1. Public Health, Health Promotion & Population Health
Week 3 & 4: Sept

2. Health Promotion
Health Promotion “A process of enabling people to increase control over and improve their health” (WHO, 1984)
Focuses on…
Broader determinants of health
Intersectoral approaches
Environmental change
Policy and organizational levels
Outcomes such as “social conditions”
Empowering individuals and changing systems (Minkler, 1989)

3. “Change will demand the attention of all individuals, NGOs, business, communities, all levels of government and all sectors of our Canadian society. Success will require leadership from our prime minister and first ministers, from our mayors, municipal leaders, community leaders, and the leaders of our Aboriginal peoples. A whole-of-government approach is required with intersectoral action embracing business, volunteers, and community organizations. This will not be easy, but it can and must be done. We cannot afford to do otherwise.”
A Healthy, Productive Canada, Senate of Canada, 2009

4. INTERSECTORAL
“The complexities of the social, political, economic and environmental factors that influence health and inequities in health and the fact that most of these determinants lie outside of the exclusive jurisdiction of the health sector, necessitate working across sectors of government and society.”
Health equity through intersectoral action: An analysis of 18 case studies, PHAC and WHO, 2008

5. How has the field of health promotion evolved?
The Public Health Era ( )
Medical Model ( s)
Health Promotion Era
Lalonde, “A New Perspective on the Health of Canadians”
Alma Ata Declaration, 1978
WHO adopts ‘Health for All by the Year 2000’,
1980s focus other health determining factors, particularly the environment

6. How has the field of health promotion evolved?
WHO, Ottawa Charter for Health Promotion
Epp, Achieving Health for All: A Framework for Health Promotion
Strategies for Population Health, 1994
Population Health Promotion Model 1996

7. How has the field of health promotion evolved?
Themes of “Decentralization” &“Participation”
Integrated programs vs. sum of a number of small scale programs
Multiple goals and sectors
Active participation of both health and non-health sectors
consumer demand
community coalitions

8. Lalonde Report (1974)
“A New Perspective on the Health of Canadians” Lalonde, 1974
Term ‘health promotion’ used for the first time
Identified factors other than health care that contribute to health
No structural reform-health promotion added to the medical system
Led to lifestyle campaigns-healthy eating, seatbelt, impaired driving

9. Health Field Concept (1974)
Human Biology
Lifestyles
Health
4 fields for health improvement --
Environment
Organization of
Medical Care

10. Health Promotion Touchstones
International Conference on Primary Health Care
Canada’s Health Promotion Directorate established
Declaration of Alma-Alta
health is a human right
gov’ts responsible for health of citizens
people have a duty to participate in health decisions

11. Health Promotion Touchstones
WHO adopted Health for all by the year 2000
Primary health care emphasis
Broad definition of Health
Values for health articulated

12. Health Promotion Touchstones
First International Conference on Health Promotion held in Ottawa
Ottawa Charter for Health Promotion as means towards “Health for All”

13. Ottawa Charter for Health Promotion, 1986 What is the significance?
Defined health promotion as “the process of enabling people to increase control over and to improve their health”
Defined health as “a resource for everyday life”
Belief that the health sector alone cannot create health – intersectoral coordination

14. Ottawa Charter Five strategies for action: build healthy public policy
strengthen community action
develop personal skills
create supportive environments
reorient health services
Includes in definition of health promotion --
-- creation of policies and environments that support healthful decisions and the
-- tailoring of health services to promote preventive, and not just clinical care.

15. Prerequisites for Health
Peace
Shelter
Education
Food
Income
Stable ecosystem
Sustainable resources
Social justice and equity

16. Ottawa Charter for Health Promotion, 1986 What is the significance?
5 strategies for action
Build healthy public policy
Strengthen community action
Develop personal skills
Create supportive environments
Reorient health services

17. 2nd International Conference on Health Promotion, Adelaide
Final Conference Statement
“Peace and social justice, nutritious food and clean water, a useful role in society and an adequate income, conservation of resources and the protection of the ecosystem, are prerequisites for health and social development. The vision of healthy public policy is for achievement of these fundamental conditions for healthy living.”

