Health promotion: application of the Ottawa Charter]

One of the greatest challenges for community health today is to translate the health promotion framework into specific actions. An essential step toward integration of the strategies suggested by the Ottawa Charter for Health Promotion lies in a close scrutiny of community health practice by health professionals. In the context of our own organization, we have set up a series of policy development seminars designed to bring together staff involved in different areas of community health and to have them work through clear institutional positions regarding current public health issues. We examined the policy positions in the light of the Ottawa Charter. Some of the Charter's suggested strategies were not well covered by the seminar participants. This could be partly attributed to the traditional mix of disciplines in community health. In order to approach health as defined in the Charter, a novel mix of disciplines should be invited to collaborate with the already existing professionals. The Charter is a useful tool for better focusing community health practice onto the health promotion paradigm.     

Health promotion activities in China from the Ottawa Charter to the Bangkok Charter: revolution to evolution

China has the world's largest population. In the past, the public health system in mainland China has been strongly influenced by the former Soviet Union. Hong Kong and Macao, the Special Administrative Regions (SAR), have been under colonial administration adopting a laisser-faire approach to health policy. Over the most recent decades, mainland China and the two SARs have adopted the Ottawa Charter principles and re-orientated the healthcare systems towards greater community participation, built a healthy environment in different settings and developed capacity in health promotion. Positive results have resulted from efforts to move towards a bottom-up approach to health promotion, using the overarching framework of Healthy Settings. Adequate resources will be needed to build up the infrastructure for sustainable development of health promotion initiatives. This report is selective, rather than comprehensive and will highlight specific health promotion activities in different parts of China, reflecting how the approach to health promotion has evolved since Ottawa. An analysis will be made of the potentials of these initiatives to take forward the spirit of the Ottawa Charter in paving the way for the Bangkok Charter.     

Promoting people's health: challenges and opportunities

Promoting health underlines the right of each individual to the highest attainable standard of health. It stresses the importance of the participation of people and recognizes different sociocultural values and beliefs that are prevalent throughout the world. Working on health development has a sustainable effect only when done comprehensively: personal development, community development, organizational development, and political development. The international conferences that have marked the way of health promotion have been goal posts of an energetic movement to strengthen health worldwide. The Ottawa Charter on Health Promotion has been a worldwide source of guidance for health promotion through its five strategies: building health policy, creating supportive elements, strengthening community action, developing personal skills, and reorienting health services. Moreover, the Jakarta Declaration on "Leading Health Promotion into the 21st Century" identifies five priorities in the next millennium: 1) promote social responsibility for health; 2) increase investments for health development; 3) consolidate and expand partnerships for health; 4) increase community capacity and empower the individual in matters of health; and 5) secure an infrastructure for health promotion. Increasing the investment in health development calls for the need to find new mechanisms for funding as well as reorienting existing resources towards health promotion and health education.     

What would the Ottawa Charter look like if it were written today?

The Ottawa Charter has been a phenomenal influence guiding the development of the concept of health promotion, and in shaping public health practice in the past 20 years. The world has changed somewhat since 1986 in many ways that could not have been anticipated by those drafting the Charter. Substantial social and economic changes have occurred, and continue to occur. These include the globalization of trade, the invention and development of the internet and mobile communications, as well as the emergence of new threats to health such as HIV/AIDS. Such profound changes require adaptations to established health promotion strategies and the development of new strategies. This paper considers the origins, describes changes and suggests adaptations to the five strategies of the Ottawa Charter - build healthy public policy; create supportive environments for health; strengthen community actions; develop personal skills; and reorient health services - that now routinely provide the framework for consideration of any major public health challenge.     

Measuring community empowerment: a fresh look at organizational domains

In 1986, the Ottawa Charter identified community empowerment as being a central theme of health promotion discourse. Community empowerment became a topical issue in the health promotion literature soon afterwards, though its roots also come from earlier literature in community psychology, community organizing and liberation education. Subsequent international conferences to address health promotion in Sundsvall, Adelaide and Jakarta have acted to reinforce this concept. It is as relevant today as it was more than a decade ago. The literature surrounding health promotion has since moved onto other overlapping theoretical perspectives, such as community capacity and social capital. And yet the critical issue of making community empowerment operational in a programme context remains thorny and elusive. Community empowerment is still difficult to measure and implement as a part of health promotion. This article offers a fresh look at key theoretical and practical questions in regard to the measurement of community empowerment. The theoretical questions help to unpack community empowerment in an attempt to clarify how the application of this concept can be best approached. The practical questions address the basic design characteristics for methodologies to measure community empowerment within the context of international health promotion programming. The purpose of this article is to allow researchers and practitioners to address again the important issue of making community empowerment operational.     

