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HEALTH PROMOTION IN CANADA

CRITICAL PERSPECTIVES

SECOND EDITION

EDITED BY

MICHEL O’NEILL ANN PEDERSON SOPHIE DUPÉRÉ IRVING ROOTMAN

Canadian Scholars’ Press Inc. Toronto Health Promotion 5/1/07 11:18 AM Page iv

Some images and text in the printed version of this book are not available for inclusion in the eBook.

Health Promotion in Canada: Critical Perspectives Second Edition edited by Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman

First published in 2007 by Canadian Scholars’ Press Inc. 180 Bloor Street West, Suite 801 Toronto, Ontario M5S 2V6

www.cspi.org

Copyright © 2007 Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman, the contributing authors, and Canadian Scholars’ Press Inc. All rights reserved. No part of this publication may be photocopied, reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, or otherwise, without the written permission of Canadian Scholars’ Press Inc., except for brief passages quoted for review purposes. In the case of photocopying, a licence may be obtained from Access Copyright: One Yonge Street, Suite 1900, Toronto, Ontario, M5E 1E5, (416) 868-1620, fax (416) 868-1621, toll-free 1-800-893-5777, www.accesscopyright.ca.

Every reasonable effort has been made to identify copyright holders. CSPI would be pleased to have any errors or omissions brought to its attention.

Canadian Scholars’ Press Inc. gratefully acknowledges financial support for our publishing activities from the Government of Canada through the Book Publishing Industry Development Program (BPIDP).

Library and Archives Canada Cataloguing in Publication

Health promotion in Canada : critical perspectives / edited by Michel O’Neill ... [et al.]. — 2nd ed.

Includes bibliographical references and index. isbn 978-1-55130-325-3

1. Health promotion—Canada—Textbooks. I. O’Neill, Michel, 1951–

ra427.8.h45 2007 613'.0971 c2007-901472-0

0708091011 54321

Cover art: “Happy Friends (children)” © Daniela Andreea Spyropoulos. From www.istockphoto.com. Cover design, interior design and layout: Susan MacGregor/Digital Zone

Printed and bound in Canada by Marquis Book Printing Inc. Health Promotion 5/1/07 11:18 AM Page v

During the course of the year that we spent working together on this book, the circle of life continued to touch our lives. Each of us would like to honour the past and celebrate the future by dedicating this book to the memory or new life of people near and dear to us. Michel would like to honour Laurent Pauzé-Dupuis, who passed away in Beijing on April 3, 2006, and was the best friend of Sébastien Couchesne-O’Neill, his son, to whom he wishes a great journey in his future life as a scholar and sociologist. Ann would like to celebrate the birth of Nicholas Good, her grandson, on October 31, 2005, and to remember the passing of her mother-in-law, Marion Spruston, on February 18, 2006. Irv would like to express joy for the birth of his first grandson, Tobyn Rootman, on September 23, 2005, and to acknowledge the passing of his uncle, Sam Rootman, on February 10, 2006, and his son David’s fiancé, Zoey Quarter, on December 6, 2006. Sophie would like to ded- icate this book to the memory of her grandfather, Jacques Champagne, who died on March 22, 2006, and whose passion and dedication to his family and work has always been a great source of inspiration for her. This page intentionally left blank Health Promotion 5/1/07 11:18 AM Page vii

TABLE OF CONTENTS

Acknowledgements ...... x Foreword: Health Promotion in Canada and the 19th World Conference of the International Union of Health Promotion and Health Education...... xiii Marcia Hills and David McQueen Chapter 1: Introduction: An Evolution in Perspectives ...... 1 Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman

PART I: CONCEPTUAL PERSPECTIVES ...... 17 Chapter 2: A New Appraisal of the Concept of Health ...... 19 John Raeburn and Irving Rootman Chapter 3: The Promotion of Health or Health Promotion? ...... 32 Michel O’Neill and Alison Stirling Chapter 4: Points of Intervention in Health Promotion Practice ...... 46 Katherine L. Frohlich and Blake Poland Chapter 5: Health Literacy: A New Frontier...... 61 Irving Rootman, Jim Frankish, and Margot Kaszap Chapter 6: Addressing Diversity in Health Promotion: Implications of Women’s Health and Intersectional Theory ...... 75 Colleen Reid, Ann Pederson, and Sophie Dupéré

PART II: NATIONAL PERSPECTIVES ...... 91 Chapter 7: The Federal Role in Health Promotion: Under the Radar...... 92 Lavada Pinder Chapter 8: Addressing Health Inequalities in Canada: Little Attention, Inadequate Action, Limited Success...... 106 Dennis Raphael Chapter 9: Developing Knowledge for Health Promotion...... 123 Irving Rootman, Suzanne Jackson, and Marcia Hills

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PART III: PROVINCIAL PERSPECTIVES...... 139 Chapter 10: Health Promotion Program Resilience and Policy Trajectories: A Comparison of Three Provinces ...... 141 Nicole F. Bernier Chapter 11: 12 Canadian Portraits: Health Promotion in the Provinces and Territories, 1994–2006 ...... 153 Ann Pederson

PART IV: INTERNATIONAL PERSPECTIVES...... 205 Chapter 12: Promoting Health in a Globalizing World: The Biggest Challenge of All? ...... 207 Ronald Labonté Chapter 13: Canada’s Role in International Health Promotion...... 222 Suzanne F. Jackson, Valéry Ridde, Helene Valentini, and Natalie Gierman Chapter 14: The Impact of Canada on the Global Infrastructure for Health Promotion...... 237 Maurice B. Mittelmark, Maria Teresa Cerqueira, J. Hope Corbin, and Marie-Claude Lamarre Chapter 15: Views on the International Influence of Canadian Health Promotion...... 247 Sophie Dupéré

PART V: PRACTICAL PERSPECTIVES ...... 299 Chapter 16: The Reflexive Practitioner in Health Promotion: From Reflection to Reflexivity ...... 301 Marie Boutilier and Robin Mason Chapter 17: Building and Implementing Ecological Health Promotion Interventions ...... 317 Lucie Richard and Lise Gauvin Chapter 18: Health Promotion and Health Professions in Canada: Toward a Shared Vision ...... 330 Marcia Hills, Simon Carroll, and Ardene Vollman Chapter 19: Two Roles of Evaluation in Transforming Health Promotion Practice ...... 347 Louise Potvin and Carmelle Goldberg Health Promotion 5/1/07 11:18 AM Page ix

PART VI: CONCLUDING THOUGHTS ...... 361 Chapter 20: Health Promotion: Not a Tree But a Rhizome...... 363 Ilona Kickbusch Chapter 21: Has the Individual Vanished from Canadian Health Promotion? ...... 367 Gaston Godin Chapter 22: Conclusion: The Rhizome and the Tree ...... 371 Sophie Dupéré, Valéry Ridde, Simon Carroll, Michel O’Neill, Irving Rootman, and Ann Pederson Copyright Acknowledgements ...... 389 Index ...... 392 Health Promotion 5/1/07 11:18 AM Page x

ACKNOWLEDGEMENTS

s was our experience in preparing the first edition, the enthusiasm of the contributors— A who numbered over 60 people this time as compared to 25 in 1994—has supported and inspired us throughout the process of putting the book together. We think this support for our project reflects the co-operative culture of health promotion as well as individual contributors’ personal commitment to the field of health promotion. Key ideas for our own analyses emerged through our interactions with all the contributors; however, we are especially grateful to the country and the provincial contributors whom we forced to work within tight space constraints so we could maximize the number of perspectives provided. Everybody worked graciously within tight deadlines and we are also very grateful about that, know- ing how everybody is overextended these days. We have released a version of this book in French and would like to release versions in other languages as another way of nurturing the exchanges and alliances we think are so important for the evolution of the field beyond our traditional boundaries within Canada and abroad. We therefore thank CSPI whose enthusiasm and professionalism was as great as if they had been one of our authors, particularly publisher Jack Wayne, who facilitated publication in other languages, and managing editor Megan Mueller with whom we have had an extremely rewarding partnership. We also extend our thanks to the Faculté des sciences infirmières de l’Université Laval, and especially to Carole Laverdière, for providing much appreciated support for many of the operational aspects of the book; to the Réseau de recherché en santé des populations du Québec, which helped the publication through a grant in its scholarly publications program; to the British Columbia Centre of Excellence for Women’s Health for providing support to Ann Pederson’s involvement with this project; and to the Michael Smith Foundation for Health Research for its financial support of Irv Rootman based at the Centre for Community Health Promotion Research at the University of Victoria through a Distinguished Scholar Award. We would also like to thank the two external reviewers who provided us with feedback on the draft manuscript and the large group of reviewers who commented on the first edition; all the feedback has helped us to reflect more critically upon our work and we trust it has improved the quality of the final product. Thanks also to Karine Aubin, Aïssata Moussa-Abba, and Samira Dahi, all doctoral students in the community health program at Laval University, who played a variety of crucial roles in finalizing the manuscript. Finally, we would like to thank our families and friends from whom we borrowed time to complete this book, particularly Francine Courchesne, Barry Spruston, and Barb Rootman.

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Acknowledgements ■ xi

A NOTE ABOUT THE FRENCH VERSION Une version française de cet ouvrage est disponsible aux Presses de l’Université Laval, à Québec, intitulée «La promotion de la santé au Canada et au Québec, perspectives critiques» sous la direction de Michel O’Neill, Sophie Dupéré, Ann Pederson, et Irving Rootman. On peut la commander au [http://www.pulaval.com/index.html].

A NOTE FROM THE PUBLISHER Thank you for selecting the second edition of Health Promotion in Canada: Critical Perspectives. The publisher has devoted considerable time and careful development (including meticulous peer reviews at proposal phase and first draft) to this book. We appreciate your recognition of this effort and accomplishment.

TEACHING FEATURES This volume distinguishes itself in several ways. One key feature is the book’s well-written and comprehensive part openers, which add cohesion to the section and to the whole book. The contributors have added pedagogy, including questions for critical thought, annotated further readings, and annotated related Web sites. There are also figures, tables, and boxed inserts throughout the book. This page intentionally left blank Health Promotion 5/1/07 11:18 AM Page xiii

FOREWORD HEALTH PROMOTION IN CANADA AND THE 19TH WORLD CONFERENCE OF THE INTERNATIONAL UNION OF HEALTH PROMOTION AND HEALTH EDUCATION

Marcia Hills and David McQueen he editors of this book are to be congratulated on revisiting the theme of health pro- T motion in the Canadian context, following up on the successful first edition of the book. This new edition promises to have an even greater impact on the field than the first, given that this is no mere update, but an entirely original set of chapters that push the boundaries of thinking and reflection on health promotion’s place in Canada and Canada’s influence internationally on health promotion. It also arrives on the international health promotion scene at a critical juncture when a resurgence of interest in the social determinants of health presents a great opportunity, but also a great challenge for the future of the field. It will enter the public sphere just at the time that Canada hosts in Vancouver, in June 2007, the 19th World Conference of the International Union of Health Promotion and Education (IUHPE). As co-chairs of the scientific program of the 19th World Conference, we recognize that the questions raised by this book have helped to shape this event, will guide future directions in the field, and are likely to contribute greatly to the crucial discussions raised in Vancouver. The book offers a superb retrospective survey of where health promotion in Canada has travelled in the last decade or so, both at the federal level and in each of the provinces. Readers will learn much about the wax and wane of health promotion’s prospects in the Canadian context and international readers will find these important reflections informative for their own struggles to advocate for policy change and to improve practice in their respective countries. While the latter excellent set of reflections is what a reader might expect of a new edition of a book that did such a good job the first time around, a pleasant surprise awaits in the very substantial new contributions the book makes to strengthening and informing health promotion practice with fresh theoretical perspectives. It is particularly impressive that many of the chapter authors have managed to take up this emerging concern with theory’s role in health promotion and what particular theoretical perspectives might offer for the future of health promotion research, policy, and practice. An innovative addition has been made to one of the original book’s strengths in including international perspectives on Canada’s role in health promotion globally. In the first edition, one of the authors of this foreword (McQueen) was an international contributor, along with two other authors (Larry Green and John Raeburn). The editors have obviously felt that this international perspective needed to be broadened, particularly in expanding beyond the narrow confines of the Anglo-Saxon world (the US and New xiii Health Promotion 5/1/07 11:18 AM Page xiv

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Zealand) and have managed to fashion a much larger section that includes a true diversity of global perspectives on Canada’s role in health promotion. This is a welcome addition that reflects health promotion’s important recent efforts to move beyond a Eurocentric and Western bias in its priorities and concerns as, for instance, in IUHPE’s global program on the effectiveness of health promotion in which both of us are deeply involved. Another innovation that deserves praise and credit is the decision by the original editors to bring in Sophie Dupéré as a fourth editor, signalling an effort to include the emerging leadership in the field and to reflect this inclusion with several substantive contributions from younger authors. This explicit strategy is very important as it addresses a reflection by many senior people in the field that health promotion needs to do a better job in allowing the next generation of health promoters to develop and flourish as the originators of the field pass on the torch in the long-distance struggle to impact systemic change. In conclusion, if the contents of this substantial and insightful book are any indication of where health promotion is moving, then we can be reassured that the field will meet many challenging obstacles, yet has an equally great potential to progress and to further the promotion of health. Once again, this edition shows why Canada has had such an important role to play in the development of health promotion globally and we are convinced that IUHPE’s world conference in Vancouver will be another very significant opportunity to actualize this interface. Health Promotion 5/1/07 11:18 AM Page 1

CHAPTER 1 INTRODUCTION: AN EVOLUTION IN PERSPECTIVES

Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman

he first edition of this book was released prise people who are unaccustomed to think- Tin 1994, 20 years after the Lalonde Report, ing of Canada as playing important roles on under the title, Health Promotion in Canada: the global scene—international and Canadian Provincial, National, and International developments in health promotion are closely Perspectives. In that book we looked with a crit- intertwined. Canada has been—and still is— ical eye at health promotion in Canada over perceived as an important, if not the leading, those 20 years, particularly the period follow- country for the development of the field ing the release of the Ottawa Charter for Health worldwide (though we will argue that this is Promotion in 1986. Today, more than a decade sometimes for the right and sometimes for the later, we are aware that Canada continues to wrong reasons). Second, we want to explain be regarded as a powerhouse of health pro- the aim of the first edition of the book and motion around the world. As researchers, stu- what we achieved. Together, these two ele- dents, and practitioners, we want to ments will frame our third goal, the explana- understand and document what has happened tion of the aims of this second edition. over the last 10–12 years with respect to the Some dates and events will be constantly evolution of health promotion in Canada, as referred to in the rest of the book; these are the well as to understand Canada’s role within the often-recited litany of the main milestones of field internationally. Accordingly, in contrast the field here in Canada and abroad. We want to many other books in this field, this book is to enunciate these landmarks at this point so not a “how-to” book in health promotion, the reader has the entire context and story cor- explaining how to develop and/or evaluate rect at the beginning: 1951, the year of the effective interventions (e.g., programs, policies, foundation and the first global conference of and so on), but rather a book on health pro- the International Union of Health Education motion as it is practised in Canada and how (IUHE), sending the signal that health educa- what happens in Canada links to what is hap- tion, as both a professional and scientific pening throughout the rest of the world. endeavour, was sufficiently mature to create In this introductory chapter, we therefore its own international organization; 1974, when want to accomplish three things. First, we A New Perspective on the Health of Canadians want to remind the reader of the general evo- (the famous Lalonde Report) was released; lution of health promotion as a field, interna- 1979, the year the World Health Assembly tionally and in Canada, using elements from adopted its “Health for All by the Year 2000” several chapters that appeared in the first edi- resolution as a follow-up to the Alma-Ata con- tion of the book but do not appear in the ference on Primary Health Care, which had second. As we will see—though it may sur- been held the year before; 1986, the year of the 1 Health Promotion 5/1/07 11:18 AM Page 2

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first World Health Organization (WHO) modify the health of Canadians” (Badgley, International conference on health promotion, 1994, p. 21). According to him, the “dissem- held in Ottawa, at which two major docu- ination of sanitary information” became an ments were released: an international one (the important concern in the 1880s for the provin- Ottawa Charter for Health Promotion) and a cial, and newly established federal govern- Canadian one (Achieving Health for All, also ment (following the British North America known as the Epp Report); 1994, which turned Act of 1867), but this was in a context in out to be the watershed year between health which the need for this information was “[…] promotion and population health in Canada so apparent to everybody as not to need proof” when two influential books were published: (Badgley, 1994, p. 22). This missionary zeal the first edition of this book (Pederson, O’Neill, among sanitary reformers dominated the field & Rootman, 1994) and Why Are Some People for several decades, up to the end of World Healthy and Others Not? (Evans, Barer, & War II. The production of pamphlets and Marmor, 1996); and, finally, 2007, the year in posters, the writing of books and newspaper which the health promotion world will come columns, as well as, later, the production of back to Canada, this time in Vancouver, for film strips and the broadcast of radio mes- the 19th global conference of the International sages, occupied most of the time, energy, and Union for Health Promotion and Health resources at the central levels, with scarce Education (IUHPE) and which we think is public health personnel relaying this infor- the year in which the timid renewal of com- mation in one-to-one or small group situa- mitment to health promotion that we observed tions at the local level. According to Badgley, in Canada over the last two or three years will very little interest was devoted to scientifically either flourish or vanish. grounding or evaluating these activities. We will return to these dates and events Similar developments were underway in the discussion that follows, positioning in most industrialized countries (e.g., see them within three broad time periods: the Green and Kreuter [1999] for a discussion of years prior to the Lalonde Report of 1974; developments in the United States), and it 1974–1994, which was the period covered by was only in the late 1940s and early 1950s that the first edition of our book; and 1994–2007, a more systematic and scientific approach to the period covered by this second edition. educating the public on health matters began to emerge. In 1951, in response to the need to link together those working on health edu- BEFORE 1974: THE HEALTH cation and to promote the exchange of expe- EDUCATION ERA rience and information on these new ways of In the first edition of the book, Robin Badgley working, a group of European and North (1994) traced the various types of activities American public health people, under the and programs undertaken by the public leadership of two Frenchmen, Léo Parisot authorities of Canada (be they local, provin- and Lucien Viborel, created in Paris what cial, or federal), from the early 1600s through was to become the most important interna- to the middle of the 19th century, to promote tional non-governmental organization in the the health of the “colony’s” population. He field: the International Union for Health argued that, “for a period of some 250 years, Education (Modolo & Mamon, 2001). a regulatory philosophy was the main means From then until the mid-1970s, in the by which government sought to protect and industrialized world the dissemination of Health Promotion 5/1/07 11:18 AM Page 3

INTRODUCTION: An Evolution in Perspectives ■ 3

health education information was increasingly Hopkins School of Hygiene and Public targeted toward the professional–patient Health in Baltimore. encounter (primarily the doctor–patient These developments gradually seeped relationship) to make sure that the patient into the day-to-day practice of health educa- understood and used the information pro- tors in Canada, as elsewhere (Badgley, 1994), vided. The general public also became the and were reflected in programs, manuals (e.g., target of the campaigns of health education Gilbert, 1963), and the training of personnel. specialists, initially in order to encourage the These practices were built upon a deeply proper use of the health services (especially rooted, virtually unquestioned belief that edu- preventive ones) governments were estab- cating the public was intrinsically good; the lishing in the post-World War II welfare state hope was therefore that health would era. Over time, it became clear that an epi- improve with the help of science and a more demiological pattern of so-called “diseases of systematic way of conducting health educa- civilization” was rapidly displacing the earlier tion. All this occurred, however, in a context pattern of infectious disease in industrialized in which public health and health education countries. When it was observed that the risk services, which were almost the only type of factors for these new sources of mortality (e.g., health-related governmental intervention up cardiovascular diseases, cancers, accidents) to the 1950s, were quickly dwarfed and even- were largely behavioural, these “at-risk” tually marginalized as the governments of behaviours themselves (e.g., smoking, seden- Western industrialized societies became heav- tary lifestyles, eating habits, etc.) became the ily involved in establishing public acute med- prime targets of health education. ical care systems (Gilbert, 1967). What also distinguished this era from the pre-1950s period was a conscious and sustained effort to ground health education 1974–1994: FROM HEALTH interventions scientifically and to recruit EDUCATION TO HEALTH other kinds of scholars and practitioners PROMOTION besides health personnel in this task. The It became increasingly obvious during the 1950s and 1960s thus witnessed the increas- 1970s that health education was not having ing involvement of social scientists (mostly the desired effects, and that individuals, social psychologists and sociologists) and though better informed, did not necessarily communication specialists in the develop- adopt the healthful behaviours expected of ment of models to try to understand and pre- them. A series of events resulted in signifi- dict health-related behaviour and/or in the cant revision to the way health education had design of health education campaigns. These been conceived up to that point and led to its scientific developments largely occurred in transformation into health promotion. the United States, which did not undergo the post-war reconstruction of the European nations and thus had greater resources avail- The International Scene able for such purposes. It was during this Internationally, the mid-1970s marked the end period, for instance, that the famous Health of 30 years—often called the “glorious thir- Belief Model (Becker, 1974), the first of a long ties”—of sustained growth within the Western series of theoretical models of individual post-war economies. This economic situation health behaviour, was conceived at the Johns allowed the “welfare state” to flourish in the Health Promotion 5/1/07 11:18 AM Page 4

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1950s and 1960s. In Canada, as in most It was in this context that the Lalonde Western countries (with the notable exception Report, released in 1974, received immedi- of the US, which never established the same ate worldwide attention because it was the level of welfare state infrastructure), govern- first document by the central government of ments were sufficiently wealthy to become a major developed country advocating for involved in insuring the welfare of their pop- the importance of investing resources beyond ulations through the direct or indirect provi- health services for the health of populations sion of services to fulfill basic needs, notably in (Lalonde, 1974). As seen in Box 1.1, the the sectors of health and education. “health field concept,” introduced in A New However, a major reorganization of the Perspective on the Health of Canadians, iden- world economy, triggered by the so-called tified four sets of factors—later to be called “oil shocks” of 1973 and 1976, completely “determinants of health”—that contributed changed this picture. The “glorious thirties” to the health of populations. In contrast to all were followed by 20 gloomy years of economic stagnation or minimal growth within or so, the report made the novel suggestion the Western economies, which deprived gov- that governments stop investing solely in pro- ernments of taxation revenues and forced viding more acute care services and instead them to borrow heavily to maintain the level seriously consider addressing the three other of public services they had committed to pro- sets of factors through a “health promotion” vide to their populations. approach.

BOX 1.1: ELEMENTS OF THE HEALTH FIELD CONCEPT

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In the following months and years, in the developed world and had been almost given the macro-economic context alluded irrelevant for the developing world. The to above but seldom made explicit, almost Alma-Ata conference thus suggested a every Western industrialized country pro- return to the basics—to “Primary Heath duced its own version of the Lalonde Report, Care” (PHC) and to address the set of issues encouraging investment in areas other than described in Table 1.1. health systems, which were increasingly dif- In response to these recommendations, ficult to finance through public monies. This and mindful of the economic context, the min- context also produced a major international isters of health of most countries of the world expert conference in 1978, co-sponsored by gathered in what is called the World Health two UN agencies (WHO and UNICEF), at Assembly (the supreme decision-making body which delegates proposed that the world stop of the World Health Organization), and voted investing in costly acute care systems, rec- in 1979 for the famous “Health for All by the ognizing that after more than 30 years, such Year 2000” (HFA) resolution, which pro- systems had not yielded the expected results posed a set of measures in keeping with the Health Promotion 5/1/07 11:18 AM Page 5

INTRODUCTION: An Evolution in Perspectives ■ 5

TABLE 1.1: PRIMARY HEALTH CARE AS DEFINED IN THE ALMA-ATA DECLARATION

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spirit of the Lalonde Report and the Alma-Ata played in the international developments that declaration. These measures were further followed the HFA resolution of WHO. operationalized in a global strategy in 1981 Ilona Kickbusch, then chief officer of (see Box 1.2). Health Education at the European division of the World Health Organization (WHO- Euro) based in Copenhagen, has described a The Canadian–European Connection chain of events that began with the imple- The events that took place in Canada from mentation of HFA in Europe in the early the release of the Lalonde Report to the 1980s and ultimately led to the transforma- proclamation of the Ottawa Charter are very tion of Health Education into Health well described and analyzed by Lavada Promotion (Kickbusch, 1986, 1994). Aware Pinder in Chapter 7 in this book, so we will that many of the concerns articulated by not reproduce them here. What we will high- PHC and HFA (access to clean water, basic light, however, is the central role Canada immunization of populations, etc.) were Health Promotion 5/1/07 11:18 AM Page 6

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BOX 1.2: WHO GLOBAL STRATEGY FOR HEALTH FOR ALL BY THE YEAR 2000

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largely irrelevant in Europe and that health in health education and self-help whereas in education was the key strategy to address, Canada they examined the implementation Kickbusch and her European colleagues of the Lalonde Report. It was quickly appar- toured the world and came to North America. ent that Canada’s social-democratic political In the US, they looked at the developments climate was more compatible with Europe Health Promotion 5/1/07 11:18 AM Page 7

INTRODUCTION: An Evolution in Perspectives ■ 7

than the neo-conservative one that had the First International Conference on Health already begun to take hold in the US Promotion held in Ottawa in 1986. (Kickbusch, 1994). A very close collaboration A key outcome of this collaboration was with a few Canadian individuals and insti- to demonstrate the importance of environ- tutions was then established, which led to the mental factors in health, which—although production by the European Office of WHO identified by the Lalonde Report—had of the “Yellow document” on health promo- received only limited attention in Canada tion (WHO-Euro, 1984) and ultimately to (Labonté & Penfold, 1981) and elsewhere.

FIGURE 1.1: NEW PUBLIC HEALTH FORCEFIELD

Image not available Health Promotion 5/1/07 11:18 AM Page 8

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The health education community had international Health Promotion Conferences, already begun to articulate its own internal aimed at better understanding two of the critique during the second half of the 1970s strategies proposed in the Ottawa Charter— (Brown & Margo, 1978; Freudenberg, 1978), healthy public policy and creating support- conscious that providing health information ive environments—were held in Adelaide, alone and focusing on individual behaviour Australia, in 1988 and in Sundsvall, Sweden, could lead to “blaming the victim” for its in 1991 respectively. health problems (Ryan, 1976). Critics charged It is well documented that the years that changing the environment should immediately following the release of the become as much a concern for health educa- Ottawa Charter and the Epp Report were very tion as changing individual behaviour if it important ones for health promotion within was to ensure, as Nancy Milio (1986) Canada (see Pinder’s chapter). Some additional famously said it, that the “healthiest choice resources were given to the Health Promotion became the easiest choice.” Environments Directorate of Health and Welfare Canada, had to become supportive of, rather than bar- programs and initiatives to follow up on the riers to, individual changes. Epp Report were started, and a knowledge To signal this evolution from a tradi- development strategy was established. Many tional, individually focused health education, of these developments were described in detail the words “health promotion” were key in in the first edition of the book, as well as two the ecological, multi-level models that important federal initiatives, the Strengthening emerged in 1986 following the years of col- Community Health project (Hoffman, 1994) laboration between Canada and WHO- and the Healthy Communities initiative Euro. These models paid particular attention (Manson-Singer, 1994), both of which reflect to environmental factors without dismissing the flurry of activity of the period. the others. This is clear in Kickbusch’s own work (1986) (see Figure 1.1), in the Ottawa Charter (WHO, 1986) (see Figure 1.2), which The First Edition of the Book was the international consensus emerging out The original intuition that led us to the prepa- of the first international conference, as well ration of the first edition, which analyzed the as in the Canadian document Achieving 1974–1994 period, was a strong sense of cog- Health for All (Epp, 1986) that was launched nitive dissonance between what we heard in then (and which is discussed in greater detail our travels about the role of Canada in health in Pinder’s chapter). promotion and what we observed at home. More specifically, while Canada may have been regarded as the world leader in health 1986–1994: promotion, we observed a large gap between The Golden Era of Health Promotion the international reputation of the federal After 1986, health promotion received sig- government and the actual practice of health nificant international attention. Following promotion provincially (the provinces and the development of the European program, territories having the constitutional respon- its main international champion, Ilona sibility for health services). We wanted to Kickbusch, was moved to WHO headquar- explore this intuition from a historical and ters in Geneva to develop a global health pro- critical perspective using a sociology of motion strategy. The second and the third knowledge approach. Our view was that Health Promotion 5/1/07 11:18 AM Page 9

INTRODUCTION: An Evolution in Perspectives ■ 9

FIGURE 1.2:THE OTTAWA CHARTER

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what happens in a field can be better under- tually become more aware of these issues and stood if we observe the various actors who are better equipped to deal with them. promoting it or blocking it at one moment in What we concluded at the end of the first time, and what discourses and instruments of book (O’Neill, Rootman, & Pederson, 1994) power they use to do so in the general socie- was related to both Canada’s position in the tal context in which they operate. Our intent global health promotion scene and to the evo- was to help the field reflect on itself and even- lution of health promotion within Canada. Health Promotion 5/1/07 11:18 AM Page 10

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Immediately prior to our conclusion, though, social democratic and conservative political in a provocative paper, one of the key pioneers parties to justify their reorganization of the of the health promotion movement both in health care system of their respective juris- Canada and internationally argued that in diction. Moreover, we saw a persistent, 1994 the movement had “won a battle,” but entrenched approach to health promotion as was far from having “won the war” (Hancock, individual lifestyle change rather than the 1994). Hancock argued vociferously that to more structural ones espoused in official dis- really make a difference, health promoters course. Finally, despite the fact that some should become more political and enrol in people may have hoped otherwise, we con- party politics, especially in the Green Party as cluded that health promotion was clearly not its value base was closest to the one promoted a widespread social movement in Canada, by health promotion. despite the growing importance in the gen- However, as editors, we did not go in the eral population of lifestyle and quality of life same direction as Hancock. With respect to issues. Rather, it appeared to us to be more international developments, we were able to of a “professional movement” promoted by document the impact of the WHO- small groups of public health professionals, Euro/Canada alliance in the evolution of the academics, and community leaders. Later, field from health education to health promo- and probably supported by other movements tion, as noted above, and to identify key indi- with related discourses and ideologies like viduals and institutions. We also noted the the feminist or the environmentalist ones, beginnings of the mainstreaming of health health promotion had proposed (with a cer- promotion, as was evident, for instance, in its tain degree of success) a new discourse on use in the reconstruction of the health systems health, which had been adopted by various of Central and Eastern European countries. political constituencies but, as mentioned We recognized the potential tensions of this above, was used in a variety of ways (if at all). transition when, in the words of sociologist We were thus interested in what would Max Weber, the “charisma” of the early pio- happen in the next decade and offered a few neers is “routinized” and loses some of its predictions for what we thought might original purity and vision, but is embraced happen both in Canada and internationally. and serves a much larger group of people. We will return to those at the end of this Finally, we were convinced that the future of second edition, but let us now consider the health promotion would be directly influ- time period covered by this book. enced by the future direction of the general political economy of the world. With respect to Canada, we were 1994–2007: HEALTH already observing the stagnation, if not the PROMOTION: DECLINE, beginning of the decline, of the federal lead- TRANSFORMATION, OR ership in the field, and we wondered who RENEWAL? would champion health promotion in The title of this subsection plays with the Canada in the future if this decline actually titles of some of the papers we have published occurred. In comparing and contrasting since the release of the first edition of the provincial and territorial developments, we book as we continued to track the evolution realized how the ambiguity of the health proof the field (O’Neill, Pederson, & Rootman, motion discourse had been used both by 2000; Pederson, Rootman, & O’Neill, 2005). Health Promotion 5/1/07 11:18 AM Page 11

INTRODUCTION: An Evolution in Perspectives ■ 11

It is clear to us that 1994 marked the begin- wrote to describe the evolution of the field ning of an era of weakened support for health and reminds us that in this context, several of promotion both in Canada and abroad. Since the key institutions that had been instru- then, has it declined or simply been trans- mental in the birth of health promotion formed by becoming more mainstream? Is almost abandoned it after 1994. For example, health promotion experiencing a revival at after the Sundsvall conference of 1991, instead the moment or is it actually fading from the of continuing its pattern of hosting interna- radar screen? Let us examine a few major tional conferences almost every other year (as trends and then address the main intent of it did initially) to address the three remain- this second edition of the book. ing strategies of the Ottawa Charter, WHO was forced to hold them at irregular intervals and on topics that addressed the interest of Some General Trends the host countries rather than its overall strat- Internationally, it is important to note that egy. The Djakarta (1997), Mexico (2000), and from the mid-1990s on, the shift away from Bangkok (2005) conferences each reflected the welfare state that began in the late 1980s, this new order of things. Consequently, the due to the macro-economic evolution of the global health promotion community publicly world since the mid-1970s, was clearer. The voiced its concern about the WHO’s lack of litany of the rhetoric of balanced government commitment at the Mexico conference budgets, of deficit reduction, of a diminished (Mittlemark et al., 2001) and about the inclu- role for the state and an increased one for the sion of the private sector as a key partner in market, of the necessity of global economic the Bangkok Charter (see the debate in the competition in a neo-liberal era: all this has series From Ottawa to Vancouver on the elec- been more present and operative. The domi- tronic journal RHPEO, details of its Web site nance of this economic view of the world over at the end of the chapter). the more social one that the welfare states had Moreover after 1994, as fully described in promoted for several decades has had conse- this edition’s Chapter 7 by Lavada Pinder, the quences; for example, it has led to a decrease federal government abandoned its interna- in the importance and influence of most tional and Canadian leadership as the popula- organizations of the United Nations system tion health approach gained greater currency. (such as WHO) and to an increase in the power of transnational corporations and economic global institutions such as the World Main Intentions of the Second Edition Bank, the International Monetary Fund, and The general orientation of this second edition the World Trade Organization. As described remains the same: this is not a book in but a by Ron Labonte in Chapter 12 of this book, book on health promotion, which looks criti- these global tendencies, in conjunction with cally at the evolution of the field since 1994 the collapse of the former communist world and at Canada’s engagement with health pro- in the early 1990s, which left the US virtually motion relative to the rest of the world. Three alone to define the “new world order,” have sets of modifications were made, however, in had important consequences for the evolution compiling this new edition. of health promotion. First, following discussion with our new In the concluding section of this book, publisher, we agreed that the audience of the Ilona Kickbusch updates an earlier story she book needed to be re-examined. For the first Health Promotion 5/1/07 11:18 AM Page 12

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version, we envisioned several audiences: state of affairs. Consequently, to enrich the graduate students; scholars; and practition- perspectives proposed in the book, we have ers, professional or lay, interested in health made a deliberate effort to introduce a mix of promotion from a variety of health, social sci- younger and more experienced contributors. ence, and other backgrounds in Canada and To foster diversity, we have also approached abroad. However, over the years, a variety of a variety of academics, practitioners, students, sources have revealed that the largest group and policy makers as well as people from var- of readers of the first edition has been under- ious parts of Canada and from a wide sample graduate students in health sciences within of countries to contribute to this book. Canada, with the other groups forming an The book is therefore organized into six important, but smaller, audience. We have sections dealing successively with Conceptual, assumed that this will continue to be the case National, Provincial, International, and for this second edition and have therefore Practical perspectives followed by some addressed this understanding explicitly in the Conclusions, each of which we have tried to design and content of the book. Without infuse with a spirit of critical reflection. As the altering the general intent or the rigour of book’s new subtitle is intended to suggest, these the analysis, we have used a style and format perspectives are “critical” in various ways. First, that we hope makes this edition more usable they introduce what we think are “important in undergraduate courses, while maintain- or crucial” elements of reflection and analysis. ing an orientation that is also useful for other Moreover, they do so with the rigour and the readers here and abroad. “inclination to criticize,” which are used in Second, we also realized from feedback “critical social science” not to lay blame but on the first edition that we should more rather to assess without complacency the status explicitly address how and why reflecting on of a phenomenon. Two other meanings of a field is crucial for the practice of this field. “critical” are also relevant here. On the one We have thus introduced a new section in hand, we use the term “critical” in the sense of this edition on “Practical Perspectives.” In its meaning in nuclear reactions; that is, has this new section, contributors address a series health promotion reached sufficient “critical of issues that aim to demonstrate how being mass” to trigger a chain reaction that will make or becoming a more reflexive practitioner it explode and mushroom both in Canada and increases a person’s capacity to be relevant internationally? On the other hand, we will and effective in practice. Hence, in this also try to determine whether 2007 will be— second edition, we encourage the reader to for both Canadian and global health promo- not only think about but also to apply this tion—a “critical turning point” or juncture as thinking to his or her actual practice, what- were 1951, 1974, 1986, or 1994. ever and wherever it is. We hope that this book will successfully Third, given that health promotion is still engage in critical appraisal of the health pro- a very young field, its original pioneers in motion field, and, in the conclusion, we will many places are still active. For the field to synthesize, through an intergenerational dia- survive and evolve, however, we need to logue, what the various chapters have told us ensure the place of the younger generations as about the past and the present, and our cur- we move from the activism of the pioneers to rent vision of the future of health promotion a more mainstream (although always fragile) in Canada. Health Promotion 5/1/07 11:18 AM Page 13

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REFERENCES Badgley, R. (1994). Health promotion and social change in the health of Canadians. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 20–39). Toronto: W.B. Saunders. Becker, M.H. (1974). The health belief model and personal health behavior. Thorofare: Charles B. Slack. Brown, R.E., & Margo, G.E. (1978). Health education: Can the reformers be reformed? International Journal of Health Services, 8(1), 3–26. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Santé et Bien-être social Canada/Health and Welfare Canada. Evans, R.G., Barer, M.L., & Marmor, T.R. (1996). Être ou ne pas être en bonne santé. In Biologie et déter- minants sociaux de la maladie. Paris/Montréal: Les Presses de l’Université de Montréal/John Libbey Eurotext. Freudenberg, N. (1978). Shaping the future of health education: From behavior change to social change. Health Education Monographs, 6(4), 372–377. Gilbert, J. (1963). L’éducation sanitaire. Montréal: Presses de l’Université de Montréal. Gilbert, J. (1967). The grandeur and decadence of health education. Canadian Journal of Public Health, 58, 355–358. Green, L.W., & Kreuter, M. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View: Mayfield. Hancock, T. (1994). Health promotion in Canada: Did we win the battle but lose the war? In A. Pederson, et al. (Ed.), Health promotion in Canada (pp. 350–373). Toronto: W.B. Saunders. Hoffman, K. (1994). The strengthening community health program: Lessons for community development. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 123–139). Toronto: W.B. Saunders. Kickbusch, I. (1986). Health promotion: A global perspective. Canadian Journal of Public Health, 77, 321–326. Kickbusch, I. (1994). Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 8–18). Toronto: Saunders. Labonté, R., & Penfold, S. (1981). A critical analysis of Canadian perspective in health promotion. Health Education, 19(3–4), 4–10. Lalonde, M. (1974). Nouvelle perspective de la santé des canadiens/A new perspective on the health of Canadians. Ottawa: Gouvernement du Canada/Government of Canada. Manson-Singer, S. (1994). The Canadian healthy communities project: Creating a social movement. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 107–122). Toronto: W.B. Saunders. Milio, N. (1986). Promoting health through public policy (2nd ed.). Ottawa: Canadian Public Health Association. Mittelmark, M.B., Akerman, M., Gillis, D., Kosa, K., O’Neill, M., Piette, D., et al. (2001). Mexico conference on health promotion: Open letter to WHO director general, Dr. Gro Harlem Brundtland. Health Promotion International, 16(1), 3–4. Modolo, M.A., & Mamon, J. (2001). A long way to health promotion through IUHPE conferences (1951–2001). Perugia: University of Perugia, Inter university Experimental Center for Health Education. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Health Promotion 5/1/07 11:18 AM Page 14

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O’Neill, M., Rootman, I., & Pederson, A. (1994). Beyond Lalonde: Two decades of Canadian health promotion. In A. Pederson et al. (Eds.), Health promotion in Canada (pp. 374–387). Toronto: W.B. Saunders. Pederson, A., O’Neill, M., & Rootman, I. (Eds.). (1994). Health promotion in Canada: Provincial, national, and international perspectives. Toronto: W.B. Saunders. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future? In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). London: Palgrave Macmillan. Ryan, W. (1976). Blaming the victim (rev. ed.). New York: Vintage Books Edition. UNICEF. (1978). The declaration of Alma-Ata. International Conference on Primary Health Care. Alma- Ata: United Nations Children’s Fund and World Health Organization.WHO. (1981). 64th plenary meeting, Resolution 36/43. WHO. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. WHO-Euro. (1984). Health promotion: A discussion document on the concept and principles. ICP/HSR 602 (m01). Unpublished manuscript, Copenhagen.

CRITICAL THINKING QUESTIONS 1. What have been the four main periods in the evolution of health promotion in Canada? 2. What has been the role of Canada on the international health promotion scene before 1986? 3. Can we consider that the Ottawa Charter for Health Promotion is a Canadian document? Why? 4. Why has the Lalonde Report received so much international attention? 5. Given what you know now, do you think 2007 will be the beginning of a new era in Canadian health promotion?

FURTHER READINGS Modolo, M.A., & Mamon, J. (2001). A long way to health promotion through IUHPE conferences (1951–2001). Perugia: University of Perugia, Inter university Experimental Center for Health Education. A most interesting history of the main international organization in Health Promotion, published on the 50th anniversary of its foundation. Pederson, A., O’Neill, M., & Rootman, I. (Eds.). (1994). Health promotion in Canada: Provincial, national, and international perspectives. Toronto: W.B. Saunders. The first edition of the book, which analyzes the 1974–1994 period of Canadian Health Promotion.

