Charting the Future: A Concept Plan and
Strategic Planning Guide for the Prairie Region
Health Promotion Research Centre.
Lewis Williams, PhD
Prepared for the Strategic Planning Event
May 18th - 19th 2004
The Willows, Saskatoon.
Introduction
This report is the result of consultations with Centre stakeholders (both present and
potential) throughout the province of Saskatchewan. It presents an overview of present
challenges to population health promotion, emergent issues and stakeholder opinion
regarding future Prairie Region Health Promotion Research Centre (PRHPRC) directions.
The report is intended to provide a conceptual overview of how the Centre might develop
and to serve as a basis from which the strategic planning will proceed.
Consultations took the form of presentations to various organizations, regarding the
Centre’s past and emerging directions, group dialogue and semi-structured interviews. In
some situations organisational representatives were not familiar with PRHPRC. In these
cases, conversation tended to focus more on the activities of each organisation and
possible synergies, rather than follow a more formalised interview. Over thirty
stakeholder groups were consulted1. These range from Federal and provincial
government branches, Regional Health Authorities, University-based stakeholders, large
non-government organizations and grass roots activist groups.
Since its inception in the 1970s health promotion practice has passed through a number of
developmental phases. At a global level, a number of issues such as trade, urbanization,
marginalisation, environmental threat and new epidemics (e.g. SARS and AIDS)
transcend regional and local boundaries with influences on contemporary practice
conditions. Within Canada, and Saskatchewan more specifically, practice is nested within
a range of cultural and economic contexts, issues and associated policies and initiatives.
For the past ten years the PRHPRC to some extent has played a mediating role between
these local, national and international levels of practice through its partnerships and
initiatives.
This particular phase of the Centre’s development is also marked by the collaboration of
the Extension Division with the Department of Community Health and Epidemiology,
University of Saskatchewan in the hiring of the Director as a tenure track position. This
leverages a new combination of resources, such as expertise in distributed learning, and
ecological approaches to population health, creating a range of new synergies between
the Centre and its stakeholders.
The essential question, then, posed by the strategic planning event is ‘given contemporary
global and local themes, issues, conditions, and resources, how should the Centre
position itself in terms of health promotion research, evaluation and practice to best
contribute to the health and well-being of the communities it ultimately serves?’
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These are listed in appendix A. Information collected focused on the mandate and needs of stakeholder
groups as these relate to population health promotion, barriers and facilitating conditions encountered in
this work, and stakeholder views regarding how PRHPRC may contribute to moving the agenda of
population health promotion forward. In some cases more specific information was sought such as
potential learning event themes and Centre website development.
2
Where have we been?
The Prairie Region Health Promotion Research Centre was established in 1993 in the
College of Medicine, University of Saskatchewan for the purpose of strengthening
population health promotion through fostering research into ways of promoting health.
Since its establishment the Centre has been active in establishing links between
organisations, practitioners, researchers and policy makers; disseminating research
findings; and working through partnerships to offer training in health promotion practice
and research. At the conclusion of it core Health Canada and SSHRC funding in 1998,
the majority of centre activities were implemented through two main initiatives; the
Saskatchewan Heart Health Program – Dissemination Phase (1998-2003) and the
Training for Health Renewal Project (1998-present).
The Training for Health Renewal Project (THRP) currently represents the international
component of the Centre’s work and has been based in Mozambique and Canada. Its aim
is to strengthen the capacities of educational institutions to train health workers in
creating more egalitarian and effective relationships with the communities they serve.
Activities have been focused on those working at the Primary Health Care and
community interfaces in Mozambique. More latterly the project has evolved into a
learning exchange between health practitioners in both countries. Due to finish in 2005,
the Project Co-ordinator would like to see the project evolve into an initiative that
continues to develop the knowledge gained from THRP to inform Canadian and
internationally based practice.
Overall objectives of SHHP (Dissemination Phase) were to reduce the prevalence of risk
factors for cardiovascular and related chronic diseases through the development of
effective health promotion and prevention strategies. In practice much of the work
focused on:
♦ Helping Health Districts build their capacity to plan, implement and evaluate health
promotion activities; and
♦ To understand capacity-building processes to improve health promotion practice.
The evaluation and research elements of this work were secondary to education, training
and general health promotion capacity building elements. The latter consisted of
participation in a range of population health promotion partnerships, in particular with
Sask Health, bi-annual week-long summer schools and Regional training events for
health promotion practitioners. It also included HP Link and “on line” information
exchange opportunities, development of health promotion resources and running
Northern Capacity Building workshops in partnership with the Northern Diabetes
Prevention Coalition.
These activities have been very successful in shifting health promotion discourse and
practice throughout the province from a previous emphasis on health behaviours and
lifestyles to a greater focus on underlying determinants of health and risk conditions.
Findings continue to be influential at provincial and national levels and may even yet
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prove to be of international significance2 and in many respects have put PRHPRC on “the
map”.
Whilst some intersectoral work has been increasingly undertaken in recent years, much of
the PRHPRC’s work in building health promotion capacity has focused within the “health
sector” in the southern half of the province, more representative of culturally dominant
groups3. Much remains to be done regarding the health promotion needs of
Saskatchewan’s Northern and Indigenous communities, as well as other cultural
communities (e.g. ethnic minority groups, women, people with disabilities, children and
youth, lesbians, gay and transgender people) experiencing inequitable access to health
determinants. Changes in the broader (global) context referenced earlier pose new
challenges and opportunities for health promotion. It is not sufficient to consider simply
how the PRHPRC should continue its work; but what that work should be.
