Shaping the Future of Health Promotion: the Ottawa Charter revisited: Part 2

1. Shaping the Future of Health Promotion: the Ottawa Charter revisited: Part 2 Flora Douglas University of Aberdeen Dec 2nd, 2008

2. Aims • Highlight some of the key values and principles of health promotion (HP), and the tensions and challenges that exist for HP professionals working within the NHS. • Revisit some of the recommendations of the global and national reviews of the future scope of health promotion for the 21st century. • Consider your current practice, and explore how well equipped you feel or otherwise to put HP ideals and values into action in your day-to-day work. • Identify areas for future training and development

3. Another aspiration! • To inspire your thinking about what your need to ‘provide the evidence’ for health promotion – tell its local story – whether it worked…. or not! • What was the problem? • Who did you reach? • What you did you do, and why? • What difference did it make? • What information can you use to ‘evidence’ this? • Otherwise it gets lost in translation – targets and waiting times – (things that are easily measured!) • Policy makers and people are influenced by ‘real life stories’ of the impacts of the socio-economic influences on individuals’ health and well-being.

4. What a difference three months makes! FSTE 100 Share index Jan 2008 till the present

7. Our mandate! • “Scotland’s health is improving rapidly but it is not improving fast enough for the poorest sections of our society. Health inequalities remain our major challenge”. Equally Well 2008

8. Basis of the Ottawa Charter • Prioritised the social model of health. • Targeted wider determinants – health inequalities. • Championed structural adjustment through political, economic and social change – shaped public health at a global level for the past 20 years. • Stated that health promotion must be taken into other sectors, and to and by politicians. Scriven, A., & Speller, V. (2007)

9. 1986 - Health Promotion Principles Inter-sectoral collaboration Participation Empowerment Equity Wills et al 2008

10. Global Human Poverty - one iniquitous driver of the Health Promotion movement http://www.sasi.group.shef.ac.uk/worldmapper/

11. Health promotion: Core values and principles “These values and principles form the habits of mind that provide a common basis for the practice of health promotion.” “These include: a social-ecologic model of health that takes into account the cultural, economic, and social determinants of health; a commitment to equity, civil society and social justice; a respect for cultural diversity and sensitivity; a dedication to sustainable development; and a participatory approach to engaging the population in identifying needs, setting priorities, and planning, implementing, and evaluating the practical and feasible health promotion solutions to address needs.” Galway Consensus Conference Statement 2008

12. Health - pathogenic or salutogenic? Part of the tension lies in the different ways we think about health Or more commonly, negative notions of disease - associated with the medical tradition Positive notions of well-being

13. Just a war of words …or a paradigm struggle? • Debates about terminology have been described as indulgent navel gazing – but Wills and Douglas (2008) argued that this is: • “more than just a struggle over semantics and reflect intense differences in purpose and scope”. • It matters because …..it determines: what we do, and what we are asked to do by government health policy – and, the criteria that is used to judge HPs effectiveness!

14. Health Promotion - Lost in translation? • 1970s - Health promotion first came to be identified as an activity that was a form of education of health for individuals - main purpose was to get people to live healthily. • 1980s – Turning point - recognition that health reflected the contexts and structures in which people lived and worked. • What’s happened since - Polarisation between downstream efforts focussed on the individual change and upstream efforts aimed at tackling social and economic determinants through public policy - characterised much health promotion work for the last 30 years.

