–167 current actions and future directions, 157–160 francophone minority communities, 202–204 health sector reform, context of, 155–157 Manitoba, 176–181 New Brunswick, 189–190 Newfoundland and Labrador, 194 Nova Scotia, 190–191 Nunavut, 199–201 Ontario, 181–183 Prince Edward Island, 192–193 Quebec, 184–186 reflections on a practical situation, 309 Saskatchewan, 171–176 Case Study: Partners in Practice Port Colbourne, Ontario, 315 Caughey, Amy, 199–201 CDC Evaluation Working Group, 359–360 Centre de recherche Léa-Roback sure les inégalités sociales de santé de Montréal, 187 Centre for Community Health Promotion Research, 166 Centre for Health Promotion, 101, 183–184, 225, 226, 227, 360 Centre for Health Promotion Studies, 171 Centre for Social Justice (CSJ), 89, 122 Centre for the Health Professions, 346 Centre national d’études de la sécurité sociale, 225 Centres of Excellence for Women’s Health, 77, 89 Cerqueira, Maria Teresa, 237–243 children Annapolis Valley Health Promoting Schools Project (AVHPSP), 321 healthy children, 190 healthy schools, 193–194 in poverty, 113f Chile, 226–227, 227, 265–266 Chin-Yee, Fiona, 187–189, 195 China, 226 CHN classification scheme, 39–40 choices, 54 classification system, 34–35, 39–40
Click4HP, 31, 38–39, 45, 127, 137–138, 159 climate change, 210 clinical epidemiology, 351–352 coastal health, 194–195 collaboration, 251–252, 304–305 collaborative reflection, 306 Collective Health Unit OPAS Brazil, 264 collective lifestyles, 54–56 College of Education, University of North Texas, 315 Commission on Social Determinants of Health (CSDM), 388 communication difficulties, 305 communication of information, 228 communities, 48 community-based approach, 81–82 community capacity building, 25 community development, 25 Community Health Research Unit (CHRU), 226 concepts of health Bangkok Charter for Health Promotion, 26–27 capacity, 23–25 capacity building, 23–25 community capacity building, 25 community development, 25 conclusions, 27–28 equity, 25 fundamental issue, 19 indigenous peoples, 25–26 influences since 1994, 21–27 introduction, 19–20 mental health promotion, 22 migration, 25–26 minorities, 25–26 multiculturalism, 25–26 multiplicity of, 20 in 1994, 20–21 population health, 22 “positive” concept, 26–27 poverty, 25 qualitative approaches, 26 quality of life, 23, 24f resilience, 22–23, 23f used by Canadian health promoters, 21 Consortium for Health Promotion Research. See Canadian Consortium for Health Promotion Research Consortium national de formation en santé, 204 constraints on individual capacity, 55 Corbin, J. Hope, 237–243 Council of Chief State School Officers (CCSSO), 61 CPHA Literacy and Health Program, 73 Cric.ca, 152 Croatia, 226 Crowell, Sandra, 187–189 cultural/behavioural explanation, 107
Index ■ 395 D Dalil, Suraya, 259–260 dangerous consumptions, 25 debates about “real” health promotion, 38–39, 45 debt relief, 212 debt service obligations, 212–213 deconstruction of health promotion, 38 definitions of health, 19, 20 definitions of health promotion approaches, 35–39 broad health promotion approach, 39–40 in Canada, 34 CHN classification scheme, 39–40 conceptual avenue to definitional dilemma, 40–41 disciplinary reasons for definition, 32–33 expert consensus, 38–39 health promotion assessment checklist, 39–40, 45 health promotion vs. other related concepts, 35–37 importance of, 32–35 Ottawa Charter definition, 40, 242, 330 political reasons, 33–34 practical reasons, 34–35 professional reasons for definition, 32–33 solving the definitional dilemma, 39–41 working definition, 39–40 demographics, 147–149, 177 Denmark, 280–282 determinants of health, 97–98, 157, 172–173 determinants of health inequalities, 107–110, 112–113 developing countries. See globalization; international health promotion diagrams as reflection, 310 Dinca, Irina, 287–288 disadvantaged groups, 53 disciplinary reasons for defining health promotion, 32–33 diversity in health promotion gender and health, 77–78 intersectional theory, 79–80, 81–82 introduction, 75–76 women’s health. See women’s health Djakarta conference, 11 Donchin, Milka, 270–271 donor country influence, 250, 283 double jeopardy, 80 Dowbor, Tatiana Pluciennik, 263–264 downstream approach, 51 Dupéré, Sophie, 1–12, 75–84, 247–257, 371–383
E e-mail bulletins, 128 ecological, 27 ecological health promotion interventions
