2. HEALTH PROMOTION What is Health Promotion all about?

3. It is the process of enabling people to increase control over and improve their health. (Ottawa H.P. Charter). It is a process which empowers families and communities to improve their quality of life, and achieve and maintain health and wellness. It emphasizes not only prevention of disease but the promotion of positive good health.

4. What is Health Promotion all about? It is a positive concept emphasizing personal, social, political and institutional resources, as well as physical capacities. Health promotion is any combination of health, education, economic, political, spiritual or organizational initiative designed to bring about positive attitudinal, behavioral, social or environmental changes conducive to improving the health of populations.

5. Health promotion is directed towards action on the determinants or causes of health Health promotion, therefore, requires a close co- operation of sectors beyond health services, reflecting the diversity of conditions which influence health. Government at both local and national levels has a unique responsibility to act appropriately and in a timely way to ensure that the ‘total’ environment, which is beyond the control of individuals and groups, is conducive to health. What is Health Promotion all about?

6. Definitions of health promotion “Any combination of health education and related organizational, economic and political interventions designed to facilitate behavioral and environmental changes conductive to health”. (Green LW 1979) "Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual, and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change". (American Journal of Health Promotion, 1989,3,3,5)

7. Health promotion ……. “is the process of enabling people to increase control over and to improve their health” (Ottawa Charter ’86) “involves the facilitation of skills in individuals and change in environments which impact positively on health” (VicHealth 2005) “is everyone’s business” (CEO DHCS 2004)

8. 7 The key principles of health promotion as determined by WHO are as follows: Health promotion involves the population as a whole in the context of their everyday life, rather than focusing on people at risk from specific diseases. PRINCIPLES OF HEALTH PROMOTION

9. 8 Health promotion is directed towards action on the determinants or cause of health. This requires a close co- operation between sectors beyond health care reflecting the diversity of conditions which influence health. PRINCIPLES OF HEALTH PROMOTION

10. 9 Health promotion aims particularly at effective and concrete public participation. This requires the further development of problem-defining and decision-making life skills, both individually and collectively, and the promotion of effective participation mechanisms. PRINCIPLES OF HEALTH PROMOTION

11. 10 Health promotion combines diverse, but complementary methods or approaches including communication, education, legislation, fiscal measures, organisational change, community change, community development and spontaneous local activities against health hazards. PRINCIPLES OF HEALTH PROMOTION

12. 11 Health promotion is primarily a societal and political venture and not medical service, although health professionals have an important role in advocating and enabling health promotion. PRINCIPLES OF HEALTH PROMOTION

13. Health Promotion includes … Promoting healthy lifestyles. Getting people involved in their own health care. Creating an environment that makes it possible to live a healthy life. Recognition of lifestyle diseases as major causes of illness and death. Strengthening community participation.

14. Build healthy public policy Create supportive environments Strengthen community action Develop personal skills Re-orient health services The Ottawa Charter for Health Promotion

15. Examples of preventable health problems related to lifestyle Chronic non-communicable diseases such as diabetes and hypertension. These are major causes of illness and death. They are related to… – Overweight and obesity. – Unhealthy diet. – Insufficient physical activity. HIV/AIDS is related to unsafe sexual lifestyle, and causes many deaths.

16. Intersectoral approach Health Promotion brings together many sectors to work towards the achievement and maintenance of health and wellness. – The Health sector alone cannot achieve a healthy society. – All sectors, both government and non- government, need to work together. – Health Promotion can provide the link between the various sectors. – Within Health the various disciplines also need to work together towards wellness.

17. Some non-health sectors with an input into Health Promotion… Education/ schools Agriculture Community Services Sports Media Non-Governmental Organizations (NGO’s) Community groups Youth Private sector

18. Health sectors with an input into Health Promotion Environmental Health Nutrition Community nursing Mental Health Dental Epidemiology Hospital (secondary) care School of Nursing Occupational therapy

19. Some other sectors which are important Legal Public Works Housing Water Authority Religious Council Alternative medicine

20. Formulating healthy public policy Promotes healthy policies in all sectors, eg healthy workplaces, schools, homes, buildings, villages and communities. Health aspect should be thought of and included in the policies of the various sectors. Health Policies should also emphasize the prevention and promotion.