18. Achieving Health for All: A framework for health promotion
Jake Epp -- National Minister of Health
Companion document to the Ottawa Charter
Outlined realistic actions for government
READ overhead
SWITCH to FRAMEWORK DIAGRAM
Three Challenges -- reduce inequities
-- increase prevention of disease
-- enhance coping
Three Health Promotion Mechanisms
-- to take care of yourself -- Self Care
-- to take care of your family and community -- Mutual Aid
-- to take care of your environment -- Healthy Environments
Three Implementation Strategies
-- fostering public participation
-- strengthening community health services
-- coordinating healthy public policy

19. Epp Report
“. . . We cannot invite people to assume responsibility for their health and then turn around and fault them for illnesses and disabilities which are the outcome of wider social and economic circumstances.”
The Epp Report, 1986
“It’s not that lifestyle choices such as good nutrition and exercise don’t matter – they do.
But a substantial body of evidence has shown that the broader determinants of health have an impact on our lives that is just as strong, if not stronger.”
-- stepping it up, Health Council of Canada, 2010

20. Achieving Health for All, Epp 1986 What is the significance?
Outlined realistic action for government
Three challenges
Reduce inequities
Increase prevention of disease
Enhance coping
Health promotion mechanisms identified
Companion document to Ottawa charter Epp.
Health promotion mechanisms – self care, mutual aid, healthy environments

21. Achieving Health for All Framework (Epp Paper)

22. Strategies for Population Health, 1994 What is the significance?
First time “population health” term is used
The document
Summarized the determinants of health
Provided a framework to guide policy development
Gave strategic direction for cooperation and action
Population Health:
Strategies address the entire range of factors that determine health
Strategies are designed to effect the entire population

24. The Determinants of Health
Income & Social Status
Social Support Networks
Education
Employment & Working Conditions
Physical Environment
Biology & Genetic Endowment
Personal Health Practices & Coping Skills
Healthy Child Development
Health Services
Gender
Culture

25. Population Health & Health Promotion
Created a rift between health promotion and population health
 Population Health Promotion Model

27. Primary Health Care Renewal
Action for Healthier Nova Scotians – 2003
To improve health by a primary health care system that is:
Community-based, family-focused, person-centred
Comprehensive
Responsive & flexible
Accessible
Integrated, collaborative & innovative
Accountable
Sustainable

28. Bangkok Charter for Health Promotion in a globalized world, 2005
To complement & build upon Ottawa Charter
Strategies
Advocate
Invest
Build Capacity
Regulate and legislate
Partner
Commitments to health for all
Make the promotion of health:
Central to global development agenda
Core responsibility for all government
Key focus of communities and civil societies
Advocate for health based on human rights and solidarity
Invest in sustainable policies, actions, and infrastructure to address the determinants of health
Build capacity – policy dev. leadership, health promotion practice, knowledge transfer and research, and health literacy
Reg. and leg. – ensure high level of protection from harm and enable equal opportunity for health and well being for all people
Partner – with public, private , NGOs and civil society to create sustainable actions
Commitment == psychological and designation of institutional resources

29. Inequity or Inequality?
Refers to health differences that may be reduced but not eliminated; may be due to genetics or aging.
Inequity
Refers to differences that are unfair and preventable; action can be taken to reduce inequities
Stepping it Up, Health Council of Canada, 2010

30. Inequities in Health Status
Does higher income and social status provide a buffer or defence against disease?
Does lower income and social status undermine the body’s defenses?
Single most important determinant of health

31. Why Higher Income=Better Health?
Higher income improves ability to:
purchase basic needs such as housing & food
make more choices and feel more in control
Feeling of being in control is basic to good health.

