National opportunities for health promotion: the Canadian experience

Health promotion is a fundamental strategy to address the majorissues which confront health systems in developed and developingcountries alike. Chief amongst these issues are unhealthy environments,health inequities and non-communicable diseases. The infrastructuresfor health promotion include mechan isms for development andimplementation of health policy; policies and programs supportiveof community involvement in health promotion programs; reorientationof the health care system towards prevention; and research.Consensus building among key stakeholders from the public andprivate sectors is at the core of the policy development process.A New Perspective for the Health of Canadians (1974) and theWHO Ottawa Charter for Health Promotion (1987) have guided healthpromotion policy and program development at both the nationaland provincial levels, in Canada, a number of initiatives haveplaced into pra ctice the policy frameworks, among them: HealthyCommunities, the Canadian Heart Health initiative, integrationofpreven lion into clinical practice, and structures to supportresearch in health promotion.     

Informing best practice with community practice: the community change chronicle method for program documentation and evaluation

Health promotion professionals are increasingly encouraged to implement evidence-based programs in health departments, communities, and schools. Yet translating evidence-based research into practice is challenging, especially for complex initiatives that emphasize environmental strategies to create community change. The purpose of this article is to provide health promotion practitioners with a method to evaluate the community change process and document successful applications of environmental strategies. The community change chronicle method uses a five-step process: first, develop a logic model; second, select outcomes of interest; third, review programmatic data for these outcomes; fourth, collect and analyze relevant materials; and, fifth, disseminate stories. From 2001 to 2003, the authors validated the use of a youth empowerment model and developed eight community change chronicles that documented the creation of tobacco-free schools policies (n = 2), voluntary policies to reduce secondhand smoke in youth hangouts (n = 3), and policy and program changes in diverse communities (n = 3).     

Essential Resources for Implementation and Sustainability of Evidence-Based Health Promotion Programs: A Mixed Methods Multi-Site Case Study

As of October 2016, use of federal Older Americans Act funds for health promotion and disease prevention will be restricted to the Administration on Aging’s criteria for high-level evidence-based health promotion programs. Dissemination of these programs to rural communities remains limited. Therefore a strong need exists to identify strategies that facilitate program implementation and sustainability. The objective of this study was to compare organizational readiness and implementation strategies used by rural communities that achieved varying levels of success in sustaining evidence-based health promotion programs for older adults. We utilized a qualitative multi-site case study design to analyze the longitudinal experiences of eight rural sites working to implement evidence-based health promotion program over 3 years (8/2012–7/2015). Multiple sources of data (interviews, documents, reports, surveys) from each site informed the analysis. We used conventional content analysis to conduct a cross-case comparison to identify common features of rural counties that successfully implemented and sustained their target evidence-based health promotion program. Readiness to implement evidence-based programs as low at baseline as all site leaders described needing to secure additional resources for program implementation. Sites that successfully utilized six essential resources implemented and sustained greater numbers of workshops: (1) External Partnerships, (2) Agency Leadership Commitment, (3) Ongoing Source of Workshop Leaders, (4) Health Promotion Coordination Tasks Assigned to Specific Staff, (5) Organizational Stability, and (6) Change Team Engagement. The six essential resources described in this study can help rural communities assess their readiness to implement health promotion programs and work secure the resources necessary for successful implementation.     

School climate and the institutionalization of the CATCH program.

School climate refers to various physical and psychosocial structures that shape schools' social and physical environments. The Child and Adolescent Trial for Cardiovascular Health (CATCH) study provided an opportunity to study how aspects of school climate are associated with continued implementation of the CATCH program. Nutrient analysis of menus, observations of physical education (PE) classes, and teacher and staff self-reports were used to measure CATCH program components. Results of this study indicate that aspects of school climate were associated with continued implementation of the CATCH classroom component but not the CATCH food service or PE components. These findings have implications for how we plan for the progression of innovative school health promotion programs from the initial trial stage to institutionalization. Measures of school climate may be useful in determining a school's readiness to adopt and implement an innovative health promotion curriculum.     

School-Based Cardiovascular Health Promotion: The Child and Adolescent Trial for Cardiovascular Health (CATCH)

The Child and Adolescent Trial for Cardiovascular Health (CATCH) is a multisite intervention research study that builds on significant progress made in school health education research in the 1980s. The study has three phases: Phase I deals with study design, intervention, and measurement development, Phase II involves the main trial in 96 schools in four states, and Phase III focuses on analysis. The intervention program targets third-fifth grade students and focuses on multiple cardiovascular health behaviors, including eating habits, physical activity, and cigarette smoking. Classroom curricula, school environmental change, and family involvement programs are developed for each grade level and behavioral focus. This paper describes Phase II of CATCH with a rationale for cardiovascular health promotion with youth. The process of change that appears to be necessary for school-based health promotion and that will be tested in CATCH are presented as a framework to guide these efforts.     

Social determinants of health: implications for environmental health promotion.

In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities--and associated health disparities--are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.     