21. Healthy public policy is a pre-requisite for successful health promotion. A Healthy Public Policy is characterized by a concern for health and equity and an accountability for health impact. Health should be made a priority item on the agenda of policy-makers in all sectors. Policy-makers should be made aware of the health consequences of their decisions. They should create pro-health policies, whether in the area of development, legislation, taxation etc. Formulating healthy public policy

22. According to the Adelaide Conference (1988), “The main aim of HPP is to create a supportive environment to enable the people to lead healthy lives. Healthy choices are thereby made possible and easier for citizens”. All relevant government sectors like agriculture, trade, education, industry and finance need to give important consideration to health as an essential factor during their policy formulation. Formulating healthy public policy

23. Healthy public policy is a pre-requisite for successful health promotion. A Healthy Public Policy is characterized by a concern for health and equity and an accountability for health impact. Health should be made a priority item on the agenda of policy-makers in all sectors. Policy-makers should be made aware of the health consequences of their decisions. They should create pro-health policies, whether in the area of development, legislation, taxation etc. Formulating healthy public policy

24. Reorienting health services Since lifestyle is linked to many of today’s health problems, prevention and promotion should decrease the burden on secondary (curative) health care. – Greater emphasis and resources placed on health promotion and primary health care. – Less emphasis on purchase of high tech equipment for secondary health care. – Equity in health care.

25. Shift of emphasis from provision of curative services. Health care system must be equitable and client-centered. May necessitate reengineering and organizational change, especially in the areas of professional education and training, management, recruitment and deployment of health personnel, and planning, development and delivery of services, Reorienting health services

26. Empowering communities to achieve well-being Involvement of the community in health decisions, a multisectoral and participatory approach. Provide communities with the information and tools to take actions to improve health and well-being.

27. According to the Ottawa Charter, “health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health”. There are many ways of defining community. Factors used are geography, culture and social stratification. Community action is any activity undertaken by a community in order to effect change (including voluntary and self-help services). Empowering communities to achieve well-being

28. Community participation covers a spectrum of activities At the low end, it may be token participation in the form of consultation or endorsing plans drawn up by the health authorities. At the high end, it may be in the form of ‘people power’ where they have full say in identifying needs, setting priorities, planning strategies and activities and implementing the programme. Empowering communities to achieve well-being

29. Full community participation occurs when communities participate in equal partnership with health professionals as stakeholders in setting the health agenda. A Definition (Rifkin et al. 1988) Community participation is a social process whereby groups with shared needs living in a defined geographic area actively pursue identification of their needs, take decisions and establish mechanisms to meet these needs Empowering communities to achieve well-being

30. According to the Jakarta Declaration (1997), “health promotion improves both the ability of individuals to take action, and the capacity of groups, organizations or communities to influence the determinants of health”. Empowerment is an important strategy, based on the notion that health is significantly affected by the extent to which one has control or power over one’s life. Empowering communities to achieve well-being

31. Creating supportive environments Healthy physical, social and economic environment. All development activities should aim for a healthy environment – healthy buildings, roads, workplaces, homes, surroundings and schools.

32. A supportive environment is essential for health. Supportive environments cover the physical, social, economic, and political environment. Supportive environments encompass where people live, work and play. Everyone has a role in creating supportive environments for health. Creating supportive environments

33. Developing /increasing personal health skills Information and education for personal and family health. Take account of values, beliefs and customs of the community. Continuous process at all stages of life. Guided and supported in developing skills (not imposed on them). Build on existing knowledge and attitudes.

