Community action for health promotion: a strategy to empower individuals and communities

Health status is directly affected by environmental conditions and by personal health-related behaviors, and it is indirectly affected by environmental conditions that themselves influence health behaviors. A comprehensive approach to health promotion, therefore, should encourage individuals to adopt and maintain personal behaviors that would prevent disease and promote health; discourage health-damaging personal behaviors by individuals and facilitate people engaging in health-promoting behaviors; and eliminate health hazards from the physical and social environment and make that environment more health-promoting. This comprehensive approach would require social and community action to change environmental conditions as well as efforts to change individual behavior. A model of health promotion interventions is developed within which community action plays a central role. The author then presents a model of community organization to influence public policy to achieve health promotion goals. The community organization model, previously tested in comparative case-study research, is illustrated with examples drawn from appropriate health promotion programs.     

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.     

Future directions for mental health services in Australia

Abstract: The last decade has seen a marked increase in the attention given to mental health policy and services at both a state and national level. Mental health consumers, carers, service providers, and a number of professional bodies have contributed to the scrutiny of what had been a relatively neglected area. The release of Australia's first National Mental Health Policy is a milestone in the development of a national focus on mental health promotion, prevention and the provision of enhanced services for persons with mental disorder and mental health problems. This paper discusses briefly the directions promoted in the national policy, including mental health promotion, reorientation of mental health services, the nongovernment sector, consumer rights, intersectoral links, service quality, research and evaluation.     

Toward a post-Charter health promotion

The past 25 years have seen enormous shifts in the environmental, political, economic and social landscapes that condition people's abilities to be healthy. Climate change is now a reality. China, India, Brazil and other 'developing' countries are emerging as new axes of political and economic power. Global capitalism has become increasingly predatory and crisis ridden, a result of unregulated and irresponsible greed of unimaginable scale. The elite response has been the increased erosion of the health and other social protection policies of redistribution that characterized the first-world run-up to the Ottawa Charter. These new realities challenge health promoters in ways unforeseen a quarter century ago. It is imperative that local determinants of health, to which health promoters give their attention, be traced to broader, even global levels of determinants. Support for groups acting at these levels should become a fundamental practice tenet. So, too, should advocacy for the social state, in which progressive taxation and hefty social investment blunt the health inequalities created by unfettered markets. As environmental and economic insecurities and inequalities increase in many of the world's countries, so does the risk of xenophobia and conflict. The roots of racism are complex; but weeding them out becomes another health promotion practice of the new millennium. There are some hopeful signs of health promoting political change, much of it emanating now from countries in the global South; but the threat of a return to health behaviourism in the face of the new global pandemic of chronic disease is real and must be confronted.     

Reflection a neglected art in health promotion

Evaluation and quality assurance have, over time, become the bedrock of health promotion practice in ensuring effectiveness and efficiency of programme planning and delivery. There has been less emphasis, however, on formal recognition of the contribution of the personal characteristics and perspectives of those who plan and deliver programmes and to the more subtle underlying effects of prevailing societal and professional norms. This paper seeks to highlight the neglect of formal reflection as a key professional skill in professional health promotion practice. It outlines key theories underpinning the development of the concepts of reflection and reflective practice. The role of reflection in critical health education as it contributes to critical consciousness raising is highlighted through its contribution to the empowerment of change agents in a societal change context. A conceptual typology of reflective practice is described which provides a flexible structure with which professionals can reflect on the role of self, the context and the process of health promotion programme planning. Its use is illustrated from the author's published work in health promotion which is related to prevention of workplace violence.     

International environmental law and global public health

The environment continues to be a source of ill-health for many people, particularly in developing countries. International environmental law offers a viable strategy for enhancing public health through the promotion of increased awareness of the linkages between health and environment, mobilization of technical and financial resources, strengthening of research and monitoring, enforcement of health-related standards, and promotion of global cooperation. An enhanced capacity to utilize international environmental law could lead to significant worldwide gains in public health.     

Health Promotion: An Effective Tool for Global Health

Health promotion is very relevant today. There is a global acceptance that health and social wellbeing are determined by many factors outside the health system which include socioeconomic conditions, patterns of consumption associated with food and communication, demographic patterns, learning environments, family patterns, the cultural and social fabric of societies; sociopolitical and economic changes, including commercialization and trade and global environmental change. In such a situation, health issues can be effectively addressed by adopting a holistic approach by empowering individuals and communities to take action for their health, fostering leadership for public health, promoting intersectoral action to build healthy public policies in all sectors and creating sustainable health systems. Although, not a new concept, health promotion received an impetus following Alma Ata declaration. Recently it has evolved through a series of international conferences, with the first conference in Canada producing the famous Ottawa charter. Efforts at promoting health encompassing actions at individual and community levels, health system strengthening and multi sectoral partnership can be directed at specific health conditions. It should also include settings-based approach to promote health in specific settings such as schools, hospitals, workplaces, residential areas etc. Health promotion needs to be built into all the policies and if utilized efficiently will lead to positive health outcomes.     

