Introduction to Health
Promotion and
Population Health
Presentation by Irving Rootman
to SFU Class on Principles and
Practices of Health Promotion
September 13, 2010
Purpose

To provide an introduction to health
promotion and population health
Outline
1. Milestones in the development of health
promotion and population health
2. Concepts and elements of health promotion
and population health
3. Differences and commonalities between
health promotion and population health
1. Milestones in health promotion
and population health
Milestones

1974:
Health Field Concept (Lalonde,
1974)

Human biology

Environment

Lifestyle

Health care organization
Strategies (Lalonde, 1974)

Health promotion

Regulatory

Research

Health care efficiency

Goal setting
Milestones (Cont.)

1978: Health Promotion Directorate
established

1984: Beyond Health Care Conference
(Toronto)
Concept and Principles Document
(WHO-EURO)
Definition of Health Promotion

“the process of enabling people to
increase control over, and to improve,
their health” (WHO-EURO, 1984)
Principles of Health Promotion
(WHO-EURO, 1984)

Involves population as a whole

Acts on the determinants of health

Combines diverse approaches

Aims at public participation

Health professionals have enabling role
Milestones (Cont.)

1986: First International Conference
Ottawa Charter for Health Promotion
(WHO)
Ottawa Charter: Pre-requisites for
Health (WHO, 1986)
Peace...shelter....education...
Food...income
Stable eco-system
Sustainable resources
Social justice
Equity
Health Promotion Action Areas
(WHO,1986)

Building healthy public policy

Creating supportive environments

Strengthening community action

Developing personal skills

Reorienting health services
Health Promotion Approaches
(WHO, 1986)
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Communication
Education
Legislation
Fiscal Measures
Organizational Change
Community Development
Spontaneous Local Activities
Epp, 1986
Milestones (Cont.)

1987: CIAR Population Health Program

1990: Determinants of Health Model (Evans
and Stoddart)
(Evans and Stoddart, 1990)
Milestones (Cont.)

1994:
Milestones (Cont.)

1994:
Health Promotion in Canada (Pederson,
O’Neill and Rootman)
Strategies for Population Health (FPT
AC on Population Health)
Determinants of Health (FPT ACPH,
1994)

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Income & social status
Social support networks
Education
Employment & working conditions
Physical environments
Biology & genetic endowment
Personal health practices & coping skills
Healthy child development
Health services
Strategic Directions (FPT
ACPH, 1994)

strengthening public understanding of the
determinants of health

building understanding of the determinants of
health among sectors outside of health

developing comprehensive intersectoral
population health initiatives
Milestones (Cont.)

1995: Health Promotion Directorate replaced
by Population Health Directorate

1996: Population Health Promotion Workshop
and Paper (Hamilton and Bhatti)
Action Statement for Health Promotion
in Canada (CPHA)
Population Health Milestones

1998: Population Health-Putting Concepts into
Action (Zollner and Lessof, 1998)
Strategies for putting population health
into practice (Zollner and Lessof, 1998)






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Leadership (securing a champion)
Building partnerships across public sector
Engaging private sector
Putting public health to work
Looking for evidence and monitoring success
Making population health attractive
Raising the stakes towards accountability
Population Health Milestones

1998: Population Health, Sustainable
Development and Policy Futures (Hayes
and Glouberman)
Conclusions regarding link between
population health and sustainable
development (Hays and Glouberman, 1998)

Major overlap between population health and
sustainable development is connection between social
sustainability and socio-economic influences on health

Must consider not only short-term, but also medium, and
to some extent long-term goals and outcomes in
creating health policy

Development of policy envelope that considers short,
medium and long-term policy initiatives separately may
be helpful
Milestones (Cont.)

1996: Establishment of Canadian Consortium
for Health Promotion Research

1999: Publication of IUHPE Review on
Effectiveness of Health Promotion
(IUHPE, 1999)

2001: Publication of Evaluation in Health
Promotion (Rootman et al., 2001)
Milestones (Cont.)

2005: 6th WHO Global Conference on Health
Promotion
Bangkok Charter for Health Promotion
in a Globalized World
Required Actions by Bangkok
Charter

advocate for health based on human rights and solidarity

invest in sustainable policies, actions and infrastructure to
address the determinants of health

build capacity for policy development, leadership, health
promotion practice, knowledge transfer and research, and health
literacy

regulate and legislate to ensure a high level of protection from
harm and enable equal opportunity for health and well-being for
all people

partner and build alliances with public, private,
nongovernmental and international organizations and civil society
to create sustainable actions
Key Commitments of Bangkok
Charter
To make the promotion of health:
1. Central to the global development agenda
2. A core responsibility for all of government
3. A key focus of communities and civil society
4. A requirement for good corporate practice
Milestones (Cont.)

2005: Federal Health Promotion Centre
established in PHAC

2007: 19th IUHPE Global Conference on
Health Promotion and Health
Education
Milestones (Cont.)

