Chapter 1
Part 1
Introduction to
Health Promotion
© John Hubley & June Copeman 2008
Refocusing upstream
"I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I
jump into the cold waters. I fight against the strong current and force my way to the
struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank
and revive him with artificial respiration.
Just when he begins to breathe, I hear another cry for help.
I jump into the cold waters. I fight against the strong current, and swim forcefully to the
struggling woman. I grab hold and gradually pull her to shore. I lift her out on the bank
beside the man and work to revive her with artificial respiration.
Just when she begins to breathe, I hear another cry for help.
I jump into the cold waters. Fighting again against the strong current, I force my way to the
struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay
him out on the bank and try to revive him with artificial respiration.
Just when he begins to breathe, I hear another cry for help.
Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore,
applying artificial respiration that I have no time to see
who is upstream pushing them all in...."
A story told by Irving Zola - but is used in an article by John B. McKinlay in "A Case for Refocusing
Upstream: The Political Economy of Illness" McKinlay, J.B. (1981)
healthy
person
Primary
prevention
onset of
symptoms
(reversible)
Secondary
prevention
screening
case finding
early prevention
advanced
symptoms
(not reversible )
disability
death
Tertiary
prevention
rehabilitation
Death rates from lung cancer (per 1000) by
number of cigarettes smoked, British doctors,
1951-61
Average number of cigarettes smoked per day
Health Field Model
Human Biology
(Genetics)
Lifestyle
(Human
behaviour)
Health
Services
Environment
Human behaviours important for
health promotion
• Community action - actions by communities to change their
surroundings include community participation in health decision-making
• Health behaviours – actions people undertake to be healthy
• Utilization behaviours – utilization of health services
• Illness behaviours - recognition of symptoms and prompt self-referral
• Compliance (adherence) – following course of prescribed medicines
• Rehabilitation behaviours – what people need to do after an
illness/surgery to recover
Saving Lives – Our Healthier Nation
(1999)
This White Paper from the Department of Health for England set the agenda for
health policy for the next decade. Lifestyle and human behaviour was given a
prominent role through its “Ten Tips for Better Health”
1.
2.
3.
4.
Don't smoke. If you can, stop. If you can't, cut down.
Follow a balanced diet with plenty of fruit and vegetables.
Keep physically active.
Manage stress by, for example, talking things through and making
time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practise safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC - airways, breathing, circulation
Mortality from Coronary Heart Disease
men aged 20-64 by social class, England and Wales, 1991-93
England and Wales = 100
Social Class
63
Professional
73
Managerial
107
Non-manual skilled
125
Manual skilled
121
Partly skilled
182
Unskilled
0
50
100
150
200
Standardized mortality
ratios
Source: Office for National Statistics (ONS), Health Inequalities
charts.ppt
Perinatal Mortality Rate
By mother’s country of birth, England and Wales, 1997-99 combined
Rate per 1,000 live & still births
20
15
14.3
13.5
10.2
10
9.6
8.8
7.9
5
0
Pakistan
Caribbean Bangladesh
India
E Africa
UK
The Rainbow model - The main determinants of health
Independent Inquiry into Inequalities in Health report Chairman: Sir Donald Acheson 1998
Jason’s story
"Why is Jason in the hospital?
Because he has a bad infection in his leg.
But why does he have an
infection?
Because he has a cut on his leg and it got infected.
But why does he have a cut
on his leg?
But why does he live in that
neighbourhood?
Because he was playing in the junk yard next to his
apartment building and there was some sharp,
jagged steel there that he fell on.
Because his neighbourhood is kind of run down.
A lot of kids play there and there is no one to
supervise them.
Because his parents can't afford a nicer place to
live.
But why can't his parents afford
a nicer place to live?
Because his Dad is unemployed and his Mom is
sick.
But why is his Dad unemployed?
Because he doesn't have much education and he
can't find a job.
But why was he playing in
a junk yard?
But why ...?"
Towards a Healthy future : second report on the health of the Canadians (1999)
Causes of poor health
Inequality
Social Injustice
Alienation
Lack of
empowerment
Tobacco use
Poor education
Anxiety
Low prestige
Reckless riskPoverty
taking
Excess
illness
Low
productivity
Early
death
Proximal and distant causes of illness and premature mortality,
JR Seffrin Journal of health education Sep – Oct 1997. Vol 28.No4.
An effective response should
• Provide the information and power for
the community to make decisions
• Make the healthy choice the easiest
option
• Remove barriers to action
Health Promotion
The process of enabling people
to increase control over, and to
improve, their health
Ottawa Charter 1986
Ottawa Charter for Health Promotion
Health Promotion - the process of enabling people to increase
control over, and to improve, their health.
Strengthen
Community
Action
Enable
Mediate
Advocate
Develop
Personal
Skills
Reorient
Health
Services
Create
Supportive
Environments
Source: Canadian Public Health Association - An International Conference on Health
Promotion - November 17-21 1986
Promoting health
Health Education
Communication directed
at individuals, families
and communities to
influence:
Behaviour change
Determinants of behaviour
change:
awareness/knowledge
decision-making
beliefs/attitudes
empowerment
community participation
Service
improvement
Advocacy
Improvements in
quality and quantity
of services:
Agenda setting and
advocacy for healthy
public policy:
accessibility
case management
counselling
patient education
outreach
social marketing
policies for health
income generation
removal of
obstacles
discrimination
inequalities
gender barriers
Health education. ‘A process with intellectual,
psychological and social dimensions relating to activities that
increase the abilities of people to make informed decisions
affecting their personal, family and community well-being.
This process, based on scientific principles, facilitates
learning and behavioural change in both health personnel
and consumers, including children and youth.’ (Ross and
Mico, 1997)
Service improvement. Promoting change in services to
make them more effective, accessible or acceptable to the
community.
Advocacy. Activities directed at changing policy of
organizations or governments.
Advocacy
• Influencing policy makers,
leaders and media to raise profile
of health programmes
• Addressing legal, financial and
service obstacles to health action
• Tackling discrimination and
inequalities
Service Delivery
• Improvement in capacity of staff – training
and support
• Development of new activities
• Reorienting existing activities to make them
more effective/acceptable
• Strengthening communication/health
education within services
• Improved patient education
• Outreach to schools, community, workplace
• Involvement of personnel in supporting
community health promotion
Define health promotion
strategy
•
Health promotion
needs/situation analysis
•
•
•
•
•
•
•
•
•
Current situation?
Health needs?
Influences on health
Influences on health actions?
Target groups?
•
•
Health
Promotion
Planning Cycle
Evaluate, reflect, learn
•
•
•
Were our targets
achieved?
What lessons were learnt?
How can we make our
programmes better?
Mix of health education, service
improvement and advocacy?
Health Education approach?
Methods?
Settings?
Persons/groups involved in
delivery?
Timing?
Targets?
Implement
•
•
•
How to put it all together?
How do we overcome barriers?
How to monitor activities?
The ten areas of competencies in public
health identified by
Faculty of Public Health
1.
2.
3.
4.
5.
Surveillance and assessment of the population's health and wellbeing.
Promoting and protecting its health and wellbeing.
Developing quality and risk management within an evaluative culture.
Collaborative working for health.
Developing health programmes and services and reducing
inequalities.
6. Policy and strategy development and implementation to improve
health.
7. Working with – and for – communities to improve health and
wellbeing.
8. Strategic leadership.
9. Research and development to improve health and wellbeing.
10. Ethically managing self, people and resources to improve
health/wellbeing.