The various charters and declarations of the six WHO international conferences on health promotion, including the most famous of all, the Ottawa Charter. Can be found on the WHO Web site indicated in the Web sites section below. Health Promotion 5/1/07 11:18 AM Page 15

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RELEVANT WEB SITES

International Union of Health Promotion and Education (IUHPE) www.iuhpe.org/ The International Union for Health Promotion and Education (IUHPE) is the only global organization entirely devoted to advancing public health through health promotion and health education. This site is an important source for news and events in health promotion in three languages (English, Spanish, French).

Reviews of Health Promotion and Education Online www.rhpeo.org/ The Web site of IUHPE’S electronic journal, the Reviews of Health Promotion and Education Online (RHPEO); see especially the series Ottawa 1986–Vancouver 2007: Should we revisit the Ottawa Charter?

World Health Organization www.who.int/healthpromotion/conferences/en WHO Web site on global Health Promotion conferences, including charters, declarations, etc., as well as the complete text of the Alma-Ata Declaration on Primary Health Care. This page intentionally left blank Health Promotion 5/1/07 11:18 AM Page 17

PART I

CONCEPTUAL PERSPECTIVES

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e qui se conçoit clairement s’énonce facilement et les mots pour le dire arrivent aisément” C (What is clearly conceived is easily said and words to say it come easily), said French preacher Bossuet a few centuries ago. And, “There is nothing more practical than a good theory,” said American social psychologist Kurt Lewin a few decades ago. In a nutshell, these two sentences capture why we open this book with a section on conceptual perspectives. While many people, particularly those with practical demands on them, resist conceptual discussions or perceive them as irrelevant intellectual or academic debates of little use in their day-to-day work, we think that addressing conceptual perspectives up front is central to improving our practice. Indeed, it is a consistent observation by health promotion scholars that despite the availability of much solid conceptual and theoretical work, most programs are not developed with a theoretical base, resulting in both less effective and fewer interventions. Hence in this first part we try to address some of the major conceptual issues of the field and how they are relevant to Canada and to reveal some of 17 Health Promotion 5/1/07 11:18 AM Page 18

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their practical consequences. If we are promoting health, what exactly are we promoting? Is health promotion distinct from health education, or public health, or population health? If not, then there is no reason to have a distinct scientific and practical field by this name, or jobs in health promotion. If so, then we need to clarify and agree on what it is so we can practise it, teach it, and build the scientific base required to understand and improve it. This part deals with these basic and several other related issues. In Chapter 2, Raeburn and Rootman review the dilemmas generated by the enlarge- ment of the concept of health over recent decades, how developments since the first edition of this book in 1994 have had an impact on the concept, and, using the definition of health proposed in 2005 in the Bangkok Charter for Health Promotion, suggest their own way for Canadian health promoters to address these dilemmas. In Chapter 3, O’Neill and Stirling argue that there has been and continues to be a conceptual confusion about what constitutes “health promotion.” After showing some of the very practical consequences of such confusion using work done for the Internet-based Canadian Health Network, they propose a way to clarify the confusion, at the same time showing that there is indeed a specific field of health promotion for which specific skills are needed. In Chapter 4, Poland and Frolich show that health promotion interventions have been traditionally approached either from the perspective of health issues, population groups, or the settings in which people live, work, or play as entry points. They discuss the conceptual and practical consequences of using one or the other or a combination of these entry points and show how the notions of social context and collective lifestyles help clarify how we might enhance our approach to thinking about health promotion interventions. In Chapter 5, Rootman, Frankish, and Kaszap, using the current international developments in health literacy—to which Canadian scholars and practitioners have made significant contributions—illustrate how a new concept moves from theory into research and practice. In Chapter 6, Reid, Pederson, and Dupéré write about the lessons those working in the health promotion field can draw from theoretical and practical developments in the field of women’s health. They specifically point to the value of intersectional theory for addressing issues of diversity, a question that feminists, women’s health researchers, and theorists have been considering for some time. At the end of this section, the reader should thus have a clear idea of the major current conceptual debates in the field of health promotion, should be able to state his or her own positions on these debates, and should be able to see the practical consequences of these positions for her or his work. Health Promotion 5/1/07 11:18 AM Page 19

CHAPTER 2 A NEW APPRAISAL OF THE CONCEPT OF HEALTH

John Raeburn and Irving Rootman

INTRODUCTION like education or justice—as in the name he concept of health we implicitly or “Health Canada.” The other defines an aspect T explicitly use in our health promotion of the human condition, having to do with work provides the whole framework and the status of body and/or mind, as exempli- context for how we think about the health fied by the 1947 World Health Organization’s promotion enterprise. In this chapter, we definition of health (see below). It is the present a point of view about the kind of con- body–mind condition version we are mainly cept we feel is needed to advance health pro- concerned with here. Each of these two broad motion in Canada and elsewhere in the light usages of “health” can be construed in posi- of the challenges and new health promotion tive or negative ways to do with healthiness environment of the 21st century. or illness respectively (we are using the term Considerations of concepts of health in “illness” loosely here to cover negative condi- a health promotion context immediately raise tions of the organism). We would argue that a fundamental issue—that of a broad, posi- health promotion’s concerns are ultimately to tive, and predominantly social concept of do with promoting healthy states of the health versus the more disease-oriented, bio- human condition, especially the body and medical concept of health favoured by most mind dimensions. Viewing health this way is, of the health sector. We strongly believe in however, a minority position. For example, in the former. Indeed, we feel that what ulti- 2005, only 5.5 percent of Canadian publicly mately distinguishes health promotion from funded health services were in the category of the rest of the health endeavour is its positive “public health” (which would presumably nature—its building of healthiness rather than include much of health promotion) (CIHI, just the prevention or treatment of illness and 2005), so it is reasonable to assume that almost other negative conditions. What we write always when one hears the term “health” in here is from this healthiness perspective (the the health sector, it actually means “illness,” term “healthiness” is the noun derived from conceived in a medical/clinical frame. And “healthy,” defined as “having or showing this is also the case even of public health or good health,” where “health,” in turn, is heath promotion work, which is generally defined as “soundness of body or mind” done within an illness rather than in a health- (Concise Oxford Dictionary, 1982). iness orientation (see Chapter 4, for instance). In a health promotion context, the term In this chapter, we thus look briefly at “health” can largely be seen as relating to two how we considered the concept of health in broad areas. One defines a sector of societal the first edition of this book, then suggest activity, different from other public sectors how influences since that time should be fac- 19 Health Promotion 5/1/07 11:18 AM Page 20

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tored into current concepts of health for holism, and lay people (see Box 2.1). The con- health promotion. Our sense is that health cept deemed most influential internationally promotion has languished to some extent in from a health promotion perspective was the Canada and internationally in the past few 1946 World Health Organization constitution’s years, and that we now need new concepts to definition of health as “a state of complete reinvigorate it. We believe a meaningful, physical, mental, and social wellbeing, and not new, positive, and inclusive concept of health merely the absence of disease and infirmity” for health promotion in the 21st century is (World Health Organization, 1946). Probably essential to set both the conceptual frame and the other most influential concept of health for the goals of our undertakings for the future. health promotion internationally was “the health field concept” from the 1974 Canadian federal government document A New WHAT WE FOUND IN 1994 Perspective on the Health of Canadians, dubbed The 1994 version of this chapter emphasized the Lalonde Report (see below) (Lalonde, the multiplicity of concepts of health, describ- 1974), discussed next. We concluded that con- ing the territory as a “minefield.” These concepts of health were largely determined by cepts came from medicine, nursing, the World their context and who was expressing them. Health Organization, the Ottawa Charter for We thus looked at the Canadian health Health Promotion, academics, American promotion context. The landmark Lalonde

BOX 2.1: SOME DEFINITIONS OF HEALTH

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Report, named after the then federal minis- common conceptual feature was that it related ter of Health (Lalonde, 1974), said that health to a broad domain of life that could be differ- was determined by more than just health entiated from other broad domains, such as services, and listed four broad contributory those of economics, politics, justice, and edu- factors or “elements” making up the “health cation. The distinctive feature of this domain field”: human biology, environment, lifestyle, was that it related to the human organism’s and health care organization. For health condition, well-being, and functioning. promoters, it was especially the Lalonde We concluded by asking whether a con- Report’s introduction of lifestyle and envi- cept of health as used by Canadian health ronment into the health determinants dis- promoters could be discerned (“CHP course that came to be remembered, especially Health” for short), and came up with the fol- lifestyle, a concept that dominated Canadian lowing somewhat awkward statement: and international health promotion thinking and action for a decade, and still lingers on. Health as perceived in a Canadian health pro- During the 1980s, there was a move away motion context has to do with the bodily, mental from individualistic behavioural views of and social quality of life of people as determined health promotion to more social and policy in particular by psychological, societal, cultural views. In Canada, 1984–1985 were important and policy dimensions. Health is seen by for Hancock’s influential concepts of “healthy Canadian health promoters as being enhanced cities” and the “Mandala of Health” by a sensible lifestyle and the equitable use of (Hancock & Perkins, 1985), although these public and private resources to permit people to tended to focus on disease reduction as an use their initiative individually and collectively output rather than health. Then, in 1986, to maintain and improve their own well-being, came the revolution of the Ottawa Charter, however they may define it. (Rootman & with its concept of health as a resource for Raeburn, 1994, p. 69) living, and its cementing in of a broad social determinants model of health (World Health Organization, 1986). This social model of INFLUENCES SINCE 1994 health was echoed in the 1986 Canadian gov- Much has happened in Canada and the ernment document Achieving Health for All: world since 1994, and much has happened in A Framework for Health Promotion (Epp, health and health promotion. These changes 1986), albeit with a more personal and make what we were talking about in 1994 friendly tone (using concepts like “self-help” seem somewhat dated, and we feel it is time and “mutual aid”), and a strong emphasis on to explore new concepts more relevant to the equity, as befits Canadian culture. 21st century. We wish to tackle this here by In 1989, the authors of this chapter tried considering some of the changes and devel- to combine the health concepts of the Lalonde opments in the past few years as pointers to Health Field Concept and the Ottawa Charter how we might reconceptualize health for (Raeburn & Rootman, 1989), and in 1993, health promotion in the 21st century. Our Labonté (1993) took up the issue of subjective choice of influences and how we interpret and objective views of health, a precursor of these are based on our own experience and the qualitative revolution to come. The 1994 values as health promoters, and we present chapter went on to say that, while the term what follows as a trigger for discussion rather “health” covered many different concepts, its than as the last word on the topic. Health Promotion 5/1/07 11:18 AM Page 22

22 ■ PART I: Conceptual Perspectives

Population Health ability to enjoy life and deal with the challenges As outlined in Chapter 7 by Pinder, perhaps we face. It is a positive sense of emotional and the greatest single new influence on spiritual well-being that respects the importance Canadian health promotion at the national of equity, social justice, interconnections and per- level has been the population health para- sonal dignity. (Joubert & Raeburn, 1998; p. 16) digm. It is hard to say what this means in terms of an underlying concept of health. This concept is quite different from the However, Canadian health promotion tra- disease-oriented concepts that have tended to ditionally embraced core values like empow- dominate the professional and academic erment, mutual aid, participation, and mental health field. Certainly, it seems that “enabling,” and gave primacy to community the time has come for mental health to get action. In contrast, the medical-epidemiol- more attention in health promotion, even if it ogy ethos of the population health movement seems ironic that we need to use disease sta- seemed to represent a more top-down, deper- tistics to justify this. For example, mental sonalized, and less community perspective health issues currently comprise five of the top (e.g., Poland et al., 1998). According to six burden of disease categories in industrial- Poland and several other critics, the centre ized countries (World Health Organization, of gravity has, in spite of population health’s 2001). In addition, depression is becoming social determinants rhetoric, subtly moved increasingly evident in developing countries, back to a more “old-fashioned” public health especially among women, to the extent that and medicalized viewpoint (versus a more depression is predicted to be the second largest socially oriented “new public health”). Our global disease burden category by 2020 view is that health promotion now needs to (Murray & Lopez, 1996). reassert its own identity outside the popula- Canada was one of the first countries to tion health paradigm, and return to a more put the area of mental health promotion on the positive, empowering, and community con- agenda; however, it now appears to have fallen cept of health as its basic frame of reference. behind what is happening in the rest of the world (c.f. Saxena & Garrison, 2004). Although mental health promotion is a distinctive field, Mental Health Promotion it has much in common with conventional Although the concept of mental health pro- health promotion, and the two fields need to motion has been around notionally since the look at how each can integrate with the other. 1980s, in the mid-1990s it emerged as a sig- An inclusive concept of health could help us nificant new area, spearheaded in Canada do that, as we will illustrate below. and the world by the work of the Mental Health Promotion Unit in Health Canada, Ottawa (Joubert, 1995). In 1996, a trail-blaz- Resilience ing international workshop at the University A particular contribution of mental health of Toronto on the concept of mental health promotion to the field of health promotion promotion came up with the following con- worthy of mention in its own right is the concept of mental health: cept of resilience. Resilience refers to people’s capacity to draw on their own resourcefulness Mental health is the capacity of each and all of to deal effectively with the demands of life, to us to feel, think and act in ways that enhance our return to full functioning after setbacks, and Health Promotion 5/1/07 11:18 AM Page 23

CHAPTER 2: A New Appraisal of the Concept of Health ■ 23

to learn from such experiences to function ago in a notable Alberta think tank on the better in the future (Mangham, Reid, & topic (Kulig & Hanson, 1996). We feel that Stewart, 1996). This is illustrated in Figure such a concept of resilience could be extended 2.1, a Canadian conceptualization (Joubert & to the whole of health promotion as a key Raeburn, 1998). The concept is also applica- marker of healthiness, independent of pathol- ble to communities, as discussed some years ogy measures.

FIGURE 2.1: A schematic representation of resilience as it relates to individuals in a mental health promotion context, where the arrow represents the lifespan from birth to death, and the wavy line the ups and downs of life. Good mental health is seen as flourishing where there are resilient people in supportive environments.

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Quality of Life a powerful concept to drive health promotion Related to the above types of concepts are considerations, and the present authors have several years of studies in Ontario on sub- suggested a concept of “health-related QOL” jectively experienced quality of life (QOL) to do this (Raeburn & Rootman, 1995, 1998). (Renwick, 2004). Although it originated in the developmental disability sector, we think the Ontario concept of QOL is universally Capacity and Capacity Building applicable, can be applied to whole commu- Two of the strongest health promotion con- nities as well as individuals, and can be quan- cepts to emerge since the mid-1990s regard- titatively measured. ing a positive rather than a deficit or disease QOL is defined as “The degree to which concept of health have been those of “capac- a person enjoys the important possibilities of ity” and “capacity building.” “Capacity” is his or her life” (Quality of Life Research Unit, closely allied to other positive concepts, such 2006), and is represented in nine life sectors as “strengths” (Rapp, 1998) and “assets” grouped as Being, Belonging, and Becoming, (Kretzmann & McKnight, 1993). Of partic- as shown in Figure 2.2. What we have here is ular interest is the concept of “community Health Promotion 5/1/07 11:18 AM Page 24

24 ■ PART I: Conceptual Perspectives

FIGURE 2.2: CENTRE FOR HEALTH PROMOTION QUALITY OF LIFE MODEL

Image not available Health Promotion 5/1/07 11:18 AM Page 25

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capacity,” and Canada has led the way with Poverty and Equity studies of community capacity building (e.g., Of particular importance to health promot- Jackson et al., 2003). Capacity is both quan- ers in the new globalized world are the very titatively and qualitatively measurable, with large numbers of people who are impover- a notable review of measures for community ished. It is well known that health declines capacity being that of Smith and colleagues with poverty, and we believe that issues of in Alberta (Smith, Littlejohns, & Thompson, poverty should be a primary concern for 2001). “Capacity building” is a term used to health promoters. Equity (the gap between describe the development of both personal rich and poor) seems to have suffered under and social abilities, and there is strong evi- the New Right regimes seen in Canada and dence that interventions based on the con- around the world. In Canada, the gap cept of capacity may be more effective than between rich and poor is increasing, and it is conventional prevention approaches known that this is a major predictor of ill (Pransky, 1991; Raeburn et al., 2005). It could health and other negative indicators be argued that capacity building, which is (Wilkinson, 1996), as well as being a social close to the concept of empowerment justice issue. This is part of a larger picture (Laverack, 2005), is the way of the future for of the consumer and globalized world of the health promotion practice. past 15 years, and here, poorer people are especially vulnerable to what in some countries are called “dangerous consumptions” Community Development and (Adams, 2006), i.e., commercially driven Community Capacity Building lifestyle forces such as electronic gambling Our sense is that community development and fast foods, which typically take their (and its more recent manifestation as com- greatest toll on the poor and minority groups. munity capacity building) has been perhaps Social justice and equity have always been a the most salient characteristic of Canadian part of public health and health promotion health promotion at provincial and local thinking, and it is imperative that we retain levels for many years. However, the popula- and strengthen this dimension in our future tion health approach seems to have weak- concepts of health. ened the status of this area in that population health tends be primarily concerned with populations larger than communities, and its Multiculturalism, Minorities, approach is philosophically different. Yet Migration, and Indigenous Peoples other than policy development and advocacy, Perhaps one benefit of a population health community development/capacity building approach is that it alerts us to the various is arguably the most important single “populations” of which our society consists. approach available to health promotion prac- Although Canadian health promotion has titioners, one that fully embodies the central traditionally given attention to the rights of health promotion principles of empower- women, gays, children, and the disabled, the ment, participation, and a sense of control by globalization perspective brings to our atten- ordinary people. We argue that the commu- tion the plight of many ethnic minorities both nity development dimension needs to be in Canada and around the world, including strongly re-endorsed in current and future those in multicultural settings, indigenous concepts of health for health promotion. peoples, internally displaced people because Health Promotion 5/1/07 11:18 AM Page 26

26 ■ PART I: Conceptual Perspectives

of commercial or war pressures, those health concept point of view, a qualitative affected by environmental catastrophes, and perspective has a more experiential and per- the stresses generally of being a migrant or sonal aspect compared with concepts of refugee. Canada has generally been very open health based primarily on disease statistics. with regard to immigration and accepting If health promotion is to be true to its people- refugees, with the result that multicultural- centred origins, and since health is largely ism is a major Canadian reality. What this about how people feel, a qualitative concept signifies, among other things, is that our con- of health is probably one that should increas- cepts of health probably have to be pluralis- ingly dominate health promotion consider- tic, since different cultures have distinctive ations. views of health, which are often holistic in nature, and which are tied into the deepest parts of their identity, well-being, and spiri- The Bangkok Charter tuality. Similarly, the concepts and rights of At the time of writing, we are still in the early First Nations as indigenous peoples are stages of digesting the import of the Bangkok extremely important to know about and Charter for Health Promotion. While most respect, since the power of the mainstream is people will probably focus on the globaliza- a constant threat to them. Therefore our con- tion, action, and commitments aspects of the cept of health has to be able to accommodate Charter, one of its resounding contributions and honour the diversity seen in different is its new concept of health. After affirming cultures and groups, with primacy given by “the values, principles and action strategies” right to First Nations perspectives. of the Ottawa Charter, the Bangkok Charter (World Health Organization, 2005) says: “[Health promotion] offers a positive and Qualitative Approaches inclusive concept of health as a determinant If one thing were to characterize today’s of the quality of life and encompassing Canadian health promotion to the outsider, mental and spiritual well-being.” it would be a significant investment in uni- Although this seems slightly garbled, it versity-based research (see Chapter 8). With does contain some important components at least 16 university-based centres of health that could lead us toward a new overall con- promotion research, Canada is strong in this cept of health for health promotion. area. Increasingly, the realization is that First, the concept is “positive.” As stated health promotion research is probably best earlier, although health promotion is osten- served by a predominantly qualitative sibly a positive enterprise, the pressures from research methodology, a trend started in the dominant system often lead instead to a Canada in the early 1990s. Most medical and focus on disease and deficit rather than health science, including most public and “healthiness.” The positive–negative dis- population health science outside health pro- tinction has profound repercussions for how motion as such, is still driven by a positivist we health promoters conceptualize what we paradigm, whereas the more subjective, life are doing. A positive approach is about capac- experiential, and naturalistic ethos of health ity building, empowerment, resilience, and promotion is probably better suited to qual- QOL, whereas a disease/deficit approach is itative methods or, at least, to a mix of qual- about dealing with risks and negative states itative and quantitative methods. From a of the organism. Hopefully, the Bangkok Health Promotion 5/1/07 11:18 AM Page 27

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Charter’s clear statement about positivity will being.” This indeed brings us into the 21st put this clearly back on the health promotion century, where it is clear that spiritual (a term agenda. going well beyond “religious”) issues are at Second, the Bangkok Charter concept is the core of health and well-being for a major- “inclusive,” for which read “ecological” or ity of the world’s people (Raeburn & “holistic.” This is helpful for the same reason Rootman, 1998), yet spirituality has not been as above—that is, it takes our concept of recognized as such in most official health health beyond disease and narrowly con- promotion thinking. Indeed, given their fun- ceived risks and determinants. It will hope- damental importance to so many, one won- fully also encourage thinking beyond the ders why there is so much resistance to both current social determinants model of both mental health and spiritual concepts in con- public and population health in that there are ventional health promotion. What does this more types and levels of health determinants say about us? In spite of the resistance to than are generally represented in this model. acknowledging the role of spirituality among These include culture, psychological factors, many health promoters, there is a growing interpersonal dealings, stress, spirituality, and research literature that supports the positive social behaviour. Hopefully, the use of the role of spirituality in health (e.g., Miller & term “inclusive” in the Bangkok Charter will Thoreson, 2003). Indeed—but this will be open up the rather limited conceptual base going too far for many—one could argue that for health and its determinants we have lived spiritual health (that is, health at the deepest with in health promotion for many years. level of our being, and which is to do with Third, the concept of “quality of life” is our relationship to the whole scheme of included. This is, of course, both positive and things) is what health promotion is ultimately inclusive. As we saw before, QOL could be about. But we may need to wait until the a very useful way of conceptualizing what 22nd century before this is accepted! we are dealing with in health promotion, Overall, then, the Bangkok Charter especially when thinking of health as a goal appears to lead us toward a new concept of or an output, and its inclusion in the Bangkok health, one to which it is likely that Canadian Charter should open up this discussion. health promotion can relate easily given its Fourth, the Bangkok Charter’s concept of established history of interest and leadership health encompasses “mental well-being.” At in much of what is discussed here. last, the mental health area gets a mention in a mainstream World Health Organization health promotion document! Moreover, its CONCLUSIONS representation as “mental well-being” As stated, we believe a new concept of health encourages us to think beyond “mental ill- for health promotion is necessary for the 21st ness” when we talk about mental health in a century to help in a much needed reinvigo- health promotion context. We argued above ration of health promotion, and to make it that mental health is a major issue facing more relevant to the present and the future. modern health promotion and the allusion This concept not only needs to incorporate to it here puts it squarely on the health pro- the valued efforts and principles of the past, motion agenda. but needs also to take into account directions Fifth, and most surprisingly, the that have appeared in recent times, some of Bangkok Charter mentions “spiritual well- which we have covered in this chapter. Health Promotion 5/1/07 11:18 AM Page 28

28 ■ PART I: Conceptual Perspectives

An overview of what has been said in this while summarizing much of what we have chapter suggests that such a concept would covered here. It is as follows: need to be: • positive—not based on pathology or In the health promotion domain, health is equiv- deficit alent to healthiness and is related to concepts of • inclusive—with a broader set of deter- resilience and capacity. It refers primarily to minants and attributes than are cus- mental and physical dimensions of healthiness, tomarily used has strong experiential and social aspects, and is • particularly attentive to the mental determined by many internal and external fac- health dimension, and inclusive of qual- tors, including those of a personal, collective, ity of life and spirituality environmental, political, and global nature. • able to be used both as a framework and as an overall goal We realize that the risk of offering a con- • able to accommodate scientific meas- cept like this is that if it is rejected out of urement, while fully capturing the qual- hand, it may therefore seem to invalidate the itative dimension rest of the chapter. However, we hope that if • able to represent the current realities of such rejection occurs, consideration will still what affects health and mental health in be given to our contention that a new con- Canada and the world of the 21st century cept of health is needed for health promo- • able to inspire and give clear guidance tion, and that the other points made in this as to where future health promotion chapter still warrant consideration. should go We close in the hope that what we have offered here will help to stimulate a robust Taking these points into account, a pos- discussion on how we can have a strong, possible concept of health for health promotion itive, exciting, and relevant concept of health in the 21st century is now given. We have for health promotion, one that will take us aimed to make this as concise as possible, forward in the 21st century.

REFERENCES Adams, P. (2006) Identity talk on dangerous consumptions down-under. Addiction Research and Theory, 13(6), 515–521. Alster, K.B. (1989). The holistic health movement. Tuscaloosa: University of Alabama Press. CIHI. (2005). National health expenditure trends 1975–2005. Ottawa: Canadian Institute for Health Information. Concise Oxford Dictionary. (1982). Oxford: Clarenden Press. Contandriopoulos, A.P. (2005). A “topography” of the concept of health. In R. Lyons (Ed.), The social sciences and humanities in health research (pp. 13–15). Ottawa: Canadian Institute of Health Research. Critchley, M. (Ed.). (1978). Butterworth’s medical dictionary. London: Butterworths. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Health and Welfare Canada. Hancock, T., & Perkins, F. (1985). The mandala of health: A conceptual model and teaching tool. Health Education, 24(1), 8–10. Jackson, S., Cleverly, S., Poland, B., Burman, D., Edwards, R., & Robertson, A. (2003). Working with Health Promotion 5/1/07 11:18 AM Page 29

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Toronto neighbourhoods toward developing indicators of community capacity. Health Promotion International, 18(4), 339–350. Joubert, N. (1995) Mental health promotion: The time is now. Ottawa: Mental Health Promotion Unit, Health Canada. Joubert, N., & Raeburn, J. (1998). Mental health promotion: People power and passion. International Journal of Mental Health Promotion (Inaugural Issue), 1(1), 15–22. Kretzman, J.P., & McKnight, J.L. (1993) Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Chicago: ACTA Publications. Kulig, J., & Hanson, L. (1996). Discussion and expansion of the concept of resiliency: Summary of a think tank. Lethbridge: University of Lethbridge. Labonté, R. (1993). Community health and empowerment. Toronto: Centre for Health Promotion. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Health and Welfare Canada. Laverack, G. (2005). Public health: Power, empowerment, and professional practice. Hampshire: Palgrave Macmillan. Mangham, C., Reid, G., & Stewart, M. (1996). Resilience in families: Challenges for health promotion. Canadian Journal of Public Health, 87(6), 373–374. Miller, W.R., & Thoreson, C.E. (2003). Spirituality, religion, and health: An emerging research field. American Psychologist, 58(1), 24–35. Murray, C.J., & Lopez, A.D. (Eds.). (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Global burden of disease and injury, vol. 1. Cambridge: Harvard School of Public Health. Poland, B., Coburn, D., Robertson, A., & Eakin, J. (1998). Wealth, equity, and health care: A critique of a “population health” perspective on the determinants of health. Social Sciences and Medicine, 46(7), 785–798. Pransky, J. (1991). Prevention: The critical need. Springfield: Burrell Foundation & Paradigm Press. Quality of Life Research Unit, University of Toronto. Retrieved July 14, 2006, from www.utoronto.ca/ qol/concepts.htm. Raeburn, J., Akerman, M., Chuengsatiansup, K., Mejia, F., & Oladepo, O. (2005). Building community capacity to promote health. Technical paper for 6th Global Conference on Health Promotion, Bangkok, August 7–11, 2005. Geneva: World Health Organization. Raeburn, J., & Rootman, I. (1989). Towards an expanded health field concept: Conceptual and research issues in a new era of health promotion. Health Promotion International, 3(4), 383–392. Raeburn, J., & Rootman, I. (1995). Quality of life and health promotion. In R. Renwick, I. Brown, & M. Nagler (Eds.), Quality of life in health promotion and rehabilitation: Conceptual approaches, issues, and applications (pp. 14-25). Newbury Park: Sage. Raeburn, J., & Rootman, I. (1998). People-centred health promotion. Chichester: John Wiley & Sons. Rapp, C. (1998) Strengths model: Case management with people suffering from severe and persistent mental illness. New York: Oxford University Press. Renwick, R. (2004). Quality of life: A guiding framework for practice with adult with developmental disabilities. In M. Ross & S. Bachner (Eds.), Adults with developmental disabilities: Current approaches in occupational therapy (pp. 20–38). Bethesda: AOTA Press. Rootman, I., & Raeburn, J. (1994). The concept of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–152). Toronto: W.B. Saunders Canada. Health Promotion 5/1/07 11:18 AM Page 30

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Rootman, I., & Raeburn, J. (1998). Quality of life, well-being, health, and health promotion: Toward a conceptual integration. In W. Thurston et al. (Eds.), Doing health promotion research: The science of action (pp. 119–134). Calgary: University of Calgary. Sarafino, E.P. (1990). Health psychology: Biopsychosocial interactions. New York: John Wiley & Sons. Saxena, S., & Garrison, P. (Eds.). (2004). Mental health promotion: Case studies from countries. Geneva: WHO/WFMH. Smith, N., Littlejohns, L., & Thompson, D. (2001). Shaking out the cobwebs: Insights into community capacity and its relation to health outcomes. Community Development Journal, 36(1), 30–41. Spector, R.E. (1985). Cultural diversity in health and illness. Norwalk: Appleton-Century-Crofts. Wilkinson, R. (1996). Unhealthy societies: The afflictions of inequality. New York: Routledge. World Health Organization. (1946). Constitution. Geneva: Author. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. World Health Organization. (2001). The world health report 2001—Mental health: New understanding, new hope. Geneva: Author. World Health Organization. (2005). Bangkok Charter for Health Promotion. Geneva: Author. www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html

CRITICAL THINKING QUESTIONS 1. What concept or concepts of health do you prefer? Why? 2. Do you agree that the concept of health for health promotion needs to be positive and inclusive? Why or why not? 3. Does everyone who is interested in health promotion need to agree broadly on what we mean by “health” in a health promotion context? Why or why not? 4. Do you think we need a new concept of health for health promotion for the 21st century? Why might a new concept of health for health promotion rejuvenate the field? Or should we just leave things as they are? 5. What do you think of the concept of health suggested at the end of this chapter? If you do not like it, can you think of another that would suit you? If there could be only one commonly accepted concept of health for health promotion, what might it be? Why?

FURTHER READINGS Antonovsky, A. (1979). Health stress and coping. San Francisco: Jossey Bass; and Antonovsky, A. (1987). Unravelling the concept of health. San Francisco: Jossey Bass. These two books raise the question of what creates “health” rather than “disease.” Antonovsky suggests and discusses the term “salutogenesis” to encourage more thinking and research about the determinants of health rather than of disease. A recent commentary on the concept has been published by Lindstrom and Erickson (Lindstrom, B., & Erickson, M. (2005). Salutogenesis. Journal of Epidemiology and Community Health, 59, 440–442). Lindstrom has recently established a research centre in Finland built around salutogenic research (see Chapter 16). Health Promotion 5/1/07 11:18 AM Page 31

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Contandriopoulos, A.P. (2005). A “topography” of the concept of health. In R. Lyons (Ed.), Social sciences and humanities health research (pp. 13–15). Ottawa: Canadian Institute of Health Research. This is an interesting article about the concept of health that considers contributions from the social sciences and humanities to thinking about the concept. Also in the same volume is a one-page article (p. 120) by Contandriopoulos and other Canadian colleagues on a proposed project to integrate approaches and perspectives about the concept of health from the social and life sciences.

Rootman, I., & Raeburn, J. (1994). The concept of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 139–152). Toronto: W.B. Saunders. This chapter, which appeared in the first edition of Health Promotion in Canada, presents an overview of the development of the concept of health in Canada up to 1994, along with some useful diagrams.

World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. This Charter is important for all students of health promotion to read and understand. It can be obtained at www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

World Health Organization. (2005). Bangkok Charter for Health Promotion. Geneva: Author. The Bangkok Charter is the most recent international agreement regarding future directions for health promotion. It can be obtained at www.who.int/healthpromotion/conferences/6gchp/bangkok_char- ter/en/index.html

RELEVANT WEB SITES

Click4HP www.lsoft.com/scripts/wl.exe?SL1=CLICK4HP&H=YORKU.CA Click4HP is a listserv that was established by the Ontario Health Promotion Clearinghouse in 1996 and is operated by York University. It has an archive of discussions that have taken place since it was established on a wide range of health promotion topics, including the concept of health.

Quality of Life Research Unit www.utoronto.ca/qol/unit.htm This site provides information about the Centre for Health Promotion Model of Quality of Life, including a description of the conceptual framework developed over the last decade by researchers associated with the Centre as well as the tools that have been developed to measure quality of life and how to order them. Health Promotion 5/1/07 11:18 AM Page 32

CHAPTER 3 THE PROMOTION OF HEALTH OR HEALTH PROMOTION?

Michel O’Neill and Alison Stirling

INTRODUCTION in a society at one point in time, needs to be here are several important reasons for considered and legitimized. All health-related T having a clear definition of health pro- professions are caught up in these debates. Let motion. In this chapter, we will first explain us take nursing as an example to identify the why we think defining health promotion is terms of the issue, and then apply them to so crucial. Second, we will look at two ways look at health promotion. in which defining the field has been under- In Canada, in all provinces, nursing is taken. Finally, we will make suggestions currently a profession regulated by specific about two possible avenues to solve the laws. How a specific group achieves the status dilemmas raised by this definitional issue: a of a recognized, and even more, a legally reg- more operational one, showing how the ulated profession in modern societies has health promotion affiliate of the Canadian been studied by sociologists for decades, with Health Network (CHN) decided to address special attention devoted to the health pro- and try to solve it, and a more conceptual one fessions, given their diversity and the “dom- by suggesting differentiating “health pro- inant” power of medicine in relation to the moting” from “health promotion” activities. others (Coburn, 1988; Freidson, 1977). These We think the latter has a significant poten- authors usually agree that a profession is tial to clarify the definitional confusion that defined by a certain number of features: a has plagued the field for a long time. specific body of knowledge, a code of ethics, and a self-regulated practice to insure quality control and protect the public from dan- WHY DEFINING HEALTH gerous practitioners (see Chapter 17 for PROMOTION IS IMPORTANT additional elements on professions). In contrast to other countries such as Disciplinary and Professional Reasons Australia, in Canada, health promotion has There is much debate about whether or not not gained the status of a profession. Is this health promotion is or should be considered a problem? In the international literature, a discipline like medicine, nursing, sociology, there is no unanimity (Ottoson et al., 2000). or biology (Bunton & MacDonald, 2004). The In this debate, we believe both positions have notion of a discipline is itself a complex one, pros and cons. Some people argue that, in with scientific and practical dimensions. order to make sure that the public gets the These concerns, which exist for any best possible services, health promoters domain, are more evident when a professional should be trained properly according to the category of practitioners, which is recognized latest scientific or practice developments, that 32 Health Promotion 5/1/07 11:18 AM Page 33

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there should be quality-control mechanisms, 2003; Raphael, 2000): Are they scientific dis- that it is very important to professionalize ciplines of their own or fields of practice health promotion, that specifically identified drawing on a variety of other sources to do health promotion jobs exist, etc. On the other their job properly? We will not enter into hand others believe that health promotion these debates here, which have been thor- skills should be part of the training of all oughly conducted elsewhere (Bunton & health professionals and even of some other MacDonald, 2004; McQueen & Anderson, types of professionals working on the non- 2000), but state our own position. Specifically, medical determinants of health; for them, we think that because they do not have a spe- there is no need for a specific profession, cific substantive area of study of their own notably because the current health promo- (the main criterion used by epistemologists, tion body of knowledge (at the scientific or sociologists, and philosophers who study the practice levels) does not justify the exis- what is required to constitute a science), none tence of a distinct profession. of the health disciplines mentioned above are When we speak about a distinct body of sciences; they are rather fields of practice, knowledge, we open up another avenue of drawing on a variety of sources, including reflection on the field of health promotion, scientific knowledge from other disciplines, notably around the notion of its scientific to construct the body of knowledge required nature as required to define a discipline, to intervene optimally. which in our societies is a very important element. Going back to nursing as an example, as for many other health-related professions, Political Reasons its definitions often allude to “the art and the If health promotion in Canada is not a pro- science of,” as is also the case in Winslow’s fession or a scientific discipline, but a field of (1920) famous old definition of public health practice, does it have a specificity that dif- still echoed in a recent glossary of health pro- ferentiates it from the other health-related motion: “Public Health is the science and art fields of practice? The answer to this ques- of promoting health, preventing disease and tion has a lot of consequences that we will prolonging life through the organized efforts qualify here as political and which are a of society” (Nutbeam, 1998, p. 3). second set of reasons for paying attention to A lot of words have been used in nurs- the definition of health promotion. ing to discuss if, beyond the art of practising If health promotion has no identity of its it, it is a scientific discipline of its own or if it own, it becomes very difficult to decide what is a practical field drawing the knowledge it to include in the training of people who are needs to intervene properly from a variety of supposed to practise it and then to justify scientific disciplines and from other sources having programs devoted to it in universi- (e.g., Donaldson, 2000; Thorne, 2005). In an ties, colleges, or elsewhere. It also becomes era where science is believed to be a major, if very difficult to establish what kind of not the major, basis to organize human life knowledge needs to be scientifically (through in modern societies as reflected in the cur- academic research notably) or otherwise rent and lively debates around “evidence- developed to properly ground its practice. based” professional practices, the same And this, in turn, will have consequences for question can be asked of medicine, public whether or not specific skills in health pro- health, and now health promotion (O’Neill, motion will be required from certain sets of Health Promotion 5/1/07 11:18 AM Page 34

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people in certain types of jobs, be they actu- for over 15 years, whose mandate is to sup- ally labelled health promotion jobs or not. port the capacity of people involved in health Overall, then, it will have a lot of impact on promotion practice to do their work effec- the amount and the nature of scarce resources tively. Simply trying to organize resources on that a specific society will be willing to allo- different definitions of health promotion cate for this purpose. highlights conceptual confusion on the If we look at Canada on that count, since nature, values, and purpose of the field the Lalonde Report of 1974, can we say that (Seedhouse, 1997). Should the “practice” of health promotion is clearly enough defined health promotion be organized according to as to have found its niche? As is made obvi- risk conditions, diseases, or issues (e.g., ous in the rest of this book, the answer is not lifestyles and/or living conditions), or by really, and not enduringly. Even if there has functions and strategies (e.g., education, been a health promotion discourse, health policy, communication), or by settings (e.g., promotion training programs, research schools, workplaces, communities)? Of endeavours, and even health promotion gov- course, the scope of health promotion prac- ernmental programs and eventually a few tice encompasses all of these aspects and policies, it has never known as much sub- much more: principles, processes, causes, stantial development as other sectors of soci- cross-discipline approaches (Duncan, 2004; ety or of the health system have; using the Nyamwaya, 1997; Raphael, 2000). The prac- image of Pinder in Chapter 6, it has even titioner needs all of these resources, but may been just below the radar screen for almost consider health promotion to be limited to a decade. We think that one of the main rea- one focus, such as “workplace health.” A sons for this has been health promotion’s clearinghouse has thus a double duty: to incapacity as a field to properly differentiate anticipate the breadth of possible needs for itself from neighbouring fields because of its information and resources on what might fall inability to define itself clearly, internally, and under the rubric of “health promotion” and for others; it has thus been very vulnerable to assist its users in considering and applying when others became politically attractive as interrelated elements of the field instead of was the case when population health became just a single strategy, issue, or setting. trendy around 1994. It is thus obvious that In order to be retrieved and made avail- health promotion, if it wants to exist and sur- able to practitioners, information has thus to vive, must go beyond the self-promoting be organized or classified in a way that reflects interest of its academic and practitioner com- the core categories and boundaries of a field munity and clearly articulate what it is and and still remain understandable. For exam- what it has to offer the world, otherwise the ple, a classification system for health promo- world might have no use for it. tion indicators that uses the Ottawa Charter for Health Promotion has been proposed by a European group; it includes systems, struc- Practical Reasons tures, and processes in action areas, health The lack of agreement on what health pro- capacities, and health practices (Bauer et al., motion is about and what it does also has 2003). It is an elegant model in structure and practical consequences. Take the example of concept, but it would be difficult for users to a health promotion clearinghouse, a type of browse through the terms and know that they facility one of us (AS) has been working in are looking at health promotion practice. Health Promotion 5/1/07 11:18 AM Page 35