32. Inequity and Illness www.unnaturalcauses.org
Unnatural Causes: Is inequality making us sick?
Video series – brief online intro

33. Income & Social Status Perceived Health Status
47% of Canadians in the lowest income bracket rate their health as very good or excellent compared to 73% in the highest income group
Lower Income Canadians doubly worse off
shorter life expectancies
higher burden of ill health during shorter lifetimes
Compared with higher income groups, regardless of their age, sex, race or place of residence
Influences the degree of control in which people have over their life circumstances

34. Income and Social Status
Top 20% income bracket vs. bottom 20%
Men
live 6 years longer
expect 14 more years disability-free life
Women
live 3 years longer
expect 8 more years disability-free life
Review
After rent incomes of food bank users in 2002 ½ of what they were in 1993
Income differences account for 23.7% excess in premature CVD deaths among Canadians – Dennis Raphael
SWITCH to opaque projector for Whitehall graphs

35. Costs of Poverty In 2005, overall poverty rate – 11% Canadians
BUT 26% lone-parent families; 21% work-limited; 19% recent immigrants; 17% off-reserve aboriginals
11.5% of children under 18 live in poverty
OECD indicates rate in Canada is 15%
Lowest income quintile (working poor & on social assistance) rates of DM & CVD double those in the richest quintile
Income inequality growing in Canada over past 10 years
Now higher than the OECD average
Disproportionate – inequity
OECD – Organization for Economic co-operation and Development
growing poverty rates x10 years – even though had been declining for 20 years – AND higher than OECD average

36. Health Care Costs of Health Inequity
Saskatoon Study
Residents from lower SES areas use disproportionate levels of doctor, medication and hospital services
Mainly due to higher prevalence of disease
Consume 35% more health care resources than higher income
$179 million more than middle-income groups

37. Health Care Costs of Health Inequity
Winnipeg study
Eliminating gap between richest & poorest neighbourhoods could reduce
Heart attacks by 22%
Hip fractures by 20%
Health care costs by $62 million in 1999 or 15% of physician & hospital expenses
PHAC working on report on health status & health care cost by income level in Canada
To be released in 2011

38. Economic Downturn: Coping strategies
Economy tops list of concerns (22%)
Job security second (13%)
Cut household expenses
Out-of-home entertainment (63%)
Spend less for new clothes (55%)
Switch to cheaper grocery brands (55%)
Eat at home more often now
Breakfast (23%); Pack Lunch (26%); Dinner (39%)
Look for deals
Only buy when on sale (44%); use coupons (23%); stock up at sales (18%)
Today – expenditures on food constitute the largest single category for the world at large –
-- 21% in Western developed nations
-- 50+% in developing nations (Paul Rozin, APA journal, 1996)
Canadians surveyed – second on list was job security (13%)
Nielsen, 2009

39. Debt, Obesity, Food Access
German study of household spending during economic downturns
People borrow to make ends meet
7.6% over-indebted (over 6 million people)
Higher prevalence of overweight, obesity, depression, tobacco use
Authors noted
Depression could lead to increased food intake
Eating offers compensation & gratification
Less money may limit leisure & sporting activities resulting in less energy expenditure
Obesity might affect job prospects
First time indebtedness has been shown to be linked to negative health outcomes
-- younger, less educated, lower income
-- higher prevalence of overweight, obesity, depression and tobacco use
Muster, et al., (in press), BMC Public Health

40. Social Support Networks
Support from families, friends and communities
Believing that one is valued as a provider of support for others in need
Helps people solve problems, deal with adversity and give them a sense of control
Results in feelings of satisfaction, well-being and comfort
Social Support Affects:
Mortality (death rate)
Psychological/emotional health
Physical health
Health perceptions
How individuals and families manage disease and illness

41. Social Supports and Health
Most NB health protecting feature is perception of available support
Quality more NB than quantity
Importance placed on support networks varies with situation
Healthiest support relationship is reciprocal
1. My family and friends will always be there for me when I need help
2. My family may be far away, but I can always count on them when I need help.
3. My family and friends have been there for me in the past to share my joys and sorrows.
4. Members of my family will support me when I need it and come to me for support when they need it.
My family and friends know they can always confide in me and ask me for advice.