Annapolis Valley Health Promoting Schools Project (AVHPSP), 321 challenges, 323–324 conclusions, 324–325 ecological approach, 317–318 example programs, 318–323 multi-level “possibility framework” for initiatives, 320t Promoting Action toward Health (PATH) Project, 318–319 Quebec Ministry of Health and Social Services, 321–323 rise of the ecological perspective, 317–318 tobacco control initiative, 321–323 ecological model, 49–50 education, health promotion, 128–132 effectiveness movement, 378 emerging issues. See issues environmental factors importance of, 7–8 epidemiology, 50, 50f, 53 Epp Report, 2, 8, 93 equity, 25 Eriksson, Monica, 280–282 Europe Canadian-European connection, 5–8 EC funding, 242 health literacy concept, 63 European Union Master’s in Health Promotion Consortium (EUMAHP), 242 evaluation Canadian Heart Health Initiative, 354, 356 conclusions, 354–355 definitions of, 347–348 experimentalist tradition, 352–353 in health promotion, 348–350 health promotion interventions, 348 health promotion programs, reasons for evaluation, 350–354 increasing effectiveness of interventions, 351–353 program, as core type of intervention, 349–350 quasi-experimental designs, 352 realistic evaluation, 378 support of innovative practices, 353–354 tools, 229 two roles of, 347–355 Evaluation Center, Western Michigan University, 360 evaluation theory, 228–230 evidence base of health promotion, 377–379 evolution of health promotion Canadian-European connection, 5–8 decline, transformation or renewal, 10–12 general trends, 11 golden era of health promotion, 8 health education era, 2–3
396 ■ Index from health education to health promotion, 3–10 international scene, 3–5 landmark dates, 1–2 experimentalist tradition, 352–353 expert consensus, 38–39
Frontier College, 64 La Fundación Mexicana para la Salus (FUNSALUD), 278 funding agencies, 126–127 future of health promotion, 101
F
G
fair trade, 214 Family Health Program, 264 federal government Business Line working groups, 96 determinants of health, 97–98 federal-provincial relationships, 146–147 federal/provincial/territorial landscape, 153–154 first two decades, 92–94 future of health promotion, 101 health promotion, impact on, 96–97 introduction, 92 laying the groundwork, 92–93 moving on in the 1990s, 94–98 policy, impact on, 97–98 population health approach, 95 Program Review, 95–96 programs, impact on, 97 public health, 98–101 redirecting health promotion, 93–94 Strategies for Population Health: Investing in the Health of Canadians, 95 Federal Plan for Gender Equality, 77 federal/provincial/territorial landscape, 153–154 Federal Tobacco Control Strategy (FTCS), 97 Fédération des communautés francophones et acadienne du Canada, 204 Fiji School of Medicine (FSM), 284 financing, fair, 212–213 Finland, 280–282 First Canadian Conference on Literacy and Health, 63, 64 First International Conference on Health Promotion, 7, 93 First Nations, 26 see also Aboriginal peoples Fonds québécois de la recherche en santé du Québec, 127 food insecurity, 112 food security, 191–192 Forum on Social Development, 225 Framework Convention on Tobacco Control, 215 France, 225, 267 francophone minority communities, 202–204 francophonie canadienne, 204 Frankish, Jim, 61–70, 162–167 Frohlich, Katherine L., 46–56 “From Research to ‘Best Practices’ in Other Settings and Populations” (Green), 298
Gauvin, Lise, 317–325 gender Bangkok Charter, 78 concept of gender, 77 empowerment, global, 211 and health, 77–78 in HIV/AIDS programs, 83 Ottawa Charter, 78 vs. sex, 79 gender inequality, 77–78 Gerontology Research Centre, 166 Gierman, Natalie, 222–231 Global Forum for Health Research, 388 Global Fund to Fight AIDS, Tuberculosis, and Malaria, 213 global governance, 214–215 Global Health Watch, 221, 388 global infrastructure Canada’s contributions, 250 conclusions, 242–243 international governmental infrastructure, 237–239 international non-governmental infrastructure, 239–240 international research collaboration, 240–241 introduction, 237 global professional capacity, 250 globalization see also international health promotion binding trade rules, 210 climate change, 210 conclusions, 215–218 debt service obligations, 212–213 drivers of contemporary globalization, 209–210 as emerging issue, 376–377 fair financing, 212–213 fair governance, 214–215 fair trade, 214 global recession, 208 and health, 210–211 healthy global public policy, 211–215 HIV pandemic, 209 international private financial flows, 209–210 from international to global, 207–208 reorganization of production across borders, 210 Globalization and Health, 221 Go Healthy Newfoundland Labrador, 198 Godin, Gaston, 367–369
Index ■ 397 Goldberg, Carmelle, 347–355 golden era of health promotion, 8 Govereau, Wayne, 199–201 governance, fair, 214–215 government. See federal government; provincial governments Government of Commonwealth of Puerto Rico, 286 Green, J., 36 Green, Lawrence W., 296–297 Gregson, Carol, 199–201 growth-health-growth virtuous circle, 211 Guillaumie, Laurence, 267