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Without the guide of a common definition, much broader way to see things, soon to be how can we expect anyone to search for called ecological (see Chapter 18), was seen “health promotion” and get usable results? as required to understand and influence health-related behaviours. For many, the transition from traditional APPROACHES TO DEFINING individualistic health education toward a HEALTH PROMOTION more ecologically oriented health promotion If we agree then that, even if difficult, it is cru- requesting to intervene at a variety of levels cial to define health promotion, there are many was difficult (Green & Raeburn, 1988). For ways to do it. Information science, for instance, instance, it is only at the very end of 1993 that would sort out a set of concepts that provide the main professional and scientific global overall structure, pointers, and access for a organization in the field, the International body of works, which would guide the infor- Union for Health Education (IUHE), decided mation searcher into the ideas and knowledge to follow the trend and rename itself the encompassed by a field (Albrechtsen & Jacob, International Union for Health Promotion 1997; Kwasnik & Rubin, 2003). We will explore and Education (IUHPE), keeping the two two of these ways here. On the one hand, we expressions within its new title. will look at what is meant by health promo- Even today, in several countries like the tion in contrast with other closely related con- US or France, the words “health education” cepts or areas, i.e., health education, population have more currency than “health promotion” health, and public health. On the other hand, in many quarters, sometimes to designate the we will look at two attempts, mostly under- old version of individualistic health educa- taken by Canadian experts, to reach a consen- tion, sometimes using these words to desig- sus on what health promotion is all about. nate the new, enlarged field called “health promotion” elsewhere. Chapter 16 in this book shows several of these variations world- Health Promotion versus Other wide. We can thus say: “Health education Related Concepts comprises consciously constructed opportu- Health Promotion versus Health Education nities for learning involving some form of As seen in Chapter 1, for most people, health communication designed to improve health promotion as a field emerged as an evolution literacy, including improving knowledge, of the field of health education, which had and developing life skills which are con- formalized itself at the beginning of the 1950s ducive to individual and community health” and worked from then on to influence indi- (Nutbeam, 1998, p. 4). vidual health-related behaviours. However, Box 3.1, written especially for this book at the end of the 1970s, many health educa- by the former editor of one of the most tors realized that trying to influence indi- important journals in the field, Health vidual behaviours without altering the Education Research, shows that the debate is environments in which they occurred pro- far from over. No wonder people are still duced very limited results. In the mid-1980s, confused today when asked how to differ- the field as a whole relabelled itself “health entiate the two! Let us conclude this section promotion” to signify notably that from then then by agreeing with most people today that on, just working to change individual health education is one strategy within the lifestyles was no longer a viable option. A larger field of health promotion. Health Promotion 5/1/07 11:18 AM Page 36

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BOX 3.1: HEALTH EDUCATION: Resurrection and Reinvention

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Health Promotion versus Population Health ically conservative as well as epidemiologi- The way in which, in Canada, a “population cally, economically, and individually driven; health” vision replaced the health promotion in contrast, for many, health promotion is discourse from 1994 on and for about 10 years practical, politically progressive, sociologi- has been thoroughly addressed elsewhere in cally and policy-oriented, as well as collec- this book, especially in Chapter 6. We share tively driven (Labonté, 1995; Robertson, Pinder’s conclusion that both have now 1995). We think, however, that it is carica- found their respective niches in the recent turing both orientations and “in general, the structural and conceptual developments that proponents of population health can be seen have taken place since 2002. What is worth as allies [of health promotion] in the move mentioning, though, is that from its towards the new public health, particularly Canadian origins in the early 1990s, the pop- since overall, neither framework has signif- ulation health vision has globalized to the icantly challenged the dominance of bio- point that in 2003, the famous American medicine in the health field” (O’Neill, Journal of Public Health devoted a special Pederson, & Rootman, 2000, p. 141). issue to the topic. So, what differentiates health promotion Health Promotion versus Public Health from population health? Not much, as some Finally, we will argue here that for most of us have argued elsewhere (Pederson, people involved in the field, health promo- Rootman, & O’Neill, 2005) because, as we will tion is seen as one of the essential functions of see below, they are slight variations on the public health, as defined above by Nutbeam. theme of the “new public health,” itself the Public health functions are usually identified current reincarnation of a public health vision as protection, surveillance, prevention, and as old as the human species itself. But dif- promotion as indicated in several recent doc- ferent enough to have crystallized the belief uments, but especially the ones derived from that population health is theoretical and polit- a large consensus-building process organized Health Promotion 5/1/07 11:18 AM Page 37

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by the Pan-American Health Organization. according toBreslow, embarks on the jour- In that document, health promotion is ney toward health and not against diverse defined primarily as: “The promotion of types of diseases. This is illustrated in changes in lifestyle and environmental con- Figure3.1, where we can see that with the ditions to facilitate the development of a cul- evolution of humankind, of the epidemio- ture of health” (Pan-American Health logical patterns of disease and of the techno- Organization, 2002, p. 67). logical means available, the various functions It is also interesting to note that health of public health have successively developed promotion (as symbolized by the Ottawa in a series of layers like sediments, the latter Charter) has been identified as the “third not displacing but building on top of the public health revolution” of humankind former, which needs the previous ones to (Breslow, 1999); after the first, which had continue to function properly. tackled infectious diseases, and the second chronic illnesses, the health promotion era,

FIGURE 3.1: SEDIMENTATION APPROACH TO PUBLIC HEALTH THROUGHOUT HUMAN HISTORY

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Defining Health Promotion through identified 13 of the “most important” defini- Expert Consensus tions of the concept and thoroughly analyzed In addition to definition by differentiation them according to goals, objectives, processes, from close concepts, expert consensus is and activities. At the end of their content another way that has been frequently chosen. analysis, they conclude endorsing the “pre- A good example of that approach is the so- eminence” of the definition proposed by the called “yellow document.” As WHO regu- Ottawa Charter (see below) and by the fact that larly does, a group of international experts “[…] the primary criterion for determining if was convened to address a specific topic—the an initiative should be considered health pro- concept and principles of health promotion— moting, ought to be the extent to which it and came up with what is the forerunner of involves the process of enabling or empower- the Ottawa Charter (WHO-Euro, 1984). It is ing communities” (Rootman et al., 2001, p. 14). also through such a process that a group of the Canadian Institute of Advanced Research, The “What Is ‘Real’ Health Promotion” Debates an institution funded mostly through private on Click4HP monies that convenes task forces on topics The Click4HP (Click for health promotion) that are of major importance for the future listserv started in April 1996 as a short-term of Canada, came up with the famous “popu- pre-conference public discussion on the uses lation health” framework after a couple of of the Internet for health promotion, but rap- years of intensive work (Frank, 1995). We will idly grew into a long-lasting, vibrant inter- explore here two of these efforts of experts to national online forum on the nature of health define heath promotion, led largely by promotion and its applications. Click4HP Canadians: a more systematic one, done in has grown from 350 to a constant 1,200 sub- the context of a major reflection on the eval- scribers since 2000, engaging in exchanging uation of health promotion (Rootman et al., information, seeking solutions, and building 2001), and a collection of spontaneous ones connections in more than 10,500 postings in that emerged over the last 10 years on 10 years, at an average of 85 postings a Click4HP, an electronic international discus- month. On top of being used as a platform sion list monitored out of Toronto. to exchange information of all kinds to facilitate the day-to-day work of practitioners, Deconstructing Health Promotion more general debates and exchanges have In an exemplary effort to define what health occurred regarding empowerment, advocacy, promotion is all about, in order to discuss how healthy lifestyles, wellness, illness prevention, to evaluate it, Rootman and his colleagues and rehabilitation, foundations and values,

BOX 3.2: CLICK4HP: AN ELECTRONIC VENUE FOR DEBATING HEALTH PROMOTION ISSUES

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settings and strategies, and the myriad deter- topic areas and link to hundreds of organiza- minants of health. tions that contribute electronic resources to Regularly, there are vigorous debates on the CHN Web site; affiliates select resources, the list on the definitions and the breadth of produce feature articles, and respond to health health promotion. The longest of these was in information requests. September 1996 with more than 30 postings on “What is ‘real’ health promotion” (see anno- Why a Definition of Health Promotion Was tated Web sites below), followed by a 1998 Needed across CHN learned discussion among HP scholars on Although CHN was labelled from the outset foundations and limits of the field (18 long a “health promotion network,” there had postings), a lively exchange in 1999, and again been little consistent vision of what that in the fall of 2000 on what is HP (contrasting meant in practice. With the proliferation of definitions of population health, HP, and pre- health information Web sites by governments vention), and, finally, a vigorous exchange in and health agencies, CHN needed to make 2004, rekindled in 2005, following a question clear what it did differently. In 2003, CHN’s of whether health promotion was dead or Advisory Board set new strategic directions heading there. Each time, these debates show for 2004–2007, the first of which was to that HP is alive and kicking, but at the same strengthen its focus on health promotion, time that “health promotion continues to be including all of the determinants of health, constrained by the lack of a consistent, clear across the entire network (CHN, 2003). and usable definition” (Click4HP, 2004), which However, a commitment to health promo- explains why such debates erupt over and over tion is not enough to ensure consistency in again on Click4HP and in many other venues. application across so broad an organization. In the 2004 round of affiliate renewals, a new health promotion affiliate was thus estab- TRYING TO SOLVE THE lished with a dual goal of building the online DEFINITIONAL DILEMMA resources as well as health promotion capacity of CHN as a whole. The CHN Classification Scheme of Health Promotion CHN’s Working Definition of Health Promotion In 1998 the Canadian Health Network and a Tool to Assess It (CHN) was launched as a federally funded A working definition of health promotion was health promotion initiative to provide, agreed upon through a series of workshops through a national bilingual Web site, high- held in 2005. It integrated the Ottawa Charter’s quality, credible, and relevant health infor- definition with a recognition of levels of inter- mation for the general public and health vention and attention to determinants that professionals. It has been seen as a public sector encompassed the breadth of perspectives given response to consumers’ increasing use of the the many affiliates. A simple one-page tool was Internet to search for health information then developed to assess how this definition among a morass of very uneven sources (Cline could be reflected in all the work of CHN. The & Haynes, 2001; Fox & Rainie, 2000; Health health promotion assessment checklist (see Canada, 2000; Korp, 2006). CHN operates annotated Web sites below) uses a matrix-like through a unique collaboration involving affil- frame addressing who, where, why, how, and iates who are key partner organizations in 22 what is considered in an initiative. Each term Health Promotion 5/1/07 11:18 AM Page 40

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on the bilingual HP checklist is hyperlinked pointed out by so many people, even among to a Web-based definition or explanation of the most knowledgeable? Our answer is yes, what it means in context. The checklist is and for this it is helpful, as one of us proposed designed to be concise, comprehensive, and yet in the first edition of this book (O’Neill & simple, customizable by affiliates, and com- Cardinal, 1994), as well as in several other patible with other forms, tools, and quality- venues since then (O’Neill, 1997, 1998, 2003), testing mechanisms required for CHN to distinguish between two things. On the collection of resources. Testing took place in one hand, there is the discourse on the place spring 2006, with a subsequent evaluation and of health in societies, often called the “new modifications. public health” discourse, which we will label here the promotion of health. On the other Is CHN’s Problem Solved? hand, there is the specialized field of interven- Integrating a broad health promotion tion within the broader field of public health, approach that requires considering multiple aimed at the planned change of behaviour strategies, determinants, and levels into what and environments related to health, which used to be a rather individualistic health we will call health promotion. This distinc- information service is difficult. It comes at a tion is well illustrated if we contrast two of time when there are pressures for quality the best-known definitions of the field, the assurance of all content on CHN through peer one from the Ottawa Charter (WHO, 1986, review, evidence-based resource selection, and p. 1): “The process of enabling people to establishment of standards of practice (Balka, increase control over, and improve, their 2005). Demonstration of health promotion health” with the one (Green & Kreuter, 2005, “competencies” for all CHN affiliates in p. 462): “[…] any planned combination of staffing and organizational practice is expected educational, political, regulatory and orga- for the next round (Fall 2006) of affiliate appli- nizational supports for actions and conditions cation process for three-year contracts. As we of living conducive to the health of individ- have been able to observe thus far, for many uals, groups or communities.” of the diverse health and social organizations The Ottawa Charter’s definition, as well forming the CHN collaboration, there seems as the preface to this book by Kickbusch and to be little difference between their usual work most governmental health policy documents through individual lifestyle behaviour-change in Canada or around the world since the mid- messages and the health promotion approach 1970s, are typical of the reflections on what and definition that they now are expected to health is or should be; on the place health apply. Consequently, concerns from govern- should have in societies; and on who should ment and health agencies in CHN that health undertake health promoting, health restoring, promotion is not a clearly defined area are or health-maintaining endeavours (individu- likely to continue, at least for a while. als, governments, civil society, corporations, the health sector—including public health professionals—other sectors, etc.), hence the The Promotion of Health versus Health idea of naming this a discourse on the promo- Promotion: A Conceptual Avenue to tion of health. Basically, it is nothing but the Solve the Definitional Dilemma? old public health discourse, which has been So, is there such a thing as health promotion? around for centuries (Fassin, 2000) and which Are there ways to solve the confusion that is tries to reflect upon what health is in societies Health Promotion 5/1/07 11:18 AM Page 41

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or populations; what produces or hinders it; the Ottawa Charter (social justice, participa- and what can be done to improve it, reduce tion, empowerment, etc.) is in no way the risk of losing it, or restore it when com- restricted to specialized health promotion promised. The discourse on the promotion of interventions, but belongs to anybody work- health in modern societies, which has been ing in the new public health era, be they rekindled by the efforts of the European public health, health or other professionals, Office of WHO and is so strongly symbolized or even lay people. Finally, if they want to be by the Ottawa Charter since the mid-1980s, is as effective as they can be, planned change usually referred to as the “new” (Ashton & health promotion interventions need to be Seymour, 1988; Martin & McQueen, 1989) or knowledge-based or even evidence-based the “ecological” public health (Chu & Simpson, when that type of information is available. 1994; Kickbusch, 1989) in order to differenti- The relationship between the promotion of ate it from the more classical discourse of health and health promotion is illustrated in “hygiene” or “old” public health, which is Figure 3.2. better adapted to traditional societies with an epidemiological pattern of infectious disease. Consequently, it is why we argue here that CONCLUSION population health, as it emerged in Canada in As discussed in this chapter, it is obvious that 1994, is but a variation of this new public the two elements are often present together health discourse on the promotion of health. when people use the words “health promo- Conversely, if we look at Green and tion,” which maintains the confusion and the Kreuter’s definition, it is more in line with impression for many that health promotion as the idea that health promotion is a specialized a specialized subfield of public health does subarea, or essential function, of the public not exist. This is due notably to the fact that health sector of health systems whose speci- the Ottawa Charter’s definition, and the value ficity is the planned change of lifestyles and base it carries, are by far dominant on the life conditions having an impact on health, planet when one hears “health promotion.” using a variety of specific strategies, includ- As seen throughout this book, it gives a very ing health education, social marketing, and clear and distinct orientation to how people mass communication on the individual side, perceive Canadian health promotion, despite as well as political action, community organ- the fact that different value bases and differ- ization, and organizational development on ent ways of approaching health promotion the collective side. If we agree with this, then do exist here as well. Hence, in conclusion, the planned change skills of properly trained we suggest using the words “new public health promoters can be used at whatever health” or “ecological public health” when stage in the natural history of any illness or we talk in general about the discourse on the health problem (thus in primary or second- promotion of health, and reserve the expres- ary prevention, in acute care, in rehabilita- sion “health promotion” to designate the spe- tion, or in tertiary prevention) and at any cific planned change skills needed to level, from the individual to the societal, complement the types of skills developed in including the family and the community. other subareas of public health practice in Moreover, a variety of value bases can be used order to achieve the results desired by the to work with these health promotion skills “new public health” discourse. and, conversely, the value base promoted by Health Promotion 5/1/07 11:18 AM Page 42

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FIGURE 3.2: THE PROMOTION OF HEALTH VERSUS HEALTH PROMOTION

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REFERENCES Albrechtsen, H., & Jacob, E.K. (1997). Classification systems as boundary objects in diverse information ecologies. In E. Efthimiades (Ed.), Advances in classification research: Proceedings of the 7th ASIS SIG/CR Classification Research Workshop (pp. 1–13). Medford: Information Today. Ashton, J., & Seymour, H. (1988). The new public health. Philadelphia: Open University Press. Balka, E. (2005). Redefining P3: Political economy, policy, and privacy issues on the Canadian health information highway. In L. Shade & M. Moll (Eds.), Communications in the public interest, vol. 2: Seeking convergence in policy and practice (pp. 512–547). Ottawa: Canadian Centre for Policy Alternatives. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp, U., & Hill, C. (2003). Advancing a theoretical model for public health and health promotion indicator development. European Journal of Public Health, 13(3 Suppl.), 107–113. Breslow, L. (1999). From disease prevention to health promotion. JAMA, 281(11), 1030–1033. Bunton, R., & MacDonald, G. (Eds.). (2004). Health promotion: Disciplines and diversity (2nd ed.). London and New York: Routledge. Health Promotion 5/1/07 11:18 AM Page 43

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CHN. (2003). Canadian Health Network Advisory Board proceedings. Retrieved November 2003 from www.canadian-health-network.ca/servlet/ContentServer?cid=1086089762068&pagename=CHN- RCS/Page/ShellCHNResourcePageTemplate&c=Page&lang=En Chu, C., & Simpson, R. (1994). Ecological public health: From vision to practice. Toronto: Centre for Health Promotion; University of Toronto; Participaction. Click4HP. (2004). Posting made September 27, 2004. Cline, R.J.W., & Haynes, K.M. (2001). Consumer health information seeking on the Internet: The state of the art. Health Education Research, 16(6), 671–692. Coburn, D. (1988). The development of Canadian nursing: Professionalization and proletarianization. International Journal of Health Services, 18(3), 437–456. Donaldson, S.K. (2000). Breakthroughs in scientific research. The discipline of nursing: 1960–1999. Annual Review of Nursing Research, 18, 247–311. Duncan, P. (2004). Dispute, dissent, and the place of health promotion in a “disrupted tradition” of health improvement. Public Understanding of Science, 13, 177–190. Fassin, D. (2000). Comment faire de la santé publique avec des mots. Une rhétorique à l’œuvre. Ruptures, revue transdisciplinaire en santé, 7(1), 58–78. Fox, S., & Rainie, L. (2000). The online health care revolution: How the web helps Americans take better care of themselves. Washington: Pew Internet & American Life Project. Frank, J. (1995). Why population health? Canadian Journal of Public Health, 86(3), 162–164. Freidson, E. (1977). Professional dominance: The social structure of medical care. Chicago: Aldine Publishing Company. Green, L.W., & Kreuter, M.W. (2005). Health program planning: An educational and ecological approach (4th ed.). Boston, Toronto: McGraw-Hill Higher Education. Green, L.W., & Raeburn, J.M. (1988). Health promotion: What is it? What will it become? Health Promotion, 3(2), 151–159. Health Canada. (2000). Blueprint and tactical plan for a pan-Canadian health infostructure. Federal- Territorial Advisory Committee on Health Infostructure. Ottawa: Health Canada, Office of Health and the Information Highway. Kickbusch, I. (1989). Good planets are hard to find. Copenhagen: FADL Publishers. Korp, P. (2006). Health on the Internet: Implications for health promotion. Health Education Research, 21(1), 78–86. Kwasnik, B.H., & Rubin, V.L. (2003). Stretching conceptual structures in classifications across languages and cultures. Cataloging & Classification Quarterly, 37(1/2), 33–47. Labonté, R. (1995). Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health, 86(3), 165–168. Martin, C.J., & McQueen, D.V. (Eds.). (1989). Readings for a new public health. Edinburgh: Edinburgh University Press. McQueen, D.V., & Anderson, L.M. (2000). Données probantes et évaluation des programmes en promotion de la santé. Ruptures, revue transdisciplinaire en santé, 7(1), 79–98. Nutbeam, D. (1998). Health promotion glossary. Geneva: World Health Organization, WHO/HPR/HEP/98.1. Nyamwaya, D. (1997). Health promotion practice: The need for an integrated and processual approach. Health Promotion International, 12, 179–180. O’Neill, M. (1997). Health promotion: Issues for the year 2000. Canadian Journal of Nursing Research, 29(1), 71–77. Health Promotion 5/1/07 11:18 AM Page 44

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O’Neill, M. (1998). Defining health promotion clearly for teaching it precisely: A proposal. Promotion & Education, 5(2), 14–16. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? SPM International Journal of Public Health, 48(5), 317–326. O’Neill, M., & Cardinal, L. (1994). Health promotion in Québec: Did it ever catch on? In A. Pederson et al. (Eds.), Health promotion in Canada (pp. 262–283). Toronto: W.B. Saunders. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Ottoson, J.M., Pommier, J., Macdonald, G., Frankish, J., & Dorion, L. (2000). The landscape in health education and health promotion training. Promotion & Education, 7(1), 27–32. PAHO. (2002). Public health in the Americas (Technical publication #589). Washington: Pan-American Health Organisation. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). London: Palgrave. Potvin, L. (2005). Présentation dans le séminaire doctoral SAC-66008, Université Laval, octobre 17, 2005. Raphael, D. (2000). The question of evidence in health promotion. Health Promotion International, 15(4), 355–367. Robertson, A. (1995). Theory divides, data unite: Health promotion meets population health. Unpublished manuscript, Toronto. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). Copenhagen: WHO-Euro. Seedhouse, D. (1997). Health promotion philosophy, prejudice, and practice. Auckland: Wiley. Thorne, S. (2005). Conceptualizing in nursing: What’s the point? Journal of Advanced Nursing, 51(2), 107–107. Tones, K., & Green, J. (2004). Health promotion: Planning and strategies. London: Sage. WHO. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. WHO-Euro. (1984). Health promotion: A discussion document on the concept and principles. ICP/HSR 602 (m01). Unpublished manuscript, Copenhagen. Winslow, C.E.A. (1920). The untilled fields of public health. Science, 51, 23.

CRITICAL THINKING QUESTIONS 1. If you had to define health promotion to the following people, what would you say? • Your uncle Jack in a family gathering • A graduate student in physics • Ms. Jones at the neighbourhood centre community group 2. Do you now personally think that defining health promotion is important? Why? 3. Following the instructions in Box 3.2, browse the archives of Click4HP for at least an hour; after that, do you think you should subscribe to keep current about Canadian developments in health promotion? Why? Health Promotion 5/1/07 11:18 AM Page 45

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4. Explain the difference between the promotion of health and health promotion. Do you believe it is a useful distinction or not? Why? 5. After browsing the CHN Web site at www.canadian-health-network.ca for at least an hour, do you think it is a health promotion site? Why?

FURTHER READINGS

Savoie, D.J. (2003). Breaking the bargain: Public servants, ministers, and Parliament. Toronto: University of Toronto Press. This book provides historical background on how the federal government works and the traditional roles of public servants and politicians in setting and implementing policies. It goes on to discuss current realities, emergent issues, and thoughts on how they might be resolved.

RELEVANT WEB SITES Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR The Consortium, with 16 members, aims to enhance health promotion research through collaborative research projects, advocating funding for health promotion research, and acting as a focal point for international activity.

Canadian Population Health Initiative (CPHI) www.cihi.ca/cphi CPHI is a source of research information on the determinants of health. It was established in response to a recommendation from the National Forum on Health to foster better understanding of factors that affect individual and community health and contribute to policy development.

Canadian Public Health Association www.cpha.ca/english/ CPHA is a national, independent, not-for-profit, voluntary association representing public health in Canada with links to the international public health community. Health Promotion 5/1/07 11:18 AM Page 106

CHAPTER 8 ADDRESSING HEALTH INEQUALITIES IN CANADA: LITTLE ATTENTION, INADEQUATE ACTION, LIMITED SUCCESS

Dennis Raphael

INTRODUCTION health inequalities on the public health and ealth promotion is about improving the public policy agendas (Canadian Population H health of the population by increasing Health Initiative, 2002). Not surprisingly, control over the determinants of health Canada also lags behind other developed (Nutbeam, 1998). An important component nations in researching health inequalities and of this agenda should be the reduction of the sources of such inequalities, and devel- inequalities in health and influencing the oping and implementing means of reducing determinants of these health inequalities these inequalities (Raphael et al., 2005). (Whitehead, 1998). Health promotion ini- The past few decades have seen a tiatives that fail to consider the source of diminution of health inequalities among health inequalities may actually increase Canadians for certain conditions (Wilkins, inequalities by employing approaches that Berthelot, & Ng, 2002).2 But these declines favour those already enjoying good health at cannot be attributed to directed action by the expense of those whose health is already governments and public health agencies poor (Graham, 2004).1 motivated by a health inequalities agenda Profound health inequalities exist in (Sutcliffe, Deber, & Pasut, 1997; Williamson, Canada. These inequalities result from 2001; Williamson et al., 2003). Instead, many Canadians’ experiencing varying exposures recent governmental policies have widened to both health-enhancing and health-threat- known determinants of health inequalities ening living conditions (Raphael, 2002). among the population (Dunn, Hargreaves, These differential exposures are related to & Alex, 2002; Raphael, Bryant, & Curry- where Canadians live; the social classes and Stevens, 2004). And Canadian public health income groups in which they find them- action continues to be focused on issues that selves; whether they are of Aboriginal, play a relatively little role in producing or European, or non-European descent; or male reducing health inequalities (Raphael, 2003; or female (Raphael, 2006a,b). These health Raphael & Bryant, 2006). There are troubling inequalities are apparent in general health implications for the health of Canadians that status, life expectancy, and in the incidence result from these developments. of, and mortality from, a wide range of med- In this chapter the extent and sources of ical conditions. health inequalities among Canadians is exam- Canada was one of the first jurisdictions ined. The reason why addressing health to identify addressing health inequalities as inequalities is a marginal issue in Canada is important, but Canada now lags far behind considered by contrasting our situation with many other developed nations in having developments in other nations. To do so will 106 Health Promotion 5/1/07 11:18 AM Page 107

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require political and institutional willingness health inequalities and their sources. In con- to address key issues related to the societal or trast, Canadian efforts are limited to reports social determinants of health. on how poverty and income inequality influence health mostly by non-governmental organizations (Canadian Population Health ADDRESSING HEALTH Initiative, 2004; Phipps, 2002; Ross, 2002, INEQUALITIES IN CANADA 2004). Outside of governmental attention AND ELSEWHERE devoted to Aboriginal health, the extent of Canadian activity directed toward the issue of health inequalities is minimal and varies Health Inequalities Elsewhere across provinces. Health inequalities exist in every nation on Health promotion and population health the planet (Amick, Lavis, & Lopez, 2000). discourses in Canada, for the most part, do There are two primary discourses that have not explicitly focus upon reducing health been applied to explain the existence of these inequalities. As compared to developments inequalities. The cultural/behavioural explain several European countries, reducing nation is that individuals’ behavioural choices health inequalities in Canada takes a back (e.g., tobacco and alcohol use, diet, physical seat to policy statements about improving inactivity, etc.) are responsible for their devel- social and physical environments (Health oping and dying from a variety of diseases. Canada, 2001). There has been no defining The materialist/structuralist explanation Canadian “Black Report” (Black & Smith, emphasizes the material conditions under 1992) or “Independent Inquiry into Health which people live (Raphael, 2006). These con- Inequalities” (Acheson, 1998) focused on ditions include availability of resources to health inequalities, as was the case in the access the amenities of life, working condi- United Kingdom. tions, and quality of available food and housing among others. Access to health-enhancing conditions is also related to the way govern- Health Inequalities in Canada: Income ments behave (Ross et al., 2000). Evidence and Other Determinants clearly favours the materialist explanation of In contrast to other nations where research the sources of health inequalities (Acheson, and policy concern with health inequalities 1998; Gordon, Shaw, Dorling, & Davey Smith, has a long-standing history such as the UK, 1999; Raphael, 2006a; Shaw, Dorling, Gordon, few Canadian researchers explicitly focus on & Smith, 1999; Townsend, Davidson, & the extent and source of health inequalities Whitehead, 1992). (Raphael et al., 2005). And when these Jurisdictions differ profoundly to the researchers do, many are likely to attribute extent that these inequalities are seen as a such differences to behavioural risk factors cause for concern requiring action to address such as tobacco use, physical inactivity, and them (Bryant, 2006). A recent review exam- diet. As one example, a report from Statistics ined how 13 developed nations are address- Canada devoted most of its content to docu- ing health inequalities. Some, like the UK menting how health behaviours (e.g., smok- countries, New Zealand, and Sweden, have ing, exercise, weight, etc.) and psychosocial undertaken systematic governmental efforts variables (e.g., stress and depression) helped to identify the existence and magnitude of explain differences in health status among Health Promotion 5/1/07 11:18 AM Page 108

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health regions (Shields & Tremblay, 2002). and working conditions as well as food secu- This was done even though data from the rity (Raphael, 2001). Income also is a deter- same study showed that self-reported income minant of the quality of housing, the need was far and away the best explanation for for a social safety net, the experience of social these regional differences in health outcomes exclusion, and the experience of unemploy- (Tremblay, Ross, & Berthelot, 2002). ment and employment insecurity across the Such a fixation on individual behaviours lifespan (Raphael, 2004a). and psychosocial risk conditions is surpris- Income level is the best predictor of just ing as Canada has been seen as a leader in about every health indicator experienced by developing health promotion and population Canadians (Auger, Raynault, Lessard, & health concepts that outline the importance Choinière, 2004). The most definitive work to health of societal factors such as income in Canada on income and health is done by and its distribution, employment security and Wilkins and colleagues at Statistics Canada working conditions, early childhood, and (Wilkins, Berthelot, & Ng, 2002). Essentially, other social determinants of health (Restrepo, his analyses are conservative estimates of the 2000). Nevertheless, there is Canadian relationship between income level and mor- research that identifies inequalities in health tality rates. In both 1986 and 1996, those as being related to Aboriginal status, income Canadians living within the poorest 20 per- and its distribution, geographic location, and cent of urban neighbourhoods were much gender. Somewhat less work examines how more likely to die from cardiovascular dis- health inequalities result from early life expe- ease, cancer, diabetes, and respiratory dis- riences, inadequate housing, food insecurity, eases—among other diseases—than other lack of access to health services, immigrant Canadians (Wilkins, Berthelot, & Ng, 2002). status, and social exclusion (Galabuzi, 2004, In 1986, 21 percent of premature years of life 2005; Raphael, 2004b; Raphael, Bryant, & lost for all causes prior to age 75 in Canada Rioux, 2006). And important research focuses could be attributed to income differences and on the political economy of health inequali- this estimate increased to 23 percent by 1996. ties and how changes in economic structures This figure is obtained by using the mortal- and processes associated with increasing eco- ity rates in the wealthiest quintile of neigh- nomic globalization and the adoption of neo- bourhoods as a baseline and considering all liberal public policies drive increasing deaths above that rate to be excess related to inequalities in these social determinants of income differences. Figure 8.1 shows how health (Coburn, 2000, 2004; Teeple, 2000). excess mortality associated with income man- In this chapter, I focus on health inequal- ifests itself in premature mortality associated ities related to income as it is the most stud- with various diseases. ied factor; other chapters cover factors such Moreover, as shown in Table 8.1, the as gender and Aboriginal status and the lit- burden of ill health is concentrated in the erature cited in this chapter provides ample lowest income quintile of neighbourhoods in additional information. Income is an espe- urban Canada. For just about every cause of cially important determinant of health death, the richest neighbourhoods fare much inequalities as it is a marker of differential better than the others. A recent study reinforces experiences with many social determinants these findings. In this Ontario study, self- of health.3 Income is a determinant of the reported health status, as well as a functional quality of early life, education, employment, measure of health, were examined in relation Health Promotion 5/1/07 11:18 AM Page 109

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TABLE 8.1: Age-Standardized Mortality Rates Per 100,000 Population, for Both Sexes, or for Males and Females When Rates Differ by Gender, for Selected Causes of Death by Neighbourhood Income Quintile, Urban Canada, 1996

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to both personal and area variables. Findings As mentioned earlier, we could have indicated that individual level of income was gone in great detail on many other determi- a primary determinant of both self-reported nants of health and would have seen repro- and functional health (see Figures 8.2 and 8.3). duced the same patterns of health inequities Income-related health inequalities are higher between males and females, Aboriginal or than would be expected from income distri- not, immigrant or not, etc. Let us address bution and health data derived from other now how this problem can be tackled. nations (Humphries & van Doorslaer, 2000).

FIGURE 8.1: INCOME-RELATED PREMATURE YEARS OF LIFE LOST (0–74 YEARS) ASSOCIATED WITH DISEASE ENTITY, URBAN CANADA, 1996

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FIGURE 8.2: REPORT OF FAIR OR POOR SELF-RATED HEALTH:ODDS RATIOS FOR INDIVIDUAL AND AREA FACTORS, ONTARIO, 1996

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FIGURE 8.3: POOR SCORES (<50TH PERCENTILE) ON THE HEALTH UTILITIES INDEX: ODDS RATIOS FOR INDIVIDUAL AND AREA FACTORS, ONTARIO, 1996

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BOX 8.1: DETERMINANTS OF HEALTH INEQUALITIES IN CANADA

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AN AGENDA FOR in health is high on the agenda of Canadian ADDRESSING HEALTH researchers, policy makers, and the health INEQUALITIES IN CANADA promotion community. We will look at this Despite the increasing availability of research first by looking at the common source of funding to address “disparities in health” and health inequities, the social determinants of the “health of vulnerable populations” by the health. We will then look at how concern for Canadian Institutes of Health Research, there health inequities is absent from the federal is little evidence that addressing inequalities and provincial political agenda and then look Health Promotion 5/1/07 11:18 AM Page 112

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at the UK, which has explicitly decided to rioration in their quality (Raphael, Bryant, & tackle the problem. Curry-Stevens, 2004; Raphael & Curry- Stevens, 2004). The case of poverty is particularly illuminative. Identifying the Source of Health Poverty is a particularly important deter- Inequalities:The Social Determinants minant of health inequalities as it represents a of Health situation by which virtually every social deter- Despite the constant drumbeat of govern- minant of health is compromised (Auger et al., mental, disease associations, and media mes- 2004). Canada has some of the highest general sages concerning the role that “lifestyle and child poverty rates for developed nations choices” play in determining health, it is well (see Figure 8.4) (Campaign 2000, 2004; Inno- established that the primary determinants of centi Research Centre, 2005). This is the case health concern the living conditions to which despite Canada being wealthier than just about Canadians are exposed throughout their lives every other nation whose poverty rates are (Raphael, 2004b). Box 8.2 provides a list of below 10 percent (Organisation for Economic these social determinants of health. The view Co-operation and Development, 2003) and that living conditions—and governmental despite its signature on the international con- actions that shape the quality of these living vention against child poverty (Raphael, 2001). conditions—are the primary determinants Income and wealth inequality is increas- of health is consistent with a raft of state- ing in Canada (Curry-Stevens, 2004; Frenette, ments, conference resolutions (Canadian Green, & Picot, 2004; Myles, Picot, & Pyper, Public Health Association, 2001), and find- 2000). Food insecurity—represented by use of ings from numerous Canadian research stud- food banks—continues to grow across Canada ies quoted in this chapter, many showing that (Canadian Association of Food Banks, 2005; just about every quality indicator of these McIntyre, 2004). Homelessness—and related social determinants of health shows a dete- housing insecurity represented by the propor-

BOX 8.2:THE SOCIAL DETERMINANTS OF HEALTH OF PARTICULAR RELEVANCE TO HEALTH INEQUALITIES IN CANADA

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FIGURE 8.4: HOW CANADA COMPARES TO OTHER RICH NATIONS IN PERCENTAGE OF CHILDREN LIVING IN POVERTY

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tion of families spending either more than 30 review revealed that only Manitoba, Nova percent or more than 50 percent of income on Scotia, and Saskatchewan had explicit goals housing is also very high (Shapcott, 2004). The related to health equity and only British security and quality of work is deteriorating Columbia had a goal related to the health of (Jackson, 2004; Tremblay, 2004). Similar trends subgroups. There were many more goals concerning other social determinants of health, related to the social and economic environment such as early childhood and the social safety (13 goals in 10 jurisdictions), healthy public net, are observable (Canadian Council on policy (7 goals in 7 jurisdictions), and the phys- Social Development, 2000; Raphael, 2004b). ical environment (7 goals in 7 jurisdictions). In any event, the researchers found that these health goals had minimal impact on Is Canada Addressing Health strategic planning within each jurisdiction. Inequalities? Policy makers in BC, Newfoundland, the Is addressing health inequalities on the NWT/Nunavut, and Quebec continued to Canadian public policy agenda? The answer refer to these goals, but this was not the case is simply no. Williamson and colleagues in any other jurisdiction. More so, only a examined the degree of implementation of minority of local health regions (between 9 provincial/territorial health goals in Canada percent and 16 percent) reported acting upon (Williamson et al., 2003). Their document goals in provinces where goals related to Health Promotion 5/1/07 11:18 AM Page 114

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social and economic development, health health. In 1980 the Black Report revealed equity, and the physical environment existed. that despite a generation of accessible health care, class-related health inequalities had not only been maintained but in many instances Addressing Health Inequalities had widened (Black & Smith, 1992). The Elsewhere report appeared at the onset of the conserva- To consider why addressing health inequal- tive Thatcher era and its recommendations ities—with significant exceptions—is a mar- for promoting health were ignored for two ginal concern in Canada, we need to consider decades. Instead, during this period, numer- what might be called the political economy ous policies widened income and health of health. Raphael and Bryant recently exam- inequalities. The election of the new Labour ined how issues such as health inequalities government in 1997 saw the ongoing aca- and the sources of such inequalities become demic and policy concern with health prominent in national health agenda policies inequalities translated into a government- (Raphael & Bryant, 2006). Their analysis of wide effort to address this issue through the the Canadian, US, UK, and Swedish experi- implementation of public policy initiatives. ence concluded that political and economic In 1997, the new Labour government forces play a strong role in the extent to which commissioned the Acheson Commission into policy makers are prepared to view health Inequalities in Health. The commission con- inequalities as a significant policy concern. sidered a wide range of evidence and in its More specifically, nations governed by synopsis concluded that: political parties that are guided by principles of equity, democratic participation, and equal- The weight of scientific evidence supports a ity of opportunity are more likely to develop socioeconomic explanation of health inequali- public policies that will distribute resources ties. This traces the roots of ill health to such more equitably, provide greater supports for determinants as income, education and employ- citizens, and work to reduce social inequali- ment as well as to the material environment and ties that drive health inequalities (Navarro et lifestyle. (Acheson, 1998, p. iv) al., 2004; Navarro & Shi, 2002). Canada has never had “left party” participation in the fed- It offered 13 sets of recommendations eral Cabinet and therefore, with the US, has that spanned a range of determinants of one of the least developed welfare states among health that include poverty, income, tax, and wealthy nations (Alesina & Glaeser, 2004; benefits; education; employment; housing and Rainwater & Smeeding, 2003). In contrast, the environment; mobility, transport, and pollu- case of the UK is particularly illuminative in tion, among others. It emphasized that: (1) all that a new Labour government was elected policies likely to have an impact on health upon a commitment to reduce health inequal- should be evaluated in terms of their impact ities. They moved quickly to establish a wide on health inequalities; (2) high priority should range of cross-cutting initiatives to improve be given to the health of families with chil- the living conditions of the most vulnerable, dren; and (3) further steps should be taken to thereby reducing health inequalities (Benzeval, reduce income inequalities and improve the 2002; Raphael & Bryant, 2006). living standards of poor households. The UK has a long-standing intellectual Among the major policy initiatives in and academic concern with inequalities in response to the Inquiry’s findings was Health Promotion 5/1/07 11:18 AM Page 115

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Reducing Health Inequalities: An Action focused on health inequalities. These reviews Report (Department of Health, 1999). This are being used by departments to inform report focuses on raising living standards spending plans for the 2003–2006. and tackling low income, improving educa- There is little evidence that Canadian tion and early years, increasing employment, policy makers and public health advocates improving transport, building healthy com- are close to advancing such an agenda to munities, providing housing, and strength- address health inequalities in Canada. ening public health. There is also an Despite Canada’s impressive reputation as a important role for the National Health source of health promotion and population Service to address health inequalities. health ideas, there is little evidence of com- Key aspects of the government’s agenda mitment by federal and provincial authori- and related documents such as Opportunity ties to follow such an agenda (Raphael & for All—Tackling Poverty and Social Exclusion Bryant, 2006; Williamson et al., 2003). (Department for Work and Pensions, 1999), Further, public health agencies appear A New Commitment to Neighbourhood inclined to follow in their neglect of broader Renewal: National Strategy Action Plan (Social issues (Raphael, 2003). The retreat to non- Exclusion Unit, 2001), and From Vision to structural behaviourally oriented approaches Reality (Department of Health, 2001) con- to health promotion and population health trast with the position of the public health is strikingly apparent. When there has been sector in Canada in many ways. The first is public policy moves to strengthen social the recognition that health inequalities are a determinants of health such as housing and cause for serious concern. The second is gov- early childhood, these have come about in ernment authorities’ serious use of available response to a minority government situation research evidence. The third is the recogni- in Ottawa.4 It has not resulted from con- tion that these areas are cause for concern not cerned action on the part of public health only by health ministries and departments authorities and health promotion advocates but also the entire government. Fourth, there to have governments strengthen the social is a commitment to action through the devel- determinants of health.5 opment and implementation of public policy. And fifth, there is a goal for the National Health Service to promote equitable access CONCLUSIONS to services in relation to need and their taking Whitehead outlines an action spectrum on the lead in working with other agencies to inequalities in health (Whitehead, 1998). The tackle the broader determinants of health. first step is measuring health inequalities fol- In addition, UK goals were set for the lowed by recognition that there is a problem elimination of health inequalities. The 2002 that needs to be addressed. Once these occur, Spending Review Public Service Agreement— movement can be made to raise awareness, and a kind of business plan—for the Department action taken to develop initiatives to reduce of Health contained the goal “By 2010 to these inequalities. There is currently no sys- reduce inequalities in health outcomes by tematic effort in Canada to measure health 10% as measured by infant mortality and life inequalities. Indeed, even the United States is expectancy at birth” (UK Government, 2002). further along than Canada in measuring and To facilitate and support action, the govern- recognizing that health inequalities are a cause ment set up “cross-cutting spending reviews” for concern (United Health Foundation, 2004; Health Promotion 5/1/07 11:18 AM Page 116

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US Department of Health and Human Such a political approach would recog- Services, 1998). nize that governmental policy making cre- It has been argued here that reducing ates the conditions necessary for health. These health inequalities requires addressing the conditions include equitable distribution of sources of these health inequalities. The wealth and progressive tax policies that create sources of health inequalities are primarily a large middle class; strong programs that in Canadians’ living conditions, which result support children, families, and women; and in large part by government decision making economies that support full employment. concerning the allocation of resources among Instead, Canadian public policy has been the population. Canada falls way behind moving more and more toward a neo-liberal other nations in addressing issues of equi- US-type model. Nevertheless, reversals are table resource allocation, eliminating child possible. The recent UK experience illus- and family poverty, and meeting Canadians’ trates how decisions can be made to address basic needs (Bryant, 2006). health inequalities by improving the quality This being the case, there are two issues of citizens’ living conditions. The best means to be faced by health promoters in Canada. of reducing health inequalities therefore The first is to confront the continued domi- involves Canadians being informed about the nance of lifestyle and behavioural approaches political and economic forces that shape the to health promotion among practitioners and health of a society and the degree of health the understandings held by the media and inequalities within that society. Once so public concerning the sources of health and empowered, they can consider political and illness. The second problem is to have those other means of influencing these forces. To who recognize the importance of the social date, the health promotion community has determinants of health to take an explicitly not seen fit to take on a leadership role in this political approach as a means of moving the effort. This is rather a daunting task, but one health inequalities agenda along. that holds the best hope of improving the health of the Canadian population.