42. Connectedness & Health
Review of 148 studies (n=300,000+) by Brigham Young University on quality of life
Clear that stronger social relationships increased chance of survival by 50%
Effect consistent across age, sex, health status
Social support likely a ‘buffer’ against stress
-- provides emotional and tangible resources to help us deal with adverse events and illness
-- being part of a social network gives us meaningful roles that boost self-esteem and purpose in life  improve health
-- “We take relationships for granted. We’re like fish that don’t notice the water.” – Timothy Smith, one of the researchers
Low Social Support has been associated with non-adherence at 1-year point to CVD diet suggesting greater risk for CVD
-- study of Family Intervention Trial for Heart Health (FIT Heart)
-- cardiac patients (n=458) 66% female; 35% non-white; mean age 50 years
-- low SS had 2.7 times greater odds of being non-adherent to diet at 1 year vs those with higher SS
Aggarwal, B., Liao, M., Allegrante, J.P., & Mosca, L. (2010). Social support level is associated with non-adherence to diet at 1 year in the Family Intervention Trial for Heart Health (FIT Heart). Journal of Nutrition Education and Behavior, 42(6),

43. Social Cohesion -- Roseto Effect
Study showed a loss of social solidarity
mutual dependence
AND
homogeneity (similarity due to common descent)
led to more deaths from heart attacks
READ -- Roseto synopsis from binder (C-2.20-C-2.21

44. Education & Literacy Higher education = greater health
More opportunities for jobs, job security, and job satisfaction
Improves the ability for individuals to understand the information that will keep them healthy
Supporting Evidence
 self-rated health status
 activity limitations
fewer workdays lost to illness or injury
Equips people with the skills for problem solving
National Population Health Survey
19% of participants with less than high school education rated their health as excellent compared to 30% of University graduates

45. Working Conditions
Variety of factors relate health to employment and working conditions
What are some of these factors?
Hazards/safety issues
injuries
unemployment.fear of unemployment
status
control of participation in decision-making
interactions with co-workers
job demands
physical environment (air, temp, lights, furniture, etc.)
degree of supportiveness for healthy choices (food exercise, day care, job sharing, flex hours)
adequate salary and benefits
stress levels

46. Underemployment and Overemployment
Both issues of concern
Skills not being used
Workers around after lay-offs typically have to work harder or longer than in the past

47. Employment & Working Conditions
People that have more control over their working environment tend to have lower stress levels and often live longer
Supporting Evidence
Between the proportion of Canadian Workers who were very satisfied with their work declined;
Females = 58%  49%
Women aged were most likely to report higher work stress than the average Canadian worker

48. Unemployment and Health
Longer term unemployment
die prematurely
 suicide rates
 cardiovascular disease rates
Spouses and children of unemployed workers
 emotional and behavioral problems
Recovery of physical and mental health after unemployment is neither immediate nor complete.

49. Determinants & Obesity
US study released Dec/2010
Poor women more likely to be obese
Education level linked for both sexes
NCHS study, 2010
N=5000 – part of national surveillance studies

50. Physical Environments
Natural
Human-built
Natural -- land, air, water
Human-built -- housing, workplaces, community facilities, communicaiton links, transportation, indoor air quality

51. Housing and Health Children’s health affected by
overcrowded, poor-quality housing
Children of low income families
more likely to live in poor-quality housing
Children from poorest families almost twice as likely to live in housing needing major repairs than those from wealthiest families.
Over 18% Cnds live in substnd housing
1 in 5 renters spend 50%+ income on housing

52. Personal Health Practices
Individual decisions people make that directly affect their health
Knowledge, behaviours, attitudes, values
Behaviours people choose to do or not do in daily lives
EXAMPLES?? Smoking, food choices, activity patterns

53. Healthy Child Development
Prenatal & early childhood experiences key
Child development greatly affected by housing, neighborhood, family income, and level of parents‘ education, access to nutritious foods, physical recreation, genetic makeup and access to dental and medical care
Supporting Evidence
Experiences from conception to 6 yrs have the most important influence of any time on the life cycle on the connecting and sculpting of the brains neurons.
90% Canadian families lack access to affordable licensed childcare

54. Gender Gender roles defined by culture
Sex-specific difference in disease are biology based
Impact of gender NOT due to biology but to societal attitudes
E.g., differences in income and social status between men and women have major impact on health. These differences are NOT due to biology but to societal attitudes.
Roles, personality traits, attitudes, behaviours, values, relative powers, and influences society assigns to the two sexes
Supporting Evidence
Women are 3 times more likely than men to be poor