2008: Report of the WHO Commission on the
Social Determinants of Health (CSDH, 2008).
CSDH Principles of Action
1.
Improve the conditions of daily life—the circumstances in which
people are born, grow, live work , and age
2.
Tackle the inequitable distribution of power, money, and
resources---the structural drivers of those conditions of daily
life—globally, nationally and locally
3.
Measure the problem, evaluate action, expand the knowledge
base, develop a workforce that is trained in the social
determinants of health, and raise public awareness about the
social determinants of health
(CSDH, 2008, p.2)
Milestones (Cont.)

2009: 7th Global Conference on Health
Promotion (WHO)
Nairobi Call to Action

2010:
Questions? Comments?
2. Concepts and other elements of health
promotion and population health
Key Concepts of Health
Promotion

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
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Health
Health Promotion
Empowerment
Healthy Communities
Determinants of Health
Health Literacy
Quality of Life
Definitions of “health”

“...a state of complete physical, mental, and
social well-being and not merely the absence
of disease or infirmity” (WHO,1946)

The normal physical state, i.e. the state of
being whole and free from physical and
mental disease or pain, so that the parts of
the body carry on their proper function"
(Critchley, 1978, p. 784)
Definitions of Health (Cont.)

“the bodily, mental and social quality of life of
people as determined in particular by
psychological, societal, cultural and policy
dimensions.” (Rootman and Raeburn, 1994)
Definitions of “health” (cont.)

“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.
Health is therefore seen as a resource for everyday
life, not the objective of living. Health is a positive
concept emphasizing social and personal resources,
as well as physical capacities.” (WHO, 1986)
Well Being-Being Well Wheel, Circle of Change, 1998
Concept of health for health
promotion in the 21st Century

“In the health promotion domain, health is
equivalent to healthiness and is related to
concepts of resilience and capacity. It refers
primarily to mental and physical dimensions
of healthiness, has strong experiential and
social aspects, and is determined by many
internal and external factors, including those
of a personal, collective, environmental,
political and global nature” (Rayburn and
Rootman, 2007)
Definitions of health promotion

a strategy “aimed at informing, influencing and
assisting both individuals and organizations so that
they will accept more responsibility and be more
active in matters affecting mental and physical
health” (Lalonde, 1974)

“the implementation of efforts to foster improved
health and well-being in all four domains of health”
(physical, social, psychological and personal) (Perry
and Jessor, 1985)
Definitions of health promotion
(cont.)

“the maintenance and enhancement of existing
levels of health through the implementation of
effective programs, services, and policies”
(Goodstadt, et al.,1987)

“the advancement of wellbeing and the avoidance of
health risks by achieving optimal levels of the
behavioral, societal, environmental and biomedicial
determinants of health” (Kar, 1987)
Definitions of health promotion (cont.)

“the process of enabling people to increase
control over, and to improve, their health: (WHO,
1984, 1986; Epp, 1986)

“the process of enabling [individuals and
communities] to increase control over [the
determinants of health] and [thereby] improve
their health” (Nutbeam, 1985)
Definitions of Empowerment

“the mechanism by which people, organizations and
communities gain mastery over their lives”
(Rappaport, 1984)

“a process of helping people to assert control over
the factors which affect their lives” (Gibson, 1991)

“where people are unambiguously in control and
self-determining”(Raeburn & Rootman, 1998)
Psychological and Community
Empowerment

Psychological empowerment is “a feeling of greater
control over their own lives which individuals
experience following active membership in in groups
or organizations” (Rissel, 1994)

“Community empowerment includes a raised level of
psychological empowerment among its members, a
political action component in which members have
actively participated, and the achievement of some
redistribution of resources or decision-making
favorable to the group or community in question”
(Rissel,1994)
Community Empowerment
Model (Rissel, 1994)
Healthy Communities

“A healthy city is not a finished product created at one point in
time; it is a dynamic place where citizens and government have
established relationships and processes that allow them to
collaborate in tackling any problems that arise. The healthy city
approach calls for collective action, in which all the sectors—local
government as well as community, religious and other groups
and individual citizens—work together for a common purpose.”
(Duhl & Hancock, 1997).

A healthy community works to improve its environments and
share its resources so that people can support each other in
achieving their highest potential (World Health Organization,
1997)

A Healthy Communities approach integrates four key building
blocks: community involvement, intersectoral partnerships,
political commitment and healthy public policy (BC Healthy
Communities, 2006)
Determinants of health: definitions

“factors that enhance the health and well
being of the overall population” (PFT ACPH,
1994)
The Mandala of Health, (Hancock and Perkins, 1985)
Social Determinants of Health
“ the high burden of illness responsible for
appalling premature loss of life arises in large
part because of conditions in which people
are born, grow, live, work and age. In their
turn, poor and unequal living conditions are
the consequence of poor social policies and
programmes, unfair economic arrangements,
and bad policies” (CDOH, 2008, p.1)
Social Determinants of Health
“ The Commission focuses on the ‘causes of
the causes’—the fundamental global and
national structures of social hierarchy and the
socially determined conditions these create in
which people grow, work, live and age”
(CSDH, 2008, p.42)
Social Determinants of Health