H habitus, 54 Harvard School of Public Health, Health Literacy Studies, 73 Haut Comité de la Santé Publique (HCSP), 268 health see also concepts of health definitions of health, 20 determinants of health, 97–98, 157, 172–173 and gender, 77–78 and globalization, 210–211 positive conceptualization of health, 76 right to health, 216 social model of health, 76 WHO definition, 19 women’s health. See women’s health Health Action International, 215 Health and Social Services Department of Nunavut, 202 Health Canada, 96, 97, 98, 125, 133, 135, 159 Health Canada Population Health Approach, 122 health care resilience, 144–145 Health Communication Unit, University of Toronto, 360 health education era of, 2–3 evolution to health promotion, 3–10, 35 in France, 35 vs. health promotion, 35 resurrection and reinvention, 36 “revitalized” definition, 36 in US, 35 Health Education Assessment Project (HEAP), 61 health field concept elements of, 4 influence of, 20 “Health for All by the Year 2000” (HFA) resolution, 4–5, 5t, 6 Health in Action, 328 health inequalities addressing, 379–380 agenda for addressing, 111–115
in Canada, 107–110 conclusions, 115–116 cultural/behavioural explanation, 107 determinants of, 107–110, 112–113 identification of source of, 112–113 income, as determinant, 107–110 international perspective, 107, 114–115, 255 introduction, 106–107 materialist/structuralist explanation, 107 social determinants, 112–113 health literacy in Canada, 63–65 Canadian contribution, 65–68 conceptual contributions, 65–66 criticism of, 62 definitions of, 67, 69 described, 61 and health promotion, 68–70 history of, 61–65 Institute of Medicine health literacy framework, 63, 63f international perspective, 61–63 introduction, 61 introduction of, 64 issues, 68–70 literacy and health research conceptual framework, 66f moving beyond the conceptual, 69–70 plain language materials, 64 practice and policy contributions, 67–68 proponents of, 62–63 research contributions, 65–67 study of, in Nova Scotia, 65, 68 Health Literacy in Rural Nova Scotia Project, 74 The Health of Canadians — The Federal Role, 99 health professions in Canadian health promotion movement, 373–374 capacity building, 226 conclusions, 340–341 and definitions of health promotion, 32–33 global professional capacity, 250 health professional practice, health promotion in, 334–338 introduction, 330–331 lack of professional status, 32–33 medical education, health promotion in, 332–333 nursing clinical practice, health promotion within, 336–338 nursing curriculum, health promotion within, 333–334 nursing education, 338 physician clinical practice, health promotion within, 335–336, 337–338 physician education, 337–338
398 ■ Index primary care workers, 226 primary health care as key strategy, 338–340 primary health care/health promotion alliance, 338–339 reflexive practice, 302 trends in health promotion engagement, 331–338 health promotion Aboriginal approaches, 173 academics, 373–374 alignment with settings, 49 broad health promotion approach, 39–40 broad policy focus, 237 bureaucrats, 373–374 Canada’s international leadership, 375 CHN classification scheme, 39–40 competencies, 40 concepts of health. See concepts of health continuing development of, worldwide, 363–366 debates about “real” health promotion, 38–39, 45 deconstruction of, 38 definitions of. See definitions of health promotion education and training, 128–132 effectiveness movement, 378 electronic resources, 159 evaluation in, 348–350 evidence base, 377–379 evolution of. See evolution of health promotion expert consensus, 38–39 federal role. See federal government future of, 101 globalization, 376–377 golden era of health promotion, 8 vs. health education, 35 health inequalities, addressing, 379–380 and health literacy, 68–70 in health professional practice, 334–338 individual approach, status of, 367–369 individualistic behavioural views, 21 influence of new or borrowed concepts, 61 and intersectional theory, 81–82 lack of agreement about, 34 as leading public health strategy, 237 main emerging issues, 376–381 marginal nature of, 371–373 within medical curriculum, 332–333 mental health promotion, 22 modernism, 382 need for theory, 378–379 within nursing clinical practice, 336–338 within nursing curriculum, 333–334 and organization and classification of information, 34–35 points of intervention. See health promotion intervention policy views, 21
vs. population health, 36 postmodernism, 382 and primary health care, 338–340 professional status, lack of, 32–33 professionals in Canadian health promotion movement, 373–374 vs. promotion of health, 40–41, 42f in the provinces and territories. See provincial governments vs. public health, 36–37 realistic evaluation, 378 redirection of, 93–94 reflexivity as to social location of, 56 resilience of, 371–373 rhizome analogy, 363–366, 381–383 scientific nature, 33 social views, 21 structural vs. individual change, 373 summer schools, 129t as “third public health revolution,” 37 training programs, 129t tree analogy, 363–366, 380–383 trends in engagement, by physicians and nurses, 331–338 voluntary sector, 374 and women’s health, 78–80, 81–82 worldwide presence, lack