Translating social ecological theory into guidelines for community health promotion

Health promotion programs often lack a clearly specified theoretical foundation or are based on narrowly conceived conceptual models. For example, lifestyle modification programs typically emphasize individually focused behavior change strategies, while neglecting the environmental underpinnings of health and illness. This article compares three distinct, yet complementary, theoretical perspectives on health promotion: behavioral change, environmental enhancement, and social ecological models. Key strengths and limitations of each perspective are examined, and core principles of social ecological theory are used to derive practical guidelines for designing and evaluating community health promotion programs. Directions for future health promotion research are discussed, including studies examining the role of intermediaries (e.g., corporate decision-makers, legislators) in promoting the well-being of others, and those evaluating the duration and scope of intervention outcomes.     

Health promoting schools

Promoting the health of children through schools has long been an important task of the WHO. Guided by the recommendations of the Expert Committee on Comprehensive School Health Education and Promotion, the Initiative seeks to strengthen health promotion and education activities at the local, national, regional, and global levels. It aims to increase the number of schools that can truly be called "Health-Promoting Schools". The four strategies undertaken by WHO in creating Health-Promoting Schools are: 1) strengthening the ability to advocate for improved school health programs, 2) creating networks and alliances for the development of Health-Promoting Schools, 3) strengthening national capacities, and 4) research to improve school health program. Finally, WHO recognizes that the success of the Global School Health Initiative lies on the extent to which partnerships can be formed at local, national, and international levels.     

Slip! Slop! Slap! and SunSmart, 1980-2000: Skin cancer control and 20 years of population-based campaigning.

The Anti-Cancer Council of Victoria has been running sun protection programs for more than 20 years: Slip! Slop! Slap! from 1980 to 1988 and SunSmart from 1988 to the present. The Victorian Health Promotion Foundation has provided funding for the SunSmart program for the past 13 years. These programs have played an important role in changing the whole society's approach to the sun and have resulted in marked reductions in sun exposure. This article describes the social, political, economic, and organizational context within which these programs developed. Then 10 areas are discussed that illustrate a critical aspect of the development and implementation of this successful systemwide health promotion program. These areas focus on key aspects of the context within which the program operates and on issues that derive from the experience of implementing program strategies. In summary, the success of the two programs is described as having been built on two key foundations: the vital integration of research and evaluation, on one hand, and a strong basis of consistency and continuity, on the other.     

The community health advisor program and the deep South network for cancer control: health promotion programs for volunteer community health advisors

The Community Health Advisor program is a proven, community-driven health promotion program that identifies and trains natural helpers who then seek to improve the health of individuals and their communities. This article details the basis of the Community Health Advisor model and describes early pilot programs in the Mississippi Delta. Also described is the formation of the Community Health Advisor Network, which provides technical assistance to Community Health Advisor programs and the proliferation of Community Health Advisor programs nationally. Specifically, details are presented of the modification of the model for the Deep South Network for Cancer Control and of early findings showing a decrease in health disparities in Alabama.     

The Jakarta Declaration on health promotion in the 21st century

The Fourth International Conference on Health Promotion, held in Jakarta, Indonesia, in July 1997, focused on the theme: New Players for a New Era--Leading Health Promotion into the 21st Century. Health promotion strategies can change life-styles as well as the social, economic, and environmental conditions that determine health. Most effective are comprehensive approaches that combine public policy efforts, the creation of supportive environments, community action, the development of personal skills, and a reorientation of health services. Also required is the creation of new partnerships for health between different sectors at all levels of society and government. The conference identified five priorities for health promotion in the 21st century: 1) promote social responsibility for health; 2) increase investments for health development, especially for groups such as women, children, older persons, the indigenous, the poor, and marginalized populations; 3) consolidate and expand partnerships for health to enable the sharing of expertise, skills, and resources; 4) increase community capacity and empower the individual; and 5) secure an infrastructure for health promotion through new funding mechanisms, intersectoral collaboration, and training of local leadership.     

Community-based suicide prevention program in Japan using a health promotion approach

Suicide prevention programs at a national level in developed countries were briefly reviewed, and the community-based suicide prevention programs in Akita Prefecture, in the Tohoku Region of Japan, were also outlined. Suicide prevention programs were proposed in Western countries in the 1980s. A famous example is the national prevention program in Finland that was started in 1986. The national suicide prevention programs in Western countries share some common features such as their comprehensiveness and diversity. Typical policies of suicide prevention programs were categorized according to primary, secondary and tertiary prevention. Regarding community-based suicide prevention programs using a health promotion approach, the Akita prefectural government incorporated a suicide prevention program into the local health promotion strategy “Health Akita 21” in 2001. An outline of the four action programs was as follows: to raise awareness of suicide prevention, to increase opportunities for mental health consultation, to promote both primary and secondary prevention of depression, and to create a supportive environment for mental health promotion. Community-based suicide prevention programs were started in some communities of model projects that are financially supported by Akita Prefectural government. Efforts to evaluate the effectiveness of community-based suicide prevention programs are needed in the future.     