NOTES 1 This would be the case where health education and behavioural change are emphasized as a health promotion strategy. Individuals with superior economic and social resources—already more likely to be enjoying good health—will be the ones most likely to take up these messages, thereby increasing health inequalities. 2 The best evidence is that inequalities by income have been narrowing in mortality from ischemic heart disease, injuries (except motor vehicles accidents and suicides), cirrhosis of the liver, uterine cancer, prenatal conditions, and pedestrians struck by motor vehicles. Causes of death with mixed results are those of motor vehicle occupants’ deaths, lung cancer and prostate cancer among men, breast cancer for women, and suicide for both sexes. Wider inequalities by income and increased mortality is being seen for lung cancer for females, infectious diseases, ill-defined conditions, mental disorders, and diabetes for both sexes (Wilkins et al., 2002). 3 Many argue that income is a poor proxy for measuring social class, which is a much more profound indicator of socio-economic position. Unlike the situation in the United Kingdom, there are very little data available on the social class position of Canadian study participants. What data are available on social class and health are consistent with the income and health data reported here. See Muntaner and colleagues’ Health Promotion 5/1/07 11:18 AM Page 117

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recent analysis of the role that social class plays in health in developed nations such as Canada (Muntaner et al., 2006). 4 A minority government situation occurs when the party with the most seats in the House of Commons (Parliament) does not command an absolute majority. In the current case (2004–2005) the governing Liberal Party was dependent upon the support of the New Democratic Party to maintain power. In return for its support, the New Democrats extracted a commitment to increased program spending in the areas of housing, child care, and public transportation. 5 There are a few promising developments. The Health Council of Canada recently called for policy makers to use “strong language” to describe the existence of health inequalities and their sources in Canada (Health Council of Canada, 2005). In Ontario the Association of Local Health Authorities, which represents both the medical officers of health and local health boards, called for the province to incorporate the determinants of health into the mandatory public health practice guidelines in order to reduce health inequalities. A handful of local health units are expanding their focus on the social determinants of health (Raphael, in press).

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Coburn, D. (2004). Beyond the income inequality hypothesis: Globalization, neo-liberalism, and health inequalities. Social Science & Medicine, 58, 41–56. Curry-Stevens, A. (2004). Income and income distribution. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Department for Work and Pensions. (1999). Opportunity for all: Tackling poverty and social exclusion. First annual report. Presented to Parliament by the secretary of state for Social Security. Copies of the Opportunity for all annual reports for 1999–2002 (first-fourth) by e-mailing [email protected]. Department of Health. (1999). Reducing health inequalities: An action report. London: Department of Health. Retrieved January 30, 2005, from www.dh.gov.uk/PublicationsAndStatistics/Publications/ PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/ en?CONTENT_ID=4006054&chk=ZOOf4d. Department of Health. (2001). From vision to reality. London: Department of Health. Retrieved July 23, 2006, from www.dh.gov.uk/assetRoot/04/05/94/59/04059459.pdf. Dunn, J., Hargreaves, S., & Alex, J.S. (2002, March). Are widening income inequalities making Canada less healthy? Retrieved August 2002 from www.opha.on.ca/publications/income_inequalities.pdf. Frenette, M., Green, D.A., & Picot, G. (2004). Rising income inequality amid the economic recovery of the 1990s: An exploration of three data sources. Ottawa: Analytic Studies Branch, Statistics Canada. Galabuzi, G.E. (2004). Social exclusion. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Galabuzi, G.E. (2005). Canada’s economic apartheid: The social exclusion of racialized groups in the new century. Toronto: Canadian Scholars’ Press Inc. Gordon, D., Shaw, M., Dorling, D., & Davey Smith, G. (1999). Inequalities in health: The evidence presented to the Independent Inquiry into Inequalities in Health. Bristol: The Policy Press. Graham, H. (2004). Tackling health inequalities in health in England: Remedying health disadvantages, narrowing health gaps, or reducing health gradients? Journal of Social Policy, 33, 115–131. Health Canada. (2001). The population health template: Key elements and actions that define a population health approach. Strategic Policy Directorate, Population and Public Health Branch, Health Canada. Retrieved June 2002 from www.hc-sc.gc.ca/hppb/phdd/pdf/discussion_paper.pdf. Health Council of Canada. (2005). Health care renewal in Canada: Accelerating change. Ottawa: Health Council of Canada. Humphries, K., & van Doorslaer, E. (2000). Income-related health inequality in Canada. Social Science & Medicine, 50(5), 663–671. Innocenti Research Centre. (2005). Child poverty in rich nations, 2005. Report card no. 6. Florence: Innocenti Research Centre. Jackson, A. (2004). The unhealthy Canadian workplace. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. McIntyre, L. (2004). Food insecurity in Canada. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Muntaner, C., Borrell, C., Kunst, A., Chung, H., Benach, J., & Ibrahim, S. (2006). Social class inequalities in health: Does welfare state regime matter? In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying Alive: Critical perspectives on health, illness, and care. Toronto: Canadian Scholars’ Press Inc. Myles, J., Picot, G., & Pyper, W. (2000). Neighbourhood inequality in Canadian Cities. Statistics Canada, Business and Labour Market Analysis Division. Retrieved July 2002 from www.statcan.ca/english/research/11F0019MIE/11F0019MIE2000160.pdf. Health Promotion 5/1/07 11:18 AM Page 119

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Navarro, V., Borrell, C., Benach, J., Muntaner, C., Quiroga, A., Rodrigues-Sanz, M., et al. (2004). The importance of the political and the social in explaining mortality differentials among the countries of the OECD, 1950–1998. In V. Navarro (Ed.), The political and social contexts of health. Amityville: Baywood Press. Navarro, V., & Shi, L. (2002). The political context of social inequalities and health. In V. Navarro (Ed.), The political economy of social inequalities: Consequences for health and quality of life. Amityville: Baywood. Nutbeam, D. (1998). Health promotion glossary. Geneva: World Health Organization. Organisation for Economic Co-operation and Development. (2003). Health at a glance: OECD indicators 2003. Paris: Author. Phipps, S. (2002). The impact of poverty on health. Ottawa: Canadian Population Health Initiative. Rainwater, L., & Smeeding, T.M. (2003). Poor kids in a rich country: America’s children in comparative perspective. New York: Russell Sage Foundation. Raphael, D. (2001). Canadian policy statements on income and health: Sound and fury—signifying nothing. Canadian Review of Social Policy, 48, 121–127. Raphael, D. (2002). Addressing health inequalities in Canada. Leadership in Health Services, 15(3), 1–8. Raphael, D. (2003). Barriers to addressing the determinants of health: Public health units and poverty in Ontario, Canada. Health Promotion International, 18, 397–405. Raphael, D. (2004a). Introduction to the social determinants of health. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (Ed.). (2004b). Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (2006a). Social determinants of health: An overview of concepts and issues. In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (2006b). Social determinants of health: Present status, unresolved questions, and future directions. International Journal of Health Services, 36, 651-677. Raphael, D., & Bryant, T. (2006). Public health concerns in Canada, USA, UK, and Sweden: Exploring the gaps between knowledge and action in promoting population health. In D. Raphael, T. Bryant, & M. Rioux (Eds.), Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. Raphael, D., Bryant, T., & Curry-Stevens, A. (2004). Toronto Charter outlines future health policy directions for Canada and elsewhere. Health Promotion International, 19, 269–273. Raphael, D., Bryant, T., & Rioux, M. (Eds.). (2006). Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. Raphael, D., & Curry-Stevens, A. (2004). Addressing and surmounting the political and social barriers to health. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D., Macdonald, J., Labonte, R., Colman, R., Hayward, K., & Torgerson, R. (2005). Researching income and income distribution as a determinant of health in Canada: Gaps between theoretical knowledge, research practice, and policy implementation. Health Policy, 72, 217–232. Restrepo, H.E. (2000). Health promotion: An anthology. In H.E. Restrepo (Ed.), Health promotion: An Anthology (pp. ix–xi). Washington: Pan-American Health Organization. Ross, D.P. (2002). Policy approaches to address the impact of poverty. Ottawa: Canadian Population Health Initiative. Health Promotion 5/1/07 11:18 AM Page 120

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Ross, N. (2004). What have we learned studying income inequality and population health? Ottawa: Canadian Population Health Initiative. Ross, N., Wolfson, M., Dunn, J., Berthelot, J.M., Kaplan, G., & Lynch, J. (2000). Relation between income inequality and mortality in Canada and in the United States: Cross-sectional assessment using census data and vital statistics. British Medical Journal, 320(7239), 898–902. Shapcott, M. (2004). Housing. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Shaw, M., Dorling, D., Gordon, D., & Smith, G.D. (1999). The widening gap: Health inequalities and policy in Britain. Bristol: The Policy Press. Shields, M., & Tremblay, S. (2002). The health of Canada’s communities. Health reports, 13(Suppl., July), 1-25. Social Exclusion Unit. (2001). A new commitment to neighbourhood renewal. National strategy action plan. London: Social Exclusion Unit, Cabinet Office. Retrieved July 23, 2006, from www.cabinet-office.gov.uk/seu. Sutcliffe, P., Deber, R., & Pasut, G. (1997.). Public health in Canada: A comparative study. Canadian Journal of Public Health, 88, 246–249. Teeple, G. (2000). Globalization and the decline of social reform: Into the twenty-first century. Aurora: Garamond Press. Townsend, P., Davidson, N., & Whitehead, M. (Eds.). (1992). Inequalities in health: The Black Report and the health divide. New York: Penguin. Tremblay, D.G. (2004). Unemployment and the labour market. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Tremblay, S., Ross, N.A., & Berthelot, J.-M. (2002). Regional socio-economic context and health. Health Reports, 13(Suppl.), 1–12. UK Government. (2002). SR 2002: Public service agreements. London: The Treasury Department. United Health Foundation. (2004). America’s health: State health rankings. Minnetonka: United Health Foundation. US Department of Health and Human Services. (1998). Health, United States, 1998: Socioeconomic status and health chartbook. Washington: Author. Whitehead, M. (1998). Diffusion of ideas on social inequalities in health: A European perspective. Millbank Quarterly, 76(3), 469–492. Wilkins, R., Berthelot, J.-M., & Ng, E. (2002). Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports (Stats Can), 13(Suppl.), 1–28. Williamson, D. (2001). The role of the health sector in addressing poverty. Canadian Journal of Public Health, 92, 178–182. Williamson, D., Milligan, C.D., Kwan, B., Frankish, C.J., & Ratner, P.A. (2003). Implementation of provincial/territorial health goals in Canada. Health Policy, 64, 173–191.

CRITICAL THINKING QUESTIONS 1. Review the health-related stories of your local newspaper over the next few weeks. If you based your understanding of health inequalities on these stories, what would be your views of what makes some people healthy and others ill? 2. What evidence is available concerning the extent of health inequalities in your jurisdiction? What are the current indicators of incidence of poverty, homelessness, and food bank use in your area? Have conditions been improving or declining? Health Promotion 5/1/07 11:18 AM Page 121

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3. To what extent have other health-related courses you have taken addressed issues of health inequalities? What could be done to increase your discipline’s emphasis on health inequalities? 4. What could be done to improve the public’s understanding of the importance of tackling health inequalities? What should be the role of your local public health unit or health care professionals? 5. To what extent is public policy in your city, region, or nation concerned with reducing health inequalities? Why are some nations more concerned with dealing with this problem than others?

FURTHER READINGS Acheson, D. (1998). Independent inquiry into inequalities in health. London: Stationary Office. This defining work documents how health inequalities result from the experience of people being exposed to differing material conditions of life. Provides the basis for the current UK governmental approaches to reducing health inequalities. Available from www.official-documents.co.uk/document/doh/ih/contents.htm.

Davey Smith, G. (2003). Health inequalities: Life-course approaches. Bristol: Policy Press. This book provides an overview of the social and economic factors that are now known to be the most powerful determinants of population health in modern nations.

Raphael, D. (2004). Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. This book summarizes how socio-economic factors affect the health of Canadians, surveys the current state of 11 social determinants of health across Canada, and provides an analysis of how these determinants affect Canadians’ health.

Raphael, D., Bryant, T., & Rioux, M. (Eds.). (2006). Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press Inc. This volume emphasizes the political economy of health and contains chapters on the social determinants of health and health inequalities associated with social class, gender, and race. It has a strong emphasis on how public policy influences health in general and health inequalities in particular.

Wilkins, R., Berthelot, J.-M., & Ng, E. (2002). Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Reports (Stats Can), 13(Suppl.), 1–28. Russell Wilkins and colleagues’ work on income and health inequalities is among the best in Canada. This report summarizes health inequalities as measured by death rates among areas in urban Canada as a function of income.

RELEVANT WEB SITES

Canadian Institute of Children’s Health www.cich.ca The Institute produces biannual reports on the state of health of Canada’s children, highlighting the determinants of health inequalities. Health Promotion 5/1/07 11:18 AM Page 122

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Centre for Social Justice (CSJ) www.socialjustice.org The CSJ works on narrowing the gap between rich and poor, challenging corporate domination of Canadian politics, and pressing for economic and social justice. It has numerous reports on health inequalities issues.

Health Canada Population Health Approach www.phac-aspc.gc.ca/ph-sp/phdd/ This Web site provides details about how the population health aims to improve the health of the entire population by acting upon the broad range of factors and conditions that influence health.

Montreal Region Public Health Unit www.santepub-mtl.qc.ca Medical officer Richard Lessard has been a Canadian leader in monitoring health inequalities and identifying means of reducing these through concerted action. See especially the annual reports Social Inequalities in Health and Urban Health.

UK Department of Health www.dh.gov.uk/Home/fs/en This Web site contains numerous governmental reports on how England is addressing health inequalities. Health Promotion 5/1/07 11:18 AM Page 123

CHAPTER 9 DEVELOPING KNOWLEDGE FOR HEALTH PROMOTION

Irving Rootman, Suzanne Jackson, and Marcia Hills

INTRODUCTION research through sharing examples of suc- n the first edition of this book, the chapter cessful efforts to do so and providing I on “Developing Knowledge for Health opportunities to develop the required skills Promotion” (Rootman & O’Neill, 1994) cov- • give more legitimacy to the collection ered the period 1986–1993 in terms of efforts and sharing of practical experience as an to develop knowledge for health promotion acceptable mode of knowledge devel- in Canada. Specifically, it described and ana- opment in Canada by bringing practi- lyzed the “Knowledge Development” proj- tioners into the process of developing ect initiated and carried out with leadership knowledge at all stages from what was then the Health Services and Promotion Branch of Health and Welfare This chapter explores the extent to Canada. Based on reflections about the which such suggestions have been acted on, process, it made some suggestions for the as well as how knowledge development has future. Key suggestions were to: occurred in health promotion in Canada. In • encourage the federal government to doing so, it should be noted, as was done in invest more resources in knowledge the first edition, that the term “knowledge development for health promotion in development” was retained here as it was closer collaboration with other levels of chosen then by Health and Welfare Canada government and the voluntary sector because it includes more than scientific • encourage the six health promotion research, i.e., the “practical experiences of research centres that were funded in practitioners and/or lay people” (Rootman & 1993 by the National Health Research O’Neill, 1994, p. 140). In addition, it includes Development Program (NHRDP) and not just creating knowledge through research the Social Sciences and Humanities and synthesis of information or experience, Research Council (SSHRC) to play an but also developing capacity to do so through active role in knowledge development training, information sharing, and other in collaboration with others, including means, as well as developing the infrastruc- practitioners, communities, voluntary ture for both knowledge creation and skill organizations, the private sector, various development. Thus, this chapter will con- levels of government, and other mem- sider all three aspects of knowledge devel- bers of the research community in health opment for health promotion in Canada and related fields covering the period from 1994–2007. • expend more resources in supporting Specifically, the chapter will present and interdisciplinary and multi-disciplinary discuss what has happened in Canada to 123 Health Promotion 5/1/07 11:18 AM Page 124

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develop infrastructure for knowledge devel- KNOWLEDGE DEVELOPMENT opment in health promotion, to increase INFRASTRUCTURE SINCE 1994 capacities of researchers and practitioners, and to improve our knowledge base on health pro- Canadian Consortium for Health motion. It will then critically analyze these Promotion Research developments, and discuss their implications One of the key components of the infrastruc- for Canada and other countries. Even if it is ture for health promotion knowledge devel- impossible to cover all of the context and com- opment that has emerged over the past decade plexity of knowledge development in health is the Canadian Consortium for Health promotion in Canada in this chapter, we hope Promotion Research (CCHPR), which cur- that we will have covered enough to raise the rently consists of 16 university-based centres key issues related to that most significant topic. that conduct health promotion research across Canada, as shown in Table 9.1.

TABLE 9.1: LIST OF MEMBERS OF THE CANADIAN CONSORTIUM FOR HEALTH PROMOTION RESEARCH NETWORK

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1993, partly as a result of funding of six cen- type of funding arrangements. The basic ten- tres by NHRDP and SSHRC mentioned sion has been between the need for basic above. The second phase, which lasted from infrastructure funding and the opportunities 1994–1996, involved meetings and informal arising from specific health promotion collaboration among existing centres facili- research and capacity development projects. tated by funding from Health Canada. The The period where basic infrastructure fund- third, which lasted from 1996–1998, involved ing dominated was the fourth phase, when the naming of the participating centres as the there was a coordinator who specifically sup- Canadian Consortium for Health Promotion ported collaborative activities between cen- Research and informal meetings and activi- tres and fostered information sharing and ties independent of Health Canada, but asso- development of an agenda for health pro- ciated with meetings sponsored by Health motion activities nationally. In this phase, Canada. The fourth, which lasted from there was an exchange of tools on evaluation 1997–2001, involved direct funding of the activ- and discussions about how to influence ities of the Consortium through a grant from applied research in Canada either via open NHRDP, which allowed the Consortium to research competitions or via collaboration hire a coordinator and provided some sup- with Health Canada. port for formal meetings and activities. When The sixth phase (2004–2007) represents the funding ended in 2001, the Consortium the establishment of the Consortium as a reverted to the previous arrangement of formal non-profit corporation with a board holding meetings supported directly by of directors and formal ability to control Health Canada, particularly by one of the finances. Signing on to a formal Consortium regional offices (i.e., fifth phase). The current was difficult for some of the members of the sixth phase began in 2004 when Health Consortium because of university concerns Canada and subsequently the Public Health regarding liability; however, the Consortium Agency of Canada awarded a grant to the Society now has most of the 16 centres as Consortium to organize the Global Conference members. The other issue in relation to this of the International Union for Health phase as far as knowledge development is Promotion and Education (IUHPE) in concerned is that the funding has been tied Vancouver in June 2007. This required the to very specific (though of broad significance) Consortium to establish a corporation involv- project outcomes (IUHPE conference and ing several members of the Consortium, but Effectiveness of Community Interventions also provided some funds to allow the larger Project). This intense focus on two major Consortium to meet from time to time. Thus, activities has meant the Consortium so far over the period of 1994–2007, the Canadian has not been able to engage in many other Consortium for Health Promotion Research significant activities at the national level took shape, with various kinds of funding during this current phase. However, it is arrangements supporting its activities, most quite likely that profits realized from the of which had to do with capacity development IUPHE Conference, as well as the height- and research and which will be described in ened profile of the Consortium Society, will the sections that follow. allow the Consortium to expand its activities One key issue to note about these phases significantly. of development of the Consortium is that infrastructure was very dependent on the Health Promotion 5/1/07 11:18 AM Page 126

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TABLE 9.2: PHASES OF INFRASTRUCTURE OF CCHPR

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Funding Agencies development activities, although as men- Since 1994, there were also substantial tioned, Health Canada continued to provide changes in the funding agencies that have had some support though NHRDP and its a significant impact on the infrastructure for national and regional offices. health promotion knowledge development There were also some very substantial in Canada. As indicated in Chapter 7, there changes in the funding agencies for health were numerous changes at the federal level research, which have had a significant, gener- in the infrastructure for health promotion in ally positive effect on the funding of health general. For one, Health and Welfare Canada promotion research in Canada. Probably most was split into two departments in 1993, and important were the elimination of the Medical the Health Promotion Directorate, which had Research Council of Canada and the estab- been the bulwark for the support of national lishment of the Canadian Institutes for Health activities in health promotion, including the Research (CIHR) in its place in 2000. The latter knowledge development activities described significantly expanded the funding opportu- in the first edition of this book (Rootman & nities for health promotion research through O’Neill, 1994), was eliminated in 1995. This the recognition of “population health” as one substantially weakened the federal govern- of the four pillars of the CIHR program and ment’s support and leadership for knowledge the establishment of several institutes, such as Health Promotion 5/1/07 11:18 AM Page 127

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the Institute for Gender and Health, the Research Institute (CPRI), the Canadian Institute for Population and Public Health, Council on Learning (CCL), and the Michael and the Institute for Aboriginal Peoples Smith Foundation for Health Research in BC, Health, all of which were favourable to and the Alberta Heritage Foundation for Health supported the expansion of health promotion Research, as well as the Fonds québécois de la research in their domain. In particular, the fact recherche sur la société et la culture and the that the first director of the Institute of Gender Fonds de la recherche en santé du Québec in and Health was a former director of two of the Quebec. All of these organizations have pro- university-based centres for health promotion vided funding for health promotion knowl- research that made up the Consortium, and edge development projects. In addition, the that members of the Consortium were establishment of the Public Health Agency of appointed to advisory boards and review com- Canada (PHAC) will likely have significant mittees, helped to establish the legitimacy of implications for health promotion knowledge health promotion research in the CIHR. This development. Although it is still a bit early to key development, a unique experiment in tell how this will play out in practice, the health research funding (and one being looked strong leadership at the top of this new organ- at closely by other countries as an exemplar), ization has already had an impact, symboli- represents a major strategic victory for those cally demonstrated by the resurgence of the (health promotion researchers being among language and terminology of health promo- the most prominent) who have long advocated tion (there is now a Centre for Health a shift from biomedical dominance in health Promotion in PHAC), the creation of a health research. The fact that members of the promotion research agenda, and the estab- Consortium were very successful in obtaining lishment of collaborating centres, some of peer-reviewed grants through the CIHR also which focus on topics related to health pro- contributed to this legitimacy. motion. Members of the Consortium have On the other hand, as a result of the estab- established a working relationship with these lishment of CIHR, the budget of NHRDP collaborating centres, particularly the National was reduced and its mandate changed, which Collaborating Centre for Determinants of eliminated an important source of support for Health. These relationships are likely to con- policy-oriented and applied research in health tinue along with the development of rela- promotion, although at the same time creat- tionships with the PHAC itself, as the fact that ing opportunities for policy-relevant and inter- the head of the agency is the co-chair of the vention research. This has presented major IUHPE Conference in 2007 would suggest. challenges, but also great opportunities for health promotion to continue to establish itself as a legitimate health research field in the Other Infrastructure Developments: broader health research community. Funding Sharing Knowledge for health promotion research in Canada In addition, over the last decade, Canada has increased substantially over the past decade, successfully established new and productive not only because of the establishment of infrastructures for sharing knowledge about CIHR, but also because of the establishment health promotion with colleagues. One of the and growth of other national and provincial most successful of these has been Click4HP, organizations that have supported such the electronic discussion forum presented in research. These include the Canadian Policy Chapter 3. Another vehicle for sharing infor- Health Promotion 5/1/07 11:18 AM Page 128

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mation is the Ontario Health Promotion e- DEVELOPMENT OF CAPACITY: mail bulletin, which provides information on HEALTH PROMOTION health promotion weekly to over 4,000 sub- EDUCATION AND TRAINING scribers, with the largest group from Ontario, but now including a significant proportion of Contribution of Canadian Consortium people from other parts of Canada (about one- for Health Promotion Research third) and other countries (about one-quar- Several centres associated with the Canadian ter). Similar electronic portals or bulletins have Consortium for Health Promotion Research been developed in most provinces, like have played a role in contributing to both Promosanté (www.promosante.org) for formal degree-based university training in instance, which aims at disseminating fran- health promotion and continuing education cophone health promotion information in for practitioners. Several summer schools on Québec and across Canada. health promotion were established since 1993 As also discussed in Chapter 3, in 2004, the and are now offered on a regular basis with Canadian Health Network (CHN), a Web- a variety of university and continuing edu- based health information system funded by the cation credits (see Table 9.3). Also, in terms Public Health Agency of Canada for all of continuing education, the Centre for Canadians, created a health promotion affili- Health Promotion, in collaboration with the ate. The Ontario Prevention Clearinghouse Ontario Prevention Clearinghouse and the and the Centre for Health Promotion at the Ontario Health Promotion Resource System, University of Toronto formed this affiliate and developed an interactive online course on subsequently provided leadership, not only in health promotion and made it readily avail- creating the resource base on health promotion able (www.ohprs.ca/hp101/main.htm). on the Web but also by coordinating the health In addition, there has been a significant promotion components of all affiliates of CHN. expansion of graduate level academic training As a result of this work, all affiliates have devel- opportunities for people interested in health oped a common protocol about how to ensure promotion. The Centre for Community that their collections include health promotion, Health Promotion Studies at the University and that the marketing and dissemination of Alberta launched a master’s degree (MSc) strategies are consistent across the network. program in health promotion studies in 1996 Another important contribution to the with a distance learning option. As noted in Canadian infrastructure for health promotion the commentary on Alberta by Wilson and knowledge development has been the estab- colleagues in Chapter 11, more than two-fifths lishment of structures for the support of edu- of the students have been from outside the cation and training in health promotion, which province. This augments the long-term are described in more detail in the next section. ongoing MHSc program in health promo- Thus, overall, since 1993, the infra- tion in public health sciences at the University structure for supporting knowledge devel- of Toronto, the MA program in health edu- opment in health promotion in Canada has cation at Dalhousie University, as well as the improved in terms of support for a national graduate training in the domain offered network of centres involved in health pro- within other public or community health promotion (CCHPR), funding for research, elec- grams as described in Table 9.3. tronic information exchange mechanisms, In addition, many more ad hoc opportu- and additional educational opportunities. nities have become available for practitioners, Health Promotion 5/1/07 11:18 AM Page 129

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TABLE 9.3: HEALTH PROMOTION SUMMER SCHOOLS/TRAINING PROGRAMS IN CANADA

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policy makers, researchers, and others to as on an interactive listserv. A national survey improve their knowledge and skills related to was conducted to examine the state of the art health promotion. These include workshops, in health promotion education in Canada and seminar series, lectures, interest groups, con- a book chapter was published based on the ference presentations, and publications, many results of the survey (Hills & Green, 2001). of which are done or provided through the As indicated by some of the commen- individual member centres of the CCHPR. taries in the Global Perspectives Section of this The Consortium as an organization has book, over the last decade, Canadians have also provided support to develop some of also made a significant contribution to capac- these ad hoc information and education ity development in health promotion globally. opportunities. An example would be the For example, the chairs of the Education and series of national conferences on health pro- Training Committee of the Consortium motion research and practice that have been organized, edited, and published a special issue organized by individual centres in partner- on training in health promotion for the offi- ship with the Consortium as a whole and cial journal of the International Union of other Consortium members. Since 1993, Health Promotion and Education (O’Neill & there have been five conferences in various Hills, 2000) in addition to organizing training parts of the country (Toronto, Calgary, and education streams during the three last Montreal, Halifax, and Victoria). Each one global IUHPE conferences in Puerto Rico, helped to move the field of practice and Paris, and Melbourne. Organizing the forth- research forward as well as provide skill coming IUHPE Global Conference on Health development, networking, and information- Promotion in 2007 is also a significant contri- exchange opportunities for participants. bution both to global and Canadian capacity The Training and Education Committee in health promotion. Other international con- of the Consortium has played a critical role tributions of CCHPR members to the devel- in capacity development. For example, the opment of capacity are noted in chapters 13 committee organized a series of workshops and 14. for teachers of health promotion in conjunc- Thus, as was the case with respect to tion with the annual Canadian Public Health infrastructure development, members of the Association conference, and initiated a proj- Canadian Consortium for Health Promotion ect to allow the organizers of the various Research have played a significant role in health promotion summer schools to work increasing the number of continuing educa- together, share resources, and improve their tion opportunities, graduate education spe- curricula. In addition, the committee has cialties, and ad-hoc training and knowledge stimulated opportunities for academic train- exchange events both in Canada and through- ing programs in health promotion to work out the world. together. For example, a joint distance-learning course was developed and offered by faculty of the University of Alberta and Contributions of Others University of Toronto health promotion pro- Others who have contributed to capacity devel- grams. The committee also consolidated opment include the Canadian Institutes for English and French language resources for Health Research, which, among other things, teaching health promotion and made them introduced a program for supporting research available on the Consortium’s Web site as well training. Some of the projects supported by Health Promotion 5/1/07 11:18 AM Page 132

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this program, such as the “Partnering in (e.g., HIV/AIDS, falls), chronic disease man- Community Health Research” project co- agement (e.g., self-care, mutual aid), the directed by the Institute of Health Promotion effectiveness of various kinds of health pro- Research at the University of British Columbia, motion interventions (e.g., policies, health have provided training opportunities for grad- communication), and outcomes (e.g., quality uate students and community agency mem- of life).1 Given the fact that each of these bers in community-based research, including topics involves multiple projects, it is impos- research with vulnerable populations. As noted sible to summarize here the net contribution in Chapter 6, the recently established Canadian to new knowledge easily. As an alternative, Council on Learning and other organizations we will present a couple of examples of proj- have also supported capacity development ects completed by some member centres of related to health promotion such as a National the Consortium working together and of the Summer Institute on Literacy and Health Consortium as a whole over the last decade. Research held in 2005. An example of a study involving multi- Thus, clearly progress has been made in ple centres was on quality of life among older Canada over the last decade in building skills adults in Canada, which was led by the for better health promotion practice and Centre for Health Promotion at the University research across Canada. The limitations are of Toronto and developed out of the Quality that this progress is somewhat uneven across of Life Research Program of that Centre. In the country and greatly dependent on the this particular case, several other centres from presence of the Consortium, some members across Canada were recruited as collabora- of which are somewhat fragile in terms of tors. The project focused particularly on long-term funding and support. policy decisions affecting the quality of life of older adults. It was a participatory study in which seniors controlled the direction and DEVELOPMENT OF NEW shape of the project in each city and it used KNOWLEDGE focus groups and individual interviews with older adults and stakeholders, and qualita- Contribution of Canadian Consortium tive methods to see the world through the eyes for Health Promotion Research of participants. Participants highlighted access The Canadian Consortium for Health to information, health care, housing, income Promotion Research and its members have security, safety and security, social contacts been very active in developing new knowl- and networks, and transportation as key edge related to health promotion over the last issues that affect the quality of life of older decade. All of the members have active adults in Canada. This project showed the research programs on a wide range of topics value of participatory activities that involve in health promotion, including topics related seniors working with other sectors as a pro- to the impacts of individual and environ- ductive policy-informing approach. (Bryant mental factors on health (e.g., physical activ- et al., 2004) ity, school, or workplace settings), health Although there have been many more of issues in different population groups (e.g., these joint ventures involving several children, women, older adults), health pro- Consortium members (the first edition of this motion issues in different types of commu- book, for instance, was a joint project of the nities (e.g., rural, Aboriginal), prevention Centre for Health Promotion at the University Health Promotion 5/1/07 11:18 AM Page 133

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of Toronto and the Groupe de recherche et would help to collect data relevant to the key d’intervention en promotion de la santé de mechanisms that are at the heart of successful l’Université Laval, which involved several community health promotion initiatives (Hills, other members of CCHPR), the one briefly Carroll, & O’Neill, 2004). The project is now described should at least give the reader a in its third phase, with a primary focus on indi- sense of the type of collaborative research that cator development. has been facilitated by the Consortium. Thus, it should be clear that a consider- With regard to research projects carried able amount of new knowledge relevant to out by the Consortium as a whole, most of health promotion and various stakeholders them had to do with synthesis and analysis has been generated in Canada by members of research and knowledge on particular of the CCHPR working individually or topics that were of interest to Health Canada together. In addition, a preliminary search or other federal departments (such as the for papers published by individual members Department of Defense). One such project of the Consortium revealed over 200. involved the synthesis of knowledge on the However, the question remains whether or concept of “lifestyle” to be used in the devel- not we might have achieved as much as we opment of the national “Healthy Living would have liked. And if not, what might we Strategy” (Lyons & Languille, 2000). It was do better in the future? suggested that the concept of “lifestyle” should include not only traditional behavioural aspects, but also the roles of social con- CRITICAL ANALYSIS texts and community views as argued also in We now return to the four suggestions that Chapter 4. The paper that was produced is were made in the first edition as stated ear- now available on both Health Canada’s Web lier in this chapter and assess the progress site and the Consortium’s site (see below for made over the last decade. URLs). Another project carried out in the With regard to the suggestion that the context of the government’s “Healthy Living federal government invest more resources in Strategy” was a review of the evidence on the knowledge development for health promo- effectiveness and cost effectiveness of active tion in closer collaboration with other levels living strategies (Spence, 2000). of government and the voluntary sector, it Another key consortium project, which should be apparent that this has, in part, been is still underway in partnership with the Public achieved over the past decade. Most of this Health Agency of Canada, involves a series of investment has come through the establish- studies on the effectiveness of health promo- ment of CIHR with a broadened mandate tion interventions. It began with a study to that allows it to support health promotion assess the methods and concepts used to syn- research on a competitive basis. The support thesize the evidence of the effectiveness of of Health Canada for infrastructure (either health promotion by reviewing 17 national and for the centres or the Consortium) has waxed international initiatives (Jackson et al., 2001). and waned over the last decade and certainly This study identified a framework for con- has not been coordinated with other federal ducting a synthesis of the evidence in health departments, other levels of government, or promotion and some of the particular issues the voluntary sector. Part of this was due to faced by reviewers. Following that, the proj- the fact that the department was constantly ect moved to identify evaluation strategies that being reorganized over this period, subject Health Promotion 5/1/07 11:18 AM Page 134

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to pressures to focus on “population health” interested in health promotion. There is no rather than “health promotion,” forced to reason to believe that this will not continue. reduce expenditures, and ultimately to Finally, with regard to giving more legit- reduce its size to accommodate the estab- imacy to the collection and sharing of prac- lishment of the Public Health Agency of tical experience as an acceptable mode of Canada. Although it is encouraging that the knowledge development in Canada by bring- term “health promotion” has come back into ing practitioners into the process of develop- vogue at the federal level, it is too early to say ing knowledge at all stages, there also have whether or not the challenge of investing been significant positive changes over the past additional resources to develop knowledge decade. This was perhaps in part stimulated in this domain in collaboration with other by the Royal Society of Canada report on par- levels of government and the voluntary sector ticipatory research in health promotion pro- will be accepted by the federal government duced by the Institute of Health Promotion and the Public Health Agency of Canada. Research in collaboration with other health With regard to the second suggestion, promotion centres across the country (Green four of the six health promotion research cen- et al., 1994). Whatever the reason, it is clear tres that were funded in 1993 by NHRDP that participatory research has become more and SSHRC survived after the funding acceptable as an approach, with virtually all ended. What is more significant is that at of the centres in Canada adopting it for some least 10 more centres with a focus on health projects, as well as other researchers or promotion were created in Canada over the research units doing so as well. It is especially last decade. All of these centres play an active interesting to note that following up on the role in research, training, and information work done in Canada, the US Centers for exchange in collaboration with others, Disease Control have held at least one com- including practitioners, communities, vol- petition to support participatory research untary organizations, the private sector, and projects in health. The CIHR Institute of various levels of government as well as other Aboriginal People’s Health and Institute for members of the research community in Gender and Health has also held competi- health and related fields. It is also significant tions specifically for community-based to note that a lot of non-academic relation- research, which has become identified in ships have been developed despite a lack of Canada as invariably requiring a participa- academic rewards for this kind of work in tory methodological approach (Hills & some universities and the ongoing struggle Mullett, 2000a, 2000b). It can be hoped that to find core funding. the latter efforts are only the sign of more to As for the third suggestion of expend- come. In addition to using a participatory ing more resources in support of interdisci- research approach, all Consortium members plinary and multi-disciplinary research have built up good relationships with their through sharing examples of successful local practitioner communities. These rela- efforts to do so and providing opportunities tionships are demonstrated by collaborative to develop the required skills, it is clear that research, continuing education opportunities CIHR has made this one of their priorities such as health promotion summer schools, and has invested significant resources in and electronic information processes such as doing so. As noted above, at least some of those as described earlier in this chapter or these resources have been awarded to groups in the list of resources below. Health Promotion 5/1/07 11:18 AM Page 135

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However, although we have reason to CONCLUSIONS be proud of our progress in health promo- Our suggestions are as follows: tion knowledge development over the past The Canadian Consortium for Health decade in Canada, we do have some reasons Promotion Research should accept a mandate for concern. In addition to the ones that have to coordinate and lead knowledge develop- been noted, some others that we need to pay ment in health promotion in Canada through attention to are the following: the following activities: • Some of the people who are involved in • expanding its membership to include behavioural research on health feel that organizations interested in disease pre- they are excluded from participating in vention and behavioural research; health promotion knowledge develop- • coordinating formal and informal train- ment efforts, particularly through the ing in health promotion to take advantage CCHPR, which has tended to empha- of current opportunities for expanding size the importance of the social deter- public health training in Canada; minants of health. • developing a long-term plan for the future • There is some sentiment among those that highlights priorities for new knowl- involved in academic training in health edge development and begin implement- promotion in Canada that we are not ing it using the IUHPE Conference in paying sufficient attention to health pro- 2007 as a springboard for the future; motion in the context of current plan- • discussing with the Public Health ning for expanded funding for public Agency of Canada and Health Canada health education and training through- the idea of supporting a knowledge out the country. development initiative for health pro- • Some members of the Canadian motion that will actively involve other Consortium for Health Promotion federal departments, other levels of gov- Research feel that the current emphasis ernment, voluntary organizations, and on specific projects funded by the PHAC professional organizations. diverted the Consortium from some of The Public Health Agency of Canada, its ongoing and long-term work as a CIHR, and other funding agencies should body that can support the development make a commitment to support health proof a national, coordinated health promotion research infrastructure in Canada motion knowledge development agenda. through the following activities: • developing a strategic research initiative None of these or other issues that have to support health promotion research; been identified in this chapter is irresolvable. • providing special grants for health pro- However, they need to be addressed in a forth- motion research infrastructure right and honest manner. To this end, we conclude this chapter with several suggestions. If we take these steps, we can be assured that we will build on our strengths and continue to develop the knowledge that is required to promote the health of all Canadians. Health Promotion 5/1/07 11:18 AM Page 136

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NOTE 1 For listing of research priorities of each of the members of the Consortium, see the Consortium Web site (www.utoronto.ca/chp/CCHPR/index.htm).

REFERENCES Bryant, T., Brown, I., Cogan, T., Dallaire, C., Laforest, S., McGowan, P., et al. (2004). What do Canadian seniors say supports their quality of life? Findings from a national participatory research study. Canadian Journal of Public Health, 95, 299–303. Green, L.W., George, M.A., Daniel, M., Frankish, C.J., Herbert, C.P., Bowie, W.R., et al. (1994). Study of participatory research in health promotion: Review and recommendations for the development of participatory research in health promotion in Canada. Report to the Royal. Society of Canada. Prepared by IHPR and the BC Consortium for Health Promotion Research. Hills, M., Carroll, S., & O’Neill, M. (2004). Vers un modèle d’évaluation de l’efficacité des interventions communautaires en promotion de la santé: compte-rendu de quelques développements nord-améri- cains récents. Promotion and Éducation, 11(Suppl. 1), 17–21. Hills, M., & Green, K. (2001). Health promotion courses and programs in Canadian universities: A survey. In H. Arroyo-Acevedo (Ed.), Formacion de Recursos Humanos en Educacion para la Salud y Promocion de Saude Modelos y Practicas en las Americas. San Juan: Universidad de Puerto Rico. Hills, M. & Mullett, J. (2000a). Collaborative community-based research for social change. Vancouver: British Columbia Health Research Foundation. Hills, M. & Mullett, J. (2000b). Research methods for community-based research. Vancouver: British Columbia Health Research Foundation. Jackson, S.F., Edwards, R.K., Kahan, B., & Goodstadt, M. (2001). An assessment of the methods and concepts used to synthesize the evidence of effectiveness in health promotion: A review of 17 initiatives. From Consortium Web site, noted below. Lyons, R., & Langille, L. (2000). Health lifestyle: Strengthening the effectiveness of lifestyle approaches to improving health. From Consortium Web site, noted below. O’Neill, M., & Hills, M. (2000). Education and training in health promotion and health education: trends, challenges, and critical issues. Promotion and Education, 7, 7–9. Rootman, I., & O’Neill, M. (1994). Developing knowledge for health promotion. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–151). Toronto: W.B. Saunders Canada. Spence, J.C. (2000). Compilation of evidence of effectiveness of active living interventions: A case study approach. From Consortium Web site www.utoronto.ca/chp/CCHPR/.