Contextual overview
Among prominent features shaping the contemporary population health
promotion landscape are:
♦ Health promotion theory. Bio-medical theory continues to predominate in framing
health issues in popular and political discourse, exerting continuous pressure on
health promotion to focus upon disease processes and/or individual behaviours.
Health promotion as a population health/social practice remains under theorised and
subsumed within bio-medical theory. Some progress was made in the late 1980s and
early 1990s to develop socio-environmental or socio-ecological models of health
promotion, later incorporated into various ‘population health promotion’ approaches.
The regulatory and redistributive requirements of government inherent in such
approaches, however, are inconsistent with the neoliberal model of state minimalism
that dominated the political landscape of the 1990s. More recent efforts to theorize
health, and health promotion, invoking human rights discourse, emphasizing equity
and social justice theory, and building upon more sophisticated social
epidemiological models, are creating a stronger evidence-based argument for a social
determinants-focused practice. This work needs to be capitalised upon, with strategic
research initiatives developed with other Centres to further these tentative
developments.
♦ In from the margins – positioning health promotion. Despite declining marginal
utility in disease treatment, healthcare spending continues to account for the major
share of the health budget (and the public purse). Public pressure for healthcare
2
Research findings have been disseminated via peer refereed journal articles, presentations at local and
international conferences and a monograph by Mclean et al is due to be published shortly.
3
For example, First Nations and Métis communities comprise approximately 15% of the province’s
population and have higher health needs than other groups, health promotion approaches tend to be
Western based, with resources largely concentrated in the Southern half of the province, and only one of
the Health Region health promoters is indigenous.
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spending remains high and few resources are available for public health and health
promotion initiatives. Health promotion’s already marginal position within public
health is to some extent further threatened by burgeoning disease-specific
surveillance and prevention agendas in response to outbreaks of SARS and West Nile
Virus in Canada, and the perceived threat of bio-terrorism. Such initiatives are about
preserving what is a precarious quality of life for many (hence fulfilling health
promotion’s communitarian function of the greatest good for the greatest number),
but with an opportunity cost of interventions that would enhance opportunities for
marginalized/disadvantaged/excluded people to realise improvements in their health
and well-being (hence fulfilling health promotion’s equity function of reducing
preventable inequalities in health between groups). Different positioning challenges
arise with the new pandemics of chronic disease (particularly Type II diabetes and its
correlates in obesity and dietary changes) and health system reform (in particular,
primary health care). In the former case, the risk is a health promotion focus on
individual behaviours; in the latter case, health promotion could be subordinated to
supporting improved access to primary medical care. As a practice, health promotion
needs to consider how it will position itself relative to new public health threats, new
chronic diseases and new medical care reforms to utilise such developments as entry
points for its contributions to interventions on underlying health determinants.
♦ Economic globalisation. International capital flows continue to be significant in
shaping people’s health status and experience of well-being. The introduction of
policies supporting economic globalisation, via liberalized investment and trade in
goods and services, has paralleled increased wealth and health inequities within and
between communities including those of Canada and Saskatchewan. Free trade
policies pose a number of direct health challenges (related to increased privatization
of public services and goods such as health care, education, water/sanitation) and
indirect health challenges (via reductions in national and provincial public health
regulatory capacities that might be challenged for being ‘trade restrictive’). Only
recently have health promotion organizations begun to initiate impact assessments of
these powerful global trends.
♦ Cultural change. The globalisation of capital also structures dynamics of cultural
change within Canada and, to a lesser degree at present, within Saskatchewan.
Transformations of communities and cultural identities are taking place as people
respond to and affect changes in local contexts shaped by the presence of
transnational companies, associated suffusion of largely Western culture (and
certainly of Western products, lifestyles and consumption practices), and workmigration patterns. While such dynamics are less significant in shaping the local
health contexts of Saskatchewan’s communities than in other parts of Canada, the
consolidation of mass media communications in a few Western transnational
corporations means that no Saskatchewan community is immune to the powerful
influences of corporations over public discourse (culture), community life (access to
health determinants) and individual perceptions (beliefs). Given the centrality of
identity and culture to well-being and the promotion of healthy communities, the
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challenge remains for the PRHPRC to engage with these issues of cultural change in
meaningful health promotion research and practice.
♦ The role of health promotion in environmental sustainability. Tensions continue
to exist between environmental sustainability (development that meets the needs of
the present without compromising the ability of future generations to meet their own
needs), economic development and health needs of populations. To date, health
promotion has successfully articulated the importance of economic equity and
associated opportunities for economic self-determination. It has largely failed to
contextualise people as part of the larger biosphere and the entirety of complex
interrelations of which we are part. Environmental sustainability remains a critical
health promotion issue. Health promotion practice must be embedded within
ecological frameworks that aim to achieve harmony between economic,
environmental and health needs, including cultural and spiritual well-being; but that,
of survival necessity, give superordinancy to preservation of life-supporting
ecosystems. An important potential role here is advancing work on health impact
assessments that avoid the technical detailing of environmental impact assessments,
but have sufficient rigour to incorporate an analysis of intergenerational health equity
effects of economic and social development strategies that create environmental
externalities.