Development of an integrated diabetes prevention program with First Nations in Canada

Type 2 diabetes mellitus is a major cause of morbidity and mortality among First Nations in Canada. We used multiple research methods to develop an integrated multi-institutional diabetes prevention program based on the successful Sandy Lake Health and Diabetes Project and Apache Healthy Stores programs. In-depth interviews, a structured survey, demonstration and feedback sessions, group activities, and meetings with key stakeholders were used to generate knowledge about the needs and resources for each community, and to obtain feedback on SLHDP interventions. First Nations communities were eager to address the increasing epidemic of diabetes. Educating children through a school prevention program was the most popular proposed intervention. Remote communities had poorer access to healthy foods and more on-reserve media and services than the smaller semi-remote reserves. While the reserves shared similar risk factors for diabetes, variations in health beliefs and attitudes and environmental conditions required tailoring of programs to each reserve. In addition, it was necessary to balance community input with proven health promotion strategies. This study demonstrates the importance of formative research in developing integrated health promotion programs for multiple communities based on previously evaluated studies.     

Urban health: challenges and opportunities

Urban health issues are multidimensional. Some effort has been made to identify their complexities in this presentation. Health providers working with inner-city populations must consider an array of social, health, and environmental factors in their assessments of health problems. Many of the societal issues which negatively impact health, such as poverty, lack of a universal health program, unemployment, violence, drugs, and other factors, can be corrected in our society only if the political will to do so is present. Health workers have a responsibility to advocate for programs and environments in which all citizens can maximize their full potential. Populations in urban areas who are at risk for disease, disability, and premature death make cities special places for focusing on the promotion of health and the prevention of disease. The contributions that can be made by health workers should be directed toward improving the quality of life for urban residents. The challenges to do so are essentially unlimited.     

Quality assessment in worksite health promotion.

The rapid expansion of worksite health promotion programs and the proliferation of service providers have resulted in increased concern about the quality of such programs. And while employers may view health promotion programs as a service to be purchased, in general, quality standards, price, and outcomes are less well established for primary prevention programs than for other medical services. This trend creates substantial potential for inappropriate expenditures, undermining the general credibility of such programs. Recognizing the limits of epidemiologic data and the potential for misuse of health promotion activities in the workplace, the California Department of Health Services (CDHS) undertook the development of guidelines for employers' use in assessing the quality of the numerous employee health promotion or chronic disease risk reduction programs available to them. To make the use of such programs as productive as possible, the CDHS developed recommendations in two main areas: (1) general recommendations for six fundamental program planning and development activities that underlie sound health promotion programs, and (2) specific criteria for seven types of health promotion programs commonly implemented in work settings. Optimally, worksite-based health promotion programs should be part of a comprehensive effort that provides for appropriate medical oversight, referral, and follow-up procedures. These programs should be complemented by appropriate changes in the work environment and in organizational policies. Programs should also include strategies to assist employees in initiating healthier behaviors and maintaining the new behaviors once they are established. Preventive medicine and occupational medicine practitioners and medical directors should be familiar with the issues addressed by these recommendations.     

A community education monitoring system: methods from the Stanford Five-City Project, the Minnesota Heart Health Program and the Pawtucket Heart Health Program

Understanding the process of behavior change interventions is critical to achieving campaign effectiveness and successful program replication. The present article presents a community education monitoring system (CEMS) using data from the Stanford Five-City Project (FCP), the Minnesota Heart Health Program (MHHP) and the Pawtucket Heart Health Program (PHHP). CEMS records the number and type of intervention activities, outcome objectives, targets of change (individual, organizational or environmental), channel(s) of dissemination and proportion of programs funded by the community. These data illustrate (1) the application of theory for each project, (2) data-based program administration, (3) feedback for revising programs and (4) type of reach or 'dose' information obtained from intervention monitoring. Process evaluations such as CEMS provide critical links between field realities and evaluation outcomes. This type of evaluation develops standards for measuring program reach and allows comparisons with other programs. CEMS also illustrates how programs enact theory. Validation studies are critical to the continued successful use of CEMS. The first step, however, is to develop a uniform way of describing complex multichannel behavior change programs. CEMS in a refined form should prove invaluable to health promotion program planners whether in research or service settings.     

A commentary on "Achieving Health for All: a Framework for Health Promotion".

In November 1986, the Minister of National Health and Welfare released a discussion paper called Achieving Health for All: A Framework for Health Promotion. The aim of this document is to present a new vision for health in Canada and to propose health promotion as a process to improve health for all Canadians. A framework of health challenges, health promotion mechanisms and implementation strategies is presented as a model to guide health programs and policies. Achieving Health for All builds upon the concepts and principles of health and health promotion that have been developing in Canada and other countries over the last 10-15 years. This article reviews the strengths and limitations of the framework and suggests its use in conjunction with the Ottawa Charter for Health Promotion, which was released in November, 1986. Implications of the framework for The Canadian Dietetic Association and dietitian/nutritionists are also presented. Dietetic and nutrition professionals are challenged to become familiar with the concepts and principles of Achieving Health for All and to assume a leadership role in promoting food and nutrition programs and policies as part of this new vision for health for all Canadians.