34. Strategies for empowering the community include leadership training, learning opportunities for health, and access to resources including material and funding Empowerment helps people to identify their own needs and concerns, and gain the power, skills and confidence to act upon them. It is a bottom-up strategy which requires the health promoter to act as a facilitator and catalyst for change. Developing /increasing personal health skills

35. Skills which can promote an individual’s health include those pertaining to identifying, selecting and applying healthy options in daily life. Health education is life-long, so that people can develop the relevant skills to meet the health challenges of all stages of life, and to be able to cope with chronic illness and disabilities. Health education should be conducted in all settings. Developing /increasing personal health skills

36. Building alliances with special emphasis on the media Media key players, influence on health of people. Partnership with media ensures their collaboration and that correct information is passed on. Free flow of information both ways, on matters vital to health.

37. 36 Building a healthy public policy Creating supportive environments Developing personal skills Strengthening community action Reorientating health services IMPORTANT AREAS FOR CONSIDERATION IN HEALTH PROMOTION

45. Health promotion policy and practice Evidence based interventions EVIDENCE CURRENT HEALTH PROMOTION POLICY AND PRACTICE Evidence Based Interventions Figure 1. Increasing the use of health promotion evidence in policy and practice

46. Capacity Building framework: key action areas Organisational Development Workforce Development Resources Partnerships Leadership NSW Health. 2001 on NSW website

47. 10 Key Action Areas for Health Promotion (Ottawa Charter and Jakarta Declaration) Build healthy public policy Create supportive environments Strengthen community action Develop personal skills Reorient health services towards primary health health care Promote social responsibility for health Increase investment for health development to address social inequalities leading to poor health Consolidate and expand partnerships for health Strengthen communities and increase community capacity to empower the individual Secure an infrastructure for health promotion

48. . Build Healthy Public Policy Both within and outside the health sector (social determinants of health) Approaches such as legislation, fiscal measures, taxation and organisational change. OHS, Council bylaws, school sun care Policy to influence culture e.g. bullying Create supportive environments Create environments (work, home and leisure) that support healthy living? e.g. food choices, suncare, smoke free

49. . Strengthen community action Enable and empower communities, provide resources so they actively participate in health decisions which leads to better health outcomes. They can apply those skills to other situations themselves need to determine what their needs are and how they best can be met. Community development. Capacity building. Reorient heath services Aim for a balance between health promotion and treatment services? How can we work with other sectors whose work impacts on health? Include health promotion in job descriptions, a designated role.

50. Develop Personal Skills (the one we are most familiar with) Provide information, education and skills. Those who gain skills are often the least likely to need them So be creative and reach others e.g. display or health screening or other activity – those who you need to reach may not attend/be able to read etc Build skills at all levels - support others to work in a health promoting way.

51. The health promoting way of working…….. Work with the community to identify priorities Support local initiatives Find out what is already happening Find out what people know and what they think is important Share information Assist with skills development Assist with research & information collection Help to plan community action Provide or assist to locate resources if needed

52. Spectrum of health promotion interventions Strive to develop a mix of evidence based health promotion interventions with a balance of interventions at both an individual and population level that meet the priority outcomes Support these with capacity building strategies (skills and organisational support)

53. Spectrum of interventions e.g. smoking cessation Using smoking cessation as an example and going from the individual to the population level, health promotion action can range from ‘brief interventions’ and advice to community based health promotion and social marketing (media etc.) to policy and legislation such as smoke free areas and access to purchasing.

54. Working in Partnerships Working together toward shared objectives Networking exchange of information, updates and meetings Coordinating exchange information and change activities fro a common purpose eg meet and agree to lobby for better youth services Cooperating exchange info, change activities and share resources. Involves more time and high level of trust eg pool resources to run a health week to address an issue Collaborating all of the above, plus build the capacity of the other partner for mutual benefit and common purpose eg provide funds, staff, facility or other resources (source VicHealth MH Promotion short course)

55. The Swedish Public Health Policy

56. Historical background to the Swedish Public Health policy A good system for vital statistics since 1750 From 1800 construction of community health services A long tradition of popular struggle against the negative health effects of alcohol The concern for the health of mothers and children was an important part of the welfare policy in the 1930’s and further on Universal health insurance. Regional councils responsible for health services A strong political commitment to health Gunnar Ågren 2005