55. Culture Whole complex of shared values, beliefs, practices
Binds people together
Gives sense of who we are & where we belong
Shapes our actions
Supporting Evidence
Infant mortality rates among First Nations people between 1979 & 1994 were twice as high compared to the Canadian pop. as a whole
Complex of relationships, knowledge, languages, social institutions, beliefs, values & ethical

56. Culture How we interact with health care system
Participation level in prevention and health promotion programs
Access to health information
Health-related lifestyle choices
Understanding of health and illness
1. Comfortable with technology or traditional medicine?
-- traditionally use health system or rely on family?
-- “allowable” to interact with health professional of diff gender
2. What are customs related to food prep? Which V/F or meats eaten?
-- timing of meals?
-- fasting days?
3. Is info presented in culturally appropriate manner?
-- What is literacy level?
-- transportation available? Child care available?
-- Is asking for help part of culture?
4. Does culture attach high status to risk-taking recreational activities?
-- what items are considered food?
-- does culture support recreational fitness activities?
5. Are beliefs fatalistic or do they believe they have some control?

57. Culture
Determines much of our defn of food, its symbolic meanings, uses, and the social context in which it is consumed or avoided
Culture is in dynamic interaction with biology, the physical environment, and other social and economic forces
David Himmelgreen, 2002, Nutritional Anthropology 25(1), 2-12.
1. Defn of Nutritional Anthropology
This interaction and its effects on food choice will be further explored when we discuss ecological models in the next section.

58. Biology and Genetics
Genetic endowment appears to predispose certain individuals to a particular disease or health problem
Genes can be turned on or off by the environment
ASK for examples
-- rheumatoid arthritis/ lupus
-- cystic fibrosis
-- obesity
-- diabetes – NW ON Cree dx at a rate 5x Cnd nat’l avg (less active lifestyle, new foods, more stress)
-- colon, prostate, breast cancer
-- heart disease, stroke
Visible minorities earn 30% less than whites
2X as likely to be poor
Women, aboriginal people, Cnds of colour, & New Cnds especially vulnerable

59. Spirituality That which gives meaning to life
Not solely based on religious beliefs
Evidence
blood pressure control
strengthened immune system
coping with disease & death
recovery & survival
self-worth and self esteem

60. Health Services
Health services, particularly those designed to maintain and promote health, prevent disease, and to restore health and function contribute to population health
Supporting Evidence
Disease & injury prevention activities in areas such as immunization and mammography are showing positive results
Facilitate community development, empowerment, health promotion
Prevent disease & injury
Educate re: risks and choices
Ensure safe food, water, air
Help maintain independence
Treat & cure emergency injury or illness

61. Interrelated Determinants
“Income is a determinant of health in itself, but it is also a determinant of the quality of early life, education, employment and working conditions, and food security. Income is also a determinant of the quality of housing, the need for a social safety net, the experience of social exclusion, and the experience of unemployment and employment insecurity across the lifespan.”
Social Determinants of Health, Dennis Raphael, 2009

62. Population Health Underlying Assumptions
Health determined by complex interactions
Health of population closely linked to distribution of wealth
Strategies address entire range of determinants
Focusing on population leads to greater health gains
Improving health a shared responsibility
Health is determined by the complex interactions between individual characteristics, social and economic factors and physical environments.
The health of a population is closely linked to the distribution of wealth across the population.
Strategies to improve population health must address the entire range of factors that determine health. Important health gains can be achieved by focusing interventions on the health of the entire population (or significant sub-populations) rather than individuals. Improving health is a shared responsibility that requires the development of healthy public policies in areas outside the traditional health system.