CRITICAL THINKING QUESTIONS 1. What is meant by the term “knowledge development”? Do you think it is a useful concept? Why or why not? 2. What are some of the factors that contribute to knowledge development in health promotion or other fields? 3. What is the potential value added to knowledge development of bringing active research centres together into a consortium? Are there any disadvantages? Health Promotion 5/1/07 11:18 AM Page 137

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4. What do you think is the main thing that should be done to develop knowledge in health promotion? Why? 5. In your opinion, what is the most important priority for knowledge development in health promotion? Why?

Rootman, I., & O’Neill, M. (1994). Developing knowledge for health promotion. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–151). Toronto: W.B. Saunders Canada. Chapter on knowledge development in health promotion that appeared in first edition of this book.

Stewart, M. (1997). Centres for health promotion research in Canada. Canadian Journal of Nursing Research, 29(1), 133–154. An earlier article on the Canadian Consortium for Health Promotion Research.

Williamson, D.L., Stewart, M.J., Hayward, K., Letourneau, N., Makwarimba, E., Masuda, J., et al. (2006). Low-income Canadians’ experience with health-related services: Implications for health care reform: Another example of a collaborative study involving more than one member Centre of the Consortium. Health Policy, 76, 106–121.

Wilson, D.R., Plotnikoff, R.C., & Shore, C.L. (2000). Research perspectives in workplace health promotion. From Consortium Web site, noted below. A national study of the research perspectives of individuals and organizations with major commitments and experience in the field of workplace health promotion carried out for the Consortium by a working group.

RELEVANT WEB SITES

Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR/ This Web site contains information about the Canadian Consortium for Health Promotion Research as well as publications and other resources produced by the Consortium and links to Consortium member sites.

Click4HP https://listserv.yorku.ca/archives/click4hp.html This is a listserv managed by York University that provides an opportunity for people in the field of health promotion to communicate with each other on issues of interest. To subscribe, send mail to [email protected] with the command (paste it!): Health Promotion 5/1/07 11:18 AM Page 138

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SUBSCRIBE CLICK4HP. Archives can be obtained at https://listserv.yorku.ca/ archives/click4hp.html.

Ontario Health Promotion E-Mail Bulletin The Ontario Health Promotion e-mail bulletin is a weekly newsletter for people interested in health promotion. It is produced by the Ontario Prevention Clearinghouse and the Health Communication Unit at the Centre for Health Promotion at the University of Toronto. To subscribe, go to www.ohpe.ca/.

Promosante www.promosante.org This is a virtual resource centre that provides health promotion documents in French.

Social Determinants of Health https://listserv.yorku.ca/archives/sdoh.html This listserv on the Social Determinants of Health spun out of the Click4HP listserv in 2004. Also managed by York University, it is an electronic forum for discussion of issues related to the social determinants of health. Archives can be obtained at https://listserv.yorku.ca/archives/sdoh.html. Health Promotion 5/1/07 11:18 AM Page 139

PART III

PROVINCIAL PERSPECTIVES

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anada is a federation, with the central government having strong taxation and leg- C islative powers and, in theory, no authority or responsibility over the provision of health services (including public health and health promotion ones) as this belongs to provinces. In practice, however, as seen in the previous section, the federal government has been a major health promotion player on the international and national scenes over the past quarter century, both through the development of an internationally visible discourse as well as through its substantial spending power. Was the decline in the popularity of health promotion on the national scene observed from 1994 onward mirrored in the provinces and territories? If so, was it in a similar or different manner? If not, what has happened? In order to address these questions, we decided to use a different approach than the one we used in the first edition of the book. In that edition, we devoted one chapter to each province or territory, with the exception of the four Atlantic provinces (the authors chose to make a joint presentation). Several comments received about the first edition mentioned that many of these chapters seemed a bit redundant and that no global analysis for the provinces was presented. To address these issues, we chose to reduce the number of chapters in the provincial section to two. In Chapter 10 Bernier presents a comparative analysis of the development of health promotion in three provinces (Alberta, Ontario, and Québec), over the last decade or so. As a political scientist, she then tries to explain why the developments have been so different in these three provinces, offering potential avenues to reflect on the others as well. Under the coordination of one of the editors of the book (Pederson), Chapter 11 addresses the problem from a different angle. For that chapter, we have asked one or more people from 139 Health Promotion 5/1/07 11:18 AM Page 140

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each province or territory to describe the evolution of health promotion in their jurisdiction since 1994 in a short commentary of a maximum of 1,000 words. None of the authors from the first edition were available or willing to undertake the task again so the analysis is made through fresh eyes. Once more, the Atlantic provinces chose to act jointly, and this time we were fortunate to be able to include material from Nunavut, which was created after the first edition of the book. Out of these commentaries, Pederson offers an analysis of common features of the development of health promotion in Canada’s provinces and territories. At the end of this section, the readers, if they are Canadian, should have a good grasp of how health promotion evolved over the last 12 years in their province or territory, and regardless of where they are from, they should have a sense of the factors that contributed to the variations seen across provinces and territories of Canada. Health Promotion 5/1/07 11:18 AM Page 141

CHAPTER 10 HEALTH PROMOTION PROGRAM RESILIENCE AND POLICY TRAJECTORIES: A COMPARISON OF THREE PROVINCES

Nicole F. Bernier

INTRODUCTION ciple of public health policy. Quebec’s policy t is not uncommon for health professionals has been progressively consolidated over the Ito wonder why Canadian health promo- same years, with a better institutionalization tion efforts have not fared better than they of its public health infrastructure at the local, have so far in governmental agendas. For regional, and provincial levels as well as sys- political scientists, however, the most puz- tematic policy efforts at all levels to address zling questions are raised from the opposite the social determinants of health and, in par- side: Why have public health and health pro- ticular, to reduce social health inequities. In a motion programs survived the austerity nutshell, policy evolution has taken the form period at all, over the past 10–15 years, as the of discontinuity in Alberta, stagnation in federal and provincial governments were pur- Ontario, and consolidation in Quebec. suing severe expenditure controls? And also, As is argued below, public health pro- why do health promotion efforts take diver- grams are at a disadvantage from an electoral gent orientations when provinces (or nations) calculus standpoint. We will expose the theo- are confronted with similar challenges? retical argument by which we should expect This chapter focuses on the experiences low levels of public commitments and high of Alberta, Ontario, and Quebec from the program vulnerability for public health and mid-1990s.1 They have been markedly dif- health promotion programs. We will also ferent from each other and will be referred to explore some arguments and data that help as concrete examples to help explore some explain the resilience of public health promo- answers to the questions raised above. As tion programs in Ontario and Quebec in the Table 10.1 indicates, Alberta’s policy orienta- past decade, as well as the diverging orientation has been characterized by discontinuity tions pursued by the three provinces. We think and the dismantlement and rebuilding of its that a realistic, macroscopic perspective on the public health infrastructure. It yielded a health politics of public health policy, as developed promotion provincial framework that focuses here, can help health professionals explore heavily on social marketing strategies to pro- new ways to advance the health promotion mote healthy behaviours among Albertans. agenda in their respective jurisdiction. Ontario’s policy, which was relatively progressive to start with, has been destabilized by large-scale public sector reforms in all areas FISCAL AUSTERITY AND of governmental intervention, beginning in PROGRAM VULNERABILITY 1995. Such reforms induced a retreat of the From the inception of Canada’s modern social determinants of health as a basic prin- welfare state in the late 1950s, the federal 141 Health Promotion 5/1/07 11:18 AM Page 142

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TABLE 10.1: ORIENTATION OF PROVINCIAL PUBLIC HEALTH, 1994–2004

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government has set basic national standards these programs from roughly 50 percent for the provinces’ social assistance and health when they were created to less than 20 per- insurance programs as requirements to qual- cent a few decades years later. ify for federal transfer payments. Starting in In addition to adjusting to the reduced the mid-1970s, the federal government has transfer payments from the federal govern- sought to reduce its health and social trans- ment, the provinces had to deal with several fers to the provinces in an expenditure-con- economic challenges of their own, including trol strategy while retaining the leverage the effects of prolonged economic stagnation necessary to ensure provincial compliance such as declining taxation revenues and low with basic national standards. This with- employment levels. At the same time, reduced drawal process was pursued and even inten- eligibility for (federal) unemployment bene- sified in the mid-1990s. Under the banner of fits was contributing to sharp increases in deficit reduction, the federal government (provincial) welfare rolls. In the mid-1990s, restructured almost every policy area and increasing deficits and debt accumulation had accelerated the schedule for reduction of become “the most pressing political issues at transfer payments to the provinces over time. all levels of Canadian governments” (Hanlon A new Canada Health and Social Transfer & Rosenberg, 1998, p. 561). program was created in 1996, replacing both From a political science theoretical per- the cost-shared Canada Assistance Plan (for spective, public health and health promotion social assistance) as well as the plan for health programs should have been very vulnerable care and post-secondary education. For to cuts. Rational choice theory argues, indeed, instance, the federal government sharply that programs that offer immediate tangible reduced its already eroded transfers to the benefits to specific groups (such as old age provinces by 9.4 percent between 1995–1996 pensions or employment insurance) will fare and 1996–1997, and by an additional 6.7 per- better than programs (such as environmen- cent the following year (Bernier, 2003; Tuohy, tal protection) that offer diffuse benefits to 1999), reducing its overall contribution to diffuse groups in an unspecified future Health Promotion 5/1/07 11:18 AM Page 143

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(Klein, 1976). Province-wide public health difficult era: state legitimacy, health care programs are among the latter category. resilience, and the need of basic social invest- Whereas for politicians programs with strong ments in neo-liberal economies. electoral consequences (like the closing of hospitals for instance) are more difficult to reform than others simply because groups State Legitimacy and communities can organize and mobilize A useful dimension that helps explain the against them (Pierson, 1994), the political resilience of public health programs is that constituencies of the public health sector are they fulfill one of the essential welfare state’s generally limited to professionals working in functions and represent a basic condition for the health sector with a few professional allies the state’s legitimacy. Whereas public health in other sectors. In addition, public health programs are normally not visible to the programs are generally not visible to the gen- public, they do become visible when not ade- eral public so their curtailment does not entail quately performing their expected roles and electoral retaliation. Furthermore, public when public health problems surface as a health programs solicit direct budgetary result of inadequate government provision. expenditures, which require maintaining tax- The malfunctioning or inadequacy of public ation or reducing other budgetary items in health programs (such as immunization and periods of cost containment. Finally, the ensuring basic sanitary conditions) exposes traceability of benefits is weak: It is difficult government leaders to potentially strong for a voter to link a specific health outcome electoral retaliation, and could even lead to to a specific preventive public health program questioning the essence of governmental insti- over which specific amounts of money have tutions. In Ontario, the Walkerton E. coli been spent. Indeed, citizens do not tend to contamination of the water supply and the reward today’s politicians for setting up pro- Toronto-area SARS crisis were dramatic grams that will reduce their probability of examples that public health does become vis- suffering from Type 2 diabetes and of dying ible when it cannot provide for basic sanitary from a given epidemic several years from conditions to prevent the occurrence of large- now. Benefits are thus harvested in a time scale disasters; when it cannot adequately horizon of several years, while the cost for protect the population from epidemics and setting up the program is immediate. other public health tragedies; and when it Clearly, provincial public health and cannot react to threatening events in an effi- health promotion programs are associated cient, coordinated manner. with a set of conditions that make them very In many respects, public health pro- vulnerable to program cuts. The question grams are similar to social assistance pro- then becomes: Why did provincial public grams, which are often kept to a minimal health and health promotion programs sur- level of functioning. Pierson pointed out in vive the austerity period of the last decade? 1994 that it can be difficult for lean programs to become leaner during budgetary cuts. But after many years of neo-liberal policies, UNDERSTANDING empirical evidence shows that lean social PROGRAM RESILIENCE assistance programs can become even leaner. At least three reasons can explain the In Canada, provincial governments such as resilience of public health programs in this Ontario and British Columbia showed their Health Promotion 5/1/07 11:18 AM Page 144

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ability and willingness to sharply reduce paigns. A rational choice perspective helps to social assistance benefits, impose stricter con- understand why such campaigns will be ditions for receiving benefits (including for chosen over other health promotion activities, beneficiaries to participate in a workfare pro- not because of the superior health outcomes gram), and even deny benefits to the “unde- they promise to yield, but because of their serving” poor (such as drug or alcohol promise of high electoral visibility at low cost. dependents or beneficiaries who are unable to show they are looking for employment) or after a time limit. For instance, Ontario Health Care Resilience reduced social assistance benefits by over 21.6 A second dimension for program resilience is percent in 1996. So based on the experience that public health programs are part of the of social assistance programs, there is no health sector and benefited from the relative apparent reason why public health and health structural and institutional stability of the promotion programs would have been health care system. All national income secu- immune to cuts even if they are kept at a rity programs and federal transfer payments minimum to start with. to the provinces underwent fundamental This being said, whereas social assistance changes as a consequence of the federal gov- programs were shaken by three decades of ernment’s restrictive policies in the 1990s, but neo-liberalism, they also proved resilient to it. in spite of some remarkable reform initiatives, Resilience can be an indication that political the principles of the Canadian medicare model leaders see a strategic advantage for govern- were not directly questioned. As Tuohy (1999) ment policy to at least appear to be dealing observed, during the period of heavy fiscal with the basic needs of the most vulnerable austerity, Canada did not attempt to change citizens and to be providing a basic social the policy parameters governing its health safety net (social assistance) in case things go institutions and the structural balance of the wrong. In the same train of thought, political system between the state, health care profes- leaders may have an interest, from a rational sionals, and private financial interests. choice perspective, to entertain the idea that Provincial governments did not withdraw their government is doing enough of what is from health policy, but even asserted their role: doable to protect the population’s health. Like With the exception of Ontario, they brought social assistance programs, the resilience of some horizontal and vertical integration in the public health appears, from this perspective, hospital sector while creating regional author- not as much as resulting from strategic con- ities for health. They had great latitude to siderations to win votes but from fears of the redefine the organization of health care deliv- negative costs associated with a public health ery and to rebalance the influence between policy failure. Public health policy thus state actors, the private sector, and the med- appears as a prerequisite for government. ical profession, but restricted their role to Within public health, certain types of adopting “blunt budget instruments to slow health promotion programs may entail low the growth of the health care budget and to financial costs and high political visibility con- reallocate within it” (Tuohy, 1999, p. 245). veying the impression and public image that The relative stability of the Canadian officials are actively trying to improve the pop- medicare system can be attributed in part to ulation’s health and welfare. This is especially health care being a great national symbol in true of mass media social marketing cam- Canada and, by the mid-1990s, to the fact that Health Promotion 5/1/07 11:18 AM Page 145

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media attention and polls across the country model seeks not simply to compensate people showed a growing public concern that for lost revenues resulting from risks such as medicare was in jeopardy (Maioni, 1998; illness or unemployment; it emphasizes the Tuohy, 1999). This was reflected nationally development of specific programs and poli- in the revision of the federal–provincial fiscal cies that are focused on reforming individu- framework in the mid-1990s: On the one als and communities, often by targeting the hand, this revision eliminated the obligation most vulnerable individuals and groups in for provinces to provide social assistance ben- society. It seeks to control or prevent the efits on a needs basis, which opened the door occurrence of individual problems where to conditional benefits and even denial of they are most likely to occur, be it in socio- benefits at the provincial level. On the other economic groups, ethnic groups, age groups, hand, and consistent with the Canadian or geographical areas. public agenda focused on health care, the five Clearly, public health and health pro- principles of the Canada Health Act were motion approaches are quite usable in such a maintained in the new fiscal framework. The social investment model. It is not impossible amalgamated block funding for social and that the growing influence of social epidemi- health transfer program thus entailed that ology as a field of professional investigation federal requirements and national norms for and university research has even actively con- health care and social assistance contributed tributed to the flourishing of this paradigm. to protect health care budgets because the Illustrations from Ontario and Alberta principles were maintained and therefore no help to show our point. In Ontario, public flexibility existed, while the federal frame- health professionals directed their efforts to work made it permissible for social assistance persuade the conservative Harris govern- programs to be fundamentally revised in all ment that cutting in certain public health Canadian provinces. Public health and health expenditures was detrimental to the popula- promotion programs have thus benefited tion’s health and costly to the province’s from the broader resilience of Canadian finances and health care in the long term. health and health care policy relative to The line of argumentation, supported by epi- Canadian social policy and programs. demiological studies and financial data,2 was largely organized around the idea that public health problems that are not dealt with now Neo-liberalism and Social Investment would be much more costly to the public A third dimension for program resilience is purse later. After the election of the Harris the fact that such programs are consistent government, accessibility to politicians was with the “social investment” paradigm for denied to several groups. However, the public social policy design. This paradigm is closely health sector discourse could be articulated associated with the rise of neo-liberalism and in terms that were compatible with the was developed in OECD countries from the “Common Sense Revolution” of the Harris early 1980s, but accelerated in the 1990s. It government and was heard and acted upon emphasizes the role of government in pro- (interview data). The Harris government tecting the public against social risks that pri- thus chose to emphasize the promotion of vate corporations then don’t have to assume healthy lifestyles and chronic disease pre- (Jenson & Saint-Martin, forthcoming). In the vention, as opposed to pursuing a more com- area of income security, the social investment prehensive approach. Health Promotion 5/1/07 11:18 AM Page 146

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In Alberta, the Health Sustainability fiscal austerity since the mid-1990s has been Initiative (HSI) was set up in the year 2000 described as a “deviant case” because while as a priority initiative involving 10 ministries adopting certain economic policies influenced and related government agencies, as well as by neo-liberalism, it has largely resisted the the Premier’s Advisory Council on Health. neo-liberal model of development espoused HSI’s central objective is to reduce the rate by the other provinces, even if it elected in 2003 of growth for the provincial health care a liberal government whose legacy is still system. “Staying healthier” is the number one unclear (Clark, 2002; Vaillancourt et al., 2000). governmental effort to curb expenditure Quebec’s approach to reforming its health growth, which translates in efforts to reduce sector and its social assistance programs has preventable chronic diseases and injuries. been less drastic than elsewhere. When other Alberta’s framework for health promotion provinces were sharply controlling the program is a direct outcome of the HSI. It growth of program expenditures, Quebec’s sets outcomes, objectives, and targets for gov- social policy went in a significantly different ernment action to promote health and pre- direction. Starting in 1996, a family policy was vent disease and injury in different settings: implemented, which included means-tested homes, schools, workplaces, and communi- family allowances as well as a universal, ties. Its insistence on reducing chronic dis- highly subsidized provincial day care system eases is closely associated with the fact that and modifications to the provincial work leg- such diseases represent a great financial islation to facilitate parental obligations burden on health care now and in the future. (Jenson, 2002). As already discussed, Quebec’s public health policy also went in a direction markedly different from other provinces. UNDERSTANDING POLICY Why is Quebec’s policy so different? DIVERGENCE Having explored some of the reasons that help explain why programs survived in what Federal–Provincial Relationships appeared a very negative environment, we will Historically, social policy has been used as an now turn to an exploration of arguments and instrument for Quebec’s national affirmation data that will help explain the diverging ori- in its relations with Ottawa and the rest of entations pursued by the provincial govern- Canada. Typically, in Canada’s post-war his- ments in their public health policy. If we are tory until this day, Quebec would design a indeed ready to accept the idea that the social program such as family allowances in resilience of public health programs is because 1972 or old age pensions in 1965, and Ottawa they were compatible with the neo-liberal would counterreact with an overlapping, policy orientations pursued by the Alberta and equally generous, but national program in a Ontario governments, this challenges us to process of competitive nation-building explain the Quebec experience. Quebec is (Bernier, 2003; Jenson, 2002). The growing indeed among Canada’s four largest provinces convergence of public health with Quebec’s (along with Ontario, Alberta, and British social policy during the 1990s and earlier Columbia), the one where social democratic 2000s is one among many other forms of traditions are stronger (Baer, Grabb, & expression of this rivalry between Quebec Johnston, 1993; Bernard & Saint-Arnaud, and Canada for affirming their national iden- 2004; Clark, 2002). Quebec’s experience with tities. This dynamic has also been present Health Promotion 5/1/07 11:18 AM Page 147

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during the discussions between Quebec and led to the election of an NDP government in Ottawa representatives in relation to the cre- 1990. Quebec, for its part, has had a strong ation of the Public Health Agency of Canada, left presence, which resulted in the forma- with tensions regarding whether the agency tion of three left-oriented (out of a total of would focus on core functions or develop a six) provincial governments since the begin- more comprehensive approach to public ning of the 1980s (see Table 10.2). health (interview data). In a nutshell, federal- The presence of a left-of-centre party in provincial dynamics help us understand provincial elections thus is a good indicator public health policy divergence among the of the core value base of a population and has three provinces and particularly Quebec’s been associated with the consistency and comprehensive approach. Of course, other comprehensiveness of public health policy in macro variables also matter. the three provinces studied.

Presence of a Left-Wing Party Demographics,Wealth, and Prosperity Political traditions help explain policy diver- It is conceivable that wealthier nations or gence. Alberta has traditionally been char- provinces would tend to incorporate a health acterized as a one-party or “quasi-party” promotion social determinants of health vision system, with a generally weak opposition and into their health policy simply because they a weak presence of the left-wing CCF-NDP have better resources than others to address party. Ontario has had a stronger tradition them. Similarly, prosperous political entities of opposition politics with a constant pres- could be more inclined to adopt progressive ence of CCF-NDP (Chandler, 1977), which policies than less prosperous ones simply

TABLE 10.2: SEAT DISTRIBUTION AMONG MAJOR POLITICAL PARTIES AT GENERAL PROVINCIAL ELECTIONS IN ALBERTA, ONTARIO,AND QUEBEC BETWEEN 1981 AND 2003

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because of the favourable economic conditions percent for Ontario and 49.3 percent for and increased policy leverage they experience. Quebec. Another indicator of wealth and Provinces with a high proportion of seniors prosperity is the unemployment rate. As may also be expected to invest in alternatives Table 10.4 indicates, Alberta has had the to health care as a cost-reduction device. lowest rate, Ontario the middle, and Quebec Provincial results over the period of the highest of the three provinces. Similarly, observation are entirely counterintuitive with the province with the lowest percentage of respect to such arguments: they show an seniors over 65 years of age (Alberta, 10.2 per- inverse relationship between economic cent) is also the one where public health and wealth and prosperity and the magnitude of health promotion programs have been more health promotion efforts. They also show an challenged and more limited. inverse relationship between the percentage We thus see that the province with the of seniors and the magnitude of health pro- greatest economic leverage (Alberta) has also motion efforts. As Table 10.3 shows, Alberta been less inclined to pursue its public health is by far the richest province in terms of its and health promotion efforts in a consistent gross domestic product per capita, while and comprehensive manner in the past Ontario stands in the middle and Quebec is decade. Inversely, the province with the small- the poorest of the three provinces. Not only est economic leverage over policy (Quebec) is is this a consistent pattern over the years, but where the most sustained and comprehensive the gap in production levels per capita health promotion efforts are found. between Alberta and the two other provinces These intriguing results lead us to the has also widened between 1994 and 2004. formulation of a hypothesis for further Alberta’s wealth has grown at a rate of 80 research: the poorer a political unit (e.g., city, percent over the period, as compared to 45.3 province, nation), the broader the magnitude

TABLE 10.3: GROSS DOMESTIC PRODUCT PER CAPITA ($), BY PROVINCE, SELECTED YEARS

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TABLE 10.4: UNEMPLOYMENT RATES (PERCENT), BY PROVINCE, SELECTED YEARS

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of its efforts in public health and health pro- and demographic condition into certain motion. Similar observations were made, policy directions rather than in others. albeit incidentally, by Greer (2004) for the UK, where the poorest country of Wales was also where a population health approach CONCLUSIONS fared best, among the four British countries, This chapter has shown that even if there are into the agenda and outcomes of the health good political reasons to expect a low level of policy adjustments that followed devolution public commitment to health promotion and in 1999. The question this raises is: Do rich public health policy, they have astonishingly countries and provinces tend to heavily invest enough been maintained over the last decade, in health care medical services and tech- even if differentially, in the three provinces nologies geared toward individual needs, studied. Health promotion policy is not a self- while poor countries and provinces tend to contained, stand-alone area of governmen- develop, as a cheaper alternative, low-tech, tal intervention. Policy outcomes in public alternative mass approaches in the form of health and health promotion are clearly asso- social and preventative medicine geared ciated with broader, non-health related, polit- toward population groups? If our hypothe- ical pursuits by provincial governments, sis holds, it could imply that health promo- which is why, for instance, a narrow definition efforts (especially when focusing on the tion of health promotion policy presents the social determinants of health, healthy public advantage of high visibility at low cost policy, and reducing social health inequali- through mass-media campaigns. We have ties) are part of public endeavours con- observed that public health policy orienta- tributing to the polarization of medicine tion does not follow a given trajectory char- between rich and poor regions. The general acterized by stages according to which we assumption that health promotion is more could expect “less” advanced provinces to progressive than biomedical approaches to follow, with a delay, a path similar to the health would then need revision. “more” advanced provinces. Rather, each In its effort to explain the differential province develops its own solutions for public behaviour of three of the largest Canadian health and health promotion, which reflect provinces toward public health and health its particular economy, demography, and promotion policies, this section has thus political traditions. This does not suggest that shown that economic leverage over policy health professionals seeking to contribute to does not work the way one would normally the advancement of health promotion should expect. It is thus essential to look at how the consider giving up their endeavours. Instead, value base of the population, as it translates as part of the reflexive practitioner attitude into political behaviour, transforms economic this book suggests, they should consider

TABLE 10.5: SENIORS 65 YEARS AND OVER AS A PROPORTION OF TOTAL POPULATION IN 2001

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exploring the constraints and possibilities for inserted in political agendas and part of a action offered within the parameters of the macro policy context. The knowledge and policy and politics of public health in their pursuit of one’s political interests, and how own province. Political realism requires us such interests compete with those of others, to realize that health promotion, as with every is thus essential to push for one’s own values! other field of public intervention, is always

NOTES 1 A detailed, comparative analysis of the three cases can be found in Bernier (in press). See also Chapter 11 of this book for a description of the evolution of health promotion over the last decade in the three provinces studied. 2 Acknowledgements: The research for this chapter was conducted while holding a CIHR/CHRSF post- doctoral fellowship and has also been supported by the Chaire Approches communautaires et inégalités de santé at the University of Montreal. The author wishes to thank several individuals who agreed to share their time and policy perspective in 2004. In Alberta: B. Hansen, S. Lewis, E. Murphy, P. O’Hara, C. Price, K. Raine, and two anonymous respondents; in Ontario: C. Acker, M. Cushing, M. Herrera, J. Lee, and D. Patychuk; in Quebec: M. Boucher, C. Colin, R. Massé, H. Morais, and J. Rochon. Thanks are extended to Geneviève Guindon for her research assistance and to Rudolf Klein and Louis Imbeau for helpful exchanges.

REFERENCES Baer, D., Grabb, E., & Johnston, W. (1993). National character, regional culture, and the values of Canadians and Americans. Canadian Review of Sociology and Anthropology, 30, 13-36. Bernard, P., & Saint-Arnaud, S. (2004). Du pareil au même? La position des quatre principales provinces canadiennes dans l’univers des régimes providentiels. Canadian Journal of Sociology, 29, 209–239. Bernier, N.F. (2003). Le désengagement de l’État providence. Montréal: Les Presses de l’Université de Montréal. Bernier, N.F. (in press). The scope of the “new public health” in Canada’s provincial agendas. In P. Bourdelais & L. Abreu (Eds.), Welfare systems, social nets, and economic growth. Evora, Portugal: University of Evora Press. Chandler, W.M. (1977). Canadian socialism and policy impact: Contagion from the left? Canadian Journal of Political Science, X, 755–780. Clark, D. (2002). Neoliberalism and public service reform: Canada in comparative perspective. Canadian Journal of Political Science, 35, 771–793. Greer, S.L. (2004). Territorial politics and health policy: UK policy in comparative perspective. Manchester & New York: Manchester University Press. Hanlon, N.T., & Rosenberg, M.W. (1998). Not-so-new public management and the denial of geography: Ontario health-care reform in the 1990s. Environment and Planning, C16, 559–572. Jenson, J. (2002). Against the current: Childcare and family policy in Quebec. In R. Mahon & S. Michel (Eds.), Child Care policy at the crossroads: Gender and welfare state restructuring (pp. 309-332). New York: Routledge. Jenson, J., & Saint-Martin, D. (forthcoming). Building blocks for a new social architecture: The LEGOTM paradigm of an active society: Policy and politics. Klein, R. (1976). The politics of public expenditure: American theory and British practice. British Journal of Political Science, 6(4), 401–432. Health Promotion 5/1/07 11:18 AM Page 151

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Maioni, A. (1998). Parting at the crossroads: The emergence of health insurance in the United States and Canada. Princeton: Princeton University Press. Pierson, P. (1994). Dismantling the welfare state? Reagan, Thatcher, and the politics of retrenchment. Cambridge: Cambridge University Press. Tuohy, C.H. (1999). Accidental logics. New York: Oxford University Press. Vaillancourt, Y., Aubry, F., d’Amour, M., Jetté, C., Thériault, L., & Tremblay, L. (2000). Social economy, health, and welfare: The specificity of the Québec model within the Canadian context. Canadian Review of Social Policy, 45–46, 55–87.

CRITICAL THINKING QUESTIONS 1. Using a rational choice perspective, give five reasons why political leaders tend to neglect health promotion policy. 2. In the mid-1990s, several public health and health promotion programs were dismantled in Alberta. In Ontario and Quebec such programs were not affected by budgetary cuts as much as could be expected. Describe three elements that help understand program resilience in Quebec and Ontario. 3. Are health professionals in Quebec and Ontario better policy advocates than their Albertan colleagues? What other elements should be considered to understand diverging policy outcomes among provinces? 4. Using a rational choice perspective, discuss the potential and shortcomings of producing evidence as a key strategy for health promotion policy advocacy. 5. Find one idea to help conceive a health promotion policy advocacy strategy that takes the decision makers’ political interests into account.

FURTHER READINGS Boussaguet, L., Jacquot, S., & Ravinet, P. (2004). Dictionnaire des politiques publiques. Paris: Presses de science po. Introduces concepts and references for policy analysis in short but critical texts.

Brooks, S., & Miljan, L. (2003). Public policy in Canada: An introduction (4th ed.). Toronto: Oxford University Press. Policy making in the Canadian context, with sectoral examples such as family, Aboriginal, and environmental policy.

Howlett, M., & Ramesh, M. (1995). Studying public policy: Policy cycles and policy subsystems. Toronto: Oxford University Press. A synthetic introductory source adapted to Canada suitable for advanced undergraduate students.

Lemieux, V. (2002). L’étude des politiques publiques: Les acteurs et le pouvoir (2nd ed.). Montreal: Les Presses de l’Université de Montréal. An introductory reference in French adapted to Quebec.

Sabatier, P.A. (Ed.). (1999). Theories of the policy process: Theoretical lenses on public policy. Boulder: Westview Press. Provides an introduction to several analytical frameworks for policy analysis, and is especially useful to students interested in writing a thesis. Health Promotion 5/1/07 11:18 AM Page 152

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Weimer, D.L., & Vining, A.R. (1999). Policy analysis: Concepts and practice (3rd ed.). Upper Saddle River: Prentice-Hall. An advanced text that is considered a classic in public policy with a practical orientation that makes it especially useful to professionals.

RELEVANT WEB SITES

Canadian Policy Research Networks/Réseaux canadiens de recherches sur les politiques publiques www.cprn.com/ CPRN’s research is informed, relevant, of high quality and useful to governments at all levels, as well as other stakeholders involved in policy development. See the health section in particular.

Canadian Social Research Links www.canadiansocialresearch.net/ Provides a wealth of commented links on Canadian health and social policy; new federal or provincial budgets, official releases, official Web sites, debates, non-governmental organizations, etc. The site is regularly updated and its archives (dating back to 1997) are searchable. The French version is not as well updated.

Cric.ca Canada’s Portal/Le portail du Canada www.cric.ca/ This site, managed by the Canadian Unity Council, provides basic official documents that are most useful to policy analysts: main legislations, official agreements, and treaties, etc. Has a special section on health care.

Policy.ca http://policy.ca/ A non-partisan resource for public discussion of issues in Canadian public policy. This newer site consists of a growing database of online public policy research publications, as well as information on policy organizations.

PolitiquesSociales.net http://politiquessociales.net/ A well-organized, thematic site on Canadian and international social policy in French. Health Promotion 5/1/07 11:18 AM Page 153

CHAPTER 11 12 CANADIAN PORTRAITS: HEALTH PROMOTION IN THE PROVINCES AND TERRITORIES, 1994–2006

Ann Pederson

INTRODUCTION policy in Canada, one needs to know that the iven two levels of government with two founding constitutional framework of Gdistinct but connected sets of responsi- Canada—the British North America Act of bilities and two official languages, no account 1867—assigned responsibility for health and of health promotion in Canada is complete welfare to the provinces (except in a few without reflection upon the development of instances) while the federal government was health promotion at the provincial and terri- given significant taxation powers. Currently, torial levels. As the activities of the federal gov- the provinces provide publicly funded health ernment are taken up elsewhere in this book insurance through individual provincial plans (see Chapter 7), this chapter addresses the and the federal government provides financial question of how health promotion has devel- support for health services in exchange for oped and evolved at the level of the provinces provincial and territorial compliance with the and territories. Accompanying this chapter terms of the Canada Health Act (1986) (see Box are 12 case studies, each of which portrays 11.1). These arrangements mean that health some aspects of the development of health pro- policy making in Canada has come to involve motion from 1994–2006 within a particular the complexities of federal/provincial/territo- province or territory (the Atlantic provinces rial (F/P/T) relations, as well as ideological, are grouped together, but each is discussed). professional, and practical battles over what constitutes “health” and “care” and who should pay for it. Indeed a central debate among those THE FEDERAL/PROVINCIAL/ working in the health field is what the actual TERRITORIAL LANDSCAPE domain of health promotion includes and OF CANADA whether health promotion is—or should be— Those interested in understanding the devel- part of the health care system (see Chapters 2 opment of health promotion in Canada should and 3). Moreover, it means that many of the examine not only the federal government’s struggles that relate to the development of very visible activities and policies, but also the health promotion in Canada are played out in programs and policies of the provinces and ter- Cabinet rooms, at caucus meetings, and in ritories and those of organizations that oper- F/P/T meetings, rather than where the Ottawa ate at the provincial and territorial levels. This Charter says that health promotion happens; is because within Canada, authority and that is, where people live, love, work, and play responsibility for health is largely a provincial (World Health Organization, 1986). Finally, and territorial rather than a federal responsi- it means that if we want to take the measure bility. To understand the dynamics of health of health promotion in Canada we must not 153 Health Promotion 5/1/07 11:18 AM Page 154

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limit our assessment to what happens at the ious regions of the country. As previously federal level but try instead to develop a more noted, this chapter is therefore accompanied nuanced understanding of the diverse geog- by a set of case studies that provide portraits of raphy, history, language, and culture of the var- some of this diversity.

BOX 11.1:THE FIVE CONDITIONS OF MEDICARE

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One additional feature of Canada that is FINDINGS FROM THE FIRST also meaningful with respect to both policy EDITION and practice in health promotion is the fact In the first edition of this book, we included that Canada has two official languages— detailed chapter-length, historical accounts English and French—which reflect both his- of health promotion in each province and ter- toric and ongoing geographic, linguistic, and ritory except Nunavut, which was established political divides. Although minority language as the eastern portion of the Arctic territory legislation, in principle, provides people with on April 1, 1999. No effort was made to stan- access to federal government services and dardize what the authors defined as health materials in either official language regard- promotion, but as most of the authors were less of where they live, the lived experience of either academics or government employees, many Canadians is that they function either they were very familiar with the discourses in English or French rather than both. Much of health promotion and health policy health promotion activity thus becomes invis- making circulating in official circles—indeed ible, even among Canadians, on either side of some of them were responsible for its pres- this linguistic divide. This is reinforced by rel- ence—and comfortable setting the bound- ative geographic separation, which means that aries of the discussion for their particular the majority of French-speaking Canadians jurisdiction. The chapters typically described are found in Quebec and some Atlantic government health policy making and Canadian provinces, whereas English domi- prominent provincial programs that fell nates elsewhere. This chapter and the case under the rubric of health promotion. The studies therefore try to give some visibility chapters also described major disease pre- both to the question of services for francoph- vention campaigns or demonstration proj- one minorities throughout Canada, but also ects, research initiatives, and organizations to the differences in approach to health pro- that were starting to examine the evidence of motion that have arisen in Quebec as com- health promotion’s effectiveness, as well as pared with the rest of the country. community or voluntary sector organizations Health Promotion 5/1/07 11:18 AM Page 155

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that were leading or supporting health pro- how health promotion has been functioning motion in the jurisdiction. at the provincial level since the mid-1990s. To varying degrees, the authors tried to We again sought contributors in each juris- account for the particular expressions of health diction who were familiar with the develop- promotion that had taken place in their juris- ment of health promotion and asked them to diction. In keeping with the historical and soci- draft brief responses to a general set of ques- ological approach of the book as a whole, most tions: What has happened in health promo- of the authors argued that health promotion tion since the first edition of this book in your in their province reflected the particular mix jurisdiction with respect to policy, research, of party politics, leadership, and political-eco- and practice? Is health promotion still in fash- nomic history of the province, as well as demo- ion or has it been displaced by population graphic issues such as population distribution health or another discourse or practice? Who and epidemiology. All the provinces and ter- have been the key actors? Who has been ritories were said to be engaged in health pro- advocating for or against health promotion? motion, but the extent to which it was a How has the concept of health promotion function of public health departments, a pro- appeared in government discourse (or not)? fessional activity, a community-based or a Are current developments continuing or feature of clinical practice varied from juris- changing earlier directions from Lalonde diction to jurisdiction. Taken as a whole, the (1974) to the mid-1990s? The case studies that chapters offered a fairly high degree of con- accompany this chapter, then, are the set of sensus that health promotion at the provincial commentaries on health promotion in and territorial level struggled for resources Canada at the provincial and territorial levels in a health care system focused on acute care presented in a west-to-east geographical and, to a lesser but growing extent, chronic order. (Regrettably, we are missing specific disease management. Community develop- contributions from the Yukon and Northwest ment was a feature of health promotion in Territories.) To reflect the impact of Canada’s some jurisdictions—and part of the discourse two official languages, we also sought infor- of most—and many provinces had thriving mation about how health promotion is avail- health promotion research communities. The able to francophone minorities outside of Healthy Communities movement and its Quebec and have a brief commentary on this French counterpart, Villes et Villages en Santé, issue as part of the case studies. were thriving in many areas of the country and increasing numbers of students were enrolling in programs of health education REFLECTIONS ON THE and health promotion. Most of the authors CASE STUDIES worried, however, about the capacity of health promotion to live up to its official A Context of Health Sector Reform rhetoric in a climate of growing fiscal con- In the first edition of this book, Lavada straint and health sector reform. Pinder (1994, p. 94) warned that “health care reform may not only control the health policy agenda for some years to come but could, in PREPARING THIS CHAPTER doing so, draw health promotion into its Bearing this loose consensus in mind, we orbit—first by taking away scarce resources approached the question of learning about and secondly by making health promotion a Health Promotion 5/1/07 11:18 AM Page 156

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function of cost containment.” To varying elements of primary care reform (usually degrees, and at the risk of overgeneralizing defined as reforms related to a person’s first from limited data, it is clear that health care point of contact with the health care system). reform has played a significant role in shap- To contextualize this list of health ing health promotion in the past 15 years. reform topics, Armstrong and Armstrong While reform has been an ongoing fea- (2001) offer a historical, political economic ture of all health care systems for the past 100 account of health care reform initiatives in years as successive reforms have altered the Canada. Their account suggests that the organization, financing, and delivery of health reforms noted above have been occurring in care services, including the introduction of a larger context marked by: welfare state national health care systems and health insur- restructuring; pressure to reduce or eliminate ance infrastructures such as in Canada (World government deficits and debt; technological Health Organization, 2000), contemporary change (including drugs, diagnostic imag- health care reform reflects larger political and ing, and information technologies); the idea social changes in the past two decades. that there were limits to public care (both as According to the WHO (2000, p. xiv), “These a function of a potentially unlimited demand include the transformation from centrally for health care and out of recognition that planned to market-oriented economies, some determinants of health arise outside of reduced state intervention in national the health care system); and a paradigm shift economies, fewer government controls, and toward thinking about health care as a busi- more decentralization.” Accompanying these ness. They thus see many of the specific changes, the WHO (2000) reports an ideo- health reforms being undertaken or con- logical shift to greater individual responsibil- templated in Canada as consistent with a ity and choice and political efforts to reduce business-oriented concern with efficiency, expectations of government. effectiveness, and accountability. From this These changes are familiar to those who perspective, health promotion becomes a tool have been monitoring health care reform in for cost containment and a shift in responsi- Canada. In what they refer to as a primer on bility from the state to provide care and for health reform issues in Canada, Fooks and citizens to reduce their demand for care. Lewis (2002, pp.1–2) identified nine themes One of the most enduring features of that characterized provincial and national health sector reform noted in the case studies government discussions of health reform: (1) is its ongoing and widespread nature. That a focus on population health; (2) financing is, change has become the norm in the health the health care system; (3) primary care care system and that means that people are reform; (4) regionalization of service deliv- required to manage change as part of their ery; (5) pharmaceutical policy; (6) health everyday lives at work. Taking regionaliza- human resource planning; (7) quality tion as one example, it is clear that in several improvements and infrastructure supports; jurisdictions, regional structures were estab- (8) governance and accountability mecha- lished and then subsequently recreated fol- nisms; and (9) home care services. In these lowing various review processes, sometimes reforms, health promotion most often within brief time periods. In British Columbia, appears as part of population health efforts for example, regionalization has been a to prevent disease and enhance wellness and, dynamic process, with successive processes of to a lesser extent, it may appear as one of the regionalization occurring, beginning in the Health Promotion 5/1/07 11:18 AM Page 157