Setting an ethical agenda for health promotion

The Bangkok Charter for Health Promotion in a Globalized Worldhas sparked lively dialogue. Welcomed by some as a Charter currentto the times, there are others who see it as an unneeded andtherefore unwelcome challenger to the Ottawa Charter for HealthPromotion. Intended or not, the Bangkok Charter seems to signala shift in discourse, from a social-ecological approach andan emphasis on individual and community capacity-building andempowerment, to an investment approach and an emphasis on globalization,macro-level factors and policy. Positively, the Bangkok Charterproclaims to build on Ottawa, and no one suggests it is meantto replace the Ottawa Charter outright. In concert with that,the dialogue today is not so much about the ascendancy of theone Charter over the other, but about the degree to which theBangkok Charter remains true to the ethic of the Ottawa Charter.It is welcome that the Ottawa and Bangkok Charters are the subjectof brisk dialogue about strategy and tactics in a rapidly changingworld, and about the foundational values of health promotion.Regarding the latter, we have unfinished work in constructingan ethic for health promotion, and the present dialogue mayinspire us to progress. Though we have the cornerstone of anethic for health promotion, in the Ottawa Charter and in otherprincipled documents that have followed, we have yet to buildsufficiently on the cornerstone; an ethic for practice has yetto be codified, and the same is true for research. Health promotionjournals, conferences and organizations can and should do moreto facilitate dialogue on ethics in health promotion, and theInternet provides the means for all to participate actively.     

Health promotion, the Ottawa Charter and 'developing personal skills': a compact history of 25 years

The challenge of understanding what has happened in the 25 years since the Ottawa Charter would be difficult enough if there had been no Charter. However, our task is to interpret to what extent the Charter has influenced the world of health promotion as it is today. The task here is to consider what has happened regarding one action component of the Charter, notably developing personal skills. In taking only one of the five components, we are deconstructing the holistic approach that was implied in the Ottawa Charter and it is somewhat strange to isolate this action area from the others, and perhaps outside the 'spirit' of the Charter. Nonetheless, the approach will be to interpret this area broadly while still being restrictive and not venturing into discussions of the other action areas except where the connection is so strong that to isolate personal skills from the other area would be unproductive. The Ottawa Charter brought to the table, for health promotion and education, a growing recognition that health was a broad concept in its own right. It made explicit that ties to disease approaches were highly related to health education and promotion, but that health promotion had to go well beyond a narrow interpretation of the field. It recognized that active participation by people, to directly affect their health and the broader determinants of it, was paramount.     

Global issues and challenges beyond Ottawa: the way forward

This article links 10 regional field reports to the statement Shaping the future of health promotion: Priorities for action, which are both outcomes of the global IUHPE and CCHPR project, Renewing our Commitment to the Ottawa Charter: The Way Forward. The Shaping the future statement has emerged from the regional field reports and will act as the driving force behind the future articulation of health promotion policy at an international level. Connections are made between the key areas of the regional field reports, which include health promotion policy, health-promoting services, health promotion funding and availability of resources, community participation in health, research and information, and the recommendations made in the Shaping the future of health promotion: Priorities for action statement. The coverage includes putting healthy policies in to practice; strengthening structures and processes for health promotion; moving towards knowledge based practice; building a competent health promotion workforce and empowering communities. There are a number of significant issues arising across all the regional field reports that have been drawn on to make the recommendations in the statement. For example, the political environment has strongly influenced the evolution of health promotion. There is a clear message from the reports that political will is essential and that political advocacy needs to continue to ensure that policy goals represent the principles of Ottawa in an appropriate manner. Examples drawn from the reports demonstrate the many and varied challenges for health promotion in addressing 21st century global health determinants. There is also a clear indication that the principles established in Ottawa, and developed in subsequent WHO declarations and charters, have been embedded in the framework of health promotion practice. Shaping the future articulates the key message from the regional field reports, and therefore ensures that the lessons learnt from implementing Ottawa over the past two decades are harnessed and will shape health promotion in the future.     