♦ Indigenous health status/Indigenous health paradigms. As with other indigenous
peoples throughout the world, inequities in health and well-being remain particularly
entrenched for Saskatchewan’s First Nations and Métis people as the impacts of
colonisation continue. These communities have significantly reduced access to
determinants of health such as housing, employment, adequate income, lower life
expectancy, and escalating rates of type II diabetes, heart disease and cancer.
Particularly relevant to issues of cultural discontinuity are extraordinarily high rates
of depression, alcoholism, injuries and suicide relative to other groups. At the same
time, in Canada and globally, indigenous knowledge and cultures are undergoing
revitalisation and development. Paralleling Western knowledge systems, Indigenous
paradigms and approaches to health are asserting themselves in new ways and in their
own right. Much remains to be done in Saskatchewan and elsewhere to ensure the
sovereignty of these approaches, particularly with respect to how health systems and
structures might promote this. In pragmatic terms, this challenges the PRHPRC to
identify its role in this process, particularly with respect to the IPHRC and other
Indigenous-driven health and health promotion initiatives.
♦ Rural depopulation. Changes in farming technology, market forces and
accompanying farm closures have led to rural depopulation in many of
Saskatchewan’s towns (although it is worth noting that this is a global trend). School,
hospital and other community service closures, and lack of educational and
employment opportunities, further threaten community stability, cohesion and
capacity. Health and human resources, in turn, have largely been channeled towards
meeting the demands of increasing urbanization. Accompanying practice frameworks
(and indicators) tend to be based upon the needs of the majority urbanised population,
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at times obscuring ways of knowing and measuring what is happening within rural
populations. There are at least two challenges this poses for the PRHPRC:
understanding better unique health promotion issues for rural communities under
stress; and also health promotion issues that might be experienced by persons moving
from small rural communities to larger urban centres.
♦ Workforce training education and development remains an issue for health
promotion in Saskatchewan and internationally. New people enter the field and
existing practitioners require ongoing training as the theories and methods of health
promotion continuously develop. Experienced practitioners are also well positioned
to inform health promotion practice and theory. Given its recent and still tentative
emergence as a discipline, health promotion also needs delineation as a distinct area
of practice. Training in Saskatchewan remains ad hoc and underdeveloped and, as
with most other regions, no core competencies have been defined. One means of
addressing this is to develop core competencies and a training and education strategy
in consultation with practitioners and managers at a regional level.
♦ Making a difference – evidence based practice and evaluation. Those trying to
promote population based health promotion initiatives more focused on ‘upstream’
determinants of health are under significant pressure to provide evidence that these
work – i.e. achieve gains in health status, whether for the whole population or for
specific groups. Evidence based health promotion as a whole remains under
developed and many organisations lack knowledge of appropriate frameworks or
skills to apply them. Key issues here also include selection of appropriate
research/evaluation paradigms for health promotion; acknowledgement and better
understanding of the plurality of ‘evidences’ (which include peoples’ experiences and
testimonies); and a more critical approach to the political processes of policy change.
In effect, the unresolved question remains: What evidence matters to whom and why?
♦ Making a difference – beyond ‘building healthy public policy’. Alongside the call
for evidence-based practice is one for ‘knowledge translation’ (KT) of research
findings into policy discourse. Health promotion has long emphasised the importance
of ‘building healthy public policy,’ partly though increased use of health impact
assessments, but, apart from early childhood development, has failed to become a
powerful voice in policy discourse on issues such as poverty and income inequality
reduction, affordable housing, social transfers, sustainable development and other
important health determining policy sectors. Health promotion research, in turn, has
tended to focus on the micro- (or meso-) levels of practice and health systems, and
not on the macro-levels of health determinants. Notions of ‘KT’ now dominant in
health research more generally often pay little attention to the role of interests and
power in shaping policy decisions. The larger question for health promotion, and for
the PRHPRC, is the role of practice, and the role of research, in advocacy with citizen
groups and social movements for alternatives to current policy directions that, over
time, may be inimical to peoples’ health.
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♦ Health promotion – local and international foci. Health promotion is becoming
increasingly internationalised both with respect to the global impacts on health and
the way in which health promotion theory and practice now simultaneously draws on
international and local knowledge and experiences. PRHPRC needs to effectively
balance its local, regional and international initiatives to maximise the health of its
local populations while contributing more widely to international initiatives in
knowledge development and health promotion practice. International initiatives,
particularly those with less economically developed countries must incorporate social
transformation goals aimed at just and sustainable solutions in collaboration with, and
in ways that build the capacities of these communities.
♦ Local level initiatives. Currently a number of initiatives are significant in shaping
provincial health promotion opportunities. These include the Population Health
Promotion Strategy for Saskatchewan, the Saskatchewan Action Plan for Primary
Health Care, the Action Plan for Saskatchewan Health Care and the Northern Health
Strategy. A significant amount of work needs to take place to ensure that the role of
health promotion within each of these embodies thoughtful advances in some of the
new features of health promotion described above, and that ensures a consistent and
reinforcing model of practice that avoids both bio-medical reductionism and a
lifestyle focus, while not negating the importance of either within a comprehensive
health promoting health system.
Saskatchewan’s Communities
Colonial relations have and continue to play an important role in shaping what is today
Saskatchewan. These resulted in the emergence of three broad cultural groupings in
Saskatchewan: First Nations, Metis, (people of indigenous and other ancestry) and the
Homesteaders, farming immigrants from Europe.