57. A background to present public health work Health has been an important part of social welfare On the other hand no comprehensive public health policy The medical perspective on public health has been very dominating especially after World War II No strong emphasis on prevention with exception for injury prevention and occupational health Primary care not very well developed Gunnar Ågren 2005

58. Factors promoting a new public health policy Increasing costs for health care – a disproportionate amount to highly specialized hospital care. Need for more preventive in health services HIV/AIDS illustrated the need for a comprehensive preventive strategy Increasing concern about inequity in health A strategy group on public health in the government administration was formed in 1987 National Institute of Public Health founded 1992 Gunnar Ågren 2004

59. Vaccination Alcohol Sanitation Rationing of alcohol Ended 1955

60. National Public Health Committee In 1997 a national public health committee was formed All main political parties were represented, a number of experts Many important NGO’s were represented Main task: to propose public health goals and strategies The committee worked for three years, a number of interim reports was delivered The task of the committee – to propose national public health goals which should guide all sectors of the society The goals were approved by the parliament in a revised version 2003. Gunnar Ågren 2005

61. 60 Swedish public health policy- main target areas 1.Participation and influence in the society 2.Economic and social security 3.Secure and favorable conditions during childhood and adolescence 4.Healthier working life 5.Healthy and safe environments and products 6.Health and medical care that more actively promotes good health 7.Effective protection against communicable diseases 8.Safe sexuality and good reproductive health 9.Increased physical activity 10.Good eating habits and safe food 11.Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling.

62. To express the goals in relation to health determinants was an important decision There is an obvious relation between the goals and political actions in order to achieve them The main area of public health work becomes placed outside the health and medical sector If the goals are broadly accepted they will guide actions in many sectors of the society Gunnar Ågren 2005

63. Some problems In some instances it may be hard to show that the fulfilment of a goal leads to improved health. Economists, administrators and others may have difficulties in accepting population health as a desirable political goal Conclusion – you have to provide good scientific evidence in order to promote public health policy Gunnar Ågren 2005

64. A new role for NIPH Monitor the public health policy Centre of excellence in the field of methods in public health policy Supervision of legislation concerning alcohol, tobacco and illicit drugs Support to regions and municipalities Specific programmes concerning HIV and gambling depency

65. How has the public health policy been implemented? The main objectives have been approved by the parliament which gives them a strong political support Indicators for all main objectives have been decided by the National Institute of Public Health after negotiations with other governmental agencies 18 agencies at national level are instructed by the government to participate in the public health policy 8 regions have been instructed to integrate public health into regional development plans More than 50% of the 290 Swedish municipalities have adopted public health programs Gunnar Ågren 2005

66. A public health policy report will be delivered to the government 2005 The report will be based on the 38 main indicators and further indicators in specific areas There will be a report on how the policy have been implemented and what actions have been taken The report will evaluate the policy and discuss prioritizations and revisions Gunnar Ågren 2005

67. 1. 1. Participation and influence in the society Lack of participation and influence harmful for Public Health Lack of participation and influence harmful for Public Health Solid scientific evidence for the causal relation between high demands-low control and disease Solid scientific evidence for the causal relation between high demands-low control and disease Support for local participation, culture, ethnic integration part of the public health policy Support for local participation, culture, ethnic integration part of the public health policy

68. 2. Economic and social security Loss of security causes economic stress Lack of employment and lack of access to social services bad for health The poverty trap: Poverty > disease > lower incomes and higher expenditures > increased poverty Social welfare and equality is good for Public Health

69. Declining employment rate

70. 3. Secure and favorable conditions during childhood and adolescence Childhood conditions important for health later in life Support and education to parents, good child care, health schools Comprehensive maternity care has been very important for the low infant mortality in Sweden Declining mental health among young people a major problem

71. 4. Healthier working life Taking good care of the workforce an important factor for social and economic developement Stress at work-places and lack of influence important problems Worse working conditions for females Large increase in work related health problems

72. 5. Healthy and safe environments and products Integrate environmental policy with public health work Noise and air pollution the most important problems from a health perspective in Sweden Global warming, air pollution – especially indoor, access to fresh water Injury protection is very effective also in economic terms Cooperation against the great global health risks

73. 6. Health and medical care that more actively promotes good health A well developed and accessible primary care important for prevention Maternity and child care of particular importance Integration of medical and social services Health promotion and disease prevention important for the entire health sector.