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.     

Social inequalities and distribution of the environmental burden among the population (environmental justice)

The paper deals with the following question: How are the environmental risks distributed across different social groups? Using the term 'environmental justice', it has been discussed in the USA for more than 15 years already that environmental risks are not distributed evenly (i.e., justly). Public attention concentrates on the high environmental burden of the black community, but differences by social status are also addressed. In Germany, there is as yet no comparable discussion. In order to contribute to its development, we focus mainly on the following topics: empirical data from Germany on socio-economic differences in environmental risks concerning the home and the home environment, combination with the discussion on environmental justice, recommendations for research and health policy. The results indicate that also in Germany the lower status groups are exposed to greater environmental risks, and that regional measures of health promotion provide a good chance of reducing this inequality.     

Emerging health issues: the widening challenge for population health promotion

The spectrum of tasks for health promotion has widened since the Ottawa Charter was signed. In 1986, infectious diseases still seemed in retreat, the potential extent of HIV/AIDS was unrecognized, the Green Revolution was at its height and global poverty appeared less intractable. Global climate change had not yet emerged as a major threat to development and health. Most economists forecast continuous improvement, and chronic diseases were broadly anticipated as the next major health issue. Today, although many broadly averaged measures of population health have improved, many of the determinants of global health have faltered. Many infectious diseases have emerged; others have unexpectedly reappeared. Reasons include urban crowding, environmental changes, altered sexual relations, intensified food production and increased mobility and trade. Foremost, however, is the persistence of poverty and the exacerbation of regional and global inequality. Life expectancy has unexpectedly declined in several countries. Rather than being a faint echo from an earlier time of hardship, these declines could signify the future. Relatedly, the demographic and epidemiological transitions have faltered. In some regions, declining fertility has overshot that needed for optimal age structure, whereas elsewhere mortality increases have reduced population growth rates, despite continuing high fertility. Few, if any, Millennium Development Goals (MDG), including those for health and sustainability, seem achievable. Policy-makers generally misunderstand the link between environmental sustainability (MDG #7) and health. Many health workers also fail to realize that social cohesion and sustainability--maintenance of the Earth's ecological and geophysical systems--is a necessary basis for health. In sum, these issues present an enormous challenge to health. Health promotion must address population health influences that transcend national boundaries and generations and engage with the development, human rights and environmental movements. The big task is to promote sustainable environmental and social conditions that bring enduring and equitable health gains.     

Global environmental change: what can health care providers and the environmental health community do about it now?

The debate about whether global environmental change is real is now over; in its wake is the realization that it is happening more rapidly than predicted. These changes constitute a profound challenge to human health, both as a direct threat and as a promoter of other risks. We call on health care providers to inform themselves about these issues and to become agents of change in their communities. It is our responsibility as clinicians to educate patients and their communities on the connections between regressive policies, unsustainable behaviors, global environmental changes, and threats to health and security. We call on professional organizations to assist in educating their members about these issues, in helping clinicians practice behavior change with their patients, and in adding their voices to this issue in our statehouses and Congress. We call for the development of carbon and other environmental-labeling of consumer products so individuals can make informed choices; we also call for the rapid implementation of policies that provide tangible economic incentives for choosing environmentally sustainable products and services. We urge the environmental health community to take up the challenge of developing a global environmental health index that will incorporate human health into available "planetary health" metrics and that can be used as a policy tool to evaluate the impact of interventions and document spatial and temporal shifts in the healthfulness of local areas. Finally, we urge our political, business, public health, and academic leaders to heed these environmental warnings and quickly develop regulatory and policy solutions so that the health of populations and the integrity of their environments will be ensured for future generations.     

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.     

Environmental health promotion: bridging traditional environmental health and health promotion.

This article highlights the juncture between environmental health and health promotion and underscores the need for health promotion involvement in environmental health practice. It begins with a synopsis of current issues in environmental public health and deficiencies in environmental public health practice that could be partly ameliorated by an increased focus on environmental health promotion. Environmental health promotion lies at the intersection between the two disciplines and can be defined as any planned process employing comprehensive health promotion approaches to assess, correct, control, and prevent those factors in the environment that can potentially harm the health and quality of life of present and future generations. An introduction is also provided to the six articles contained in this special issue focused on environmental health promotion, and a brief discussion of crosscutting themes and issues is presented.     