For First Nations people contact with Europeans through the fur trade in the 1800s
brought changes that included Christianity, starvation from wild life depletion and
diseases. As pressure for land and settlement of Western Canada grew, governments
increasingly found ways to confine First Nations people to reserves. Cultural assimilation
was a consistent goal of the Indian Act and allied initiatives such as industrial and
residential schools. Such initiatives nearly destroyed First Nations communities through
suppression of economy, language, culture, and spirituality.
Saskatchewan’s Metis people are the descendants of French and Scottish fur traders and
Cree, Dene or Ojibway women. Continually forced off the land, Metis migrated
Westwards, a majority settling in Saskatchewan and Alberta. Unable to compete with
Homesteaders for land ownership and with no legislative rights or protection, many Metis
eventually established themselves on ‘unwanted’ land in the North of Saskatchewan,
where most have since faced lives of poverty and hardship (Government of
Saskatchewan, 2003; Laliberte et al, no date). Today, both First Nations and Metis
communities are re-asserting themselves and in the process face significant challenges.
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Despite the harsh conditions, many of the Homesteaders who came from various parts of
Europe and Eastern Europe such as Germany, and the Ukraine managed to establish
prairie farms and lives for themselves. Many of their descendants make up today’s
farming communities who face significant issues of rural depopulation. Migrants, and in
later years refugees, continue to come to Saskatchewan, from parts of Africa, Asia and
Eastern Europe. These communities face their own particular sets of challenges that
include those of economic, political and cultural marginalization.
Significant demographics4 include:
! Saskatchewan is a largely rural with around 40% of its population living in the
Saskatoon and Regina, the province’s two largest cities.
! Between 1996 and 2001 the population of Saskatchewan decreased from 990, 237 –
978,933
! The proportion of indigenous peoples is significantly higher for the rest of Canada.
Around 14% of the Province’s population identify as Aboriginal contrasted to about
2.3% for the country. By 2016, it is predicted that this figure will have risen to
between 16 and 18%.
! The structure of the Aboriginal population is much different than for the rest of the
province’s population. Young people and children make up a large percentage of First
Nation’s and Metis populations, while the non-aboriginal population is aging.
! Saskatchwan’s Northern communities whose numbers are rapidly increasing face
particular challenges. Largely comprised of aboriginal peoples (84%), the mean
family income is $27,323 compared to $49,264 for Saskatchewan. Thirty seven
percent of the North’s children live in low-income families compared to 19% in
Saskatchewan generally.
! Urban poverty, inequality and polarization remain an issue for many in
Saskatchewan. Disparities between high and low-income neighbourhoods in
Saskatoon have been intensifying since 1980s. Taxfiler analysis clearly indicates
concentration of low-income in Westside neighbourhoods and concentration of lowincome in aboriginal community, many of whom live on Westside. Aboriginal people
accounted for 7.3% of the City’s population and made up 22% of low-income
population - this translates into a 65% poverty rate.
! Saskatoon alone receives 5.2% of Canada’s immigrants each year. Immigrants and
refugees experience earning inequities. They are over represented in lowest income
quintile and under represented in highest income quintile and the gap between
racialized groups and other Canadians grew over the 25 years extending into the late
1990s. Despite some evidence of a ‘healthy migrant’ effect research largely
demonstrates an association between the low educational and socio-economic status
of most migrants and their poorer health, compared to averages in their host country;
4
Sources of this data are: Saskatchewan Bureau of Statistics (2004) Saskatchewan 1996 and 2001 Census
Population; Federation of Canadian Muncipalities (2003) Falling Behind: Our Growing Income Gap;
Population Health Unit. Keewatin Yathe, Mamawetan Churchill River and Athabasca Health Authorities
(2004). Northern Saskatchewan Health Stats report to 2004. Saskatchewan Women’s Secretariat (1999).
Profile of Aboriginal Women in Saskatchewan. Williams and Labonte (2004). Theorising empowerment
for migrant communities: findings from an international study. Unpublished paper.
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and to lesser degrees, the vulnerability of migrants to stress via the disruption of
social, economic and cultural networks.
! Statistics show the increasing vulnerability of subgroups of Canadian population to
poverty and social exclusion. First Nation, Metis, recent immigrants, visible
minorities, persons with disabilities, single parent families and children are more
vulnerable to poverty than other groups.
Overall, these trends indicate the necessity of population health promotion activities
focusing on the equitable access of Saskatchewan’s different population groups to health
determinants. This discussion is continued under the section “towards a concept plan”.
University of Saskatchewan
The University of Saskatchewan is currently undergoing a significant change process as
an organisation. Among strategic initiatives relevant to the Centre’s potential range of
activities within the University’s Integrated Plan (2003/04 – 2006/07) are emphasises on
health, environmental science, Aboriginal academic programmes, out reach and
engagement and international studies. In particular, the College of Medicine’s integrated
plan signals a number of collaborative opportunities that include its Internationalization,
Primary Health Care, Rural Health Care, Urban Underserved and School of Public Health
initiatives.