A partnership approach to health promotion: a case study from Northern Ireland

In recent years there has been a renewal of interest in community development and partnership approaches in the delivery of health and social services in Northern Ireland. The general thrust of these approaches is that local communities can be organized to address health and social needs and to work with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. Since the Ottawa Charter was launched in 1986, government in Northern Ireland has stressed that community development should no longer simply be added on to key aspects of Health and Social Services, but should instead be at the core of their work. There is increasing consensus that traditional approaches to improving health and well-being, which have focused on the individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. This paper outlines the policy background to community development approaches in health promotion and delivery in Northern Ireland. Drawing on evidence from a case study of a community health project it highlights the benefits and difficulties with this approach. The findings suggest that partnerships can positively influence a community's health status, but in order to be effective they require effective planning and long-term commitment from both the state and the local community.     

Enabling children: participation as a new perspective on child‐health promotion

As fellow citizens, all children need a stimulating social environment that helps them develop self-respect and social competence. Developmental research, however, shows, that many children do not or cannot fulfil the social, moral or cognitive developmental tasks which are necessary for healthy development. A lack of opportunities for gaining meaningful social experiences can be seen as a major source of psychosocial and behavioural problems in children. On the contrary, active commitment in educational environments such as the school and the neighbourhood, helps them to get an increasingly better grip on their own lives and health. Moreover, such ‘children's participation’ appears to have a protective and preventive effect for health-related problems. Therefore, it is argued, that ‘enablement’, a key-element of both the Ottawa Charter on Health Promotion and the International Convention on the Rights of the Child, should be at the core of every child-health promotion programme.     

Enable, mediate, advocate

The authors of the Ottawa Charter selected the words enable, mediate and advocate to describe the core activities in what was, in 1986, the new Public Health. This article considers these concepts and the values and ideas upon which they were based. We discuss their relevance in the current context within which health promotion is being conducted, and discuss the implications of changes in the health agenda, media and globalization for practice. We consider developments within health promotion since 1986: its central role in policy rhetoric, the increasing understanding of complexities and the interlinkage with many other societal processes. So the three core activities are reviewed: they still fit well with the main health promotion challenges, but should be refreshed by new ideas and values. As the role of health promotion in the political arena has grown we have become part of the policy establishment and that is a mixed blessing. Making way for community advocates is now our challenge. Enabling requires greater sensitivity to power relations involved and an understanding of the role of health literacy. Mediating keeps its central role as it bridges vital interests of parties. We conclude that these core concepts in the Ottawa Charter need no serious revision. There are, however, lessons from the last 25 years that point to ways to address present and future challenges with greater sensitivity and effectiveness. We invite the next generation to avoid canonizing this text: as is true of every heritage, the heirs must decide on its use.     

HEALTH PROMOTION: CAN IT REDRESS THE HEALTH EFFECTS OF SOCIAL DISADVANTAGE?

Social disadvantage is an entrenched feature of contemporary New Zealand society and has a deleterious influence on health. Traditional health promotion activities, with their focus on the individual, have had only a limited impact. The World Health Organization is fostering a new approach to health promotion based on the Ottawa Charter, the two most important strategies being: building healthy public policy and strengthening community action. The new health promotion has great potential, especially with its emphasis on ‘empowerment’, but as yet only indirect evidence supports the effectiveness of this approach. Several current New Zealand community-based initiatives hold promise for the future and three of these are discussed. The greatest challenge is to ensure that the ‘empowering’ approach to health promotion continues to be developed by Area Health Boards and that this type of health promotion becomes a major priority at all levels of society. As social scientists, we need to support this approach and assist in the production of evidence to show whether it is capable of redressing the health effects of social disadvantage.     