of, 375–376 “yellow document,” 7, 93 Health Promotion: A Discussion Document on the Concept and Principles (WHO), 93 Health Promotion and Education Online, 59–60 health promotion assessment checklist, 39–40, 45 Health Promotion Center, 264 Health Promotion Clearinghouse (Nova Scotia), 328 Health Promotion Directorate (HPD), 92–93, 126 Health Promotion Forum of Aotearoa-New Zealand (HPF), 279 health promotion intervention “at-risk” populations, 48 collective lifestyles, as heuristic device, 54–56 ecological health promotion interventions. See ecological health promotion interventions evaluation, 348, 351–353 increasing effectiveness of, 351–353 individual-level theories, 47 introduction, 46 issues, 46–48 physical inactivity, points of intervention for, 52f program, as core type of intervention, 349–350 risk factors, focus on, 47 settings, 48–50 social context, 47–48, 50–53 structure-agency debate, 54 target of individuals vs. collectivities, 348 what can be done differently, 54–56
Index ■ 399 health promotion practice evaluation, two roles of, 347–355 program, as core type of intervention, 349–350 reflexive practice. See reflexive practice health promotion programs. See public health and health promotion programs Health Promotion WHO Afro, 289 health-related choices, 54 health research health literacy, 65–67 health research infrastructure, 158 international health promotion, 228–230 international research collaboration, 240–241 literacy and health research conceptual framework, 66f health research infrastructure, 158 health sector reform, 155–157 Health Sponsorship Council, 280 healthiness, 19, 26 healthy cities concept, 21 Healthy Communities initiative, 8 healthy living, 157 Healthy Municipalities Study, Research, and Documentation Center, 264 healthy schools, 193–194 Hiatt, Robert A., 296–297 high-risk populations. See “at-risk” populations Hills, Marcia, 123–135, 162–167, 330–341 HIV pandemic, 209 HIV programs, 83 holistic, 27 holistic approach, 82 Hyndman, Brian, 181–183
I Iceland, 280–282 inclusive, 27 income as determinant of health inequalities, 107–110 and ill health, 108–110 increasing income inequality, 112–113 predictor of health indicators, 108 indigenous peoples, 25–26, 226–227 see also Aboriginal peoples individual approach, 367–369 individual change, 373 individual-level theories, 47 individualistic behavioural views of health promotion, 21 Infant Feeding Action Coalition, 215 infrastructure. See knowledge development innovative practices, 353–354 Institut national de la santé publique du Québec, 187, 225, 329
Institut National de Prévention et d’Education pour la Santé (INPES), 268 Institute for Gender and Health, 127, 134 Institute for Population and Public Health, 127 Institute for Social Research and Evaluation, 167 Institute of Aboriginal People’s Health, 127, 134 Institute of Health Promotion Research, 134, 166 Institute of Medicine health literacy framework, 63, 63f, 66 Institute of Nutrition and Food Technology (INTA), University of Chile, 266 Institute of Population and Public Health, 99 Instituto Nacional de Salud Pública, 278 Inter-American Consortium of Universities and Training Centres, 286 Inter-American Network of Training, 225 interactions, 251–252 International Conference on Health Promotion and Health Education, 101 International Covenant on Economic, Social and Cultural Rights (ICESCR), 216 international governmental infrastructure, 237–239 international health promotion see also globalization Afghanistan, 259–260 Australia, 261–262 Brazil, 263–264 children in poverty, 113f Chile, 265–266 continuing development of, 363–366 Denmark, 280–282 discrepancies in conception, value and approaches, 255 evolution of health promotion, 3–5 Finland, 280–282 France, 267 general observations, 254–255 health inequalities, 107, 114–115, 255 health literacy concept, 61–63 Iceland, 280–282 improvement of health of population, 255–256 international health promotion. See international health promotion (Canadian influence) Iran, 269 Israel, 270–271 Japan, 272 Kuwait, 273–274 Latin America, 275–276 Mexico, 276–277 New Zealand, 278–279 Nordic Union, 280–282 Norway, 280–282 Pacific Island Nations, 283 Puerto-Rico, 284–285
