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

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)

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

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

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

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

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)

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 1997. Vol 28.No4.

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

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

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 17-21 1986 18

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

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?

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.