63. INTERSECTORAL
Best practices for addressing poverty point to a broad, integrated approach that engages community partners as well as all orders of government . . .
Reducing poverty: An action plan for Newfoundland and Labrador, 2006
Poverty reduction strategies in some P/T involve gov’t wide integrated approach based on the principles of social inclusion and collaboration
NS – working on gov’t wide child obesity strategy

64. Population Health Promotion Model What is the significance?
Health Promotion is a process for enabling people to take control over & improve their health
Population Health addresses the relationship between the determinants of health & how determinants influence the health of entire populations

65. Population Health Promotion Model What is the significance?
Integrates health promotion and population health
Uses sectors of population health, the determinants of health, and strategies from the Ottawa Charter to guide action
Who? What? How?
Focuses on “whole populations” and “all factors that determine health”
Requires collaborative action
Activity

66. Tips for Better Health: Compare & Contrast
Don’t smoke
Follow a balanced diet
Be physically active
Manage stress
Drink alcohol in moderation
Cover up in the sun
Practice safe sex
Don’t be poor
Don’t have poor parents
Don’t work in stressful low paid manual job
Don’t live in damp, low quality housing
Be able to take vacation
Don’t live next to a busy highway
Making the point of the determinants of health and which ones we might have control over and which ones we don’t and are considered our social determinants of health.
Which do you hear most often as determinants of health
Which do you think the evidence suggests is the most effective approach

67. Hmmm . . .
“. . . It is unacceptable for a wealthy country such as Canada to continue to tolerate such disparities in health.”
Senate of Canada, 2009
“Canada was once an innovative leader in promoting the importance of the determinants of ehalth, starting in 1974 with a landmark report, A new Perspective on the health of Canadians – LaLonde Report.

68. Disease Prevention Primary Prevention Secondary Prevention
How to avoid disease
Control of incidence
Secondary Prevention
How to cure it
Control of duration and hence prevalence
Tertiary Prevention
How to appease it
Control of further complications
Primary -- includes health promotion, some protection initiatives such as immunization, environmental control measures, nutrition and genetic counseling
- deals with people in a pre-disease state or with inapparent disease status
Secondary -- includes screening (for risk -- use of growth charts, cholesterol testing, waist circumference), early diagnosis (to detect and treat disease early -- pap smear, HIV testing, occult blood screening)
- deals with people without apparent disease state (preclinical) and those with manifest early clinical disease
Tertiary -- aims to minimize disability and restore function and productivity of patient (renal dialysis);
- includes rehabilitation and palliative care
- deals with people in early to advanced clinical disease states
Public health will work mainly at the primary prevention level, but with some secondary preventive activities.
Community health will work mainly at the secondary prevention level but with some primary preventive services

69. What are the differences between health promotion and disease prevention?
Health -absence of disease & medical model
Aimed at high-risk groups
One-shot strategy
Strategies focus on individuals and groups
Responsibility of health professionals
Health Promotion
Health – positive and multi-dimensional concept & participatory model of health
Aimed at total population in it’s environment
Many strategies and sectors

70. What are the differences between health promotion and disease prevention?
Language focus – deficits
Goal – problem prevention
People as problems
Eurocentric
Strategy – program, content
External control
Philosophy – control
Meets bureaucratic needs
Feelings  despair
Health Promotion
Language focus – assets, strengths
Goal – healthy development
People as resources
Multicultural, inclusive
Strategy – people, places
Internal control
Meets peoples’ needs
Feelings  hope, motivation

71. Population Health & Health Promotion: Conceptual Differences
Focus on action – strategies for health
Health ‘for the sake of’ health
Grassroots, community oriented action
Focus on qualitative or self-perceived indicators of health
Population Health
Conceptual framework for action and understanding
Gone political – links to economy & productivity
Influence agenda of policy and decision makers
Focus on epidemiology & physiological processes to quantify determinants of health

72. Health promotion vs. Disease prevention
Tensions between two are NOT irreconcilable
Needs reorientation of planners of top-down programs
Systematically consider community empowerment goals within planning framework
To “unpack” health promotion at each stage of planning, implementation, evaluation
To unpack empowerment at each stage of planning – need to ask specific questions
Objective setting – How are the programme objectives and community empowerment objectives accommodated together within the programme?
Lavarack, & Labonte, 2000, Health Policy and Planning, 15 (3),