Some bitter-sweet reflections on the Ottawa Charter commemoration cake: a personal discourse from an Ottawa rocker

The Ottawa Charter both gave health promotion a solid framework and health promoters an identity. Yet, health promotion has far from reached its potential in being internalized in public health politics. Advocacy for health is one of the core missions for health promotion and the 25-year celebration of the Ottawa Charter offers a free ride, instead of being a missed opportunity. WHO has not met the expectations in taking advantage of the momentum and outcomes from the long series of global health promotion conferences. The series represents a lifeline for health promotion. Concepts like healthy public policy, supportive environments, social determinants, health and human rights, whole of government, globalization and others have been elaborated and framed in a health promoting context. The downside is that the footprints have not been bold, in particular not internationally. An upside is the development of research and science, underscored by a rapid development of scientific journals, textbooks, academic institutions and posts. A question arising is whether practise and policy making are left behind, since implementation on a grand scale still is lacking? Further and future efforts must be devoted to explore the processes and art of policy making. There is a need for more narratives and more health promoters involving themselves in policy making and politics. Health promotion is as relevant for the twenty-first century as ever. The challenges and opportunities are evident; the increasing global burden of non-communicable diseases, ageing populations, harmful use of alcohol, social determinants and fair societies improved governance and more. Health promotion can add value and WHO can step up its engagement.     

Integrated health promotion strategies: a contribution to tackling current and future health challenges

This paper was presented as a technical background paper at the WHO sixth Global Conference on Health Promotion in Bangkok Thailand, August 2005. It describes what we know about the effectiveness of four of the Ottawa Charter health promotion strategies from eight reviews that have been conducted since 1999. The six lessons are that (i) the investment in building healthy public policy is a key strategy; (ii) supportive environments need to be created at the individual, social and structural levels; (iii) the effectiveness of strengthening community action is unclear and more research and evidence is required; (iv) personal skills development must be combined with other strategies to be effective; (v) interventions employing multiple strategies and actions at multiple levels are most effective; (vi) certain actions are central to effectiveness, such as intersectoral action and interorganizational partnerships at all levels, community engagement and participation in planning and decision-making, creating healthy settings (particularly focusing on schools, communities, workplaces and municipalities), political commitment, funding and infrastructure and awareness of the socio-environmental context. In addition, four case studies at the international, national, regional and local levels are described as illustrations of combinations of the key points described earlier. The paper concludes that the four Ottawa Charter strategies have been effective in addressing many of the issues faced in the late 20th century and that these strategies have relevance for the 21st century if they are integrated with one another and with the other actions described in this paper.     

Principles for planning the teaching of health promotion in an MPH course

The Ottawa Charter on Health Promotion defined the term Health Promotion as "the process of enabling people to increase control over, and to improve, their health". It also specifies that "to reach a state of complete physical mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment". Three main strategies for promoting health were stated: advocacy, enabling, and mediating. A great emphasis was put on policy. The Jakarta Declaration at the 4th International Conference on Health Promotion in 1997 reconfirmed the Ottawa Charter and added to it that "Health Promotion is carried out by and with people, not on or to people". The learning objectives of health promotion should refer to the values and strategies of 'Health 21', to the strategies and areas of action in health promotion as specified in the Ottawa Charter, and it should be relevant to the needs of the society that the participants are going to serve. The main goal of a training program in health promotion should be to develop competence in health promotion. "Competence" refers to the combination of three domains: attitudes, knowledge, and skills. Each school of public health or planners of an MPH course should decide upon the right mix of these three domains, according to their institute's mission and goals.     

Twenty-five years after the Ottawa Charter: the critical role of health promotion for public health

After a quarter of a century, the Ottawa Charter for Health Promotion, often recognized as a foundational document of health promotion, continues to be relevant for public health. Inspired by the WHO Constitution, the Alma Ata Declaration, and the Lalonde Report, the Ottawa Charter endorses a positive definition of health, situates health as a product of daily life, proposes core values and principles for public health action, and outlines three strategies and five action areas reaching beyond the boundaries of the health care sector. The Charter established a radical agenda for public health, specifically to expressly convey the values public health pursues, thereby increasing the potential for the reflexivity of the field and opportunities to consider complementary values in actions that promote population health. In this paper, we examine how public health has integrated health promotion by exploring examples of changes in public health systems and practice at international and national levels of governance. Nevertheless, an important challenge remains for health promotion: better use of research to understand how the values, principles and processes of health promotion can help to achieve public health mandates. A three-pronged action plan is proposed.     