15. “Health promotion does not sing with the one tune”Baum 2008 Health promotion although clearly defined within the Ottawa Charter - is, as a profession….contested! Two perspectives 1. Concerned with individuals and their behaviours. • Evidence of efficacy - medical science. • Draws on social reform movements that focus on societies, and the policies that shape the experiences of individuals. • Targets ‘causes of the causes’ - poverty, disempowered communities, toxic environments etc • Different methods of evaluation and evidence base – ethnographic and qualitative . Baum 2008

16. Implications • Ottawa Charter - developing personal skills - came to be associated with a narrow focus on information, education and communication – which reinforced the individualistic emphasis of most of our work to date .Nutbeam 2008 • But the central role of health education is not only to achieve individual outcomes, but also social and environmental outcomes too.Green et al 2008

17. Health Promotion and Globalisation “Increasing inequities and globalisation of economies and markets are bringing rapid changes to the conditions that shape health, .. and these have significant implications for the ways in which health promotion is conceived”.Baum 2008

18. The elephant in the room! Health promotion practice and the political economy. • “….perversely, the election of a Labour government rhetorically committed to healthy public policy.... has contributed to the marginalisation of health promotion as a radical concept supporting social justice and promoting empowerment… and replaced it with a health discourse imbued with an individualised technocratic version of public health” Wills et al (2008)

19. Policy imbalance makes HP life difficult! • WHO HFA marginalised in 1980s – including declaration of Alma Ata universal access to primary care and creating conditions necessary for health. • English health policy narrow epidemiological indicators shifted emphasis to disease related aspects of the European HFA strategy- (was it much different in Scotland?). • Lots of investment in health care, significant under investment in health promotion – Wanless et al 2007 estimated the entire budget for health promotion was less than that spent by the health service in one and half days.

20. Canadian Diagnosis? • The ideology of individualism as the dominant worldview of the political and economic elite. • Increasing influence of the marketplace on public policy. • Positivist approaches to health sciences and evidence making. Raphael et al 2008

21. What’s to be done? • Effective health promotion strategy needs to include interventions and actions at all levels of social organisation – from individual to societal. • And ….at all points along the causal pathway that link upstream political and socio-economic forces to downstream health outcomes. • We cannot look to central policy makers alone for such a strategy! Wills et al 2008

22. Health Promotion: Action at all levels • “[The Ottawa Charter] is a terrific lens to apply to any health area or issue. In the area of food and health for example, it is clear that citizens need personal skills to negotiate the complexities of the food supply, and to better understand what constitutes a healthy diet. However, understanding nutrition or food labelling is of limited value unless supported by environments where healthful foods are available, affordable and accessible. Community action is vital to lobby for better food supplies, and importantly, to bring about policy change….eg. legislation to ban advertising of unhealthy food for children” Coveney, 2008

23. A new role for education within health promotion? • Health promotion has always been concerned with structural as well as behavioural change! • Political and environmental change can only take place if some sort of learning taking place in the stakeholder groups concerned. • Actions to address health inequalities (for example) will be determined not just by the political acceptability of the proposed actions by those in power – but also by public opinion!Green 2008

24. New Approaches – Shaping the Future of Health Promotion 2007 • Putting healthy public policy into practice. • Strengthening structures and processes in all sectors • Empowering communities • Towards a knowledge-based practice • Building a competent health-promotion work-force

25. WHO Commission SD 2008: 3 key principles of action • Improve daily living conditions – the circumstances in which people are born, grow, live, work and age. • Tackle the inequitable distribution of power, money and resources –the structural drivers of those conditions of daily life, globally, nationally and locally. • Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health. • Raise public awareness about the social determinants of health!

26. The public’s health concerns – A key part of the ‘health discourse’ “Public concern for health is expressed in angry rallies against hospital closures and media stories about hospital acquired infections – rather community mobilisation to address the upstream socio-economic determinants of health” Wills et al 2008

27. “What we have here is a failure to communicate” Cool Hand Luke 1967

28. Towards a knowledge-based practice • Health promotion uses complex processes to act on complex social phenomena ………not readily evaluated by traditional experimental research methods. • Evaluation draws on both quantitative and qualitative methods that are the most appropriate for judging the HP actions implemented – be it policy, organisational or individual change. International Union for Health Promotion and Education (2007)

29. Towards a knowledge-based practice • Need for robust information systems to monitor progress – access to good quality data remains a key challenge! (My emphasis) • Need to develop and use indicators that demonstrate health promotion processes, to monitor progress in promoting health, in addition to reducing mortality and morbidity. • Health promoters need to increase their competence in formative and summative evaluation of interventions. --- We’ve just got to get this bit! International Union for Health Promotion and Education (2007)