Where might we go? Stakeholder perspectives
‘It’s important for the Centre to articulate what Population Health Promotion is
and to be a voice of influence at the top managerial levels. An objective, neutral
voice’
This comment articulates a major role the Centre has had and should consolidate - ‘a
voice of influence where decision-making occurs’. Ensuring this outcome means
individually and collectively strengthening each of the Centre’s Research, Evaluation and
Education functions to ensure they form a strong synthesis of theory, evidence and
practice on which to base Centre activities. The following sections (together with the
Contextual Overview section of this report) articulate stakeholder thoughts on each area5.
Research
Stakeholder comments regarding future Centre research role and work predominantly fell
into three broad categories.
5
In line with where the Centre has concentrated most of its activities in the past, much stakeholder opinion
tends to relate to the Centre’s role as a partner and advocate for population health promotion and in the
areas of education and training for practitioners. Beyond broad comments, stakeholders generally found it
more difficult to articulate how the Centre should proceed in terms of research and evaluation. This is
hardly surprising given that many stakeholders have been practitioners rather than researchers and
evaluators and the lower profile of these areas in terms of Centre activities over the past few years.
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The first of these relates to the importance of creating connection and spaces for shared
understanding between players which led to the development of strategic research
initiatives, linking theory, practice and policy. Among stakeholder comments are:
‘We hope the centre will help create a space for dialogue among the interested
research partners and stakeholders in the province’.
‘Help overcome the disconnect between researchers and policy makers and
develop meaningful avenues for partnership’
‘Help create a shared understanding of new collaborating areas around health
research’
The second category relates to the importance of research that is both participatory and
aimed at shifting dominant policy discourse.
‘Research and advocacy work would be useful. Gathering together evidence and
presenting to communities, policy people – e.g. diabetes, could lobby the
government for healthier policies re healthy eating choices’
In particular it is thought that group’s traditionally at the margins of policy discourse
should play a key role in research of this nature.
‘[To] help develop strategies to include specialised groups and communities,
such as Aboriginal and minority communities in health research’.
‘To work with communities to develop research skills. In particular the Centre
could play a role in fostering linkages between community-based women and
the university’.
The third category relates applied research in the area of participatory planning with
communities. Some stakeholders also emphasised the capacity building elements.
‘The Centre should engage in capacity building work with communities to
develop community action plans and mobilise communities’.
Among other comments by stakeholders is the need to pull data together to direct broad
strategies, the need to focus research on specific areas such as barriers and facilitators to
implementing Primary Health Care, and the possibility of the Centre playing a
mentoring role with organizations planning research with regard to a population health
focus. A further suggestion pertained to the breadth of opportunities for theory based
research to be tried out in the regions in terms of program practice and evaluation.
Practice, education and training
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Stakeholder comments regarding supporting health promotion practice through education
and training fell into three broad categories: issues and target groups, types of educational
forums and core competencies.
With respect to the first category (training issues and target groups), comments refer to
past success in shifting the focus of health promotion discourse and practice to health
determinants approaches, whilst also speaking to the importance of continuing to teach
these basic skills. One stakeholder suggests the possibility of the Centre playing a
mentoring role in program development such as ‘work with program areas such as STDs
and addiction programs to put emphasis on determinants of health’, for examples.
Participants also mention the need to teach specific skills such as group facilitation and
proposal writing. A few stakeholders spoke more in-depth about the need to ‘translate
population health promotion concepts into meaningful concrete, practical terms’ so health
promotion practitioners could readily apply these. In particular three areas were
mentioned: partnership development, mental health promotion and primary healthcare.
‘I would like to see mental health promotion [concepts] made more meaningful
in practice. I would like to see PRHPRC assisting in building mental health
promotion capacity’.
‘Capacity building work is needed in the area of partnerships. People have the
concepts, the intellectual ideals, however their practice is not up to it’.
‘There is a huge need for health promotion and community development
capacity building with saskatoon health region staff especially as Primary Health
Care comes more into being’.
Participants also consider it important to broaden the focus of education beyond health
promotion practitioners to managers and board members of Regional Health Authorities
and Family Medicine residents as well as expanding beyond the health sector.
‘[The PRHPRC] could expand its education and training role beyond the health
sector to community and other organizations’.
Particularly in remote areas with fewer resources, train the trainer programs are seen as
potentially useful.
‘I’d like to see the development of appropriate train the trainer programmes to
sustain long term change, perhaps using the concept of a learning design team’.
Stakeholders express a desire to see a greater range of learning forums and opportunities.
These include the continuation of summer schools, shorter learning events, mentoring (as
touched on already with respect to program development) and distance learning
opportunities.
One of the very important roles the PRHPRC has played is bringing
professionals together to learn, enhance their skills and analysis and share stories
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and wisdom. This has occurred through the annual summer schools…..I would
like to see the summer schools continue as well as a commitment to smaller
learning forums throughout the year with different audiences.
I’d like to see distance learning and other innovative forms of learning for
practitioners. A comprehensive health promotion distance learning course would
be very useful.
Learning events are very important – distance learning would need to be
supplemented by support i.e. local support / mentoring to people at local level
re how the long distance learning is going.
The third category signals the importance of developing health promotion standards
throughout the province.
Health promotion doesn’t exist as a profession. It would be great to see some
health promotion competencies developed.