400 ■ Index Romania, 287–288 Senegal, 288–289 strengths and weaknesses of analysis, 256–257 Sweden, 280–282 Switzerland, 290–291 Tunisia, 292 Ukraine, 292–293 United Kingdom. See United Kingdom United States, 296–297 WHO global strategy, 6 international health promotion (Canadian influence) academic contributions, 250 access to exchanges, 251 Afghanistan, 259–260 Australia, 261–262 Brazil, 263–264 Canada’s international leadership, 375 Canada’s leadership role, 224 Canadian discourse and practice, 250–251 Canadian websites, 252t capacity building, 225–228 capacity building contributions, 250 Chile, 265–266 collaborations, types of, 251–253 communication of information, 228 conclusions, 230–231, 257 country commentaries by region, 249t described, 248–254 diverse types of influences, 248–251 donor country, influence as, 250 evaluation theory, research and practice, 228–230 evaluation tools, 229 France, 267 global infrastructure, 250 global professional capacity, 250 impact, diversity of, 253–254 integrated capacity-building initiatives, 227–228 intensity levels, diversity of, 253–254 interactions, types of, 251–253 international projects in training and capacity building, 223–228 introduction, 222–223 Iran, 269 Israel, 270–271 Japan, 272 Kuwait, 273–274 Latin America, 275–276 leadership role in guiding health public policy, 250 major Canadian players, 223t Mexico, 276–277 mutual influences, 251–252 New Zealand, 278–279 Nordic Union, 280–282 Pacific Island Nations, 283
partnerships, types of, 251–253 policy recommendations, 229–230 practical experience, contribution of, 250 Puerto-Rico, 284–285 Romania, 287–288 Senegal, 288–289 strengths and weaknesses of analysis, 256–257 Switzerland, 290–291 theoretical and conceptual knowledge, contribution of, 248–250 training contributions, 250 training for educators, 224–225 Tunisia, 292 Ukraine, 292–293 United Kingdom, 293–294 United States, 296–297 WHO Collaborating Centres, 231 International Journal of Education & the Arts, 316 International Monetary Fund, 11, 208, 212, 214 international non-governmental infrastructure, 239–240 international private financial flows, 209–210 international research collaboration, 240–241 International Union for Health Promotion and Health Education (IUHPE), 2, 15, 59–60, 125, 131, 239–240, 246, 286, 290 International Union of Health Education (IUHE), 1 intersectional theory, 79–80, 81–82 intersectoral strategies, 98 intervention. See health promotion intervention Iran, 269 Israel, 270–271 issues effectiveness movement, 378 evidence base of health promotion, 377–379 globalization, 376–377 need for theory, 378–379 as point of health promotion intervention, 46–48 realistic evaluation, 378 and social context, 51 social health inequalities, addressing, 379–380 ItsLife, 316
J Jackson, Suzanne, 123–135, 222–231 Japan, 272 Jassem, Amal Hussain, 273–274 Jimba, Masamine, 272 Johns Hopkins University Press: Journals, 298 journal reflections, 307–310 Journal Writing, 316
K Kanawakhe School Diabetes Prevention Project, 354 Kaszap, Margot, 61–70
Index ■ 401 Kickbusch, Illona, 5, 8, 11, 62–63, 363–366 Kirby Report, 99 knowledge development Canadian Consortium for Health Promotion Research, 124–125, 126t Canadian Consortium for Health Promotion Research contributions, 128–131, 132–133 capacity development, 128–132 conclusions, 135 critical analysis, 133–135 funding agencies, 126–127 health promotion education and training, 128–132 infrastructure since 1994, 124–128 introduction, 123–124 new knowledge development, 132–133 sharing knowledge, 127–128 Komarova, Nadiya, 292–293 Korgak, Ainiak, 199–201 Kuwait, 273–274
L Labonté, Ronald, 207–218 Lalonde Report action following release of report, 92 cluster of concepts, influence of, 61 concept of health, 21 described, 21 health field concept, 20 HFA resolution and, 3–4 impact on international health promotion. See international health promotion (Canadian influence) implementation, 6 release of, 1 Lamarre, Marie-Claude, 237–243 Latin America, 224–225, 275–276 Latin American Regional Office (ORLA) of the IUHPE, 286 Learning from SARS: Renewal of Public Health in Canada, 99 left-wing party, 147 Levin-Zamir, Diane, 270–271 lgreen.net, 298 life chances, 54 life choices, 54 lifestyle, 54 lifestyles counselling, 330 Lindstrom, Bengt, 280–282 linguistically marginalized groups, 160 literacy and health research conceptual framework, 66f Livne, Irit, 270–271 Loubert, Kelly, 199–201 Lyons, Renee, 187–189
M Macdonald, Gordon, 293–294 MacKay, Marlien, 187–189, 189–190 mad cow disease (BSE), 98 Manchester Metropolitan University, 316 Mandala of Health, 21 Manitoba changes, challenges and future directions, 179 demographics, 177 health promotion beyond the health system, 178 health system reform, 177 Manuel, Rick, 187–189, 190–191 Marzouki, Moncef, 292 Mason, Robin, 301–311 materialist/structuralist explanation, 107 medical curriculum, 332 Medical Research Council of Canada, 126 medicare system, 144–145, 154 Melville, Lilach, 270–271 mental health promotion Bangkok Charter, 27 emergence of, 22 Mexico, 227, 276–277 Mexico conference, 11 Michael Smith Foundation for Health Research, 127, 163 midstream approach, 51 migration, 25–26 Millennium Development Goals (MDGs), 212, 236 Ministère de la santé et des services sociaux du Québec, 187 Ministry of Health, Vida Sana Section, 266 Ministry of Health (New Zealand), 280 Ministry of Health Promotion, 184 minorities, 25–26 minority language legislation, 154 Mittelmark, Maurice B., 237–243 modernism, 382 Montreal Region Public Health Unit, 122 Mozambique, 224 multi-level approach to epidemiology, 50, 50f multiculturalism, 25–26 multinational enterprises (MNEs), 210 Multiple Risk Factor Intervention Trial (MRFIT), 51 Murashova, Maryna, 292–293 Murnaghan, Donna, 187–189, 193–194 mutual influences, 251–252