Employer Role in Integrative Workplace Health Management

The health of the international workforce has been an increasing area of concern for the last two decades. Globalization of the world economy and rapid technological changes continue to change the nature of work and employment practices, exposing employees to new and serious health risks. These challenges are inescapable in any workplace, therefore it is important that employers examine how they can best fulfill their legal and leadership roles to protect and promote the health and well-being of their employees.This paper explores employer roles in employee health in the context of global and local challenges. A strategy is suggested for employers to deal with the multifaceted workplace pressures and health impacts on employees i.e. implementing an integrative holistic model of workplace health management (workplace health management is an approach to workplace health that includes health promotion, disease prevention, safety management and organizational development). Workplace health management has emerged from the latest developments in the settings approach to workplace health promotion.The changing world of work and the implications on employee health in the current climate of globalization and technological changes is also examined. In particular, it highlights mental health issues associated with the emerging epidemic of work stress from increased workplace pressures.The paper reviews the changing conceptions of the role of employers and contemporary approaches to management practices in a range of disciplines, drawing out the common principles and strategies to respond to changes. One essential message which has emerged from the review is that employers need to become change agents and visionary leaders who adopt a proactive, interdisciplinary and integrative system approach to formulate and develop company policies and workplace culture that facilitates employee participation, professional growth and team work.These contemporary management principles and strategies form the basis of the integrative model for workplace health management presented in this paper. In essence, the integrative model of workplace health management uses a participatory problem solving cycle to identify and address the numerous issues associated with health promotion and disease prevention, occupational safety and hazard reduction, and organizational improvement and human resource management. Specifically this involves the employees and employer participating in a needs-based program development and implementation cycle: identifying health priorities and addressing environmental, organizational, occupational and lifestyle determinants of employee health. The paper concludes with an overview of international development of workplace health management and reports on successful examples from European, Western Pacific and Pan American regions.     

Survey of health promotion organisational arrangements and levels of service for health promotion

This study was promoted by the Executive Committee of the Association of Directors of Public Health when faced with the need to examine the organisation of and quantify health promotion arrangements in the Health Districts of England and Wales, resulting from the concerns of many of the members of the Association. These concerns were based on the views that health promotion is a key purchasing function of the District Health Authorities and must be appropriately and effectively structured and adequately resourced if the requirements of The Health of The Nation are to be fulfilled.There are many aspects to health promotion work and the delivery of health promotion services which will need addressing in the new commissioning environment of the NHS. A need was recognised for up-to-date data about health promotion services to inform a necessary debate about future arrangements, since it appeared that organisational change was being driven by influences unconnected with the possibly most appropriate structure of health promotion departments and which relate to a contemporary view of health promotion. Reducing the size and cutting the cost of commissioning authorities was perceived as one of the most important influences. A postal questionnaire survey to all Health District and Regional Health Authorities in England and Wales was conducted covering questions about the present organisational arrangements and levels of service, and soliciting the opinions of those canvassed. A total of 185 District and Regional Health Authorities, effectively reduced to 171 because of mergers, was sent questionnaires, of which 141 were completed and returned, giving a response rate of 82.5%.Most Health Promotion Units are currently purchaser-only based or split betweenpurchaser and provider bases. The majority of Districts have an establishment for a Director of Health Promotion, who is likely to be based at the purchaser level, Most directors have support staff. The median staff level in this survey is 7 WTEs (whole-time equivalents), and the level for the population served is 2.74/100,000. A little over 50% of respondents felt that health promotion should be a split purchaser and provider function, and there is evidence that this opinion has changed in recent years. This reflects concern expressed in comments made by respondents about the practical problems inherent in the separation of the purchaser and provider elements of health promotion activities, resulting from the ostensible requirements of the purchaser/provider reorientation in the NHS. The survey provides a picture of the present organisational arrangements in health promotion across the country and forms a basis for discussion of future developments. It highlights the problems of integrating all health promotion functions under a single management umbrella, purchaser or provider, and of the perceived importance of ensuring an adequate health promotion structure at the commissioning level.     