Health promotion requires a dedicated workforce with specialist training and skills. These
can provide people with a more adequate understanding of the dimensions of the field,
may prove useful in assisting to define the boundaries of health promotion as a specialist
field and define the tasks, skills, knowledge and standards of practice expected for
different levels of expertise. However, competencies have been developed in relatively
few countries6. Countries where they have been developed included Aotearoa New
Zealand, Australia and USA and at present the International Union for Health Promotion
and Education are also in the process of developing a statement on Education, Training
and Workforce Development, including international core competencies. However, while
such work may be useful in guiding competency development, this generally needs to be
undertaken in collaboration with health promoters and communities at the local level and
may well have some contextually specific content.
Centre web site development
The Centre web site is potentially a very viable and rich source of information, learning
and networking for practitioners. It has had times of fairly high usage by those engaged in
health promotion activities. Currently this resource is in need of re-direction. The
HPLINK listserv continues to be fairly well subscribed:
The HPLINK listserv is really important – seen by many HP practitioners as a
vital information link – very valuable source of information. Such a diverse
group subscribe – frequency and volume may have slowed lately.
The web site is mentioned as being a valuable learning resource:
6
Some initial work has been undertaken by the Canadian Public Health Association in this area.
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I would really like to see the website providing on-line learning activities in very
specific areas, especially as the populations are so rural. This would be a good
way of reaching practitioners that recognizes the realities of rural Saskatchewan.
Stakeholders also speak of the web site becoming more inclusive of indigenous (First
Nation and Metis) communities and practitioners. Aboriginal specific links, both national
and international have been asked for. Other suggestions include the development of a
web-based resource on community development for practitioners. In particular the
development of key words and definitions (e.g. capacity building, community
development) definitions, learning tools and other linkages. This should be done so that
the Centre comes up when people apply these terms to search engines.
Evaluation
Evaluation of population health promotion initiatives appears to be increasingly
prominent in the minds of practitioners, policy makers and funders. This is hardly
surprising given the current emphasis on evidence-based practice. Most stakeholders
canvassed see evaluation as an important component of the Centre’s future work.
Comments regarding this came from predominantly two perspectives: policy makers and
those purchasing health promotion activities and practitioners.
For those in policy and with an influence on resource allocation roles it is important to
know how to deal with the emphasis institutions have distal population health outcomes.
The drive for the development of evidence based health promotion is driven by pressure
to prove that population health promotion initiatives warrant funding. One stakeholder’s
comments representative of others are:
There is a tendency to focus on health service delivery and accountability
mechanisms. Having population health measures – evidence for what these
programs do is really important ….[The] Provincial government is continually
under pressure to produce better healthcare delivery – more convincing evidence
is needed for effectiveness of population health promotion. There is a need to
develop intermediary measures.
From a community perspective stakeholder comments are:
There is a need for evidence based research…We know at an intuitive level that
we are doing good, but [we] need evidence to prove it – base line and indicators
data. We would like a research partnership with PRHPRC. The University would
provide us with the credibility we need.
There is a current lack of accessible evidence based health promotion – its
difficult to point to the evidential train…….The Centre could support the
development of a research base regarding what makes more effective
practice….Could provide support to community based organisations around
evaluating effectiveness of own interventions. In past [the Centre] has referred
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on, however the centre could now directly support researchers and community
based organisations through pulling information together, making more it
accessible, providing training and working alongside groups.
Several people singled out mental health promotion as an area warranting some attention
in terms of evaluations and developing evidence-based knowledge and practice.
It’s important to research the outcome of mental health promotion initiatives’.
‘Much work needs to be done around mental health promotion indicators – i.e.
evidence based indicators re what is working’.
‘Research and evaluation activities would be really useful. [For example],
evaluation of existing mental health services in relation to the population health
strategy and assistance with re-orientation of services [towards how we see
health promotion’.
PAR
Participatory action research is ideally suited to underpin population health promotion in
a wide range of research, practice and evaluation settings. Simply distilled, the term
represents the synthesis of two traditions: action research and participatory research7. Its
key components are extensive collaboration and a reciprocal education process between
researchers and the community, and an emphasis on taking action on the issues under
study. It is an ideal process for operationalising concepts integral to population health
promotion such as community empowerment, community development and capacity
building, for examples, and may be applied to a wide range of health promotion issues
and settings. It is easily operationalisable in each of the three Centre proposed action
areas – as research that promotes community capacity building and action on health
determinants, as evaluation activities aimed at building organisational capacity for health
promotion or as and education and training activity with practitioners for examples. Its
adult education, knowledge generation and evaluation functions therefore linking,
informing and supporting each Centre action area.
7
Action research is a cyclic process of enquiry through which participants move through successive phases
of action and reflection (evaluation), with each phase informing the next (Kemmis & McTaggart, 2000).
Much action research work is collaborative utilisation focused research with practical goals of systems
improvement (Wallerstein & Duran; 2003). Participatory research emphasises knowledge development
from the perspective of those who are traditionally “the researched” (De Koning and Martin, 1996). It
emanates from liberation theory and the search for new practice by the adult education and development
fields in how best to work with communities vulnerable to globalisation by economically and culturally
dominant societies (De Konning & Martin, 1996; Wallerstein & Duran, 2003). Participatory action research
combines these two functions.
