Health Promotion

The Journey of Health Promotion: From an Education Focus to a Multi-Disciplinary and Contemporary Approach that can Improve Health and Reduce Health Inequities

~Written by Karen Hicks, MA, MPH (Contact: karen_ahicks@hotmail.com)

As a concept, health promotion is not new as aspects of its approach can be traced back to ancient Greece. Since then it has continued to develop into an effective approach to address global health challenges.

Developments within health promotion date back to the beginning of the nineteenth century when there was an increased awareness of health promotion principles and an increased recognition that health was influenced by poverty and living conditions. The 1940s then observed the term health promotion being defined and the approach being used by the medical historian Henry E. Sigeres, who identified four related health promotion tasks within the field of medicine, namely the promotion of health, prevention of illness, restoration of the sick, and rehabilitation (Kumar & Preetha, 2012).

During the 1970s there was increased recognition that merely concentrating on increasing the capacity of health and medical services was not effective. Such recognition was significant for the health promotion field as this was the first acknowledgment that medical services alone could not improve health. Such challenges were recognized by Marc Lalonde, the Canadian Minister of Health, which resulted in the 1974 publication of “A New Perspective on the Health of Canadians” later known as the Lalonde Report (Lalonde, 1974). The report’s findings were momentous for health promotion as it emphasized that social structures influenced health and suggested that health care was not the most important determinant of health.

With increased recognition of the link between health and social determinants of health a conference was held by the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) during 1978 in Alma Ata, Russia. An outcome of the conference was a declaration signed by 134 world health ministers with a goal of Health for All by the year 2000 that would be achieved through the provision of universal primary health care. This became known as the Alma Ata Declaration, and was the primary international policy initiative for WHO (Godlee, 1994) that is considered by some as the founding framework for health promotion. Such acclaims are a response to the significant statements positioned within the report, namely a comprehensive definition of health, recognition of health as a human right, and the unacceptability of inequalities in health. The report also identified that primary health care was key to improving health and reducing health status inequalities alongside providing a clear political understanding of health (WHO, 1978). Such statements have resulted in Alma Ata being identified as ‘the foundation for the evolution of modern health promotion’ (Kickbusch, 2003).  Alma Ata was followed by a number of international WHO conferences during the 1980s when declarations were written and WHO Europe undertook a programme of work that identified health promotion concepts and principles (WHO, 2005). The result was health promotion emerged as a broader concept and an approach that recognized that identifying individuals as responsible for their poor health without acknowledging the structural determinants of health resulted in victim blaming (Tones, 1986). This new health promotion approach increasingly acknowledged that people’s health seeking behaviour was influenced by societal norms and socioeconomic position (Goodman et al., 1996).

Such ideology influenced and informed the first international health promotion conference in Ottawa, Canada from which the Ottawa Charter was produced (WHO, 1986). The Ottawa Charter defined health promotion and is a framework for health promotion that identifies prerequisites for health alongside key actions and approaches for health promotion practice. Through the charter’s strategies of action, namely the building of healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services (WHO, 1986), it aimed to operationalise the Alma Ata principles. As a result the Ottawa Charter contributed to the birth of the ‘new public health’ and identified a role for health promotion, placing it alongside disease prevention and health protection (Sparks, 2013) and by defining health promotion, it has augmented both its recognition and progression to an academic subject. The result of which is increased tertiary education opportunities, research, and texts with a theoretical basis that informs effective practice (Murphy, 2005).

Health promotion was later strengthened by the Commission on the Social Determinants of Health 2008 report “Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health” (WHO, 2008) which provided further evidence on the requisites for health equity and the necessity to address the structural factors affecting health and well-being (Crouch & Fagan, 2014). Since the Ottawa Charter there have been a number of international treaties, declarations, and frameworks that continue health promotion developments. Alongside a series of conferences on health promotion continue to develop health promotion globally, such as the Adelaide Conference on Healthy Public Policy (1988), Sundsvall Statement on Supportive Environments (1991), Jakarta Declaration on Leading Health Promotion into the 21st Century (1997), Mexico Ministerial Statement for the Promotion of Health: From Ideas to Action (2000), The Bangkok Charter for Health Promotion in a Globalized World (2005), Nairobi Call to Action (2009) and Helsinki Health in All Policies (2013) (WHO, 2015).