74. Main problems from a public health perspective Reduced accessability due to high fees Increasing costs for drugs Difficult to control total costs in a market system with a lot of providers Difficult to introduce prevention Lack of cooperation with other sectors in society especially in rehabilitation

75. 7. Effective protection against communicable diseases HIV/AIDS, Malaria och TBC important threats to the entire population and work-force i many countries Most new cases of HIV are infected outside Sweden International cooperation is in the self-interest of all countries

76. 8. Safe sexuality and good reproductive health Unsafe sex the second most important health risk in developing countries Sexually transmitted disease increasing Trafficing an important health risk

77. 9.Increased physical activity Sedentary life-style and lack of healthful physical activity a major health risk Main determinant of Cardiavascular disease, diabetes, osteoporosis, cancer Promotion of physical activity in schools and workplaces an important public health measure

78. 10.Good eating habits and safe food Today approximately 1 billion people suffer from malnutrition Approximately the same number are overweight which is a major cause of premature mortality A unequal distribution of food is a major problem in all parts of the world To much fat and sugar and to little fruit and vegetables the main problem

79. 11. Reduced use of tobacco and alcohol, a society free from illicit drugs and doping and a reduction in the harmful effects of excessive gambling Tobacco the first and alcohol the third determinant of global burden of disease The average taxation on alcohol beverages has decreased internationally The Swedish alcohol consumption of alcohol has increased Tobacco-related mortality increasing internationally but decreasing in Sweden Distribution of illicit drugs an organised market connected with international crime. Sweden has a restrictive policy on illicit drugs

80. Källa: Undersökningen av levnadsförhållanden, SCB Percentage of daily smokers, 16-84 years, 1980-2002 Males Females June 1st 2005 – smoking will be prohibited in restaurants

81. Gunnar Ågren 2005 80 The main tasks of the Swedish National Institute of Public Health National centre of competence in the field of public health Follow-up of the effects of the national public health policy Supervision of the legislation concerning alcohol, tobacco and narcotics Advisory functions to the government Cooperation with research funding agencies and support to coordination of public health research Strategic support to politicians and professionals at regional and local levels, who have the main responsibility for public health work ation and support to professionals at regional and local levels

82. Which are the main Swedish public health problems? 1. The increase in work-related health problems and absence from work 2. The increase in mental health problems, especially among young people 3. The increase in obesity and sedentary life-style 4. The increasing alcohol consumption

84. Possible actions Better working environment Stricter rules for certification of sick leave Better occupational health services Lower benefits during sick-leave Create jobs for people with decreased working capacity

86. Possible actions Restriction on sales and drinking in restaurants Education Harder rules against drinking and driving Information

87. Percentage of the Swedish population reporting insomnia

89. Possible actions Support to parents of small children Better maternity and child care Health promoting schools Increase work opportunities for young people Decrease negative stress in work places and schools

90. Källa: Undersökningen av levnadsförhållanden, SCB BMI, males and females 16-74 years, 1980-2002

91. Possible actions Decrease the intake of fat and sugar. Increase fruit and vegetables.- Pricing? Increase physical activity at least 30 minutes a day (60 minutes for young people) Prescriptions of physical activity and better food habits by doctors Physical activity in schools and work places. Restrictions on food advertisments in TV to children

92. Final conclusions The Swedish public health is still good in an international scale However, considerable health gaps Mental health and self-reported health decreasing, especially among young people A number of threats against the health A national public health policy is important to fight those threats International co-operation important in the field of public health