2 The rationale for health promotion comes from the scope for prevention of ill health and promotion of health. In 2005 World Heath Organization reviewed the global health and produced the breakdown in cause of deaths for UK.Projected deaths in United Kingdom by cause for all ages, 2005(WHO, 2005).
3 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.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 seewho 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)
4 Primary Secondary Tertiary prevention prevention prevention healthy onset of advanced disabilityperson symptoms symptoms death(reversible) (not reversible )Primary Secondary Tertiaryprevention prevention preventionscreening rehabilitationcase findingearly preventionMore effective to prevent people becoming ill than to treat afterwards
5 Annual lung cancer death rates Death rates from lung cancer (per 1000) by number of cigarettes smoked, British doctors,Annual lung cancer death ratesper 1000Average number of cigarettes smoked per day
6 Health Field Model Human Biology (Genetics) Lifestyle (Human Health behaviour)HealthServicesOf considerable influence was the publication in 1973 of the report New perspective on the health of the Canadians by the then Prime Minister of Canada Marc Lalonde. Central to this report was the Health Field Model. This argued that - far from being determined by health services - health was determined by human biology or genetic endowment, environment and human behaviour – See Figure 1.3. The term life style entered the discourse as a key determinant of health.Environment
7 Human behaviours important for health promotion Community action - actions by communities to change their surroundings include community participation in health decision-makingHealth behaviours – actions people undertake to be healthyUtilization behaviours – utilization of health servicesIllness behaviours - recognition of symptoms and prompt self-referralCompliance (adherence) – following course of prescribed medicinesRehabilitation behaviours – what people need to do after an illness/surgery to recover
8 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”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.If you drink alcohol, do so in moderation.Cover up in the sun, and protect children from sunburn.Practise safer sex.Take up cancer screening opportunities.Be safe on the roads: follow the Highway Code.Learn the First Aid ABC - airways, breathing, circulation
9 Mortality from Coronary Heart Disease men aged by social class, England and Wales,England and Wales = 100Social ClassProfessionalManagerialNon-manual skilledManual skilledPartly skilledInequalities in health by social classUnskilledStandardized mortality ratiosSource: Office for National Statistics (ONS), Health Inequalitiescharts.ppt
10 Perinatal Mortality Rate By mother’s country of birth, England and Wales, combinedRate per 1,000 live & still birthsInequalities in health by ethnic groupPakistanCaribbeanBangladeshIndiaE AfricaUK
12 One of the most important criticisms of was that health education approaches. based mainly on behaviour change of individuals, were failing to address inequalities in health. Figure 1.4, shows that anti-smoking programmes in the 1960s had successfully reduced levels of smoking in Great Britain. But the decline had been greater on the professional groups leading to a widening of the gap between rich and poor. Health education, as it was then being practiced, was reaching mainly better off groups of society. It was conclusions like this for smoking and other health problems that led to a rethinking of health education and the emergence of the broader notion of health promotion.
13 The Rainbow model - The main determinants of health A series of reports exposed the inequalities in health between geographic regions, social classes and ethnic groups. The most significant of these was the Acheson Report in 1998 which drew on the ‘Rainbow model’ of Dahlgren and Whitehead (1991) shown in Figure 1.5 to show that inequalities were a result of an interaction of many factors in society and called for the following actions to tackle inequalities:breaking the cycle of inequalities;tackling the major killer disease;improving access to services;strengthening disadvantaged communities;targeted interventions for specific groups.Independent Inquiry into Inequalities in Health report Chairman: Sir Donald Acheson 1998
14 Jason’s story"Why is Jason in the hospital? Because he has a bad infection in his leg.But why does he have an Because he has a cut on his leg and it got infected. infection?But why does he have a cut Because he was playing in the junk yard next to hison his leg? apartment building and there was some sharp, jagged steel there that he fell on. But why was he playing in Because his neighbourhood is kind of run down.a junk yard? A lot of kids play there and there is no one to supervise them. But why does he live in that Because his parents can't afford a nicer place to neighbourhood? live.But why can't his parents afford Because his Dad is unemployed and his Mom isa nicer place to live? sick.But why is his Dad unemployed? Because he doesn't have much education and he can't find a job. But why ...?"The chain of events by which structural factors in society influence health is shown in Jason’s story reproduced in Box 1.7Towards a Healthy future : second report on the health of the Canadians (1999)
15 Causes of poor healthInequalitySocial InjusticeAlienationLack of empowermentTobacco useAnxietyReckless risk-takingPoor educationLow prestigePovertyExcess illnessLow productivityEarly deathProximal and distant causes of illness and premature mortality, JR Seffrin Journal of health education Sep – Oct Vol 28.No4.
16 An effective response should Provide the information and power for the community to make decisionsMake the healthy choice the easiest optionRemove barriers to action
17 Health PromotionThe process of enabling people to increase control over, and to improve, their healthOttawa Charter 1986
18 Ottawa Charter for Health Promotion Health Promotion - the process of enabling people to increase control over, and to improve, their health.StrengthenCommunityActionDevelopPersonalSkillsCreateSupportiveEnvironmentsEnableMediateAdvocateReorientHealthServicesBuildPolicyPublicHealthySource: Canadian Public Health Association - An International Conference on Health Promotion - November18
19 Promoting health Service improvement Health Education Advocacy Improvements inquality and quantity of services:accessibilitycase managementcounsellingpatient education outreachsocial marketingHealth EducationCommunication directed at individuals, families and communities to influence:Behaviour changeDeterminants of behaviour change:awareness/knowledgedecision-makingbeliefs/attitudesempowermentcommunity participationAdvocacyAgenda setting andadvocacy for healthy public policy:policies for healthincome generationremoval ofobstaclesdiscriminationinequalitiesgender barriers
20 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.
21 AdvocacyInfluencing policy makers, leaders and media to raise profile of health programmesAddressing legal, financial and service obstacles to health actionTackling discrimination and inequalities
22 Service DeliveryImprovement in capacity of staff – training and supportDevelopment of new activitiesReorienting existing activities to make them more effective/acceptableStrengthening communication/health education within servicesImproved patient educationOutreach to schools, community, workplaceInvolvement of personnel in supporting community health promotion
23 Health Promotion Planning Cycle Define health promotion strategyMix of health education, service improvement and advocacy?Health Education approach?Methods?Settings?Persons/groups involved in delivery?Timing?Targets?Health promotion needs/situation analysisCurrent situation?Health needs?Influences on healthInfluences on health actions?Target groups?Health Promotion Planning CycleImplementHow to put it all together?How do we overcome barriers?How to monitor activities?In planning a health promotion intervention a number of decisions are involved that are summarised in Figure 1.9. Embedded in those decisions are the debates considered in the previous section. By adopting an approach based on needs assessment, experiment and evaluation health promotion becomes an evidence-based pragmatic iterative approach involving analysis and reflection.Evaluate, reflect, learnWere our targets achieved?What lessons were learnt?How can we make our programmes better?
24 The ten areas of competencies in public health identified by Faculty of Public Health 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.Policy and strategy development and implementation to improve health.Working with – and for – communities to improve health and wellbeing.Strategic leadership.Research and development to improve health and wellbeing.Ethically managing self, people and resources to improve health/wellbeing.