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early 1990s. The initial structure proposed accompanied regionalization and decentral- would have created a system of 82 commu- ization in most provinces and territories that nity health councils and 20 regional health these changes were accompanied by a dis- boards (British Columbia Ministry of Health course of individual responsibility for health- and Ministry Responsible for Seniors, 1993). ful living; increased concern about disease Though this vision was never implemented, prevention through immunization and mon- the first round of regionalization did produce itoring; attention to chronic disease man- a system that included 34 community health agement protocols and mechanisms; and a councils, 11 regional health boards, and seven recognition of the limits of the health care community health services societies—a total system to foster health—echoes of the 1974 of 52 regional health authorities (British Lalonde Report 32 years ago (Lalonde, Columbia Ministry of Health and Ministry 1974)—but in a different political and eco- Responsible for Seniors, 1996). Then in 2001, nomic context following years of budget this system was remodelled once again and the reductions and after two decades of an inter- current system—comprised of five geographic national discourse about the determinants of health authorities, one Aboriginal health health made visible by the Ottawa Charter.2 authority (the Nisga’a Health Authority), and a new, Provincial Health Services Authority (PHSA)—was created based on a vision artic- Current Actions and Future Directions ulated in A New Era for Patient-Centred Health In their case studies, most of the contributors Care (British Columbia Ministry of Health decry the paucity of resources directed to Planning, 2001). public health and/or health promotion as Managing such changes can challenge compared with the expenditures on acute an organization’s ability to achieve its goals health services, though there is more of a tone simply because people are focused upon of guarded optimism regarding the potential understanding and adapting to a new system. for new funding, particularly since the estab- Further, in the case of regionalization, some lishment of the Public Health Agency of of the new structures that have been created Canada in September 2004. Moreover, some are unprecedented in Canada and hence areas of activity were reported as receiving required enormous learning for people across more funding than others, namely, activities numerous sectors. Again, using BC as the directed at “healthy living” as opposed to the example, the 2001 re-regionalization process determinants of health. As is clear through- included the creation of a Provincial Health out this book, the tension between individ- Services Authority (PHSA), which is com- ual action (and responsibility) for healthful prised of several formerly autonomous health living and state-supported action to address services agencies, each with a province-wide the determinants of health remains a feature mandate, which are now linked together in of health promotion within the provinces and a larger organizational and managerial struc- territories. However, some interesting exam- ture.1 In light of this scale and frequency of ples of research and legislation point to change, it is perhaps not surprising to see that important actions on the determinants of the pragmatics of health care delivery have health, including “smoke-free” legislation, often taken precedence over the longer-term school-based nutrition, and physical activity aims of health promotion. It is also clear from programs that include limiting access to foods the numerous government reports that of limited nutritional value, and research into Health Promotion 5/1/07 11:18 AM Page 158

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the occupational health issues facing those to sustain health promotion efforts and pro- living and working in coastal communities. gram evaluations through some of the strate- The case studies illustrate how govern- gic and operating grant initiatives, though ments can support or undermine efforts at research funding is obviously in itself not an promoting health without necessarily having adequate mechanism for financing long-term, institutionalized health promotion per se. sustained programming. Currently a wide That is, the government may have policies on array of topics from health literacy to mid-life tobacco control legislation, support for social health to school-based nutrition and physical housing, funding for social assistance, and activity programs are underway across the attention to school and workplace opportu- country with the help of research monies to nities for nutrition and exercise. But it may support their development, implementation, or may not fund designated health promo- and evaluation. Moreover, each region has tion positions, training or research, or have spawned its own areas of research expertise created institutional mechanisms for health and concentration, reflective of local condi- promotion within government infrastructure. tions, institutional mandates, and research per- Notably, several contributors describe eras in sonnel. Unfortunately, health promotion which health promotion as any sort of formal research capacity is not equally distributed entity disappeared within the apparatus of across the country: while its absence is espe- government, but remained strong within cially notable in the North, it is also unevenly community and/or academic organizations. resourced in several other provinces and tends This begs the questions of the ultimate aims to be associated with urban universities with of health promotion and whether (and which) fewer research resources available to rural and institutional mechanisms and professional remote communities and issues. practitioners (and the supports to educate In addition to noting the value of them) are essential for the survival of health research infrastructure for strengthening promotion (which is a theme taken up in the health promotion capacity, the contributors conclusion of this book; see Chapter 22). often mentioned growth in the past decade In fact, these contributions make it clear in health promotion training and educational that the universities and academics have opportunities. These initiatives have included played significant roles in sustaining and regular health promotion summer schools developing health promotion in Canada. through many of the health promotion Researchers, including those associated with Consortium members as well as new under- the Consortium on Health Promotion graduate and post-graduate degree programs Research (see www.utoronto.ca/chp/CCHPR/ in health promotion and/or public health. intro_english.htm), and research-funding These educational opportunities mean organizations have generated mechanisms increased professional and research capacity for health promotion to continue to develop for health promotion across the country and even in times of limited direct funding for the introduction of issues related to accredi- designated government health promotion tation, professionalization, and certification. programs and personnel. The enlarged Ziglio, Hagard, and Griffiths (2000, health research infrastructure in Canada p. 144) have argued that, “the promotion of since the creation of the Canadian Institutes health cannot be left to the health sector of Health Research in 2000 and the growth of alone.” Indeed, in Canada’s provinces and provincial funding mechanisms have helped territories, partnerships and intersectoral Health Promotion 5/1/07 11:18 AM Page 159

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action are one hallmark of health promotion ent roles in different parts of the country. For evident from these contributions. No sector example, the Atlantic region described a alone has the resources, skills, or capacity to lengthy association with the Population and go it alone when it comes to altering the deter- Public Health Branch of the Regional Office minants of health. One manifestation of the of Health Canada (and now the Public Health emphasis on partnerships has been the creation Agency of Canada Atlantic Regional Office) of infrastructure explicitly for networking, par- that was not reported elsewhere in the coun- ticularly among the research and public health try. This suggests that federal resources are communities, and it is clear that both virtual important in health promotion efforts in the and more traditional networks have emerged region and suggests a greater potential role for over the past decade. the PHAC in the northern territories and vul- On a related note, the growth of elec- nerable areas of various provinces. It also tronic resources for health promotion—as evi- reminds us of the redistributive role of the fed- denced in part by the list of relevant Web sites eral government in allocating resources and at the end of each contribution—is another supporting programs. feature that distinguishes the era reported in To summarize, despite continued lim- this book from that of its predecessor. Some ited, dedicated funding, health promotion of these are national in scope, such as the has regained some ground in recent years. Canadian Health Network, but others are Some of this has been piggybacking on the local projects that have national and even renewal of support for public health actions international connections because of the reach following the recent SARS crisis and greater of the worldwide Web, video conferencing, government concern over the potential bur- and e-mail, such as Click4HP or the online dens of diabetes and other chronic illnesses. courses offered by the University of Alberta. It therefore remains to be seen how much of This is one area—that of electronic technol- the determinants of health discourse is sus- ogy and its associated innovations—in which tained in the face of preparations to fight the we will expect to see continuing evolution over next pandemic and clinical efforts focuses on the next decade as digitized information con- chronic disease prevention and management. tinues to migrate to smaller, more personal- Will health promotion become increasingly ized devices and as wireless networks blanket medicalized under the pressures of an aging the world. population and concerns about health care Despite the many similarities in current quality? Will a balance in attention to mental health promotion in the provinces and terri- health promotion—an area in which Canada tories, however, there are also differences evi- has shown some intellectual and political dent across the country. As noted, each leadership—accompany the current enthu- research centre within the Consortium has siasm for physical health concerns? Will the developed its own research areas and special- current rhetoric of “upstream” interventions ization, and most jurisdictions have tailored lead to investments in the underlying deter- some of their activities to addressing popula- minants of health—housing, income, edu- tion-specific needs. As expected, Quebec con- cation, working conditions, meaningful social tinues to hold its own as a social policy engagement, to name a few—or will that innovator and its public health institute is attention stop at the first level of personal- likely the envy of the other provinces. It is also ized, privatized responsibility for healthful clear that national organizations play differ- living? Will governments at all levels work Health Promotion 5/1/07 11:18 AM Page 160

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together to reduce key social and health health care reform. Led in part by the fed- inequities, particularly among First Nations eral government’s Primary Health Care and Aboriginal peoples? Will linguistically Transition Fund (see Health Canada, 2005), marginalized groups be able to access health innovative approaches to health care deliv- resources and care in their first language? It ery and the recognition of the powerful prac- will be interesting to see if, in the next gen- tical links between primary health care and eration of this book, this country’s health pro- health promotion are gaining increasing motion researchers, policy makers, and attention (e.g., Ciliska et al., 2005; Donner & practitioners report significant progress in all Pederson, 2004; Frankish et al., 2006; these areas as well as actions to improve the Moulton et al., 2006). Given their role in other determinants of health. delivering health care services, the future of Returning full circle to the discussion of health promotion in the provinces and terri- health care reform, one promising area of tories in Canada may lie in establishing close action and research to watch with respect to ties with the advocates, innovators, and eval- health promotion is the area of primary uators of primary health care.

NOTES 1 The Provincial Health Services Authority (PHSA) is responsible for managing the quality, coordination, accessibility, and cost of selected province-wide health care programs and services. The agencies that form the Provincial Health Services Authority in British Columbia are: BC Cancer Agency, BC Centre for Disease Control, BC Children’s Hospital and Sunny Hill Health Centre for Children, BC Provincial Renal Agency, BC Transplant Society, BC Women’s Hospital and Health Centre, Forensic Psychiatric Services Commission, PHSA Cardiac Services, and Riverview Hospital. 2 Examples of provincial government reports that discuss health reform and regionalization include • A Framework for Reform by the Premier’s Advisory Council on Health, Province of Alberta, 2000–2001 (The Mazankowski Report) • Caring for Medicare: Sustaining a Quality System by the Commission on Medicare, Province of Saskatchewan, 2000–2001 (The Fyke Report) • Looking Back, Looking Forward: A Legacy Report from the Ontario Health Services Restructuring Commission, Province of Ontario, 1996–2000 • Emerging Solutions by the Commission d’étude sur les services de santé et les services sociaux, Province of Quebec, 2000 (The Clair Commission) • Health Renewal by the Premier’s Health Quality Council, Province of New Brunswick, 2000–2002

REFERENCES

Armstrong, P., & Armstrong, H. (2001). The context for health care reform in Canada. In P. Armstrong, C. Amaratunga, J. Bernier, K. Grant, A. Pederson, & K. Willson (Eds.), Exposing privatization: Women and health care reform in Canada (pp. 11–48). Aurora: Garamond. British Columbia Ministry of Health and Ministry Responsible for Seniors. (1993). New directions for a healthy British Columbia. Victoria: Ministry of Health and Ministry Responsible for Seniors. British Columbia Ministry of Health and Ministry Responsible for Seniors. (1996). Better teamwork, better care: Putting services for patients first. Victoria: Ministry of Health and Ministry Responsible for Seniors. Health Promotion 5/1/07 11:18 AM Page 161

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British Columbia Ministry of Health Planning. (2001). A new era for patient-centred health care: Building a sustainable, accountable structure for delivery of high quality patient services. Victoria: Ministry of Health Planning. Ciliska, D., Ehrlich, A, & DeGuzman, A. (2005). Public health and primary care: Challenges and strategies for collaboration. Report prepared for the Capacity Review Committee, Ontario. Accessed July 16, 2006, from www.health.gov.on/ca/english/pub/ministry_reports/capacity_review06/ phealth_pcare.pdf. Donner, L., & Pederson, A. (2004). Women and primary health care reform: A discussion paper. Prepared for the National Workshop on Women and Primary Health Care, February 5–7, 2004, Winnipeg, Manitoba. Fooks, C., & Lewis, S. (2002). Romanow and beyond: A primer on health reform issues in Canada. Ottawa: Canadian Policy Research Networks. Frankish, J., Moulton, G., Rootman, I., Cole, C., & Gray, D. (2006). Setting a foundation: Underlying values and structures of health promotion in primary health care settings. Primary Health Care Research and Development, 7, 1–11. Health Canada. (2005). Primary health care transition: Fund summary of initiatives. Ottawa: Author. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Minister of Supply and Services. Moulton, G., Frankish, J., Rootman, I., Cole, C., & Gray, D. (2006). Building on a foundation: Strategies, processes, and outcomes of health promotion in primary health care settings. Primary Health Care Research and Development, 7, 1–9. Pinder, L. (1994). The federal role in health promotion: Art of the possible. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 92–106). Toronto: W.B. Saunders. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. World Health Organization. (WHO). (1999). Glossaire de la promotion de la santé. Division de la Promotion, de l’éducation et de la communication pour la santé. Service éducation sanitaire et promotion de la santé. WHO/HPR/HEP/98.1. 25 pages. World Health Organization. (2000). The world health report 2000. Health Systems: Improving Performance. Geneva: Author. Retrieved April 17, 2006, from http://www.who.int/whr/2000/en/ whr00_en.pdf. Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion developments in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.

Critical Thinking Questions 1. What are the factors that have contributed to the development or decline of health promotion in the provinces and territories of Canada? 2. What are some of the additional factors that might have been overlooked as a result of the process of preparing this chapter? 3. How does primary health care relate to health promotion in Canada? 4. What view of health and health promotion underpins most health promotion activity in the provinces and territories? 5. What do you think are the possible best next steps to improve the health of the minority language groups and other socially excluded groups in Canada? Health Promotion 5/1/07 11:18 AM Page 162

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HEALTH PROMOTION IN education resources among First Nations, BRITISH COLUMBIA: the poor, and mainstream society. So far, the A WALKING CONTRADICTION current BC Liberal government’s commit- Jim Frankish and Marcia Hills ment to make BC a world leader in health promotion is largely an aspiration; however, Introduction this provides a great opportunity to follow From 1994–2006, health promotion in British this hopeful message with concrete invest- Columbia remained a vibrant, growing field ments in broadly based health promotion that continued to attract practitioners, strategies and interventions. One recent sign researchers, and policy makers from many of this renewed commitment is the BC disciplines and backgrounds. Equally, health Ministry of Health’s financial support of the promotion remained marginalized in many Canadian Consortium for Health Promotion government commitments, academic cur- Research to host the 19th International ricula, and health-services delivery. It was “a Union for Health Promotion and Health walking contradiction—partly truth and Education World Conference in Vancouver partly fiction” (Kristofferson, 1971). The in June 2007. truth lies in the hard work and commitment of the health promotion community. The fiction lies in the notion that BC (or Canada) is Provincial Health System Reform a world leader in the actual implementation BC has undergone significant and repeated of health promotion programs or policies and change with respect to health reform, partic- in reducing health disparities or inequities in ularly in terms of regionalization. In the early quality of life among Canadians. 1990s, the Seaton Commission (Seaton, 1991) BC witnessed major changes through called for the creation of over 100 regional health systems reform, strong growth in health health boards and community health coun- promotion research and training, and the cre- cils, with subsequent transfer of responsibil- ation of new networks and partnerships in the ity by 1996. However, several reviews led to past decade. There has been growing public the creation of the current system of a and political awareness of the determinants of province-wide Provincial Health Services health. Sadly, however, BC continues to face Authority, five regional health authorities, and significant health inequities, particularly of the as yet unique Nisga’a health authority. between its rural and urban communities. Regionalization has been challenging for There remain gaps in health status, access health promotion in terms of funding, prac- to health services, and health promotion/ titioner base, mandate, and leadership. 162 Health Promotion 5/1/07 11:18 AM Page 163

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In the last reform, the provincial health population health initiatives. Regionalization officer used the Ottawa Charter (1986) as the has led to research and training at BC uni- basis for developing six comprehensive health versities as well as intersectoral networks and goals defined as “broad statements of aims partnerships with communities, schools, and for the future” (British Columbia Ministry non-governmental organizations. The of Health and Ministry Responsible to province is undertaking new work on core Seniors, 1997). These goals were supported services and public health renewal led by by objectives and indicators to measure people favourable to health promotion, which progress, but implementation presented con- holds the promise of raising both its profile siderable challenges. It was noted that and implementation over the coming years. “moving from a high-level vision of health to concrete action and monitoring of results will require continued effort, coordination, Research to Advance Knowledge and and support” (MacPhail, 1999). Nearly 10 Practice years later, it is still the case that BC’s health Research in health promotion and population goals have been implemented at a philo- health has remained strong (despite signifi- sophical level at best. cant challenges) in BC’s universities for two The presence of designated health pro- reasons. First are the dedicated efforts of the motion practitioners remains highly variable. health promotion community. Second is the Large urban regions are more likely to have improvement in funding from both a federal identifiable health promotion practices and and a provincial perspective. The Canadian designated staff and resources for health pro- Institutes of Health Research have been a motion. Smaller rural regions continue to lag major catalyst for research and training. The in access to services and resources. Roles and Michael Smith Foundation for Health responsibilities for undertaking health pro- Research (MSFHR), the province’s major motion have been ambiguous. At times, it health research funding agency established in appears that health promotion belongs to 2001, has provided substantial funding for everyone and no one at the same time. health promotion researchers, students, and Health promotion was caught in the eco- networks. nomic doldrums that plagued BC throughout Representatives of the major universities the 1990s and it faced fierce competition for completed many important initiatives, both funding. For example, only 2.6 percent of the collectively and as individual institutions, in province’s health budget was targeted toward the past decade. The BC Coalition for Health public health initiatives (British Columbia Promotion Research, comprised of members Ministry of Health and Ministry Responsible from Simon Fraser University (SFU), the to Seniors, 1999). Expenditures were directed University of British Columbia (UBC), the toward medically oriented prevention and University of Victoria (UVic), and the intervention measures. Few resources were Canadian Consortium for Health Promotion allocated to the social, cultural, environmen- Research provided an initial foundation for tal, and economic determinants of health. many collaborative efforts. The Community Since the early 2000s, there has been an Health Promotion Coalition at UVic experi- economic upsurge in BC, which has led to enced growth and change in its evolution to signs of renewed political interest and invest- a Senate-approved Centre for Community ment in public health, health promotion, and Health Promotion Research. The centre Health Promotion 5/1/07 11:18 AM Page 164

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hosted the Canadian Consortium for Health Partners in Community Health Research Promotion Research’s national health pro- Training Program, which brings together aca- motion conference and several summer demic and community mentors with aca- schools. Researchers (M. Hills, I. Rootman, J. demic and community learners. The partners Mullett, and M. MacDonald) and students include health authorities, teaching hospitals, have focused on primary health care and and multiple academic institutions. Another public health renewal, health promotion example is the Canada–Europe International effectiveness, Aboriginal peoples’ health, rural Health Promotion Advanced Learning and remote health, and international health. Program led by the Centre for Community The Institute of Health Promotion Research Health Promotion Research at the University at UBC also experienced change with a new of Victoria. director (A. Yassi), who brought interest and At an organizational level, the capacity research in workplace health promotion and for health promotion initiatives has also global health while other researchers (J. grown. New universities have contributed to Frankish and R. VanWynsberghe) expanded health promotion activities in diverse regions their research (and training) in health liter- of the province. For example, researchers (A. acy, homelessness, and community health/sus- Michalos, B. Zumbo, and A. Hubley) from tainability. At SFU, the Gerontology Research the University of Northern BC in Prince Centre (G. Gutman and A. Wister) contin- George have done significant work on qual- ued to provide leadership on health promo- ity of life and health in northern communi- tion and aging activities. ties. Provincial organizations have provided Recent developments at SFU promise to important leadership. For example, the BC change the face of health promotion in BC. Medical Association regularly provides health These include the creation of a Faculty of promotion awards. Key disease-related vol- Health Sciences, an Institute of Health untary organizations focused on heart disease, Research and Education (2002), and a new arthritis, diabetes, and cancer continue to pro- Master’s degree in population health (2005). vide funding for research, training support, These events appear to have triggered a cas- and community-based health promotion ini- cade of similar initiatives at other institutions tiatives. Finally, recent years have witnessed (e.g., the likely creation of a new School of a resurgence of the Public Health Association Public Health at UBC). of BC.

Building Capacity for Networks and Coalitions for Health Promotion Health Promotion The capacity for health promotion activities Organizations and individuals working in BC has changed over the past decade. At together in networks and coalitions to achieve an individual level, there is strong evidence of common goals have been a key feature of a renewed interest in health promotion (and advancing health promotion in BC. The BC population health) from many quarters. At an Health Promotion Coalition provided impor- interpersonal level, BC has also seen a prolif- tant initial leadership. In recent years, its eration of new networks and partnerships, members have taken part in multiple provin- many of which support health promotion ini- cial networks. Examples include the BC tiatives. One training-related example is the Homelessness & Health Research Network Health Promotion 5/1/07 11:18 AM Page 165

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and the BC Network for Health & Literacy health promotion–related policies. There has Research. The Vancouver Foundation has been a reduction in smoking based on higher also reconfigured its community research pro- taxes due to the efforts of public health coali- gram and developed a stand-alone ethics tions, and the implementation of legislated review process. This process has been paral- smoking prohibitions in most public places. leled by the creation of similar community- BC’s school system continues to be challenged based, ethics review boards in First Nations in many areas, including nutrition and obe- across BC. The MSFHR has launched an sity, tobacco and substance use reduction, and ambitious program of support for research physical activity. Recent efforts toward infrastructure and networks. Many of these “Action Schools” and the planned legacies of efforts remain focused on areas such as the 2010 Vancouver/Whistler Olympic biotechnology, human genomics, and the ill- Games hold promise with respect to creating ness care system. Given current dominant a more supportive environment and health- funding and research practices, the overall ful public policies. Much work remains to be impact of such initiatives on community done in workplace health promotion, par- health promotion remains to be determined, ticularly in areas such as mental health pro- but at least some potential is there. motion. Moreover, despite a four pillars approach (prevention, treatment, harm reduction, law enforcement), BC remains Political and Policy Processes home to many of Canada’s poorest First Health promotion has been both supported Nations, and its poorest postal code in and challenged by major political and policy Vancouver’s downtown eastside area. processes. Successive BC governments have Homelessness and health inequities are a launched major efforts toward regionaliza- growing concern in all areas of the province. tion, public health renewal, and the creation In sum, the past decade (and more) of of community health centres to provide pri- health promotion in British Columbia is per- mary health care. While these are positive haps best captured by the famous Dickens’s steps, health promotion initiatives (and prac- quote, “It was the best of times, it was the titioners) have not received a significant worst of times, it was a Winter of despair.” increase in funding, resources, or training. Given the continuing devotion and hard More work remains to be done to integrate work of committed practitioners, researchers, health promotion values and practices into and policy makers, however, and the possi- the growing networks of primary care and bilities of renewed resources and improving multidisciplinary teams in the health system government and social commitments, there (see Chapter 17). is reason to believe that health promotion in Like other provinces and territories, BC BC may be entering “a spring of hope.” has made some progress with respect to

REFERENCES British Columbia Ministry of Health and Ministry Responsible to Seniors. (1997). Health goals for British Columbia. Victoria: Author. British Columbia Ministry of Health and Ministry Responsible to Seniors. (1999). Medical Services Commission Budget 1999/2000; an overview. Victoria: Author. Health Promotion 5/1/07 11:18 AM Page 166

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Dickens, C. (1962). A tale of two cities. London: Oxford University Press. Kristofferson, K. (1971). The pilgrim in the songs of Kris Kristofferson. Los Angeles: Chappell Music Company. MacPhail, H.J. (1999). Improving health care, helping small business create jobs. (Legislature Assembly, March 30, 1999). Victoria: British Columbia Minister of Finance and Corporate Relations, BC. Seaton, P. (1991). British Columbia Royal Commission on Health Care and Costs. Victoria: The Commission. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Author.

RELEVANT WEB SITES BC Coalition for Health Promotion www.vcn.bc.ca/bchpc The BC Health Promotion Coalition is a diverse group working toward an enduring source of funding for health promotion activities inspired and implemented by communities in British Columbia. The BC Health Promotion Coalition envisions a fair and equitable process through which people at the grassroots level can more readily access funds to carry out the work that is important to them in improving their health and quality of life.

Centre for Community Health Promotion Research web.uvic.ca/calendar2005/CAL/Rese/CfCoHPR.html The Centre for Community Health Promotion Research at the University of Victoria is engaged in multidisciplinary research to investigate the complex interrelatedness of the broad determinants of health, their impact on health, and systemic changes required to promote health, particularly at the community level. Researchers at the centre direct their efforts at facilitating change within communities and health systems provincially, nationally, and internationally by linking policy, practice, and research.

Gerontology Research Centre www.sfu.ca/grc The Gerontology Research Centre (GRC) was established in 1982. The associated Department of Gerontology was established in 1983. Together, the GRC and the department serve as a focal point for research, education, and information on individual and population aging. The centre conducts research on individual and population aging with a focus on five theme areas: Aging and the Built Environment; Health Promotion/ Population Health and Aging; Changing Demography and Lifestyles; Prevention of Victimization and Exploitation of Older Persons; and Older Adult Education.

Institute of Health Promotion Research www.ihpr.ubc.ca Established within the Faculty of Graduate Studies in 1990, the Institute of Health Promotion Research (IHPR) provides a UBC focus for interdisciplinary collaboration on research, education, and community partnerships in health promotion. Health Promotion 5/1/07 11:18 AM Page 167

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Institute for Social Research & Evaluation http://web.unbc.ca/isre A greater understanding of the social issues of central British Columbia is key to the continued growth and development of the Prince George region. The Institute for Social Research and Evaluation is a research institute located at the University of Northern British Columbia dedicated to examining these issues.

Public Health Association of British Columbia www.phabc.org The mission of the PHABC is to preserve and promote the public’s health through disease and injury prevention, health promotion, health protection, and healthy public policy.

HEALTH PROMOTION IN centralization consolidated them into 9), ALBERTA: MANY MILES including two of the most populous regional TRAVELLED, MANY MILES delivery systems in Canada in Edmonton and TO GO Calgary, as well as large rural and remote Doug Wilson northern regions. Health promotion practitioners and managers were also reorganized Introduction in this process and often given different Health promotion in Alberta has walked the responsibilities in the reformed health system; talk for many miles since 1994, but has many as a result, the visibility, capacity, and coor- miles to go. The historical context of health dination of health promotion and public promotion in the province was well described health across the province were significantly previously (Kotani & Goldblatt, 1994). The diminished. past decade, however, has seen dramatic Nevertheless, certain positive changes changes in the organization of health services, have gradually followed from the establish- major increases in health promotion research ment of integrated regional health delivery and training, and the development of impor- systems in Alberta (Casebeer, Scott, & Hannah, tant provincial networks and coalitions. 2000). For example, the report of the Premier’s Advisory Council on Health began with the recommendation that “the first reform is to Provincial Health System Reform stay healthy” (Premier’s Advisory Council on In 1994–1995, Alberta became the first Health for Alberta, 2001). Health promotion Canadian province to organize the delivery priorities, usually referred to in population of all health services into geographic regions, health or chronic disease prevention terms, each under a single board and budget—so- are now discussed at the same regional board called regionalization of services. In this table as acute care or continuing care issues process over 100 hospital boards and 27 (for an example, see Capital Health, 1999). public health unit boards were abolished and Population-based funding for health regions the health system budget was significantly provides an incentive to consider “upstream” reduced. Today there are 9 health regions in health promotion and disease and injury pre- Alberta (there were originally 17, but further vention programs as a means of improving Health Promotion 5/1/07 11:18 AM Page 168

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health and controlling long-term costs; how- At the University of Alberta in ever, the urgency of acute care issues such as Edmonton, the six health science faculties waiting lists often overrides this good inten- shared their expertise and in 1995 launched tion. The growing awareness in the health the interdisciplinary Centre for Health regions of gaps in evidence and lack of skilled Promotion Studies (CHPS) to provide new personnel in health promotion have been asso- programs in research and graduate educa- ciated with exciting initiatives in both research tion (Wilson et al., 2000). Miriam Stewart, and training at Alberta universities. the founding director, built a significant research program on social support in vulnerable populations. Research at CHPS, now Research to Advance Knowledge directed by Kim Raine, has focused on the and Practice social, cultural, and behavioural determinants Research in health promotion and population of health in populations and the related policy health has flourished at Alberta universities, in issues, particularly regarding healthy eating part because of attractive personnel awards for and obesity, physical activity, and tobacco and a wide range of health researchers available substance use. through the Alberta Heritage Foundation for Medical Research (AHFMR) and the resulting increased success in securing federal research Building Capacity for Health Promotion funds. The Health Promotion Research Group When the master’s degree (MSc) program in at the University of Calgary was an early con- health promotion studies was launched at the tributor to the provincial and national scene, University of Alberta in 1996, there were clear highlighted by their hosting of the Third indications of interest in the practice commu- National Conference on Health Promotion nity. Time has certainly confirmed this impres- Research in 1994 and the release of a subse- sion; by June 2006 more than 150 students had quent book of proceedings (Thurston, Sieppert, completed the program. A comprehensive & Wiebe, 1998). In 2000, Penny Hawe took up online graduate program is available and, as a a newly created research chair focusing on result, 33 percent of students are from other community-level interventions to promote Canadian provinces, and 7 percent are inter- health. She established a CIHR centre and Alan national. Graduates have had no difficulty in Markin, the donor of the chair funds, has given finding positions in health regions, govern- a further $15 million to develop an institute. ment agencies, non-governmental organiza- The University of Lethbridge was also tions, and a wide range of other settings. significantly involved in the development of At the University of Calgary’s Depart- health promotion research in Alberta when ment of Community Health Sciences, some it was selected as one of six national Centres 120 graduate students have undertaken courses of Excellence for Health Promotion in 1993. and research in health promotion. The new The Regional Centre for Health Promotion Bachelor of Health Sciences offers a health and and Community Studies was successfully led society stream that introduces undergraduates by Judith Kulig for six years, developed a to the foundations of health promotion. number of community and academic part- To build capacity in the health regions, nerships, and focused its research on the the Swift Efficient Application of Research important concept of community resiliency in Community Health (SEARCH) program in rural communities (Walters, 1999). was developed by AHFMR, together with the Health Promotion 5/1/07 11:18 AM Page 169

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universities and regions, as a program and interactions; two more tangible products were network to train community-based health an Aboriginal health promotion summer professionals in applied health research. school and an evaluation framework that was SEARCH Canada, an Alberta-based public used to assess provincial health promotion service organization, is continuing to extend projects (Thurston et al., 2003). its scope, supporting the province-wide net- Since 2002, the Alberta Healthy Living work of expertise that has developed and Network (AHLN), with support from enhancing the use of evidence by health man- Alberta Health & Wellness, has emerged as agers, providers, and their organizations. a major provincial initiative aimed at providing leadership for integrated collaborative action to promote health and prevent Networks and Coalitions for Health chronic disease. Over 100 organizations are Promotion involved in implementing seven strategies Organizations and individuals working focusing initially on multi-level, integrated together in networks and coalitions to achieve actions to support healthy eating, active common goals have been a key feature of living, and tobacco reduction. The AHLN advancing health promotion in Alberta. Since has been recognized by WHO as a demon- 1989, the Alberta Centre for Active Living stration project for the Country-wide Non- (ACAL) has supported education, research, communicable Disease Initiative (CINDI). and networking to promote physical activity More recently, the Alberta Social and by linking practitioners, organizations, and Health Equities Network (ASHEN), sup- communities. The centre is the Active Living ported by the Alberta Public Health Ass- Affiliate of the Canadian Health Network, ociation, has been formed to bring together a Web-based public health information organizations and community groups to resource for all Canada (see Chapter 3), and address growing income inequality in Alberta provides a dynamic Web site and newsletters and its effects. The Alberta Coalition for for many thousands of individuals. Healthy School Communities (ACHSC) draws In the mid-1990s there was recognition together another set of partners focusing on of the need for more effective collaboration schools as a setting for health promotion. among the organizations involved in health In terms of reorienting the health system, promotion in the province, and out of these the Alberta Primary Care Initiative is sup- discussions the Alberta Consortium for Health porting the development of primary care net- Promotion Research and Education was works, consisting of large groups of family formed with important support from the physicians working in multidisciplinary (then) Health Promotion and Programs teams with other health providers and uti- Branch (Alberta/NWT Region) of Health lizing electronic health records to deliver Canada. Members included the three univer- more integrated and comprehensive services sity units mentioned previously (RCHPCS, that include individual-level health promo- HPRG, CHPS), ACAL, the Alberta Cancer tion and prevention. Board, the Nechi Institute for Training, At the policy level, progress has been Research and Health Promotion, and two made in tobacco reduction based on higher health regions. Although the Consortium has taxes, the efforts of coalitions, and effective now lapsed, considerable trust and mutual leaders; many municipalities now have regu- understanding was developed through these lations prohibiting smoking in all public Health Promotion 5/1/07 11:18 AM Page 170

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places, although provincial legislation is less motion remains marginal in the health system stringent. The sustained efforts of the Alberta itself, and progress in addressing poverty and Centre for Injury Control and Research have the social determinants of health has been been associated with useful policy advances to slow, and in this rich province, more attention promote safety. Within the school system, at the policy level to health inequities is quality daily physical activity has been intro- needed. duced as a requirement and soft drink machines are being removed in many districts. In summary, health promotion continues Acknowledgements to be active in Alberta, as evident from the The author wishes to thank colleagues from strong research and training programs, effec- many of the organizations involved with health tive networks and coalitions, and successful promotion in Alberta for their invaluable assis- regulatory efforts. Nevertheless, health pro- tance in the preparation of this manuscript.

REFERENCES Capital Health. (1999). Population health framework for the Capital Health Region. Edmonton: Author. Casebeer, A., Scott, C., & Hannah, K. (2000). Transforming a health care system: Managing change for community gain. Canadian Journal of Public Health, 91(2), 89–93. Kotani, N., & Goldblatt, A. (1994). Alberta: A haven for health promotion. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 166–177). Toronto: W.B. Saunders. Premier’s Advisory Council on Health for Alberta. (2001). A framework for reform report of the Premier’s Advisory Council on Health. Edmonton: Author. Thurston, W.E., Sieppert, J., & Wiebe, V. (1998). Doing health promotion research: The science of action. Calgary: Health Promotion Research Group, University of Calgary. Thurston, W.E., Vollmann, A.R., Wilson, D.R., MacKean, G., Felix, R., & Wright, M.-F. (2003). Development and testing of a framework for assessing the effectiveness of health promotion. Social and Preventive Medicine, 48(5), 301–316. Walters, M. (1999). Six years that made a difference: The Regional Centre for Health Promotion and Community Studies. Lethbridge: University of Lethbridge. Wilson, D., Glassford, R.G., Krupa, E., Masuda, J., Wild, C., Plotnikoff, R., et al. (2000). Health promotion practice, research, and policy: Building capacity through the development of an interdisciplinary study centre and graduate program in Alberta, Canada. Health Promotion & Education, 7(1), 44–47.

RELEVANT WEB SITES Alberta Centre for Active Living www.centre4activeliving.ca The Alberta Centre for Active Living works with practitioners, organizations, and communities to improve the health and quality of life people living in Alberta through physical activity. Health Promotion 5/1/07 11:18 AM Page 171

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Alberta Coalition for Healthy School Communities www.achsc.org The mission of the Alberta Coalition for Healthy School Communities is to support a comprehensive school health approach that enhances the health of Alberta children and youth.

Alberta Healthy Living Network www.ahln.ca The mission of the Alberta Healthy Living Network is to provide leadership for collaborative action to promote health and prevent chronic disease in Alberta.

Alberta Public Health Association www.apha.ab.ca The Alberta Public Health Association is a provincial not-for-profit association that strengthens the impact of those who promote and protect the health of the public by speaking out for health, advocating on issues that affect health, and facilitating educational and networking opportunities.

Centre for Health Promotion Studies www.chps.ualberta.ca The Centre for Health Promotion Studies offers interdisciplinary graduate education that prepares graduates with the knowledge and skills needed to successfully engage in health promotion activities; conducts and fosters interdisciplinary health promotion research in collaboration with other Alberta and national stakeholders; and participates in communication, networking, and community outreach activities that foster health promotion practice and policy development.

HEALTH PROMOTION IN institutions, and addresses a range of health SASKATCHEWAN: THREE determinants of which “culture” is one. DEVELOPING APPROACHES Emerging Aboriginal approaches, on the other Lewis Williams hand, take Aboriginal, identity, culture, and world view as their starting point from which Introduction all other thoughts and actions (including those The advancement of health promotion in that address underlying health determinants) Saskatchewan over the past 12 years or so is follow. That these two approaches should framed by two major developments: (1) the frame health promotion developments in this grounding of policy, practice, and research province is hardly surprising given its large in a health determinants approach and; (2) and rapidly growing Aboriginal populations, the emergence of Aboriginal approaches to who are increasingly asserting their right to health promotion that are distinctly indige- self-determination in ways that are culturally nous. The first is predominantly grounded relevant (Government of Saskatchewan, 2001) in Western world views and assumptions, is A further third entity that somewhat bridges often practised out of biomedically orientated both approaches and has a developmental Health Promotion 5/1/07 11:18 AM Page 172

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trajectory in its own right is the “Northern 1996. This intersectoral and strategic alliance Way.” This constitutes a set of beliefs, atti- has methodically and persistently introduced tudes, and approaches to health promotion a number of successive initiatives that have adopted by Saskatchewan’s northern, rural, proved formative for health promotion and largely Aboriginal communities in throughout the province. Quite quickly after response to resource shortages, their isolation, its inception, for example, this group coor- and perceived marginalization from decision- dinated the development of a conceptual making institutions. While governments may framework to guide the population health come and go, it is these three entities that con- promotion work of Regional Health tinue to give shape and meaning to popula- Authorities (Saskatchewan Health, 1999), tion health promotion in Saskatchewan, albeit produced a strategic plan of action, and within a legacy of colonial relations. worked to embed the ideas behind such conceptual initiatives in the thinking and practice of the province’s health promotion Changing Focus to the Determinants constituency. Much of this was achieved of Health through Health Promotion Summer schools The landscape of mainstream population (Feather, 2003; Prairie Region Health health promotion has seen some radical trans- Promotion Research Centre, 1999, 2000; formations, particularly where policy is con- Williams et al., 2005), satellite training events cerned. The previous emphasis on behaviour initiated by Saskatchewan Health, and eval- change and healthier lifestyles—which dom- uation research aimed at practitioner and inated health-related discourse, policy, and organizational health promotion capacity practice throughout the 1970s—has largely building, through the Saskatchewan Heart been replaced, at least at official levels, by so- Health Project 1998–2003 (Mclean, Feather, called upstream approaches focused on & Butler-Jones, 2005). These efforts set the addressing underlying health determinants. stage for the introduction of the Provincial Federal initiatives playing critical roles in Population Health Strategy (Saskatchewan these developments include Hamilton and Health, 2004), which is proving to be a water- Bhatti’s integrated model of population health shed for the province—never before has promotion (1996) and the report of the health promotion held such authority in offi- Commission on the Future of Health Care in cial policy, nor have regional health author- Canada (Romanow, 2001). Hamilton and ities been required to develop population Bhatti’s report provided a comprehensive con- health promotion strategies and embed ceptual framework on which to base provin- health promotion approaches into their pro- cial activities and the Romanow Report grams as they are today. endorsed health promotion approaches This most recent drive by long-time within primary health care. provincial health promotion proponents has Key actors partially responsible for actu- been paralleled by movement within the pri- alizing this transformation have included a mary care sector to incorporate health pro- range of government, university, and com- motion-based frameworks and strategies into munity-based organizations. Many of these and alongside its traditional treatment-based players galvanized their efforts through the programs (Fyke, 2001; Saskatchewan Health, formation of the Saskatchewan Population 2001). This has inevitably led to tensions and Health Promotion Partnership (SPHPP) in turf battles as stakeholders at the provincial Health Promotion 5/1/07 11:18 AM Page 173

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government and regional health authority new First Nations and Métis Health Office levels grapple with the concepts and what in the region. At the community level, the their articulation within various programs Four Directions Community Health Centre might look like. in Regina has promoted disease-risk knowledge and healthy choices by organizing events and projects such as neighbourhood forums, Aboriginal Approaches to modified round dances, and traditional feasts. Health Promotion These initiatives involved working collabo- The second major and far more recent devel- ratively with community volunteers, expert opmental trajectory in Saskatchewan has been cultural “knowledge keepers,” staff of com- the assertion by Aboriginal communities of munity-based and government agencies, and the value of their traditional knowledge sys- elders. The events yield significant multi-level tems and the right to apply these within con- benefits, such as cultural affirmation and temporary contexts, including the domains of learning, ease of and community engagement, primary health care and health promotion. co-operation among various agencies, and the These are very much grassroots-initiated proj- potential of social reinforcement for healthy ects in which communities are working with behaviour messages (Kotowich, 2000). groups such as the Saskatchewan Population A conceptually significant piece of work Health and Evaluation Research Unit, the that has bolstered understanding in indigenous Prairie Region Health Promotion Research health promotion is the development of the Centre (PRHPRC), health regions, and the idea of “ethical space” (Ermine, 2000; Ermine, Indigenous Peoples Health Research Centre. Sinclair, & Jeffery, 2004). This refers to the need One example is work with Sturgeon Lake for space to be envisioned between indigenous First Nation to articulate Cree concepts of and Western knowledge systems, in which well-being and to advocate for their inculca- each world view is formed and guided by dis- tion into health policy and practice frame- tinct histories, knowledge traditions, values, works (Williams, 2005). Another is research interests, and social, economic, and political with northern communities to develop cul- realities. This work is important as the act of turally specific community indicators (Abonyi teasing apart these knowledge systems makes & Jeffrey, 2006). apparent the dominance of Western concepts At the health region level, the Regina pertaining to health and essentially promises Qu’Appelle Health Region has explored part- to democratize and make more conscious the nership formation among Aboriginal agen- practice of health promotion in Saskatchewan. cies and government departments to improve While such developments may not yet have health outcomes for First Nations and Métis official currency within mainstream health people. The Working Together Towards promotion, they promise to be very significant Excellence (WTTE) project report laid the for the field, as has the articulation of indige- groundwork for intergovernmental partner- nous specific models of health promotion ships, proposed collaboration on stakeholder proven to be in other countries already. priorities, and addressed challenges that typically occur within such partnerships (Regina Qu’Appelle Health Region, 2002). As a result A Third, Northern Way of WTTE, the organizational capacity and The tenacious and unique approaches to relationships are now developing through the health promotion adopted by Saskatchewan’s Health Promotion 5/1/07 11:18 AM Page 174

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northern communities have also played a sig- Conclusion nificant role in advancing and informing its The development of health promotion in development. As a diverse range of Aboriginal Saskatchewan continues to be laced with a communities with unique needs, they are chal- number of intersecting cleavages that char- lengingly positioned in the “in between” space acterize this era of post-colonial relations. of being the unrecognized “other” where cul- The South has undoubtedly been instru- ture, geography, and way of life are concerned. mental in championing and heralding an era Perhaps two defining characteristics of the of intersectoral action and of addressing “Northern Way” are its historical emphasis underlying structural causes of well-being; on community action and community-defined these are now, at least in theory, a legitimate models of health, and its record of extensive part of the health care system’s mandate. We and successful interorganizational collabora- can also expect the “Northern Way” to tion and grappling with the cross-jurisdic- remain a predominant force in health pro- tional issues that continue to besiege the North motion, both as a response to the area’s (Brown, 2005). A current example is the unique challenges and in answer to main- Northern Healthy Communities Partnership stream, southern-initiated policies where the formed between the Northern Regional province’s bureaucrats live and work. We Health Authorities of Keewatin Yatthe, the will also undoubtedly see the proliferation of Mamawetan Churchill River, and the Aboriginal-based approaches that will prove Athabasca Health Authority to produce a to be informative in shaping health promo- North-wide Population Health Promotion tion discourse, policy, and practice. In par- Plan.1 Facing challenges of vast geography, ticular, in our view, it is these changes that high-needs populations, and prohibitive travel are likely to shape and push the theoretical costs, working together across differences is frontiers of health promotion more gener- the most feasible way to be successful across ally—both within and beyond Saskatchewan. these three health authorities.

