1. Chapter 1 Part 1 Introduction to Health Promotion
© John Hubley & June Copeman 2013

2. 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 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)

3. Primary Secondary Tertiary prevention prevention prevention
healthy onset of advanced disability
person symptoms symptoms death
(reversible) (not reversible )
Primary Secondary Tertiary
prevention prevention prevention
screening rehabilitation
case finding
early prevention
More effective to prevent people becoming ill than to treat afterwards

4. Health Field Model Human Biology (Genetics) Lifestyle (Human Health
behaviour)
Health
Services
Of 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 1.2. The term life style entered the discourse as a key determinant of health.
Environment

5. 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

6. 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 1.4 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

7. 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 his
on 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 is
a 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 1.7
Towards a Healthy future : second report on the health of the Canadians (1999)

8. Causes of poor health
Inequality
Social Injustice
Alienation
Lack of empowerment
Tobacco use
Anxiety
Reckless risk-
taking
Excess illness
Low productivity
Poor education
Low prestige
Poverty
Early death
Proximal and distant causes of illness and premature mortality, JR Seffrin Journal of health education Sep – Oct Vol 28.No4.

9. 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

10. Health Promotion
The process of enabling people to increase control over, and to improve, their health
Ottawa Charter 1986

11. Ottawa Charter for Health Promotion
Health Promotion - the process of enabling people to increase control over, and to improve, their health.
Strengthen
Community
Action
Develop
Personal
Skills
Create
Supportive
Environments
Enable
Mediate
Advocate
Reorient
Health
Services
Build
Policy
Public
Healthy
Source: Canadian Public Health Association - An International Conference on Health Promotion - November 18

12. Promoting health Service improvement Health Education Advocacy
Improvements in
quality and quantity of services:
accessibility
case management
counselling
patient education outreach
social marketing
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
Advocacy
Agenda setting and
advocacy for healthy public policy:
policies for health
income generation
removal of
obstacles
discrimination
inequalities
gender barriers

13. Health Promotion Planning Cycle
Define health promotion strategy
Mix of health education, service improvement and advocacy?
Health Education approach?
Methods?
Settings?
Persons/groups involved in delivery?
Timing?
Targets?
Health promotion needs/situation analysis
Current situation?
Health needs?
Influences on health
Influences on health actions?
Target groups?
Health Promotion Planning Cycle
Implement
How 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, learn
Were our targets achieved?
What lessons were learnt?
How can we make our programmes better?

14. 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.