“Social determinants of health are the
economic and social conditions that shape
the health of individuals, communities and
jurisdictions as a whole” (Raphael, 2009,p. 2)
Health Literacy

“the cognitive and social skills which determine the motivation
and ability of individuals to gain access to, understand, and use
information in ways which promote and maintain good health”
(Nutbeam, 1998)

The degree to which individuals have the capacity to obtain,
process, and understand basic health information and services
needed to make appropriate health decisions (I.O.M., 2004)

The degree to which people are able to access, understand,
appraise and communicate information to engage with the
demands of different health contexts in order to promote and
maintain good health across the life-course (B.C. Health Literacy
Research Team, 2006)
Quality of Life

“The degree to which a person enjoys the
important possibilities of his or her life”
(Quality of Life Research Unit, 2006)
(Renwick, 2004)
(Renwick,
2004)
Integration of HP practice
(Goodstadt, 1999)
Health promotion practice
should be guided by:
Values
Determinants of health
Theory
Evidence
Health promotion action areas
Health promotion strategies
INTEGRATION OF HEALTH PROMOTION PRACTICE
Michael Goodstadt Ph.D., Centre for Health Promotion, University of Toronto, November 10, 1998
HP Action
areas
Theory
Determinants
of health
HEALTH
PROMOTION
PRACTICE
Evidence
HP
strategies
Values
Health Promotion Values


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
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

Empowerment
Participation
Social Justice/Equity
Respect
Priority to common good
Choice
Positive health
Health Promotion Theories




Intrapersonal Health Behavior
Models/Theories
Interpersonal Health Behaviour
Models/Theories
Community and Group Intervention
Models/Theories
Planning and Ecological Models/Theories
Health Promotion Action Areas
(WHO,1986)

Building healthy public policy

Creating supportive environments

Strengthening community action

Developing personal skills

Reorienting health services
Health Promotion Approaches
(Ottawa Charter, 1986)







Communication
Education
Legislation
Fiscal Measures
Organizational Change
Community Development
Spontaneous Local Activities
Ottawa Charter: Pre-requisites for
Health (WHO, 1986)
Peace...shelter....education...
Food...income
Stable eco-system
Sustainable resources
Social justice
Equity
Determinants of health (FPT ACPH,
1994)









Income & social status
Social support networks
Education
Employment & working conditions
Physical environments
Biology & genetic endowment
Personal health practices & coping skills
Healthy child development
Health services
Health Promotion Evidence




Multi-source
Multi-disciplinary
Multi-approach
Multi-methods
Ethical Issues in Health Promotion
(McLeroy, et al.,1987)

Blaming the victim

Marketing health promotion

Determining whose side we are on
Tenets of Population Health
(Frank, 1995)
1.The major determinants of human health
status…are not medical care inputs and
utilization, but cultural, social and economic
factors—at both the population and individual
levels
2.At the population level…societies in which
there is both a high level and relatively
equitable distribution of wealth enjoy a higher
level of health status…
Tenets of Population Health
(Frank, 1995)
3. At the individual level, one’s immediate social and
economic environment and the way this
environment interacts with one’s psychological
resources and coping skills, has much more to do
with the determination of health status than was
recognized in early epidemiological studies of
chronic disease etiology
4. Causal pathways…link the early childhood
environment…to cardiovascular and other major
illnesses and deaths health half a century later
Tenets of Population Health
(Frank, 1995)
5.Extremely important that health policies take
a broad multi-sectoral view…rather than
focusing on the effective, efficient and
equitable provision of health services alone
6.New research insights concerning the current
determinants of health are more likely to
come from a rich mix of interdisciplinary skills
applied to human problems at both the
individual and societal levels
Questions? Comments?
3. Differences and commonalities between
health promotion and population health
3. Differences between Health Promotion
and Population Health (Labonte, 1995)
Health Promotion:
 Questions economic
rationalism
 Draws from broad range of
social sciences
 Health is uncoupled from
disease
 Community focus
 Emphasis on Prerequisites
for health
 Bottom-up
Population Health:
 Espouses economic
rationalism
 Draws heavily from
economics
 Forces health back into
continuum with disease
 Population focus
 Emphasis on Determinants
of Health
 Top down
Commonalities between Health Promotion
and Population Health (Labonte, 1995)
Health Promotion:
 Rejects professional
dominance

Explicitly concerned with
values and a preferred future

Values citizen participation

Aims to increase people’s
control over DOH
Focus is upstream
Aim is health of people and
communities


Population Health:
 Challenges medical
professions privileged place in
health sector
 Moves epidemiology and
health economics toward
socio-economic focus
 Values citizen participation



Recognize importance of
control
Focus is upstream
Aim is health of people and
populations
Population Health Framework
(Hamilton and Bhatti, 1997)
Questions? Comments?