NOTE 1 Between them these three regional health authorities cover the northern half of Saskatchewan, while health care services for the southern and more populous half of the province is provided by a further nine regional health authorities.

REFERENCES Abonyi, S., & Jeffery, B. (2006). Developing a community health toolkit with Indigenous health organizations. CIHR-IPPH and CPHI Knowledge Translation Casebook. Ottawa: Canadian Institutes of Health Research. Brown, S. (2005). Evaluating community and organizational transition to enhance the health status of residents of northern Saskatchewan. Interim Evaluation Report to the Northern Health Strategy Working Group. Regina: Saskatchewan Population Health and Evaluation Research Unit, University of Regina. Ermine, W. (2000). A critical examination of the ethics in research involving indigenous peoples. Unpublished Master’s thesis, University of Saskatchewan, Saskatoon, Saskatchewan. Health Promotion 5/1/07 11:18 AM Page 175

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Ermine, W., Sinclair, R., & Jeffery, B. (2004). The ethics of research involving indigenous peoples. Report of the Indigenous Peoples’ Health Research Centre to the Interagency Advisory Panel on Research Ethics. Saskatoon: Indigenous Peoples’ Health Research Centre. Feather, J. (2003). Summer school 2002: Working for change in the community and in organizations, Evaluation Report. Saskatoon: Prairie Region Health Promotion Research Centre. Fyke, K. (2001). Caring for medicare: Sustaining a quality system. Regina: Commission on Medicare. Saskatchewan Health. Government of Saskatchewan. (2001). Aboriginal identity: Canada, provinces and territories. Retrieved January 31, 2006, from www.stats.gov.sk.ca/census/aboriginal1.pdf. Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of population health and health promotion. Ottawa: Health Promotion Development Division, Health Canada. Kotowich, R. (2000). Community development coordinator year 2000 fact sheet. Regina: Four Directions Community Health Centre. McLean, S., Feather, J., & Butler-Jones, D. (2005). Building health promotion capacity: Action for learning, learning for action. Vancouver: University of British Columbia Press. Prairie Region Health Promotion Research Centre. (1999). Highlights from summer school 1999. Retrieved January 31, 2006, from www.usask.ca/healthsci/che/prhprc/programs/ss99hilites.html. Prairie Region Health Promotion Research Centre. (2000). Highlights from summer school 2000. Retrieved January 31, 2006, from www.usask.ca/healthsci/che/prhprc/programs/ss00hilites.html. Prairie Region Health Promotion Research Centre. (2003). Summer school 2002: Working for change in the community and in organizations. Evaluation report. Saskatoon: Author. Regina Qu’Appelle Health Region. (2002). Improving First Nations and Métis health outcomes: A call to collaborative action: A report of the “Working Together Towards Excellence Project.” Regina: Author. Romanow, R. (2001). Building on values: The future of health care in Canada (Commission on the Future of Health Care in Canada). Ottawa: Government of Canada. Saskatchewan Health. (1999). A population health promotion framework for Saskatchewan regional health authorities. Regina: Author. Saskatchewan Health. (2001). The action plan for Saskatchewan health care. Regina: Author. Saskatchewan Health. (2004). Healthier places to live, work, and play … a population health promotion strategy for Saskatchewan. Regina: Author. Williams, L. (2005). Healthcare policies, knowledge systems, and approaches to mental well-being in Saskatchewan: A Cree perspective. Funding proposal to the Saskatchewan Health Research foundation. Williams, L., Peterson, T., Graham, N., & Wagner, J. (2005). Evaluation report of summer school 2005: Mental health promotion identity, culture, and power. Saskatoon: Prairie Region Health Promotion Research Centre.

RELEVANT WEB SITES Prairie Region Health Promotion Research Centre www.usask.ca/healthsci/che/prhprc/programs/index.html The Prairie Region Health Promotion Research Centre was established in 1993 in the College of Medicine, University of Saskatchewan, for the purpose of strengthening population health promotion through fostering research into ways of promoting health. The centre is active in establishing links between organizations, practitioners, researchers, and policy makers; disseminating research findings; and working Health Promotion 5/1/07 11:18 AM Page 176

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through partnerships to offer training in health promotion practice and research. The centre pays particular attention to northern and Aboriginal health and health promotion issues.

Regina Qu’Appelle Health Region www.rqhealth.ca/ The Regina Qu’Appelle Health Region is the largest health care delivery system in southern Saskatchewan. It offers a full range of hospital, rehabilitation, community and public health, long-term care, and home care services to meet the needs of more than 245,000 residents living in 120 cities, towns, villages, rural municipalities, and 18 First Nation communities within the region.

Saskatchewan Health, Publications www.health.gov.sk.ca/mc_publications.html This site includes a series of publications related to the Action Plan for Saskatchewan Health Care, including the Population Health Promotion Strategy for Saskatchewan and action plans on workplace health, mental health and well-being, and substance use/abuse, as well as a plan for people with cognitive disabilities.

Saskatchewan Population Health and Evaluation Research Unit www.spheru.ca/www/html/Home/home.htm SPHERU conducts research into the social and environmental determinants of population health under two broad categories: (1) research on health-determining conditions, the relationships within and between these conditions, and the policy and programmatic implications; and (2) evaluation studies of policy and programmatic interventions to make social and environmental conditions more health-promoting, and more equitable in their allocation of health risks and opportunities across different population groups.

HEALTH PROMOTION IN Manitoba Health in 1989, set the stage for con- MANITOBA: PARTNERING tinued development with its focus to develop FOR ACTION partnerships between the province and com- Fran Racher and Robert C.Annis munities (Manitoba Health, 1989). Recent activities now move even further beyond the Introduction traditional focus of the health care system and, Health promotion has advanced in Manitoba in keeping with an understanding of the deter- since the first edition of this book and English’s minants of health, involve many other sectors (1994) historical overview and discussion. beyond health that have substantial impact on Partners for Health: A New Direction for the the health and well-being of individuals, fam- Promotion of Health in Manitoba, released by ilies, and communities. Health Promotion 5/1/07 11:18 AM Page 177

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Demographics of Manitoba identified in the title of the document, Quality Programs, research, and policy development, of Health for Manitobans, the Action Plan: A whether related to health and health services Strategy to Assure Manitoba’s Health Services or the broader determinants of health, are System. In 1997, Manitoba Health (1997) influenced by the distribution of the popula- released a new policy document, which indi- tion across the vast and varied geography of cated a significant shift in priorities and ways the province. Manitoba, centrally located and of thinking about health, healthy public the most easterly of the three prairie provinces, policy, and community participation. Figure is the sixth-largest province in Canada, with 11.1 illustrates the new framework. Manitoba the fifth-largest population (1,169,667) in 2004. Health identified the need to: move from a Winnipeg (650,850), Brandon (43,725), and focus on health services to a focus on health Thompson (14,215) are the three largest cities and the broad determinants of health; employ (Manitoba Health, 2005). Southern Manitoba an intersectoral approach beyond the health is primarily agriculture-based with numerous field; change the current illness care system small communities dispersed across the prairie to a health system; transform reliance on gov- landscape. ernment to partnership with community; progress from short-term action to investment in health promotion and disease prevention; Health System Reform and shift from a service provider-driven Manitoba Health (1992) claimed that its mis- system to focus on health outcomes using evi- sion was to promote, preserve, and protect the dence-based research. This philosophy led the health of Manitobans and its vision was way in the development of renewed partner- reflected in a set of goals to achieve this out- ships across government sectors, and inclu- come. However, its action was more clearly sive of organizations and communities.

FIGURE: 11.1: A FRAMEWORK TO PROMOTE, PRESERVE, AND PROTECT THE HEALTH OF ALL MANITOBANS

Image not available Health Promotion 5/1/07 11:18 AM Page 178

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Health Promotion beyond the for revitalization activities; $16.6 million to Health System support almost 400 community projects; and Interestingly, the Manitoba government has $9.9 million to the repair, rehabilitation, or adopted a community development lens for construction of over 1,700 housing units policy and program development. From the (Manitoba 2000, 2002, 2005). To mark the government’s perspective, community devel- five-year anniversary of NA! in 2005, Premier opment is a community-led process combin- Doer announced that core funding would be ing social and economic development to renewed for an additional five years. foster the economic, social, environmental, A third example of extended partnerships and cultural well-being of communities for health promotion can be found in (Manitoba Intergovernmental Affairs and Manitoba’s new Chronic Disease Prevention Trade, 2000). As a policy lens, these ideas Initiative (CDPI), which aims to improve the must come to bear on program development health of Manitobans through a focus on pri- and implementation in any and all sectors of mary prevention of modifiable risk factors for government activity. This lens has, in turn, non-communicable chronic diseases using a assisted in the development of several new population health approach (Chronic Disease programs that further facilitate health pro- Prevention Initiative, 2005). The CDPI is a motion and community development within five-year community-focused initiative that and beyond the health system. builds on a comprehensive, integrated Healthy Child Manitoba (HCM) is the approach emphasizing local community part- Manitoba government’s long-term, cross- nerships, citizen engagement and community departmental strategy to support healthy child development, and evidence-based planning to and adolescent development. By focusing on generate supportive environments. Manitoba a child-centred public policy that places the Health and the Public Health Agency of best interests of children and youth first and Canada are funding partners, while regional using its community development lens, HCM health authorities of Manitoba, the Northern involves seven provincial departments with and Aboriginal Population Health and numerous community organizations that put Wellness Institute, and the Alliance for the knowledge into action to achieve “the best Prevention of Chronic Disease are operational possible outcomes for Manitoba’s children” partners (Assiniboine Regional Health (Healthy Child Committee of Cabinet, 2002). Authority, 2005; Chronic Disease Prevention Healthy Baby, Families First, and Healthy Initiative, 2005). Schools are notable components of HCM. These multisectoral, multi-jurisdic- Another excellent example of health tional initiatives are also evidenced in promotion beyond the health system, Manitoba’s Non-Smokers Health Protection Neighbourhoods Alive! (NA!), was launched Act, which came into effect October 1, 2004. by the Manitoba government in June 2000. Following city bylaws in Brandon and This multi-department initiative, using com- Winnipeg, the Manitoba All-Party Task munity development principles to support Force on Environmental Tobacco Smoke and encourage community-driven revital- (2003) recommended legislation that was ization efforts, focuses on urban neighbour- implemented, calling for a complete ban of hoods within Brandon, Thompson, and smoking in all enclosed public and indoor Winnipeg. Through NA! the Manitoba gov- workplaces where the provincial govern- ernment has committed over $26.5 million ment had clear jurisdiction. Health Promotion 5/1/07 11:18 AM Page 179

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Changes, Challenges, and tion at the community level. Manitoba Health Future Directions and the RHAs are partnering with multiple Over the past 12 years, cross-sectoral and cross- and varied sectors from across government departmental work has increased in Manitoba. ministries. All-party task forces, cross-cutting Communities are becoming more creative, committees of Cabinet, and horizontal energized, action-focused, and responsible departmental planning sculpt new types of for promoting health at a community level partnerships. Although health promotion is and undertaking community development. seen by many to be the purview of the health Organizations and communities are moving ministries, other departments not only part- from an education focus to an action focus and ner with health, but also take leadership roles action is more often based on evidence in new community development initiatives. designed to support decision making and plan- While for Manitobans committed to ning. For example, A Snapshot of Early Child health promotion there is much to celebrate, Development in Manitoba (Healthy Child much also remains to be done. Manitoba’s Manitoba, 2003) and Injuries in Manitoba: A health system remains largely a system of ill- 10-Year Review (Manitoba Health, 2004) each ness care with little improvement in the por- offered important information for planning. tion of the health budget allocated to public The Manitoba Centre for Health Policy (2006) health or health promotion. Moreover, when has developed many reports that examine funding is allocated, it is frequently insuffi- patterns of illness in the population, and cient to sustain projects and programs over depict health care utilization. The Rural the longer term. Northern Manitoba’s resi- Development Institute of Brandon University dents in particular continue to face huge dif- has recently published Rural Community ficulties in gaining access not just to health Health and Well-being: A Guide to Action, which services, but also to education, employment, outlines a framework, process, and tools to stable incomes, housing, clean water, and assist rural communities in assessing and waste management. Distance and geography taking action regarding community health and continue to be a challenge. Neighbourhoods sustainability (Annis, Racher, & Beattie, 2005). Alive!, with its community development lens, Regional health authorities are developing has been effective, but has been restricted to positions designed to support planning and three urban centres. Rural and northern res- decision making, to facilitate knowledge trans- idents, who understand the problems and lation and application of existing studies, and have much to contribute to developing the to undertake research and generate local data solutions, still need to be even more engaged for planning purposes. in decision making and planning. Ultimately, all people—whether they reside in urban, rural, or northern regions—must plan and Conclusion work together to promote, preserve, and pro- In summary, the Manitoba government is tect the health of all Manitobans and the well- demonstrating leadership in health promo- being of the communities in which they live.

Acknowledgements The authors wish to express their sincere thanks to the many individuals who discussed Manitoba’s progress with us and steered us to many important initiatives across the province, Health Promotion 5/1/07 11:18 AM Page 180

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often beyond the scope of this chapter. Their commitment to health promotion has helped shape policy and practice in Manitoba, which ultimately benefits the health of its residents and communities.

REFERENCES All Party Task Force on Environmental Tobacco Smoke. (2003). Environmental tobacco smoke: What Manitobans said. Winnipeg: Manitoba Government. Retrieved March 10, 2006, from www.gov.mb.ca/health/documents/tobacco/report.pdf. Annis, R., Racher, F., & Beattie, M. (2005). Rural community health and well-being: A guide to action. Brandon: Rural Development Institute, Brandon University Press. Retrieved March 10, 2006, from www.brandonu.ca/rdi/Publications/guidebook.pdf. Assiniboine Regional Health Authority. (2005). Assiniboine Regional Health Authority chronic disease prevention initiative. Retrieved January 14, 2006, from www.assiniboine-rha.ca/newsletters/ FACT%20SHEET.pdf. Chronic Disease Prevention Initiative. (2005). Chronic Disease Prevention Initiative Project charter. Unpublished final draft document. English, J. (1994). Health promotion in Manitoba. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 195–205). Toronto: W.B. Saunders. Healthy Child Committee of Cabinet. (2002). Healthy Child Manitoba: Programs and services. Winnipeg: Manitoba Government. Retrieved January 14, 2006 from www.gov.mb.ca/healthychild/about/ index.html. Healthy Child Manitoba. (2003). A snapshot of early child development in Manitoba. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/healthychild/ecd/edi2003.pdf. Manitoba. (2000). Neighbourhoods Alive! Program launched by Manitoba Government. Retrieved January 14, 2006, from www.gov.mb.ca/chc/press/top/2000/06/2000-06-28-01.html. Manitoba. (2002). Using CED principles to build strong neighbourhoods. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/ia/programs/neighbourhoods/news/documents/forum2.pdf. Manitoba. (2005). Province celebrates and expands successful Neighbourhoods Alive initiative. Retrieved January 14, 2006, from www.gov.mb.ca/chc/press/top/2005/06/2005-06-08-02.html. Manitoba Centre for Health Policy. (2006). What does the MCHP do? Retrieved January 14, 2006, from www.umanitoba.ca/centres/mchp/whomchp.htm#b. Manitoba Health. (1989). Partners for health: A new direction for the promotion of health in Manitoba. Winnipeg: Author. Manitoba Health. (1992). Quality of health for Manitobans the action plan: A strategy to assure Manitoba’s health services system. Winnipeg: Author. Manitoba Health. (1997). A planning framework to promote, preserve, and protect the health of Manitobans. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/health/rha/planning.pdf. Manitoba Health. (2004). Injuries in Manitoba: A 10-year review. Winnipeg: Author. Retrieved July 21, 2006, from www.gov.mb.ca/healthyliving/injuryreview.html. Manitoba Health. (2005). Manitoba population report, June 1, 2004. Winnipeg: Author. Retrieved January 14, 2006, from www.gov.mb.ca/health/population/2004/pop2004.pdf. Manitoba Intergovernmental Affairs and Trade. (2000). Neighbourhoods Alive! Neighbourhood toolbox: Health Promotion 5/1/07 11:18 AM Page 181

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Guide to community economic development. Retrieved January 13, 2006, from www.gov.mb.ca/ia/ programs/neighbourhoods/toolbox/ced.html.

RELEVANT WEB SITES

Neighbourhoods Alive! www.gov.mb.ca/ia/programs/neighbourhoods/ Neighbourhoods Alive! is a long-term, community-based social and economic development strategy that recognizes that building healthy neighbourhoods requires more than an investment in bricks and mortar. The Manitoba government created Neighbourhoods Alive! to provide community organizations in designated neighbourhoods with the support they need to rebuild these neighbourhoods.

Rural Development Institute, Brandon University www.brandonu.ca/organizations/RDI/index.asp Rural populations face considerable challenges in today’s rapidly changing society. Restructuring in agriculture and industry, plus fiscal restraint and shifts in rural and northern demographics, are leading to a re-examination of the roles of governments, communities, and individuals. Brandon University’s Rural Development Institute (RDI) is a centre for excellence in rural development helping to strengthen rural and northern communities through research and information on issues unique to rural areas.

HEALTH PROMOTION of the Premier’s Council on Health Strategy IN ONTARIO: (later renamed the Premier’s Council on SURVIVAL THROUGH Health, Well-being, and Social Justice), a pro- CAPACITY BUILDING gressive health and social policy think tank Brian Hyndman that advanced health promotion concepts into the mainstream of government policy Introduction making. In their summation of the progress During the years following the release of the achieved during this period, Pederson and Ottawa Charter (1986), the field of health pro- Signal (1994, p. 244) identified “a broad view motion underwent a period of significant of health and its determinants” as “the major growth in Ontario. Key developments accomplishment of the health promotion included the establishment of a provincial movement in Ontario to date.” Health Promotion Branch to coordinate But by 1994 this “broad view of health health promotion initiatives within the and its determinants” faced a number of chal- Ontario Ministry of Health; the launch of the lenges. The provincial New Democratic gov- Toronto Healthy City Office, which provided ernment, which had been instrumental in the opportunity to apply the principles of supporting the social change movements that community organization and advocacy to gave rise to a more holistic view of health, community health priorities; and the creation was deeply unpopular due to a prolonged Health Promotion 5/1/07 11:18 AM Page 182

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economic recession and fiscal restraint poli- replacement with a “health promotion and cies that alienated its core supporters. At the wellness” division within the Public Health federal level, the shift from health promo- Branch, the arm of the ministry overseeing tion toward population health challenged the operation of the province’s public health health promoters to integrate their work into units, signalled a discernable downgrading of a new paradigm. This was also a period health promotion as a vehicle for achieving marked by growing cost containment by all provincial health priorities. levels of government, which placed increased demands on health promotion to demonstrate accountability and prove the “effec- Networking and Capacity Building tiveness” of its initiatives (O’Neill, Pederson, Beginning in the 1990s, health promotion in & Rootman, 2000). Ontario focused extensively on creating an infrastructure for networking and capacity building. In June 1994, the Centre for Health Politics and Policy Promotion at the University of Toronto The climate of fiscal restraint hampering the launched the first Health Promotion Summer growth of health promotion reached its apex School, a continuing education event devoted in June 1995 with the election of a Progressive to sharing and building the health promotion Conservative government that swept into knowledge and skill base. Since that time, the power with the so-called “Common Sense yearly summer school has evolved into the Revolution,” a neo-liberal platform combin- leading educational and training event for ing steep tax cuts with corresponding decreases health promoters in Ontario. in government spending. Somewhat ironically, Health promoters in Ontario also capi- health promotion’s placement within a larger talized on the increasing use of electronic provincial ministry encompassing the “sick- communication with the introduction of two ness care” system meant that it did not suffer major networking and capacity-building ini- from the same magnitude of cutbacks that tiatives. In 1996, York University and the befell other sectors, since health care, along Ontario Prevention Clearinghouse, a health with in-class education and law enforcement, promotion resource centre funded by the were earmarked as exempt from spending cuts province, launched Click4HP, a non-mod- by the new government. erated public listserv that provides a venue However, health promotion was by no for international dialogue on the state of means immune to the government’s cost-cut- health promotion. The following year ting agenda. In September 1995, the Premier’s marked the launch of the Ontario Health Council was disbanded along with the Promotion E-Bulletin, a weekly electronic Healthy Community Grants Program, which newsletter focusing on health promotion had provided seed funding for community- developments in Ontario. The infrastructure based health promotion projects. The health for health promotion capacity building in promotion programs maintained by the Ontario was further strengthened with the province, such as the Ontario Heart Health creation of the Ontario Health Promotion Program, were more narrowly focused on Resource System, a network of issue and disease prevention and the promotion of skill-based resource centres providing train- healthy lifestyles. In 1997 the province elim- ing and information to health promotion inated the Health Promotion Branch; its practitioners in the field. Health Promotion 5/1/07 11:18 AM Page 183

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The considerable growth in health pro- Syndrome (SARS) in Toronto the same year motion networking and capacity building at demonstrated that concerns about the sys- a time when both the political and program- temic neglect of essential services could not, matic base of health promotion in Ontario contrary to prevailing government ideology, appeared to be shrinking is a noteworthy phe- be dismissed as self-serving advocacy from nomenon that has yet to be fully analyzed. so-called “interest groups.” Increased aware- One could argue that this trend represented ness of the inadequacy of public health serv- an inward-looking, “preaching to the choir” ices was a not insignificant factor contributing reaction when health promotion’s core values to the defeat of the Progressive Conservative of equity, social justice, and empowerment government in the 2003 Ontario election. were under attack. Conversely, one could argue that the emphasis on capacity building and networking was critical for sustaining Conclusion health promotion discourse in the absence of The focus on public health renewal in the a clearly articulated vision for heath promo- wake of these crises offers uncertain impli- tion by the Ontario and federal governments cations for the future of health promotion in during much of the 1990s. Ontario. Will developments such as the creation of the federal Public Health Agency of Canada and a new Ministry of Health Public Health Crises Promotion by the Ontario government During the opening decade of the 21st cen- herald an era of new opportunities for health tury, Ontario was hit with a series of crises promoters in Ontario? Or will the current that revealed the erosion of public health serv- preoccupation with pandemic planning result ices following years of cutbacks and under- in an erosion of health promotion in an effort funding. Events such as the contaminated to shore up the traditional health protec- water crisis in Walkerton in 2000, and the sale tion/communicable disease control functions of tainted meat in Aylmer, Ontario, in 2003 of public health? The answers to these ques- and outbreak of Severe Acute Respiratory tions remain to be seen.

REFERENCES O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Pederson, A., & Signal, L. (1994). The health promotion movement in Ontario: Mobilizing to broaden the definition of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and territorial perspectives (pp. 244–261). Toronto: W.B. Saunders.

RELEVANT WEB SITES Centre for Health Promotion, University of Toronto www.utoronto.ca/chp/ The Centre for Health Promotion, established in 1989, is a community–academic partnership. The centre is committed to excellence in education, evaluation, and research. In a multidisciplinary, collaborative context it activates, develops, and Health Promotion 5/1/07 11:18 AM Page 184

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evaluates innovative health promotion approaches in Canada and abroad. The centre is an active, high-quality, internationally recognized leader in health promotion.

Ministry of Health Promotion www.mhp.gov.on.ca/english/about.asp Created in June 2005, the Ministry of Health Promotion aims to help Ontarians lead healthier lives by delivering programs that promote healthy choices and healthy lifestyles by working closely with partners, stakeholders, and all levels of government.

Ontario Health Promotion E-Bulletin www.ohpe.ca/index.php The Ontario Health Promotion E-mail Bulletin (OHPE) is a weekly newsletter for people interested in health promotion. It is produced by the Ontario Prevention Clearinghouse and the Health Communication Unit of the Centre for Health Promotion, University of Toronto.

Ontario Prevention Clearinghouse www.opc.on.ca The Ontario Prevention Clearinghouse (OPC) is Ontario’s longest-standing health promotion organization. OPC helps individuals, groups, and communities use health promotion strategies to achieve health and well-being.

HEALTH PROMOTION Directorates, and Local Community Health IN QUEBEC: Centres) were redefined at the local, regional, MORE OF THE SAME? and national levels. This period was accom- Lucie Richard panied by institutional downsizing and increased ambulatory services in the hospital Three Waves of Change in the Public subsystem. Between 1998–2001, additional Health Subsystem changes were made to the public health sub- Colin (2004) and other analysts (Health system with the creation of an Institut national Canada, 1996; Nadeau, 1996; Pineault et al., de santé publique and the adoption of a new 1993; Pineault & Tousignant, 2000) have public health law. While the purpose of the observed that the Quebec health care system first is basically to support the minister and the has undergone three waves of transformation regional agencies in their public health mis- since the early 1990s. These three waves of sion, the second is geared toward “the protec- organizational, programmatic, and legislative tion of the health of the population and the change had important implications for health establishment of conditions favourable to the promotion research, policy, and practice. maintenance and enhancement of the health In 1993–1994, the roles and mandates of and well-being of the general population” key institutions and actors in the public health (Public Health Act, R.S.Q., Chapter S-2.2, subsystem (e.g., the Ministry of Health and article 1, free translation). Article 3 of the Social Services, Regional Health and Social law refers explicitly to health promotion, defin- Services Agencies and their Public Health ing it as “[...] the means of exerting a positive Health Promotion 5/1/07 11:18 AM Page 185

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influence on major health determinants, in resources devoted to these endeavours, espe- particular through intersectoral coordination” cially in CLSCs (Bourdages, Sauvageau, & (free translation). The third series of organi- Lepage, 2003; Ordre des infirmières et infir- zational reforms was implemented in 2004 miers du Québec, 1999; Poirier, 2000). On the when facilities with different missions (CLSC, other hand, as noted by O’Neill and Cardinal CHSLD, and CH)1 were combined within a (1994) a while ago, combining preventive, cur- new type of local structure: the Health and ative, and health promotion services in Quebec Social Services Centre (CSSS), which formally created definite tensions for health promotion, networked with community groups and physi- which still struggles to gain attention and cians in private practice. resources in an era where cuts in curative serv- Accompanying these structural and ices rank high among public concerns. organizational reforms were changes in ori- Moreover, the fact that the National Public entations and programs. As early as 1992, the Health Program of 2003 is organized around Quebec government had adopted a compre- health problems rather than around their deter- hensive policy on health and well-being minants illustrates the continued dominance (Ministère de la santé et des services sociaux, of the “prevention” dimension in the “promo- 1992) clearly identifying prevention and health tion–prevention” duo. promotion as two key strategies. Following The budgetary and organizational context this, national public health priorities for of the last few years has not facilitated greater 1997–2002 were announced (Ministère de la integration of the health promotion discourse santé et des services sociaux, 1997) and, finally, in practice in Quebec. In 1994, O’Neill and a national public health program was estab- Cardinal reminded us of the neo-conservative lished for 2003–2012 (Ministère de la santé et climate that has been operating since the mid- des services sociaux, 2003). Between 1994 and 1980s, with a provincial government “con- 2006, health promotion training and research cerned mostly with dismantling the welfare also expanded. This involved the creation or state, diminishing the size of the public deficit, expansion of dedicated research structures, 2 decreasing government intervention, and pri- the development of research chairs3 and col- vatizing certain areas of government service” laborating centres,4 and the creation of new (p. 273). More than 12 years later, we can report post-graduate training programs. that health promotion today finds itself in context of, and experiencing, “more of the same.” The Status of Health Promotion Given all these changes, how “healthy” is Conclusion health promotion in Quebec in 2006? While In short, while the rhetoric of the last 12 years it has been at the centre of the discourse that of reforms has delighted those who support accompanied changes in the health care system health promotion, evidence about its financ- over the last 12 years, has it been able to flour- ing and its practice should lead them to con- ish to the same degree in practice? On the one tain their enthusiasm. Even if the situation hand, empirical evidence shows some positive is far less gloomy than that presented by impact of the reforms on the adoption of inno- O’Neill and Cardinal in 1994, there is still a vative approaches to prevention-promotion long way to go to ensure a greater integra- (Richard et al., 2004), whereas other work tion of the health promotion discourse in describes a negative impact on the level of Quebec’s policies and programs. Health Promotion 5/1/07 11:18 AM Page 186

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NOTES 1 CLSC: Centre local de services communautaires (local community health centre); CHSLD: Centre d’hébergement et de soins de longue durée (long-term care residential centre); CH: Centre hospitalier (hospital). 2 For example, GRIPSUL at Université Laval and the Centre de recherche en promotion de la santé de l’Université de Montréal. 3 For example, the Canada Research Chair on Health Education (J. Otis, UQAM), the Canada Research Chair on Behaviour and Health (G. Godin, Université Laval), and the Chair on Community Approaches and Health Inequalities (L. Potvin, Université de Montréal). 4 For example, the WHO Collaborating Centre on the Development of Healthy Cities and Towns (Université Laval).

REFERENCES Bourdages, J., Sauvageau, L., & Lepage, C. (2003). Factors in creating sustainable intersectoral community mobilization for prevention of heart and lung disease. Health Promotion International, 18(2), 135–144. Colin, C. (2004). La santé publique au Québec à l’aube du XXIe siècle (Public health in Québec at the dawn of the 21st century). Santé publique, 16(2), 185–195. Health Canada. (1996). La réforme des soins de santé au Canada (Health care reform in Canada). Ottawa: Author. Ministère de la santé et des services sociaux. (1992). La politique de la santé et du bien-être (Policy on health and well-being). Quebec: Gouvernement du Québec. Ministère de la santé et des services sociaux. (1997). Priorités nationales de santé publique (National public health priorities). Quebec: Gouvernement du Québec. Ministère de la santé et des services sociaux. (2003). Programme national de santé publique 2003–2012 (National public health program 2003–2012). Quebec: Ministère de la santé et des services sociaux. Nadeau, J. (1996). Reform of the Québec healthcare system. Leadership in Health Services, 5(4), 8–10. O’Neill, M., & Cardinal, L. (1994). Health promotion in Québec: Did it ever catch on? In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 262–283). Toronto: W.B. Saunders. Ordre des infirmières et infirmiers du Québec. (1999). Bilan de la pratique infirmière en milieu scolaire (Current status of nursing practices in school settings). Montréal: OIIQ: Direction de la planification. Pineault, R,. Lamarche, P.A., Champagne, F., Contandriopoulos, A.P., & Denis, J.L. (1993). The reform of the Quebec health care system: Potential for innovation? Journal of Public Health Policy, 14(2), 198–219. Pineault, R., & Tousignant, P. (Eds.). (2000). Transformation of the Montreal network: Impact of health. Research collective. Montréal: RRSSS Montréal-Centre, Direction de la santé publique. Poirier, L.R. (2000). Évaluation de l’efficacité du réseau de services offerts aux personnes ayant des trou- bles mentaux et vivant dans la communauté (Effectiveness of the network of services offered to non- institutionalized persons having mental problems). In R. Pineault & P. Tousignant (Eds.), Transformation of the Montreal network: Impact on health. Montréal: RRSSS Montréal-Centre, Direction de la santé publique. Richard, L., Lehoux, P., Breton, E., Denis, J.L., Labrie, L., & Léonard, C. (2004). Implementing the ecological approach in tobacco-control programs: Results of a case study. Evaluation and Program Planning, 27, 409–421. Health Promotion 5/1/07 11:18 AM Page 187

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RELEVANT WEB SITES Association pour la santé publique du Québec (ASPQ) www.aspq.org The ASPQ is a multidisciplinary, not-for-profit organization that aims to improve the health of people in Quebec. The association regularly intervenes to promote health, for example, by offering position statements or papers to government.

Institut national de la santé publique du Québec www.inspq.qc.ca/ The Web site of l’Institut de la santé publique du Québec (Quebec national public health institute). An English section is available on the site.

Centre de recherche Léa-Roback sure les inégalités sociales de santé de Montréal www.centrelearoback.ca The mission of the Léa-Roback Research Centre is to help reduce social inequalities in health and improve living conditions through facilitating research ; developing alliances among researchers, policy makers, and professionals ; and to enable knowledge transfer.

Ministère de la santé et des services sociaux du Québec www.msss.gouv.qc.ca/ The Web site of the Ministère de la santé et des services sociaux du Québec (Quebec health and social services ministry). An English section is available on the site.

Réseau francophone international pour la promotion de la santé (REFIPS) www.refips.org This Web site brings together individuals and organizations involved in health promotion in approximately 30 francophone countries.

THE ATLANTIC PROVINCES: very high need in terms of prevention and A “HAVE” OR “HAVE-NOT” promotion, but low fiscal and human REGION FOR HEALTH resources to address these needs. There are PROMOTION? a number of challenges that face the region. Renee Lyons, Monique Allain, Sandra Crowell, In comparison with other provinces such as Stacey Wilson-Forsberg, Marlien MacKay, Rick British Columbia, Atlantic Canada rates Manuel, Donna Murnaghan, Laraine Poole, poorly on many key health indicators—rates Shirley Solberg, Eleanor Swanson, Patricia L. of cardiovascular disease, asthma, cancer, Williams, Doug Willms, and Fiona Chin-Yee smoking rates, etc. (Hayward & Colman, 2003). Atlantic Canada also experiences sub- Introduction stantial social and economic disparities and Health status and health system indicators a rapidly aging population due to the fact that suggest that Atlantic Canada is a region of many young and middle-aged adults have Health Promotion 5/1/07 11:18 AM Page 188

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left the region for employment (Canadian promotion is, in essence, based on social and Rural Partnership, 2004; Statistics Canada, cultural change, is there a corresponding 2002). Illness care costs swallow up such a health promotion disparity or “poverty” in gigantic portion of provincial budgets that “have-not” regions such as Atlantic Canada? sustained investments in prevention and pro- Is Atlantic Canada a “have” or “have-not” motion have been relatively negligible region for health promotion? What are we (Mirolla, 2004). Recent reviews of the public doing in terms of action to improve health health system in the Atlantic provinces, for status, prevent illness, and address the deter- example, pointed to substantial deficiencies minants of health? Are we seeing progress? in the basic health systems infrastructure for Are advancements sufficient to tackle the protection and promotion (Committee on aging population and the plethora of health Public Health Capacity, 2004; Jensen & issues in the region? What are the conditions Kisley, 2005; Moloughney, 2006). Despite that enhance or constrain progress in health these challenges, many innovative health pro- promotion in the “far east” of Canada? motion initiatives have been launched to Health promotion is not an easy theme improve health status, prevent illness, and around which to provide a comprehensive mobilize communities to take action on the regional analysis. Health promotion is a very conditions that impact health. broad concept that encompasses a wide range This section of the chapter on health of strategies and content areas. Therefore, promotion in Canada provides a sampling of instead of claiming to provide a comprehen- health promotion advancements in Atlantic sive overview, we offer a “flavour” of health Canada. The health promotion examples we promotion in the Atlantic region. Several writ- present focus on two themes: governmental ers were selected from each province to pro- policy commitments to the promotion of vide examples of policy-based health promotion health and university-based health promo- initiatives and of health promotion research. tion research projects. The authors offer per- In addition, two examples of Atlantic-wide spectives on the status of health promotion health promotion research and action are given. in Atlantic Canada. Due to space restrictions we have not included Regions and provinces within Canada important contributions in research and action are often characterized by the media and the made by non-governmental organizations, federal government as “have or “have not” government agencies, researchers, or the pri- based on financial disparities. Since health vate sector.

REFERENCES Canadian Rural Partnership: Rural Research and Analysis. (2004). Rural repopulation in Atlantic Canada, a discussion paper. Retrieved April 2005, from www.rural.gc.ca/researchreports/popresearch/ repop_e.phtml. Committee on Public Health Capacity. (2004). Investing in health: A report on public health capacity in Newfoundland and Labrador. St. John’s: The Newfoundland and Labrador Department of Health and Community Services. Hayward, K., & Colman, R. (2003). The tides of change: Addressing inequality and chronic disease in Atlantic Canada. Retrieved April 2005, from www.phac-aspc.gc.ca/canada/regions/atlantic/pdf/ Tides_Inequity_and_Chronic_Disease.pdf. Health Promotion 5/1/07 11:18 AM Page 189

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Jensen, L., & Kisely, D.S. (2005). Public health in Atlantic Canada. A discussion paper. Halifax: Public Health Agency of Canada, Atlantic Region. Mirolla, M. (2004). The cost of chronic disease in Canada. Retrieved April 2006 from www.gpiatlantic.org/pdf/health/chroniccanada.pdf. Moloughney, B.W. (2006). The renewal of public health in Nova Scotia: Building a public health system to meet the needs of Nova Scotians. Halifax: Nova Scotia Health Promotion and Protection. Statistics Canada. (2002). Profile of the Canadian population by mobility status: Canada: A nation on the move. Retrieved April 2006, from www12.statcan.ca/english/census01/products/analytic/companion/mob/ contents.cfm.

NEW BRUNSWICK: instance, the strategy will assist the New GOVERNMENT POLICY Brunswick Youth Council in building on its AND ACTION consultation process regarding health issues Monique Allain and Marlien MacKay that impact youth. Youth leadership in health promotion and chronic disease prevention is Since June 1999, the government of New also emphasized. Brunswick has developed and implemented For the past five years, there has been a public policy initiatives and programs that strong emphasis on using schools to promote promote wellness and healthy living. These health. The Department of Health and initiatives include the Smoke-free Places Act Wellness and the Department of Education and the Healthier Foods and Nutrition in established the Healthy Learners in School Public Schools provincial policy. New Program in 2000 to improve the health and Brunswick’s recent Provincial Health Plan learning achievement of New Brunswick stu- (2004–2008) (New Brunswick Department dents (Province of New Brunswick, 2004). of Health, 2004) identified improving popu- The program supports health initiatives that lation health as its first strategic priority. will improve student wellness and learning. Within this strategic priority are measures to The goals are based on three aspects of com- promote healthy living, to improve the man- prehensive school health frameworks: knowl- agement and control of chronic diseases, to edge, attitudes, and skills to achieve wellness, reduce the incidence of cancer, and to pre- healthy and safe learning environments vent sickness and disease through an (physical and social), and access to services expanded immunization program. The and support. Health committees have been Wellness Strategy (within the plan) includes established in each school district and are the approaches to promote personal health prac- mechanism for identifying collective priority tices and to help modify the environments and developing and implementing actions that would support them. The strategy with all partners Some information (currently includes initiatives for healthy eating, phys- in revision) can be located in the Health sec- ical activity, tobacco-free initiatives, and tion of the government of New Brunswick mental health and resiliency, with an empha- Web site at www.gnb.ca. sis on partnership and collaboration. For Health Promotion 5/1/07 11:18 AM Page 190

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REFERENCES New Brunswick Department of Health. (2004). Healthy futures: Securing New Brunswick’s health care system. The provincial health plan 2004–2008. Retrieved July 22, 2006, from www.gnb.ca/0051/pdf/ healthplan-2004-2008_e.pdf. Province of New Brunswick. (2004). Healthy Learners in School Program putting health and education together for wellness. Retrieved April 2006, from www.gnb.ca/0053/programs/healthylearners-e.asp.