15
Whilst this concept had been very well received by stakeholders aware of its potential for
supporting health promotion activity, very little PAR capacity exists within
Saskatchewan. However, expertise exists within PRHPRC as Lewis Williams and Gerri
Dickson are experienced and knowledgeable in PAR and the Centre is well positioned to
harness other university and community expertise. The development of PAR as a
specialist area of Centre practice will potentially benefit a range of stakeholders including
those engaged in research and evaluation activities from community based organisations,
Regional Health Authorities and intersectoral agencies and university based
constituencies. Centre PAR activities potentially include:
♦ Education and training opportunities for PAR and potential practitioners
♦ Providing examples of best practice via the Centre Website
♦ Consultation with practitioners engaged in PAR projects
♦ Refinement of PAR methodologies as appropriate for different cultural groups and
contexts
♦ Methodological profiling of PAR alongside other knowledge development paradigms
to assist with research and evaluation funding applications.
Charting the future: towards a concept plan
Defining health promotion
Health promotion is commonly defined as activities that enable individuals, groups and
communities to take greater control over health and well-being (Williams and Labonte,
2003).
It is essentially about self-determination or the right of people to live lives they have
reason to value via equitable access to health determinants such as language, economy,
culture, housing, and political structures. Given the centrality of identity and culture8 to
health and the subjective and material elements of health and health promoting activities,
the following qualifying definition is offered:
[Health promotion is] a process of enabling individuals and communities to
express and realise evolving aspirations and consciously constructed identities
and cultural systems through access to capacities [health determinants] such as
land, language, housing, economic resources and decision making institutions
(Williams et al 2004).
Building on this definition there are three conceptualisations that might guide the Prairie
Region Health Promotion Research Centre’s health promotion research, evaluation and
practice development.
8
Culture is conceptualised as a dynamic and multi-faceted phenomenon in a state of continual flux or
evolution. It is broader than ethnicity and is defined as the web or collective matrix of influences that shape
the lives of groups and individuals. Its multi-faceted nature pertains to the variety of cultural systems
represented within any context – for example, ethnicity, gender, sexuality, age, ability.
16
Health Promotion and power-culture
Among the greatest threat to people’s health in wealthier, economically developed
nations such as Canada are economic, cultural and political inequities within these
societies (Health Canada, 2001). This is similarly the case in Saskatchewan. Whilst
absolute poverty continues to be a concern for some communities, it is the inequitable
access to a wide range of health determinants that remains the biggest barriers to health
and self-determination.
One means of conceptualising access to health determinants or capacities for selfdetermination is ‘power-culture’ or the interplay of dynamics of power and culture
operative within any context. Different levels of power (individual, group or institutional)
are brought into dynamic interaction with different cultural systems resulting in various
forms of empowerment or self-determination relations. Dominant power-culture
relations, then, tend to structure and subordinate the expression and realisation of
marginalised group’s aspirations, identities and cultures, either posing a risk to wellbeing or resulting in poorer health status relative to more structurally powerful groups
(Williams, 2001). Pertinent examples of such groups at the margins are Indigenous
peoples’, children and youth, migrant communities, people living on low incomes,
women, people with disabilities, rural communities, lesbians and gay men whose needs
continue to be inadequately reflected in public policy, the most fundamental determinant
of health.
Health promotion research and practice, then, must fundamentally concern itself with
more fully understanding and reshaping dominant power-culture dynamics so as to
increase the capacities and opportunities of such groups to be self-determining and to
live, healthy, meaningful lives, as they each define this.
Health Promotion and ecology
Within Canada and internationally health promotion practice has been largely shaped by
Western paradigms that view the natural world as separate from humankind. While
‘human centred’ approaches emphasise self-determination in relationship to social,
cultural and economic contexts, they largely ignore people’s inherent connectedness or
embeddedness within the natural world. Yet there is strong evidence that the life support
systems on which our economies, and we depend, are being overloaded and unless a shift
is made towards sustainable development, we face irreversible damage to our
environment and ultimately our species (UNEP, 1999).
It is necessary then, to take an ecological approach to health promotion that is concerned
both with the relationships between human beings as well as with the natural
environment. The health promotion context must be viewed as one in which the world
and everything in it is alive, dynamic, interdependent, interacting and infused with
moving energies (Starhawk, 1982). This is consistent with indigenous sciences or ways of
viewing the world within which Western-based, positivist ways of quantification and
measurement make a useful contribution.
17
Respect for bio-diversity or the vast web of life support systems of which we are part,
also implies respect for human diversity including cultural and spiritual practices. The
latter are also inexplicably linked to biological diversity and the range of environments
we inhabit. For indigenous peoples, biodiversity means the extended family – ‘all our
relations’…..’the nurturing, supportive and harmonious relations that link land, the gods,
humans and the forces of nature (UNEP, 2001, p.5).
Health promotion and knowledge paradigms
The third conceptualisation that must underpin centre activity is the appreciation of
different knowledge paradigms. Population health promotion practice is influenced by a
number of competing discourses. These include: 1) culturally specific discourses that
may be broadly categorised as Indigenous and Western knowledge systems; 2) discourses
that frame choices around level and approach to practice9. In summary, present research
and practice is underpinned by particular dynamics of power and culture that ensure the
dominance of some knowledge systems over others.
Particularly relevant to health promotion research and practice in Saskatchewan is the
necessity of re-asserting indigenous paradigms. Specifically, for First Nation people
these are comprised of and include ideas of constant motion and flux, existence
consisting of energy waves, interrelationships, all things being animate, space/place
renewal and all things being imbued with spirit (Cajete, 2000). Ermine’s (2000)
development of the concept ‘ethical space’ is a crucial idea that might usefully illuminate
the impacts and possibilities of cross-cultural activities relative to health promotion
research and practice. The central idea is that the space needs to be envisioned between
the two worlds of indigenous and Western peoples where lack of clarity or understanding
may exist.