Health promotion in Australia: twenty years on from the Ottawa Charter

Australia has a longstanding history of promoting health through programs that reflect the principles of the Ottawa Charter and recognising the importance of social determinants of health. Health promotion programs are delivered by a wide range of organisations, in a wide range of settings and sectors for, or with, multiple groups. Since the mid-1980s aspects of infrastructure and capacity for health promotion, such as human and financial resources, have been put in place including the establishment of health promotion foundations via tobacco hypothecation. Following neo-liberal reforms in the 1990s, however, government policies have increasingly focused more narrowly on specific diseases and risk factors. Chronic disease has become the new banner under which health promotion, social determinants and efforts to address health inequalities fit. While the importance of social determinants is often recognised within and outside the health sector, health promotion practitioners are seldom at the centre of policy development. (Promotion & Education,     

Health promotion and health systems: some unfinished business

One of the five action domains in the Ottawa Charter was Reorienting Health Services. In this paper, we reflect on why progress in this domain has been somewhat lethargic, particularly compared with some of the other action domains, and why now it is important to renew our commitment to this domain. Reorienting health services has been largely overlooked and opportunities missed, although good exceptions do exist. The occasion of the 25th anniversary of the Ottawa Charter represents an important opportunity for health promotion to: (i) renew its active voice in current policy debate and action and (ii) enhance achievements made to date by improving our efforts to advocate, enable and mediate for the reorientation of health services and systems. We outline six steps to reactivate and invest more in this action domain so as to be in a better position to promote health equitably and sustainably in today's fast changing world. Though our experience is mainly based in the European context, we hope that our reflections will be of some value to countries outside of this region.     

Three challenges to the Ottawa Spirit of Health promotion, trends in global health, and disabled people

Health promotion according to the 1986 Ottawa Charter of the first global health promotion conference "is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment". In this commentary, I explore three powerful challenges to the spirit of the Ottawa Charter and to global health. The first challenge is the departure from the WHO definition of health; the second challenge relates to the appearance of the transhumanist/enhancement model of health which includes human performance enhancement beyond species-typical boundaries as part of the concept of health. The third challenge consists of the limited involvement and understanding of disabled people with their different models of 'disability/impairment' (medical, social, transhumanist/enhancement) in the discourse of global health and health promotion. Not dealing with these challenges impairs the ability of health promotion to deal with global health problems, the 'health' needs of marginalized groups--in particular, disabled people--and the Millennium Development Goals.     

Beijing health promoting universities: practice and evaluation

The aims of this study were to create a health promoting university within the framework of the Ottawa Charter for Health Promotion. Strategies included reforming and issuing healthy policies, creating a healthy physical and social environment, developing personal health skills, reorienting the health services, and implementing intervention activities. To evaluate the study, 180 students and 120 teaching/administrative staff were sampled for an in-depth interview with open-ended questions administered 1 year after the launch of the project. To assess health knowledge and behavior, 2500 students were sampled to answer a questionnaire, both prior to and following project implementation. With respect to policies, environment and health services, 166 students and 117 teaching and administrative staff participated in the in-depth interview. Approximately three-quarters (75.90%) of university students considered that the physical environment of the campus had improved significantly and 83.73% reported they had a good social environment. All university administration departments made commitments to health promotion. Consultations on mental health, smoking cessation and STD/AIDS prevention were provided all year round. Health education was included in a curriculum as a selective course with 1-2 credits. Almost two-thirds (60.66%) of teaching/administrative staff reported that they had had a yearly physical examination. In the final stages of the research, significantly more college students reported improved mental health (38.25% compared with 17.93% at baseline) (p < 0.01) and more were knowledgeable about transmission of STDs/AIDS (57.00/35.50% compared with 51.66/28.20% at baseline, respectively) (p < 0.01). Significantly less regular smokers were found (45% compared with 15.81% at baseline) (p < 0.01). However, there was a significant increase in high-fat food intake (44.81% compared with 49.50%) (p < 0.01) and pre-marital sex (5.11% compared with 14.00%), and a significant decrease in physical exercise participation (29.41% compared with 23.50%) (p < 0.01). As a health promotion setting, the university community can benefit greatly from implementing health promotion campaigns based on the principles of the Ottawa Charter.