Challenges in teacher preparation for school health education and promotion

The health education and promotion profession is facing a series of teacher preparation challenges related to the delivery of quality school health education/promotion programmes. The challenges occurring in the United States are also present in a variety of other regions as the education structure attempts to ensure that students receive a sound preparation in health education and promotion during their school experience. The challenges can be categorised into the following areas: Quality and quantity of professional preparation for teachers during their pre-service university training; Need for in-service of teachers already in the K-12 workforce (in the USA grades K-12 are broadly equivalent to ages five to 17 years); University faculty workforce professional development needs; Research to provide baseline data for future standards development. Because there is a direct connection between community and school and parents and teachers at the K-12 level of education, the demand for highly skilled teachers and professional development is playing out at that level much more rapidly than at the university level. The relative isolation of some university faculty and programmes has developed an interesting situation in which many administrators and master teachers at the K-12 level of education have a better grasp and understanding of new teaching and learning strategies and tools than professors at the university level. This has happened at the same time when there is also a shortage of university professors entering school health education/promotion teacher education. This confluence of realities may predicate the need for a radical change in university based teacher preparation in health education/promotion. The overwhelming challenge for many countries including the United States remains the large number of teachers in the current workforce who must be provided professional development experiences. Currently both the National Health Education Standards for K-12 students and teacher preparation standards in health education reflect best practice theory only. There is no national data to support the standards. During the next ten years it is imperative that nationwide data be collected, compiled and analysed on actual learning outcomes for both K-12 students and health education teacher candidates. This will allow the next set of standards at both of the above-mentioned levels to reflect the knowledge and skills that have been actually attained and demonstrated. It will also be a basis for creating revisions and expansions in such a way that national standards can be an actual measure by which student performance can be judged. It is hoped that the rising tide of both national and international interest in having an increasingly health literate population will inspire members of the profession to be creative in the development of educational approaches, strategic partnerships, and funding to put strong systems of teacher preparation in place for the future.     

Health promotion in Canada - a case study

This case study describes and explains the development of health promotion in Canada, with particular emphasis on the social and political context. It explores how health promotion thinking emerged, was interpreted and implemented. It illustrates the balance between policy and practice, as well as outlining the role of health promotion infrastructures. The review has been developed at a time of considerable change to the landscape of health promotion in Canada. For some, this raises concerns about capacity for future leadership and continuing contribution to health reform. For others, the brief but rich legacy of experience reviewed here suggests new opportunities for further strong health promotion action in Canada-albeit in the context of new constructs and partnerships. It is hoped that this case study will contribute to a critical and timely dialogue on how health promotion values, principles and strategies can continue to inform action. This is vital as we commit to global Health for All for the 21st century in the face of challenge and change.     

South Asia's health promotion kaleidoscope

South Asia has 22 percent of the world's population but only 1.3 percent of the global income. Consequently 40 percent of the population is living in absolute poverty. However the health transition in some of its countries including India and Sri Lanka is a testimony to the fact that there are proven solutions to the problems of health and development within the region. The countries of the region have much in common, including a democratic political system, four major religions, a vibrant and living tradition of voluntarism and an extensive health infrastructure which is operating well below par. Despite the underlying unity, South Asia enjoys enormous cultural, linguistic and ethnic diversity. In this large, complex and vibrant region, health promotion is a challenging task, but it also holds the key to a dramatic change in the global health situation. Many of these solutions lie in wider areas of socio-political action. There are much needed shifts in the health promotion and development efforts, particularly in the area of poverty and social justice; gender inequity; population stabilisation; health and environment; control of communicable and non-communicable diseases; and urban health strategies. The principle of cooperation, partnership and intersectoral collaboration for health will be explored. Developing an appropriate, sustainable and people centred health and development strategy in the coming decades is an enormous challenge. There has been an attempt to focus on the emerging needs of the region, which call for health promotion, and involvement of civil society, private sector and the governments bestowed with the increased responsibility of ensuring health security for people. Strengthening the existing health systems, allocating adequate resources for health development and ensuring community participation are all prerequisites to the success of health promotion in the region.     

Urban Health Inequities and the Added Pressure of Climate Change: An Action-Oriented Research Agenda

Climate change will likely exacerbate already existing urban social inequities and health risks, thereby exacerbating existing urban health inequities. Cities in low- and middle-income countries are particularly vulnerable. Urbanization is both a cause of and potential solution to global climate change. Most population growth in the foreseeable future will occur in urban areas primarily in developing countries. How this growth is managed has enormous implications for climate change given the increasing concentration and magnitude of economic production in urban localities, as well as the higher consumption practices of urbanites, especially the middle classes, compared to rural populations. There is still much to learn about the extent to which climate change affects urban health equity and what can be done effectively in different socio-political and socio-economic contexts to improve the health of urban dwelling humans and the environment. But it is clear that equity-oriented climate change adaptation means attention to the social conditions in which urban populations live—this is not just a climate change policy issue, it requires inter-sectoral action. Policies and programs in urban planning and design, workplace health and safety, and urban agriculture can help mitigate further climate change and adapt to existing climate change. If done well, these will also be good for urban health equity.