Such developments have resulted in the transformation of health promotion as an approach that uses a range of models, strategies and approaches to improve health and wellbeing. It has moved it from a behaviour change focus to a comprehensive socio-environmental model (Harris & McPhail-Bell, 2007) resulting in a contemporary approach with a knowledge base and practices that reflect a paradigm shift in our understanding of health resulting in health promotion developing into a field of study in its own right (Davies, 2013).

This contemporary health promotion has been identified as ‘one of the most ambitious health-related enterprises of the 20th century’ (Carlisle, 2000). It has also been identified as a visionary approach due to its global concern for equity, justice, the environment and its multi-faceted approach of working in partnership across sectors and disciplines (WHO, 1997) extending the role of health promoters to one that is increasingly broad and diverse requiring an increased body of skills to address global, public health issues. Such diverse knowledge and skills are increasingly recognised and informing international development related to competencies and regulation of the health promotion workforce (Barry, 2009), escalating the recognition of health promotion within the wider public health workforce.

It is timely for us to celebrate the journey undertaken by health promotion and recognise its role in reducing inequities and addressing the global health challenges that we face. Well done health promoters!

References:

Barry, M. M. (2009). The Galway Consensus Conference: international collaboration on the development of core competencies for health promotion and health education. Global Health Promotion. Vol 16. 2: 05-11.

Carlisle, S. 2000. Health promotion, advocacy and health inequalities: a conceptual framework. Health Promotion International. Vol. 15. 4: 369-376.

Crouch, A., & Fagan, P. (2014). Are insights from Indigenous health shaping a paradigm shift in health promotion praxis in Australia? Australian Journal of Primary Health;, 20, 323-326.

Davies, J. K. (2013). Health promotion: a unique discipline. Health Promotion Forum of New Zealand.Godlee, F. (1994). WHO in retreat: is it losing its influence? British Medical Journal. 309:1491.

Goodman, R.M., Wandersman, A., Chinman, M. Imm P. and Morrissey E. (1996).An ecological assessment of community-based interventions for prevention and health promotion: approaches to measuring community coalitions. American Journal Community Psychology. American Journal of Community Psychology. Feb: 24 (1): 33-36.

Harris, N., & McPhail-Bell, K. (2007). Evolving directions in health promotion workforce development. Health Promotion in the Pacific, 14(2), 63-65.

Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health. March 93 (3) 383-388.

Kumar, S, & Preetha G.S. (2012). Health promotion: An effective tool for global health. Indian Journal of Community Medicine. International Institute of Health Management Research.

Lalonde, M. (1974). A new perspective on the health of Canadians a working document. Government of Canada.

Murphy, J. (2005). Health promotion. Economic roundup. (Winter ed.) The Treasury, Australian Government.Sparks, M. (2013). The importance of context in the evolution of health promotion. Global Health Promotion, 20(2), 74-78.

Tones, B.K. (1986). Health education and the ideology of health promotion: A review of alternative approaches. Health Education Research. 1:3-12.

WHO. (1986). The Ottawa Charter for Health Promotion. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/

WHO. (2005). Milestones in health promotion: Statements from global conferences. http://www.who.int/healthpromotion/milestones_yellowdocument.pdf.

WHO. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization.WHO. (2015). Global conferences on health promotion. Retrieved from http://www.who.int/healthpromotion/conferences/en

WHO. 1997. Jakarta Declaration on Leading Health Promotion into the 21st Century. http://www.who.int/healthpromotion/conferences/previous/jakarta/declaration/en/

Karen Hicks, RGN, BSc, Cert Ed, MA, MPH is Senior Health Promotion Strategist at the Health Promotion Forum of New Zealand and Lecturer at Unitec College of Technology