N National Aboriginal Health Institute, 98 National Adult Literacy Database, 74 National Child Benefit, 98 National Children’s Agenda, 98
402 ■ Index National Collaborating Centres for Determinants of Health, 127 National Collaborating Centres for Public Health, 100 National Federation of Family Benefit Insurance Boards, 225 National Forum on Health, 98 National Health Promotion Plan (MINSAL), 227 National Health Research Development Fund, 94 National Health Research Development Program (NHRDP), 123, 125, 126, 127 National Institute for Clinical Excellence (UK), 296 National Institute for Research and Development, 288 National Literacy and Health Program (NLHP), 64, 65 National Literacy and Health Research Program, 74 National Literacy Secretariat, 64 National School of Public Health (ENSP), 227 National Summer Institute on Literacy and Health Research, 132 Naylor Report, 99 need for theory, 378–379 Neighbourhoods Alive!, 181 neo-liberalism, 145–146 New Brunswick, 189–190 new health technologies and innovation, 210–211 new knowledge development, 132–133 A New Perspective on the Health of Canadians. See Lalonde Report New Zealand, 278–279 Newfoundland and Labrador, 194 NHS Centre for Reviews and Dissemination, 295 Nisga’a Health Authority, 157 Nomura, Yuka, 272 Nordic Medico-Statistical Committee, 282 Nordic Union, 280–282 Norway, 280–282 Nova Scotia case study, 190–191 study of health literacy, 65, 68 Nova Scotia Health Promotion, 199 Nunavut background, 199–200 capacity building, 201 Government of Nunavut website, 202 health promotion infrastructure, 200 health protection and primary care, 201 program and activities examples, 200–201 nursing education, 338 health promotion within nursing curriculum, 333–334 nursing clinical practice, health promotion within, 336–338 practice, 338 regulation, as profession, 32 scientific discipline vs. practice, 33
O official development assistance, 212 official languages, 154, 155 O’Neill, Michel, 1–12, 32–42, 371–383 Ontario capacity building, 182–183 gross domestic product per capita, 148 networking, 182–183 political traditions, 147 politics and policy, 182 public health crises, 183 public health expenditures cuts, 145 social assistance, reduction of, 143–144 Ontario Health Promotion e-mail bulletin, 128, 138, 184 Ontario Health Promotion Resource System, 328 Ontario Health Promotion Summer School, 226, 227 Ontario Prevention Clearinghouse, 184, 329 Ontario Public Health Association, 64 Ottawa Charter for Health Promotion broad goals, 46 Canada’s influence on, 248–250 concept of health, 21 gender, 78 health promotion definition, 40, 242, 330 health promotion following release of, 1 and health promotion practice in Canada, 301 implementation of strategic areas of, 237 international consensus, 8 international health promotion, influences on. See international health promotion (Canadian influence) international Health Promotion Conferences, goal of, 8 nature of programs implied by, 350 opportunity to revisit, 240 personal skills development, 46–47 release of, 2 rhizome analogy, 363–366 values-based orientation, 330 vision outlined in, 340 and working definition of health promotion, 39–40
P Pacific Island Nations, 283 Pan-American Health Organization, 37, 99, 229 Pan-Canadian Healthy Living Strategy, 97 participatory approach, 81–82 Partners in Public Health, 100 partnerships, 251–252 PATH Project, 318–319 Pederson, Ann, 1–12, 75–84, 153–160, 371–383 People’s Health Movement (PHM), 215, 221, 388 personal skills development, 46–47, 330
Index ■ 403 Perspectives on Health Promotion (CPHA), 96 physicians education, 337–338 health promotion within medical curriculum, 332–333 health promotion within physician clinical practice, 335–336 practice, 338 Pinder, Lavader, 92–102, 239 plain language materials, 64 planned change of lifestyles, 41 points of intervention. See health promotion intervention Poland, Blake, 46–56 policy Canada’s leadership role, international, 250 demographics, wealth and prosperity, 147–149 divergence, understanding, 146–149 federal government impact, 97–98 federal-provincial relationships, 146–147 healthy global public policy, 211–215 left-wing party, 147 recommendations, 229–230 social investment paradigm, 145 views of health promotion, 21 Policy.ca, 152 political reasons for defining health promotion, 33–34 PolitiquesSociales.net, 152 Pontifical Catholic University of Chile, Initiative Healthy University, 266 Poole, Laraine, 187–189, 192–193 population health federal government approach, 95 framework, 38 vs. health promotion, 36 influence on health promotion, 22 vision of, 36 Population Health Initiative, 98 Population Health Promotion: An Integrated Model of Population Health and Health Promotion, 96 positive-negative distinction, 26–27 postmodernism, 382 Potvin, Louise, 347–355 Poureslami, Iraj M., 269 poverty see also income children in poverty, 113f determinant of health inequalities, 112 and health promotion, 25 power and collaborations, 305 focus on, in health promotion, 304–305 relations, 55–56 in sexual decision making, 83