Among other paradigms relevant to population health promotion include critical theory,
feminist, constructivist, and positivist paradigms. There is a need to democratise health
promotion research and practice to enlist and enable the full scope of knowledge systems
to come into play for the best benefit of all communities. Given the cultural composition
of Saskatchewan’s communities, defining Indigenous paradigms within their own right
and the relationship of these with Western knowledge systems is of paramount
importance to health promotion within Saskatchewan. The concept of ‘ethical space’
could also be usefully applied more broadly by the PRHPRC in defining other paradigms
and approaches to health promotion.
9
The latter can be broadly categorised into positivist, medical approaches aimed at the elimination of
disease through treatment or individual behaviour change, as contrasted to approaches that start with
communities contexts and definitions of issues and are more orientated to enhancing potential.
18
These three key conceptualisations would usefully underpin the activities of the Prairie
Region Health Promotion Research Centre. In the diagram over page, research,
evaluation and practice (education and training) are identified as three distinct, but related
components. Participatory action research is an area of activity potentially common to all
three that is grounded in the articulation of community world views and aspirations,
reflective practice and public policy advocacy – areas of activity integral to health
promotion practice. In order to advance health promotion research and practice to the
fullest possible extent, this schema and associated centre activity needs to be embedded
in the concepts of power-culture, ecology, and the ethical space between knowledge
paradigms. The diagram over page is a modest attempt to articulate this.
19
POWER-CULTURE
DYNAMICS
Knowledge translation
- evidence for policy
and program action
What’s important to
know for the future
THE ECOLOGY
OF
RELATIONSHIPS
What’s important to
learn from the past
Evaluation
Research
PAR
Practice
Evidence Based
Practice
Practice Based
Evidence
What’s important to do with
knowledge and learning (wisdom)
ETHICAL SPACES
BETWEEN KNOWLEDGE
PARADIGMS
CONCEPT PLAN
Charting the Future: Conceptual Schema for PRHPRC Activities
(Appreciation is extended to Ron Labonte for his input into the development of this diagram)
Selected References
Arundel, C. and Associates (2003). Falling Behind. Our Growing Income Gap. Federation
of Canadian Municipalities.
Cajete, G. (2000). Native Science. Natural laws of interdependence. Santa Fe: Clear Light
Publishers.
Ermine, W. (2000). A critical examination of the ethics in research involving Indigenous
Peoples. Unpublished Masters Thesis. University of Saskatchewan, Saskatoon,
Saskatchewan.
Government of Saskatchewan (2003). Government Relations and Aboriginal Affairs. URL:
www.graa.gov.sk.ca/aboriginal/html/
Labonte, R. (1991) Econology: integrating health and sustainable development. Part one:
theory and background. Health Promotion International, Vol 6 (1), 49-65.
Health Canada (2001). Acting on what we know: Preventing youth suicide in First Nations.
The Report of the Advisory Committee on Suicide Prevention.
Laliberte, R. et Al. (?) The five treaties in Saskatchewan: An Historical overview.
Expressions in Canadian Native Studies. Saskatoon: University of Saskatchewan
Extension Press.
United Nations Development Programme (1999). Cultural and spiritual values of
biodiversity. London: Intermediate Technology Publications.
Population Health Unit. Keewatin Yatthe and Mamawetan Churchill River Health
Authority & Athabasca Health Authority (2004). Northern Saskatchewan Health Status
Report to December 2003.
Saskatchewan Bureau of Statistics. (2004). Saskatchewan 1996 & 2001 Census Population.
Williams, L. (2001). Identity, culture and power: towards frameworks of selfdetermination for communities at the margins. Unpublished PhD thesis. Massey
University, New Zealand.
Williams, Moewaka Barnes, McCreanor. (2004). What do mental health promotion and te
tino rangatiratanga have in common? Toward effective practice in Aotearoa and beyond.
(paper in progress, presented at IUHPE conference, Melbourne, 2004).
Appendix A. Organizations / Groups Represented
Cypress Health Region
Sunrise Health Region
Regina Qu’Appelle Health Region
Sun Country Health Region
Saskatoon Health Region
Keewatin Yatthe Health Region
Mamawetan Churchill River Health Region
Health Promotion Contacts Group
Health Canada
Saskatchewan Health
- Population Health Unit
- Primary Care Branch
- Community Care Branch
- Medical Officers of Health
Northern Medical Services
Kids First North
Saskatoon Communities for Children
Society for the Prevention of Child Handicaps
Federation of Saskatchewan Indian Nations (FSIN)
Meadow Lake Tribal Council
Counselling and Rural Quality of Life Programs, Saskatoon Health Region
Saskatoon Immigrant Women’s Society
Saskatchewan Environmental Network
Saskatchewan Native Theatre Company
Saskatchewan Population Health and Evaluation Research Unit
Prairie Women’s Health Centre of Excellence
Indigenous People’s Health Research Centre
Community University Institutes for Social Research
Centre for Distributed Learning, Extension Division
Environmental Programs, Extension Division
Native Studies, Extension Division
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