73. Key Differences between down-stream and up-stream approaches
Root/metaphor
Approach/ orientation
Defn of Problem
Main methods to effect change
Role of outside agents

74. Key Differences between down-stream and up-stream approaches Lavarack, & Labonte, 2000
Main decision makers
Community control of resources
Community ownership
evaluation

75. Health promotion strategies used in community nutrition…
Environmental Measures
Health Education
Advocacy
Mass Comm./ Social Marketing
Health Promotion Strategies
Policy/ Legislation
Self-help / Mutual Aid
Economic Support
Comm. Organization
(Obert, 1986 in Davis, 1989)

76. What is Public Health?
Protect & restore health through application of science, practical skills & collective actions.
Scope includes
Infectious diseases
Chronic diseases
Accidents
READ defn
DEFN – focuses on protecting and promoting people's health through actions of society
-- health promotion, e.g., increasing F/V consumption, reducing tobacco exposure, promote healthy weights attitudes/behaviours
-- health protection -- e.g., food safety issues - protection of the safety of the food supply through Food and Drugs Act, reduce consumption of known contaminants in foods -- posting notices re: contaminated shellfish or training for safe food handling
-- prevention -- reduce risk of chronic disease and disability (CVD, CA, osteoporosis), reducing incidence of LBW babies through high risk prenatal program.
-- surveillance and data systems -- information gathering on causes of death and disability (CVD #1 killer in Canada), surveys of food consumption patterns (Nutrition Canada ; provincial surveys - NS Nt Survey of early ‘90s);

77. What is Public Health?
Looks at person BEFORE he/she becomes a patient – Upstream Approach
Strategies focused on:
Health promotion
 optimal health
Health protection
 exposure to known contaminants
Disease/accident prevention
 risk of chronic disease/disability/accidents
Surveillance and data systems
patterns of behaviours/attitudes
While walking along the banks of a river, a passerby notices that someone in the water is drowning. After pulling the person ashore, the rescuer notices another person in the river in need of help. Before long, the rier is filled with drowning people, and more rescuers are required to assist the initial rescuer. Unfortunately, some people are not saed, and some victims fall back into the rivver after they have been pulled ashore. At this time, one of the rescuers starts walking upstream. “Where are you going?” the other rescuers ask, disconcerted. The upstream rescuer replies, “I’m going upstream to see why so many people keep falling into the river.” As it turns out, the bridge leading across the river upstream has a hole through which people are falling. The upstream rescuer realizes that fixing the hole in the bridge will prevent many people from ever falling into the river in the first place.
FROM p. 4-5, Prevention is Primary. Strategies for community well-being. Cohen, Chavez, Chehimi (2007)

78. Public Health & Community Nutrition
Assesses needs
Plans, organizes, manages, directs, coordinates & evaluates nt services
Establishes linkages
These defns differ from those in the text -- difference in American and Canadian perspectives and semantics
PHNutrition (from ADA, Self-assessment tool for public health nutritionists -- generally refers to the larger picture while Community Nutrition refers to the more specifically targeted programs
Now lets look at the Australian defn --
(from Hughes, R & Somerset S (1997). Definitions and conceptual frameworks for public health and community nutrition: A discussion paper. Australian Journal of Nutrition and Dietetics, 54(1),

79. Public Health & Community Nutrition
Art & science of promoting population health status via sustainable & equitable improvements in the food & nutrition system
Based on public health principles
comprehensive and collaborative activities
inter-sectoral in scope
Again, this defn gives the population focus -- broader community --

80. Public Nutrition
Roots: food insecurity & malnutrition in developing countries
Developed countries: slow progress to improve nutrition of large population segments
 obesity, diabetes, CVD, nutrition related cancers, food insecurity
Address population not individual levels
- first appeared in literature in mid 1990’s
- despite all the advances in biological knowledge accumulated over the last decades there is worldwide ever more increases in …

81. Population Health & Public Nutrition
Population Health Approach
Public Nutrition Approach
Focus on the health of population
Focus on the nutrition of populations
Address the determinants of health and their interactions
Address the determinants of nutrition and their interactions
Demonstrate accountability for health outcomes
Demonstrate accountability for nutrition outcomes