practical reasons for defining health promotion, 34–35 Prairie Region Health Promotion Research Centre, 175–176 primary health care, 288–289, 338–340 Primary Health Care, 346 Prince Edward Island, 192–193 Prince Edward Island Healthy Living Strategy, 199 professional reasons for defining health promotion, 32–33 professions. See health professions programs. See public health and health promotion programs Promosanté, 128, 138 Promoting Action toward Health (PATH) Project, 318–319 promotion of health, vs. health promotion, 40–41, 42f Promotion Santé Suisse, 291 prosperity, 147–149 provincial governments see also case studies; specific governments differential behaviour, 149 federal-provincial relationships, 146–147 federal/provincial/territorial landscape, 153–154 health promotion in the provinces and territories, 153–160 health promotion program experiences, 141–150 orientation of provincial public health, 142t Provincial Health Services Authority (PHSA), 157 provincial health system reform Alberta, 167–168 British Columbia, 162–163 Manitoba, 177 public health funding, 19 vs. health promotion, 36–37 respect for, 98–99 sedimentation approach, 37, 37f social capital, 78 Public Health Agency of Canada (PHAC), 99–101, 125, 127, 128, 133, 134, 135, 157, 159, 245, 329 Public Health Agency of Canada (PHAC), Atlantic Regional Office, 199 public health and health promotion programs conclusions, 149–150 as core type of intervention, 349–350 demographics, wealth and prosperity, 147–149 differential behaviour of provinces, 149 evaluation, reasons for, 350–354 federal-provincial relationships, 146–147 fiscal austerity and program vulnerability, 141–143 health care resilience, 144–145 left-wing party, 147 nature of programs implied by Ottawa Charter, 350
404 ■ Index neo-liberalism and social investment, 145–146 policy divergence, understanding, 146–149 program, described, 349–350 program resilience, understanding, 143–146 provincial experiences, 141–150 social assistance programs, similarity to, 143 state legitimacy, 143–144 Public Health Association of British Columbia, 167 Public Health Network, 100 public health nurse, 272 Public Health Training in the Context of an Enlarging Europe Project (PHETICE), 242 public policy. See policy Puerto-Rico, 284–285
Q qualitative approaches, 26 quality of life, 23, 24f, 27 Quality of Life Research Unit, 31 quasi-experimental designs, 352 Quebec federal-provincial relationship, 146–147 gross domestic product per capita, 148 public health institute, 159 public health subsystem, changes in, 184–185 social policy innovations, 159 status of health promotion, 185 Quebec Ministry of Health and Social Services, 321–323
R Racher, Fran, 176–181 Raeburn, John, 19–28 Raphael, Dennis, 106–116 rational choice theory, 142 RE-AIM, 329 realistic evaluation, 378 reflection, 303 reflective health promotion practitioner, 306–310 reflexive practice becoming a reflective health promotion practitioner, 306–310 conclusion, 310–311 contextual elements, 301–302 diagrams as reflection, 310 encouragement of, 82 health promotion practice, 301 journal reflections, 307–310 origins of, 303 power and collaboration, focus on, 304–305 and professionals, 302 “reflection,” origins of, 303 “reflexive,” origins of, 303–304 reflexivity, 303–304 “what if?” questions in collaborative reflection, 306 written reflection, 306–308
reflexivity, 56, 303–304 reform, 155–157 Regina Qu’Appelle Health Region, 176 Regional Resources Centre in Health Promotion “Promesa,” University of Concepción, 266 Reid, Colleen, 75–84 research. See health research research infrastructure, 158 Réseau Francophone des Villes-Santé de l’O.M.S., 291 Réseau Francophone International Pour la Promotion de la Santé, 290 Réseau francophone international pour la promotion de la santé (REFIPS), 187 resilience concept of health, 22–23, 23f health care resilience, 144–145 health promotion programs, 143–146 neo-liberalism and social investment, 145–146 state legitimacy, 143–144 Restrepo, Helena E., 275–276 Reviews of Health Promotion and Education Online, 15 rhizome analogy, 363–366, 381–383 Richard, Lucie, 184–186, 317–325 Ridde, Valéry, 222–231, 259–260, 371–383 right to health, 216 risk factors, 47 Ritchie, Jan, 283–284 Romania, 287–288 Romanian Ministry of Health, 288 Romanow Report, 99 Rootman, Irving, 1–12, 19–28, 61–70, 123–135, 371–383 Royal Society of Canada, 134 Rural Development Institute, Brandon University, 181 Rural Nova Scotia Project, 74