30. Towards a knowledge-based practice • There has been some progress in convincing the health care evidence ‘industry’ to recognise the importance of evaluating the intervention processes and quality, but significant gaps remain. • Rapid increase in research funding is needed to evaluate complex, community-based health promotion interventions, longitudinal studies, impacts on policy and effect on health inequalities is required. International Union for Health Promotion and Education (2007)

31. Building a competent health promotion work-force • “Workforce capacity and capability for health promotion is well developed in only a few countries and under resourced and entirely lacking in many. • Essential training for health promotion specialists • Developing the knowledge and skills for advocacy and mediation with politicians and the private sector. • Assessing the impact of policies on health and its determinants. • Accessing and using available information and evidence. • Evaluating interventions.

32. Photograph by Frank Hurley showing Mawson in a blizzard Commons Wikimedia GNU Free Documentation License".Guido Gerding Finally, how capable do you feel individually, and organisationally, to address these challenges?

33. Baying at the moon?

34. Hold the phone! • “The most successful public health measures are the ones that are the most radical and most far-reaching and boldest….”, • “The challenge for Government…..is first to get people in Scotland to acknowledge that we’ve got a problem with alcohol misuse, and then get them talking about what we should be doing about it” • Shona Robison Minister for Public Health (1st Dec 2008) Holyrood Magazine

35. Health promoters roles and responsibilities - according to the Ottawa Charter – A reminder! • Advocates - ensuring the conditions favourable to health were in place. • Enablers - facilitating health potential. • Mediators - to advocate between differing interests in society in the pursuit of health.

36. Five health promotion action areas • Building healthy public policy • Creating supportive environments • Strengthening community action • Developing personal skills • Re-orientating health services

37. References • Baum, F. (2008). The commission on the social determinants of health: Reinventing health promotion for the twenty-first century. Critical Public Health, 18(4), 457-466. • Green, J. (2008). Health education - a case for rehabilitation? Critical Public Health, 18(4), 447-456. • Shona Robison (1st Dec 2008) Most successful public health measures are the “most radical” Holyrood Magazine http://www.holyrood.com/content/view/3306/10051/. Accessed 1st Dec • International Union for Health Promotion and Education. (2007). Shaping the future of health promotion: Priorities for action. Promotion and Education, XIV(4), 199-202. • International Union for Health Promotion and Education (2008) The Galway Consensus Conference Statement Toward Domains of Core Competency for Building Global Capacity in Health Promotion 18 June 2008. http://www.vhpo.net/viewtopic.php?f=3&t=25&sid=bb48c98e5716994017ad9cdb3860fd08. Accessed 1st Dec 2008 • Nutbeam, D. (2008). What would the Ottawa charter look like if it was written today? Critical Public Health, 18(4), 435-441.

38. References • Responses to Don Nutbeam's Commentary: What would the Ottawa charter look like if it was written today?(2008). Critical Public Health, 18(4), 443-445. • Wills, J., & Douglas, J. (2008). Health promotion: Still going strong? Critical Public Health, 18(4), 431-434. • Wills, J., Evans, D., & Scott Samuel, A. (2008). Politics and prospects for health promotion in England: Mainstreamed or marginalised? Critical Public Health, 18(4), 521-531. • Raphael, D. (2008). Getting serious about the social determinants of health: New directions for public health workers. Promotion and Education, 15(3), 15-20. • Raphael, D., Curry-Stevens, A., & Bryant, T. (2008). Barriers to addressing the social determinants of health: Insights from the Canadian experience. Health Policy, 88(2-3), 222-235. • Scriven, A., & Speller, V. (2007). Global issues and challenges beyond Ottawa: The way forward. Promotion and Education, XIV(4), 194-198. • World Health Organisation: Commission on the Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organisation.