S Salinas, Judith, 265–266 SARS epidemic, 98, 159, 183 Saskatchewan Aboriginal approaches to health promotion, 173 change of focus to determinants of health, 172–173 northern communities, 174 Saskatchewan Health Publications, 176 Saskatchewan Population Health and Evaluation Research Unit, 176 schools, 193–194 Seaton Commission, 162 Seck, Awa, 288–289 Second Canadian Conference on Literacy and Health, 68 Secretan a de Salud, 278
Index ■ 405 Secretariat of the Pacific Community (SPC), 284 sedimentation approach to public health, 37, 37f Senegal, 288–289 settings alignment of health promotion work, 48–49 critique of approach, 59 as point of intervention, 48–50 and social context, 52–53 social environment approach, 49–50 support for behavioural change, 49 WHO Settings for Health approach, 60 sex, vs. gender, 79 sharing knowledge, 127–128 Signal, Louise, 278–279 Simos, Jean, 290–291 smoking, 53 social capital, 78 social context acknowledgment of, 47–48 collective lifestyles, 54–56 high-risk populations, 51–52 issues and, 51 and settings, 52–53 social environment approach to, 49–50 structure-agency debate, 54 social determinants of health, 97–98 social determinants of health inequalities, 112–113 Social Determinants of Health listserv, 138 Social Determinants of Health Task Force, 101 social environment approach, 49–50, 52–53 social health inequalities. See health inequalities social investment, 145–146 social model of health, 76 social norms, 48 social practices, 55 social science quasi-experimental designs, 352 Social Sciences and Humanities Research Council (SSHRC), 64–65, 94, 123, 125 social structure, 55 social views of health promotion, 21 Société Santé en Francais, 203–204, 204 Société Santé Mieux-être en français du NouveauBrunswick, 204 Solberg, Shirley, 187–189, 194–195 state legitimacy, 143–144 Stirling, Alison, 32–42 Strategies for Population Health: Investing in the Health of Canadians, 95 Strengthening Community Health project, 8 structural change, 373 structure-agency debate, 54 suboptimal health outcomes, 48 summer schools, 129t Swanson, Eleanor, 187–189, 194 Sweden, 280–282 Switzerland, 290–291
T The 10-Year Plan to Strengthen Health Care, 100 territorial governments. See provincial governments tobacco control, 321–323 Tones, K., 36 training, 128–132, 224–225, 250 Training for Health Renewal Program, 224 tree analogy, 363–366, 380–383 Tunisia, 292
U UK Department of Health, 122 Ukraine, 225, 292–293 UN Millennium Development Goals (MDGs), 212, 236 unemployment rate, 148, 148t United Kingdom commentary on Canadian academic publications, 293–294 Department of Health (website), 296 health inequalities, 114–115 National Institute for Clinical Excellence, 296 population health approach, 149 United Nations Development Programme: Romania, 288 United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP), 284 United Nations Population Fund: Romania, 288 United States Canada’s influence on health promotion, 296–297 health literacy concept, 61–62 University of New South Wales School of Public Health, 59 upstream approach, 51 US Centers for Disease Control, 134
V Valentini, Helene, 222–231 victim blaming, 48 Vollman, Ardene, 330–341 voluntary sector, 374
W Wahidi, Shukrrullah, 259–260 Walkerton, Ontario, 183 wealth, 147–149 wealth inequality, 112–113 Weber, Max, 54 welfare state functions, 143 West Nile Virus, 98 Western Michigan University Evaluation Center, 360 Westphal, Márcia Faria, 263–264 “what if” questions, 306 Williams, Lewis, 171–176 Williams, Patricia L., 187–189, 191–192
406 ■ Index Willms, Doug, 187–189, 190 Wilson, Doug, 167–171 Wilson-Forsberg, Stacey, 187–189, 190 Wise, Marilyn, 261–262 women’s health in Canada, 76–77 gender inequality, and morbidity, 78 and health promotion, 78–80 implications for health promotion practice, 81–82 intersectional theory, 79–80, 81–82 workplace health, 194–195 World Bank, 11, 208, 212, 214 World Economic Forum, 215 World Health Assembly, 1, 4, 215 World Health Organization (WHO) Canadian influences, 237–238 Collaborating Centres, 231 Commission on Social Determinants of Health (CSDM), 388 Commission on the Social Determinants of Health, 101 European Regional Office, 318 European Working Group on Health Promotion and Evaluation, 240–241 global network, 237 global strategy for health for all, 6 health, definition of, 19 health promotion (website), 245 International conferences, 2, 11 main contributions at global level, 237–238 settings approach, 60 website, 15 “yellow document,” 7, 93 World Social Forum, 215 World Trade Organization, 11, 210, 214 written reflection, 306–308
Y “yellow document,” 7, 93 Yunan Mother and Child Project, 226
Z Zero Hunger Program, 264