RESEARCH: HEALTHY children overcome disadvantages and have an CHILDREN opportunity to succeed. This research program Doug Willms and Stacey Wilson-Forsberg considers how to improve the learning, behav- Over the past 10 years, research initiatives of iour, and health outcomes of our children and the Canadian Research Institute for Social youth, while reducing inequalities associated Policy (CRISP) at the University of New with family background. The research pro- Brunswick (UNB) have contributed to knowl- gram focuses on five key strategies: (1) safe- edge about the risk and protective factors asso- guarding the healthy development of infants; ciated with vulnerability among Canadian (2) strengthening early childhood education; children and youth (Willms, 2002) and child- (3) improving schools and local communities; hood obesity (Tremblay & Willms, 2000; (4) reducing segregation and the effects asso- Willms, Tremblay, & Katzmarzyk, 2003). ciated with poverty; and (5) creating a family- CRISP’s most ambitious research program to enabling society. This research is being carried date, Raising and Leveling the Bar, has out by members of the network across Canada, brought together a multidisciplinary network with support from the core research team at of 30 committed, enthusiastic researchers from UNB (Canadian Research Institute for Social across Canada to pool data and ideas to help Policy, 2004).

REFERENCES Canadian Research Institute for Social Policy. (2004). Raising and leveling the bar. Retrieved April 2006 from www.unbcrisp.ca/learningbar/. Tremblay, M.S., & Willms, J.D. (2000). Secular trends in the body mass index of Canadian children. Canadian Medical Association Journal, 163(11), 1429–1433. Willms, J.D. (Ed.). (2002). Vulnerable children: Findings from Canada’s national longitudinal survey of children and youth. Edmonton: University of Alberta Press. Willms, J.D., Tremblay, M.S., & Katzmarzyk, P.T. (2003). Geographic and demographic variation in the prevalence of overweight Canadian children. Obesity Research, 11(5), 668–673.

NOVA SCOTIA: heart and lung disease, cancer, diabetes, and GOVERNMENT POLICY mental ill health are preventable (Nova Scotia AND ACTION Health Promotion and Protection, 2004). And Rick Manuel up to 95 percent of all injuries are preventable (Atlantic Network for Injury Prevention, Evidence and experience suggests that 2006). With some of the poorest health sta- approximately 40 percent of cases of chronic tistics in the country, the government of Nova Health Promotion 5/1/07 11:18 AM Page 191

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Scotia established a separate ministry in 2002 and communications and social marketing. to focus on health promotion and chronic dis- Some recent developments include hiring ease and injury prevention. Nova Scotia “school animators” to work in Nova Scotia Health Promotion (NSHP) was created by communities to increase opportunities for bringing together the former Sport and students to engage in physical activities before, Recreation Commission with portions of the during, and after school hours; developing Population Health branch of the Department and launching a province-wide policy on food of Health. New resources and responsibili- and nutrition in Nova Scotia schools; passing ties were added and by 2005, NSHP had a the toughest anti-smoking legislation in the budget of approximately $25 million and a country and seeing overall smoking rates drop staff of over 70 people. In 2006, the NSHP from about 30 percent to 20 percent over a expanded again to include all public health few short years; working with stakeholders staff, including the Office of the Chief to develop a strategy for preventing falls Medical Officer of Health. With a focus on among seniors; and developing and releasing population health, disparity reduction, a comprehensive Alcohol Indicators Report, healthy public policy, evidence-informed deci- which provides information on the kinds and sion making, and community capacity build- severity of harms and problems that result ing, Nova Scotia Health Promotion and from alcohol abuse. The first of its kind in the Protection (NSHPP) is working to address country, the report forms the basis for devel- common risk factors for the chronic diseases oping strategies to reduce harmful drinking. that take the greatest toll on Nova Scotians NSHPP’s strategic plan, annual business and their health care system. Strategic prior- plans, accountability reports, policy papers, ity areas include: public health and health pro- policy statements, newsletters, monthly tection services, physical activity, sport and updates, and program-specific updates are recreation, healthy eating, tobacco control, available on the NSHPP Web site at injury prevention, addiction prevention, www.gov.ns.ca/ohp. healthy sexuality, chronic disease prevention,

REFERENCES Atlantic Network for Injury Prevention. (2006). The economic burden of unintentional injury in Atlantic Canada. Retrieved May 15, 2006, from www.anip.ca/. Nova Scotia Health Promotion and Protection. (2004). Chronic disease prevention. Retrieved April 23, 2006, from www.gov.ns.ca/ohp/chronicDiseasePrevention.html.

RESEARCH: Resource Centres and Projects in Nova Scotia, FOOD SECURITY funded by Health Canada’s Community Patricia L.Williams Action Program for Children (CAPC) and the Canada Prenatal Nutrition Program (CPNP), In 2001, partners representing the Atlantic collaborated to develop a participatory process Health Promotion Research Centre, Nova of “food costing” throughout Nova Scotia. Scotia Nutrition Council, Mount Saint Vincent These groups recognized the need to address University, and individuals from Family the problem of growing food insecurity in Health Promotion 5/1/07 11:18 AM Page 192

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Nova Scotia by finding sustainable solutions to build food security; the development of a for system redesign through capacity build- participatory model and tools for ongoing ing. The participatory food-costing program monitoring of the affordability of a nutritious not only resulted in an analysis of what it diet; and the development of a food security costs to eat nutritiously in Nova Scotia, but policy backgrounder and lens for policy also a group of “food costers” (participants makers to assess the impacts of their decisions and staff in CAPC- and CPNP-funded on food security. family resource centres and projects) with the Findings from this research show that skills commitment and interest to continue participatory tools and processes are an effec- to build food security. tive way to build individual, organizational, From 2001–2006, the Nova Scotia community, and systems capacity to address Participatory Food Security Projects have food insecurity and the policies that need been at the forefront of provincial and national changing. The evidence gleaned through this efforts to address food insecurity through eight work has influenced both policy and practice related action research projects. These proj- within Nova Scotia (Nova Scotia, 2005) and ects have included a wide range of collabora- has been used by many other locales working tions across Canada, including women who on policy-oriented approaches to food inse- are experiencing food insecurity, community- curity. In addition, the lessons learned based organizations, government, academics, through these projects have contributed to the and health and social service professionals. development of a Web-accessible, plain-lan- The projects have involved story-sharing guage, bilingual workbook, Thought about workshops as well as community and national Food? A Workbook on Food Security & dialogues on food security and policy; a Influencing Policy. See: www.foodthought- national scan of strategies that impact policies ful.ca/ and accompanying DVD.

REFERENCE Nova Scotia Department of Health Promotion and Protection. (2005). Healthy eating. Retrieved February 2007 from www.gov.ns.ca/hpp/healthyeting.html.

PRINCE EDWARD ISLAND: resulted in many improvements in partner- GOVERNMENT AND ships and collaboration that support health COMMUNITY ACTION promotion policy and action. For instance, the Deborah Bradley and Laraine Poole departments of Health and Social Services, Education, and Community and Cultural The PEI Strategy for Healthy Living was Affairs are working together on the strategy launched in 2003 in response to the growing at the provincial level. The three departments burden of chronic disease. The strategy was provide a mechanism for interdepartmental designed to promote collaborative efforts to collaboration on planning and joint imple- address several of the most significant behav- mentation of common initiatives as related to ioural risk factors for chronic diseases: tobacco healthy living. PEI is also fortunate to have use, unhealthy diet, and physical inactivity. three strong and active alliances as partners in The PEI Strategy for Healthy Living has the Strategy for Healthy Living: Active Living Health Promotion 5/1/07 11:18 AM Page 193

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Alliance, Tobacco Reduction Alliance, and among children and the PEI Stepping Out Healthy Eating Alliance. Each alliance is com- Program is helping islanders to become more posed of member organizations and is involved active. Outcome indicators have been devel- in a number of initiatives that address specific oped for all three risk factors, and will be risk factors. As well, four regional healthy measured over time. Since the Strategy for living coordinators were hired in 2004 to help Healthy Living was launched in 2003, many develop partnerships through regional net- changes have occurred in the province of works, addressing specific needs and priorities PEI. In 2005 the PEI health system was reor- at the community level. These “temporary” ganized from a regional system to a central positions were made available through the administrative system. Currently, within the Federal Primary Health Care Transition Department of Health, a small Health Fund. Some broad-based accomplishments Promotion and Chronic Disease Prevention include the development of a Physical Activity Unit has been established. However, the risk Strategy for the Province; development and factor positions were lost and the federal implementation of School Healthy Eating funding for the healthy living coordinators Policies; implementation of the Smoke-Free ended in March 2006. Two of the positions Places Act; and development and piloting of remain temporarily funded by the province. the Active Healthy School Communities, an However, the department wants to sustain initiative aimed at improving health through the collaborations that have been developed. school–community partnerships. Many advances were made by organizations The Tobacco Reduction Strategy, in working collectively to maximize impact and place since 1999, has contributed to reduced to minimize duplication. Detailed informa- rates of tobacco use in PEI. Activities such as tion on the PEI Strategy for Healthy Living the Fruit and Vegetable Pilot Project have and related initiatives can be found at shown promise in promoting healthy eating www.gov.pe.ca/go/hls.

RESEARCH: HEALTHY program that focuses on the school as a major SCHOOLS social context for children’s health. The main Donna Murnaghan research objective is to prevent chronic dis- The Comprehensive School Health Research eases by working directly with school-aged Team (CSHRT), led by researchers at the children and youth, providing research sup- University of Prince Edward Island, is an port, and disseminating findings to policy intersectoral team of academic, government, makers and other research users. For instance, and community researchers and decision the team is currently conducting school-based makers working collaboratively toward studies that examine student health behav- building new knowledge and infrastructure iours related to healthy eating, physical activ- to support school health research in Atlantic ity, and not smoking; health promotion Canada. The primary mandate of this pro- initiatives in schools across Canada; barriers gram of research is to develop interventions and facilitators to participating in sports; and that promote healthy and active children and the development and testing of innovative youth, important contributors to learning and programs for student health promotion. Over social/physical development. The CSHRT the past year, CHSRT has created partner- uses an innovative research and training ships and collaborations with Canadian and Health Promotion 5/1/07 11:18 AM Page 194

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Atlantic research groups that foster research Control Research Initiative (CTCRI), the and academic links with universities and Prince Edward Island Health Research health units in New Brunswick, Nova Scotia, Program (PEI-HRP), Health Canada, the Newfoundland, Ontario, and Alberta. Department of Canadian Heritage, and the Funding for this program of research has been Department of Community and Cultural awarded by the Canadian Institutes for Health Affairs of Prince Edward Island. More infor- Research (CIHR), the Canadian Tobacco mation may be found at www.upei.ca/cshr.

NEWFOUNDLAND AND Prevention Coalition will conduct a review of LABRADOR: GOVERNMENT injury prevention data, initiatives, and stake- POLICY AND ACTION holders to support a province-wide approach Eleanor Swanson to injury prevention. Wellness initiatives include a “healthy students, healthy schools” In 2005, the government of Newfoundland program and community-based healthy living and Labrador launched a Provincial Wellness programs. A wellness grants program, and a Plan with a $2.4 million commitment, the food and nutrition action plan are being devel- largest single cash infusion in health promo- oped. A social marketing strategy is being tion in the history of the province. The focus designed to complement the Wellness Plan, in the first three years is on healthy eating, and new staff positions to increase capacity for physical activity, tobacco control, and injury health promotion are being created in each of prevention. A second phase will consider other the regional health authorities. Indicators of issues such as mental health promotion and effectiveness will be established to evaluate environmental health. One aim of the plan is progress (Newfoundland and Labrador to strengthen partnerships and collaboration Department of Health and Community such as those developed around tobacco Services, 2006). See http://gohealthy.ca/en. control. For example, a Provincial Injury

REFERENCE Newfoundland and Labrador Department of Health and Community Services. (2006). Achieving health and wellness: Provincial wellness plan for Newfoundland and Labrador. Retrieved April 2006 from www.health.gov.nl.ca/health/publications/2006/wellness-document.pdf.

RESEARCH: COASTAL AND Community Alliance for Health Research WORKPLACE HEALTH (CAHR) project funded by the Canadian Shirley Solberg Institutes for Health Research, and, Coasts under Stress, a project funded jointly by the New approaches to research in the form of Social Sciences and Humanities Research working with communities and specific Council of Canada and the National Science groups are changing the ways health pro- and Engineering Research Council under motion research is being done in the province the Major Collaborative Research Initiative. of Newfoundland and Labrador. Two exam- In the many research projects being carried ples of this type of research are SafetyNet, a out by teams of SafetyNet researchers and Health Promotion 5/1/07 11:18 AM Page 195

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community partners, the teams are looking coastal communities has affected human and for ways to promote health and safety in environmental health and how changes at the marine and coastal occupations. Findings policy level may promote the health of indi- from the research on shellfish asthma and vidual, families, and communities. In work-related musculoskeletal disorders among Newfoundland and Labrador the restructur- crab-processing workers is being used as a ing that has taken place has had a number of basis to consult with representatives from the negative impacts on the various social deter- workers, union, industry, and government in minants of health (e.g., unemployment, out- single-industry towns to look at community- migration, and gaps in education and health based approaches to promoting the health of services), creating a great deal of stress and workers at risk for these occupational health uncertainty in communities. Community feed- problems (see www.safetynet.mun.ca/). back by researchers has helped people look at Coasts under Stress also focuses on coastal some of the issues facing their communities communities, but has a broader mandate. In (Ommer et al., forthcoming; Sinclair & this large interdisciplinary project, researchers Ommer, in press; www.coastsunderstress.ca/ are examining how fisheries restructuring in home.php).

REFERENCES Ommer, R.E., & the Coasts under Stress research project team. (forthcoming). Coasts under stress: Restructuring and social-ecological health. Montreal: McGill-Queen’s University Press. Sinclair, P.R., & Ommer, R.E. (Eds.). (in press). Power and restructuring: Canada’s coastal society and environment. St. John’s: ISER Books.

ATLANTIC-WIDE healthy food policies in schools, and health INITIATIVES: promotion for adult survivors of abuse, includ- POLICY AND ACTION ing new immigrants. A strong focus has been Fiona Chin-Yee health-related policy that affects seniors and an aging society. Community projects are The Atlantic Regional Office of the Public enhanced by development of policy docu- Health Agency of Canada, through its fund- ments that have mined the data specifically ing programs, has provided funding for com- about health and its determinants in the munity-based projects that either contribute Atlantic region. These documents focus on to the development of healthy public policy or determinants such as poverty, literacy, mar- increase community capacity for influencing ginalization, and social exclusion. The work policy. Since 2001, the agency has funded over of the Public Health Agency of Canada, 75 community-based organizations in the Atlantic Regional Office has been important region that have been working to address in assisting community organizations within health promotion through a policy lens. the four Atlantic provinces to develop sophis- Project themes have included increasing tication and understanding of the importance awareness of the importance of early child of healthy public policy. More information is development, food security, youth sexual available at www.phacaspc.gc.ca/canada/ health, youth engagement in social policy, regions/atlantic/about/index.html. Health Promotion 5/1/07 11:18 AM Page 196

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RESEARCH: The success that AHPRC has achieved ATLANTIC HEALTH is due, in part, to strategic collaborations with PROMOTION RESEARCH researchers and diverse stakeholders from CENTRE AND ITS ATLANTIC across the region and beyond. AHPRC is also NETWORKS FOR a partner on the Nova Scotia Health PREVENTION RESEARCH Promotion Clearinghouse, a valuable resource Sandra Crowell for linking people and organizations involved in health promotion to resources and expert- The Atlantic Health Promotion Research ise. For more information about AHPRC and Centre (AHPRC) is a vibrant research facil- its research, visit www.ahprc.dal.ca. ity now in its 13th year of operation. The mission is to conduct health promotion research with a special emphasis on the health and FINAL THOUGHTS well-being of Atlantic Canadians. Over the The examples given above demonstrate that years, AHPRC has conducted large, collab- the Atlantic provinces have shown exciting orative health research projects on a wide progress in both policy and research in health range of topics, including seniors’ mental promotion. The work on children’s health, health, indoor air quality in schools, tobacco occupational health, rural health, and com- cessation, community resilience, and helping munity capacity building is groundbreaking. rural communities to use research to influ- Researchers and government health promo- ence policies that affect their health and sus- tion/policy staff have been Canadian and tainability. AHPRC’s current research international leaders in many aspects of health themes include: modification of health sys- promotion. Social and economic conditions tems to prevent stroke and improve health in this region provide a useful lab for other services, food security, oral health of seniors, countries because our circumstances mirror and healthy mid-life aging. AHPRC’s largest many resource-challenged regions that need initiative, the Atlantic Networks for models of policy and research development Prevention Research (www.anpr.dal.ca) in a less-than-favourable financial climate. focuses on environmental diagnostics and The good news is that the governments health—methods to assess settings that within the Atlantic provinces are beginning impact health. Funded by the Canadian to make investments in illness and injury pre- Institutes of Health Research, ANPR focuses vention and public health through depart- on research development in Atlantic Canada mental restructuring and new funding. In by pooling resources and supporting research addition, all of the Atlantic provinces have networks on healthy schools (University of increased their budgets for health research Prince Edward Isalnd), communities funding over the past five years, including (Dalhousie), and workplaces (Memorial modest to substantial support for health pro- University of Newfoundland). University of motion research. New Brunswick’s Canadian Research There is still considerable dependence on Institute for Social Policy (described above) federal government initiatives for programs is engaged in data development on commu- and research. The most substantial gains in nities, schools, and health. Each of the four research have resulted from new opportuni- research sites also fosters student training and ties provided by the Canadian Institutes for knowledge translation. Health Research. Nevertheless, provincial Health Promotion 5/1/07 11:18 AM Page 197

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grants have been extremely helpful in launch- Despite the constraints given above, and ing new projects and contributing to retain- the considerable effort that it takes to move ing research investigators in the region. Over innovation forward in a low-resource region the past decade, Health Canada (Health such as Atlantic Canada, major accomplish- Canada, 2002) has supported programs and ments have been made in both health pro- research in health promotion and has played motion research and action. Each province a prominent role in the region in funding has made useful strides forward given the population health projects, as well as facili- limited resources available to health promo- tating Atlantic collaboration. tion. Many of the major policy advances have Unfortunately, no funding opportuni- occurred within the past few years, and we ties provide sustained support for Atlantic- will have to test outcomes as these activities wide health promotion research and/or are implemented. Atlantic Canada is blessed action, and very few truly substantive inter- with skilled, highly motivated, committed, ventions match the current and anticipated and resourceful people in leadership positions magnitude of preventable health problems within government, university, and the pri- in the region. As indicated earlier, a persist- vate and voluntary sectors. These leaders ent problem for the region is insufficient and make things happen despite the constraints. short-term funding for health promotion. We also have our gatekeepers, people in Health promotion in Atlantic Canada is still influential positions who resist collaboration, highly dependent on initiatives funded by evidence, and change. This situation is very federal tax dollars. Approaches to health pro- characteristic of locales with limited or no motion and illness prevention can take many resources for innovation and change. In low- forms, each possessing good merit in terms resource health systems where there is little of best practice and evidence of effectiveness, money to stimulate innovation, there are but these initiatives require sustained invest- always worries about resource loss with the ments over time to yield major results. They prospect of change and considerable “unpro- need to be accompanied by solid measures of ductive” competition for scarce resources effectiveness. The constant changes in ini- (Alvaro, Lyons, & Warner, forthcoming). tiatives, human resources, approaches, and So what is the answer to the question: Is terminology (e.g., healthy living, active living, Atlantic Canada a “have” or “have-not” wellness, population health, vitality, healthy region for health promotion? At present we eating, and chronic disease prevention) at the do not have a full set of indicators to provide federal level have been particularly unpro- a clear answer to this important question. ductive and difficult for this region. If one were to conduct a systematic The possibilities for pooling resources analysis of progress in health promotion over across the region are considerably underde- the last decade within a geographic region veloped. There are still few mechanisms to such as Atlantic Canada, what indicators launch and sustain Atlantic-wide collabora- would be used? Indicators might include the tion. Atlantic Canada needs a consistent and abundance and impact of health promotion focused approach to health with investments activities, financial and human resource over time, with help from the federal gov- investments by governments, NGOs, and the ernment, to become a “have” province for private sector; a comparative status of pro- health promotion, and to build a social cul- grams, services, and policy (Atlantic as com- ture that supports health. pared to other parts of Canada); and progress Health Promotion 5/1/07 11:18 AM Page 198

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in research and research uptake. We might ally, advancements to “have” status in also examine innovations and learnings that Atlantic Canada will continue to elude us were of value to the rest of Canada and other (Evans, Barer, & Marmor, 1994). What would countries in such areas as the design and test- it take to address the disparities that con- ing of interventions, tools and methods devel- tribute to the illness burden in the region? opment, and health promotion training. These What type of commitment is required in this analyses would yield valuable insights into country to address the basic social, economic, understanding and addressing the current and cultural conditions that would make us status of health promotion in Atlantic Canada. a healthier nation, particularly for the groups At this point, we can only speculate via and regions with the poorest health status? examples. Atlantic Canada has many “Consider how the system and the health of strengths, but also huge challenges in terms our people could be if we actually practised of improving population health status and what works” (D. Murnghan, personal com- mobilizing the appropriate intervention munication). A national unity of purpose for “strength” to make a difference. Unless we improved health and social conditions in address many of the root causes of prevent- Canada is imperative. able illness both within our region and glob-

REFERENCES Alvaro, C., Lyons, R., & Warner, G. (forthcoming). Conceptualizing resource-related receptor capacity. Halifax: Atlantic Health Promotion Research Centre, Dalhousie University. Evans, R.G., Barer, M.L., & Marmor, T.R. (Eds.). (1994). Why are some people healthy and others not? The determinants of health of populations. New York: Aldine De Gruyter. Health Canada. (2002). Promoting health in Canada: An overview of recent developments & initiatives. Retrieved May 2006 from www.phac-aspc.gc.ca/ph-sp/phdd/promoting.html.

RELEVANT WEB SITES Atlantic Health Promotion Research Centre www.ahprc.dal.ca/welcome/default.asp The Atlantic Health Promotion Research Centre conducts and facilitates health promotion research that informs policies and practices and contributes to the health and well-being of Atlantic Canadians.

Go Healthy Newfoundland Labrador http://gohealthy.ca/en/about The government of Newfoundland and Labrador has been working to achieve health and wellness for this province for several years and has established a Wellness Plan for this province. The plan and its messages focus on empowering individuals, groups, and communities to take action for health and wellness. Health Promotion 5/1/07 11:18 AM Page 199

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Nova Scotia Health Promotion www.gov.ns.ca/ohp The Department of Health Promotion and Protection was established in February 2006. The new department brings together Nova Scotia Health Promotion, the Public Health branch of the Department of Health, and the Office of the Chief Medical Officer of Health.

Prince Edward Island Healthy Living Strategy www.gov.pe.ca/infopei/index.php3?number=1001897 The Healthy Living Strategy encourages and supports residents of Prince Edward Island as they improve their quality of life by reducing risk factors that contribute to chronic disease. The strategy provides support to partners as they develop and implement initiatives in the areas of reducing tobacco consumption, improving eating habits, and increasing activity levels within their communities.

Public Health Agency of Canada Atlantic Regional Office www.phac-aspc.gc.ca/canada/regions/atlantic/ PHAC Atlantic undertakes a broad range of activities to improve conditions for everyone in Atlantic Canada, as well as for specific population groups at risk. The mission of the Public Health Agency of Canada is to enable Canadians to take action on their health and the factors that influence it.

HEALTH PROMOTION IN Background NUNAVUT: With a median age of 22.1 years, Nunavut’s INSPIRED BY DESIGN population is the youngest in Canada. It is Carol Gregson, Nancy Campbell, Wayne also one of the fastest growing; with a popu- Govereau,Ainiak Korgak,Amy Caughey, Kelly lation of 30,245 as of January 2006 (Statistics Loubert, and Winnie Banfield Canada, 2006), it has grown by more than 8 percent since 1999. Inuit comprise about 85 Introduction percent of the population. Government, busi- The history of health promotion by the gov- ness, and schooling are shaped by Inuit ernment of Nunavut is short, since the terri- Qaujimajatuqangit, the traditional knowl- tory was established only in 1999. Prior to edge, values, and wisdom that are the foun- that, the policies, programs, and laws of the dation of day-to-day life here. government of the Northwest Territories Nunavut’s Legislative Assembly has 19 prevailed. Nunavut (the Inuktitut word for members (MLAs), including a premier and “our land”) was created as a result of the a seven-member Cabinet. It uses a unique Nunavut Land Claims Agreement. For mil- consensus approach to decision making: lennia a major Inuit homeland, Nunavut There are no political parties; MLAs do not today is a growing society that blends the have a party affiliation. The MLAs select the strength of its deep Inuit roots and traditions premier and the Cabinet members, and the with a new spirit of diversity. premier assigns the Cabinet portfolios. Since Health Promotion 5/1/07 11:18 AM Page 200

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1999, the government of Nunavut has 12-member Population Health Division is worked steadily on changes needed to truly the leader for developing and coordinating reflect the values, culture, and priorities of health promotion functions. Health promo- Nunavummiut. The Legislature has set the tion initiatives include improving access to mandate for the government through a doc- nutritious foods, prenatal and child devel- ument called Pinasuaqtavut (Inuktitut for opment programs, and strategies to address “That what we set out to do”).1 The two pri- communicable diseases such as tuberculosis orities and four major goals are supported by and sexually transmitted diseases. Health a framework of guiding principles, a vision Canada funding supports national programs for 2020, and a set of objectives for the gov- such as the Aboriginal Diabetes Initiative, ernment of the day. Canada Prenatal Nutrition Program (CPNP), Fetal Alcohol Spectrum Disorder, and Tobacco Reduction. Health Promotion Infrastructure Nunavut’s community health centres Nunavut covers one-fifth of the land mass of each have one or more community health rep- Canada, in 25 communities accessible only resentatives (CHR) who carry out health pro- by air. To fairly distribute services and jobs, motion activities under direct supervision of the government of Nunavut decentralized the centre’s supervisor. CHRs usually are its operations. This presents benefits as well fluent in Inuktitut or Inuinnaqtun as well as as risks to the delivery of health promotion. English, and are an important link between There are three regions: Qikiqtaaluk their community and the health care system. (Baffin) in the east, the Kivalliq (Keewatin) There are also health promotion officers in on the west side of Hudson’s Bay, and the two of the regional headquarters, a territorial Kitikmeot in the west, spanning the top of CHR coordinator, and two regional nutri- Canada from Alberta to Quebec. Inuktitut tionists. There are public health centres in the and Inuinnaqtun dialects vary significantly three regional centres. The department is cur- by region and somewhat by community. rently working on a public health strategy and French is also spoken by a significant pro- plans to develop a health promotion strategy. portion of the Iqaluit community. Over the long term, the Department of Health & Social Services (H&SS), under Examples of Programs and Activities Pinasuaqtavut, is to achieve health and social The 2004 Nunavut Report on Health Indicators conditions that meet or beat the Canadian shows that an effort to improve nutrition, average; create caring communities that increase physical activity, and maintain respond to the needs of individuals and fam- healthy weights must be a priority ilies; keep members of the community well (Department of Health and Social Services, informed, and respect the accumulated 2004). Activities and resources for youth have wisdom of the elders with decision making been developed to support the existing school combining the best of modern and traditional health curriculum. A popular Drop the Pop methods. Health promotion functions are campaign began in 2003 and has received based in the main headquarters in Iqaluit national recognition. (formerly known as Frobisher Bay), but Unlike southern Canada, Nunavut con- offered out of every community health centre. tinues to have the highest rates of smoking in (Each community has a health centre.) The Canada (48 percent c.f. 9 percent for daily Health Promotion 5/1/07 11:18 AM Page 201

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smokers aged 12–19) and higher rates of lung through special events. Print media is very cancer. Efforts to secure more funding to expensive and not effective at reaching the develop innovative programs to further engage bulk of the population. Posters, give-aways, youth not to start smoking, to enforce tobacco and television public service announcements control legislation (especially sales to minors), are the most effective communications tools. and the development of effective cessation programs is critical. In 2003, the Minister’s Youth Action Team on Tobacco (MYATT) was Health Protection and Primary Care formed to encourage youth leadership in The government of Nunavut’s focus is now reducing smoking rates among the youth. shifting so that H&SS devotes more energy and resources to protecting health rather than restoring it. The territory’s partnerships with Capacity Building the federal government and other agencies To help enhance health promotion activities have enabled H&SS to support community- by staff or by interested individuals, H&SS based health promotion efforts, but the gov- holds workshops and training sessions to build ernment must and will do more. The on existing skills and knowledge, and to territory’s strong primary health care system, develop confidence in presentation and facil- along with the schools and community health itation skills. Funding for most of these pro- committees, will have more health promotion grams come from Health Canada, the First activities to offer in the years to come. For Nations & Inuit Health Branch (FNIHB), 2006–2007, a new emphasis will be placed on with support from the Northern Secretariat tuberculosis and sexually transmitted illnesses office in Ottawa and the Public Health awareness, along with pandemic influenza- Agency of Canada. Health promotion staff linked projects on communicable diseases in also link with other territorial organizations general. such as the Qulliit Nunavut Status of Women In sum, health promotion has been a Council and the Embrace Life Council (sui- core element of health and social services in cide prevention). Nunavut since its creation in 1999. While Health promotion activities are deliv- many of the challenges facing communities ered in different ways, depending on the in the South are shared by those in the North, audience: one-on-one in health centres; the communities of Nunavut have their own through school presentations; on community unique challenges, but also their own unique radio, in Inuktitut; through interviews with resources for addressing the health concerns the CHR and/or pre-packaged shows; and facing its communities.

NOTE 1 The full text of Pinasuaqtavut is available online at www.gov.nu.ca/Nunavut/pinasuaqtavut/.

REFERENCES Department of Health and Social Services. (2004). Nunavut report on comparable health indicators. Retrieved July 22, 2006, from www.gov.nu.ca/hsssite/PIRCenglishlow.pdf. Statistics Canada. (2006). The daily: Canada’s population. Retrieved July 22, 2006, from www.statcan.ca/ Daily/English/060629/d060629d.htm. Health Promotion 5/1/07 11:18 AM Page 202

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RELEVANT WEB SITES Government of Nunavut www.gov.nu.ca This site provides an overview of the government of Nunavut’s programs and services in four languages, including English and French.

Health and Social Services Department of Nunavut www.gov.nu.ca/hsssite/hssmain.shtml This site describes the programs and services of the Health and Social Services Department of Nunavut; includes resources and publications.

THE SITUATION OF In 1999, the Understanding on Social Union, HEALTH PROMOTION established between the federal and the IN THE FRANCOPHONE provincial and territorial governments, MINORITY COMMUNITIES defined a new partnership among these IN CANADA groups to better Canadian social policy focus- Nathalie Boivin ing on social programs and health care. Along with that understanding came funds ($2.3 bil- Introduction lion for health priorities; $800 million being Health promotion, as defined by the World directed to the Fonds pour l’Adaptation des Health Organization (WHO), is the process Soins de Santé Primaires-FASSP) to improve of enabling people to increase control over, health care and access to health care for the and to improve, their health (World Health two official linguistic minority groups. At the Organization, 1999). For the Acadian and the end of the year 2000, at the request of the francophone minority communities in Fédération des communautés francophones Canada, this means improving access to et acadiennes (FCFA), the federal Health health care services in French. This section minister created a consultative committee to reviews some of the key developments taking advise him on the best ways for his depart- place over the last 20 years toward the goal of ment to implement Article 41 of the Official improving health for the Acadian and fran- Languages Act and better answer the needs of cophone minority communities in Canada. francophone communities living in a minority situation, the situation of the anglophone minority in francophone Quebec being tra- The Minority Situations of ditionally much less of an issue due to histor- Francophones and Anglophones ically less unfavourable conditions for that in Canada group than for the francophone minorities. In 1988, the addition of Article 41 to the law By then, it was clear that people’s access to on official languages stipulated that the fed- health care in the language of their choice had eral government should support the devel- a determining impact on their health and opment and the growth of minority linguistic their autonomy over their own health; lan- groups in Canada. Since then, the federal gov- guage barriers reducing access to preventive ernment, through its departments and agen- health care; satisfaction for the service pro- cies, has worked at implementing Article 41. vided; and treatment compliance. Linguistic Health Promotion 5/1/07 11:18 AM Page 203

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barriers are also known to increase consulta- holders, the health training institutions, and tion time, the number of diagnostic tests done, the community. It is in this context that the and the probability of making a mistake. Not Société Santé en Français was created in being able to speak the language of their December 2002 to act as a national network. choice also influences the quality of the services provided to the clients. In Canada, research established that 55 Mobilizing Communities through percent of the francophone communities out- Société Santé en Français side of Quebec had no or limited access to Buy-in from the community was seen as a health care in their own language. In Canada, crucial component since the community can in the fall of 2000, it was estimated that access best identify its own priorities and define the to health services was three to seven times best strategies to meet these priorities. Since easier for anglophone than for the fran- the consultative committee felt that the net- cophone minorities (Fédération des com- working and health services organization pri- munautés francophones et acadiennes, 2001). orities were to be best achieved by the new The research also presented information on group formed in December 2002, the Société the availability of services in French for dif- Santé en Français was mandated to do so. ferent types of services (such as first-line serv- This organization is made up of 17 regional, ices, psychosocial evaluation, and care) for provincial, or territorial networks. Each net- which language is crucial ( Fédération des work brings interested partners together to communautés francophones et acadiennes, improve access to health services provided in 2001). In January 2001, the Throne speech the language of their choice for all fran- spoke to two of the objectives of the consul- cophone minority Canadian communities. tative committee: the first one being a com- The vision of Société Santé en Français is to mitment to create an inclusive society have francophone and Acadian communities whereby every family would grow in a safe evolve in an environment where they can be and strong community, and the second one innovative and demonstrate initiative within being that linguistic duality was the essence a health system that respects their cultural, of the Canadian identity. The consultative social, and linguistic values. It believes that committee produced its report in September the close work of all five partners—health 2001, recommending a strategy to improve professionals, health managers, government, access to health care delivery in their lan- training institute, and community—is essen- guage for all francophones in Canada tial in this endeavour. (Health Canada, 2001, p. 4–5). In July 2003, the first round of funding In order to maximize the impact of the was announced by the Société through the proposed strategy, implementation had to be Fonds pour l’Adaptation des Soins de Santé done in a coherent and integrated way. Three Primaires (FASSP) of Health Canada. The intervention axes were prioritized: net- project promoters selected had to conduct a working, service organization, and training. project aiming at improving access to primary In 2002, a networking initiative was launched health care for the francophone minority to support the creation of Santé en Français communities. As of November 2005, 70 proj- provincial, territorial networks whose role is ects were funded. One of these projects, to bring together five partners: health pro- Préparer le Terrain, aims to help provincial fessionals, health managers, political stake- and territorial decision makers elaborate plans Health Promotion 5/1/07 11:18 AM Page 204

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for the provision and delivery of quality pri- well-being. The CNFS and Société Santé en mary health care services to answer the needs Français joined their strengths to conduct of their francophone populations by identi- consultative commissions on two strategic fying existing resources and gaps in services issues—research and information systems, and suggesting priorities for improvements. and human resources.

Training Francophone Professionals Conclusion The training component is to be conducted The Société Santé en Français and the by a new Consortium called the Consortium Consortium National de Formation en Santé National de Formation en Santé (CNFS). constitute two important structures dedicated The CNFS is made up of a group of 10 uni- to helping the Acadian and francophone versity- or college-level institutions offering minority communities improve control over training in French to future health profes- their own health through access to quality sionals. The objective of the CNFS is to health services in the languages of their increase the number of health professionals choice. Hopefully, they will help to redress and researchers capable of providing their the situation of less favourable health expe- services in French to the Canadian commu- rienced by francophone minorities of Canada nities, thus contributing to their health and over the last decades and centuries.

REFERENCES Fédération des communautés francophones et acadiennes (FCFA). (2001). Pour un meilleur accès à des services de santé en français. Ottawa: Author. Health Canada. (2001). Rapport au Ministre Fédéral de la Santé. Réalisé par le Bureau d’appui aux commu- nautés de langue officielle pour le compte du Comité consultatif des communautés francophones en situation minoritaire (2nd ed.). Ottawa: Ministre des Travaux Publics et des Services gouvernementaux. World Health Organization (WHO). (1999). Glossaire de la promotion de la santé. Division de la Promotion, de l’éducation et de la communication pour la santé. Service éducation sanitaire et promotion de la santé.

RELEVANT WEB SITES Fédération des communautés francophones et acadienne du Canada www.fcfa.ca/home/index.cfm Le Consortium national de formation en santé www.cnfs.ca La francophonie canadienne www.franco.ca La Société Santé et Mieux-être en français du Nouveau-Brunswick www.ssmefnb.ca Santé en français www.forumsante.ca Health Promotion 5/1/07 11:18 AM Page 205

PART IV

INTERNATIONAL PERSPECTIVES

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n the first edition, we asked people to reflect on the importance of Canada in the practice I of health promotion in three areas: the United States (Lawrence Green); Europe, especially the UK (David McQueen); and New Zealand (John Raeburn). This led to quite interesting views and confirmed the international leadership role played in these areas by Canada. However, we were criticized for having chosen a sample representing almost exclusively the English-speaking world; we were also conscious that globalization was a phenomenon that had progressed a lot in the last decade or so and should now be addressed. This section is thus much more important than in the first edition. In Chapter 12, Labonté presents a broad portrait of globalization, its mechanisms, its relationships to health, and examines whether health promoters in Canada or elsewhere can have any effect on it or its consequences. In Chapter 13, Jackson, Ridde, Valentini, and Gierman illustrate how several Canadian academic, governmental, and non-governmental organizations have been active internationally in bilateral or multilateral health promotion projects over the last decade. Providing several examples from their own practice, they discuss some of the issues raised when Canadian health promotion expertise is extended into international settings and contexts in various ways. 205 Health Promotion 5/1/07 11:18 AM Page 206

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In Chapter 14, colleagues from international non-governmental or governmental agencies address the question of Canada’s influence on the global infrastructure for health promotion, including its organizational base, its evidence base, and its conceptualization. Mittlemark, Lamarre, Cerqueira, and Corbin sketch how Canada has contributed to what they describe as an extensive and flourishing health promotion enterprise. Finally, Chapter 15 provides a fascinating portrait of Canada’s influence on health promotion in many counties. To develop this chapter, we asked people from 23 countries, representing all continents and a wide variety of linguistic, cultural, and economic situations, to provide us with a short (500 words) commentary. In their commentary, we asked them to reflect on the status of health promotion in their country over the last 12 years (if such a thing as health promotion exists there at all ) and to assess if Canadian health promotion had any influence in its development. This leads to an interesting collection of stories, from which Dupéré, the editor of the book who coordinated the process, derives some general analytical comments. At the end of this section, the reader should be able to position Canadian health promotion on the global and international scenes, to have a sense of what health promotion means throughout the world, and to see if Canada still has a role in the global arena. Health Promotion 5/1/07 11:18 AM Page 207

CHAPTER 12 PROMOTING HEALTH IN A GLOBALIZING WORLD: THE BIGGEST CHALLENGE OF ALL?

Ronald Labonté

INTRODUCTION wide within a matter of months (World Health uch has changed since the first edition Organization, 2004). This figure is dwarfed by Mof this book appeared in 1994. Most of the death rates from most other infectious dis- us writing about health promotion then were eases, and is a fraction of the 35,000 estimated concerned with the persisting tensions in prac- heat deaths that afflicted Europe in the summer tice: unhealthy lifestyles/living conditions; top- of 2003 (NewScientist.com, 2003). But SARS down/bottom-up programming; individual warned the sanitized and immunized in rich change/collective mobilization; professional nations that new and re-emerging infectious knowledge/community wisdom. Our locus for diseases were on a global rise and less than 24 grappling with these tensions was the com- hours air travel from almost anywhere. munity, and our major challenge was scaling Curbing the incidence of disease in other coun- up to those policy reaches that condition and tries was now as much a matter of self-interest constrain health opportunities. The limited as of international largesse. geography of our terrain was not parochial. Working to promote the health of others It was merely a product of its time. These in distant lands is nothing new. Canadians health promotion tensions and challenge still have long enjoyed a reputation for being inter- define the territory for most practitioners— nationalists in most things, including health. the important “ordinary” of our work that Our contributions run from the medical hero- needs to be celebrated, extended, and sustained ism of Norman Bethune in pre-Communist into the future. But, though necessary, health China and the (usually anonymous) volunteers promotion’s empowering localism—even with Médecins sans frontières (Doctors with- nationalism—is no longer sufficient. As the out Borders), to public health efforts to pre- 2005 Bangkok Charter for Health Promotion vent the spread of HIV/AIDS or slow down states: “Health promotion must become an the advancing double burden of chronic dis- integral part of domestic and foreign policy ease in poorer countries. This is still the main- and international relations” (World Health stay of what we might call international health Organization, 2005). What changed? promotion, well described in other chapters of this section. But a series of world events over the past three decades require us to consider a FROM THE INTERNATIONAL global health promotion, one that recognizes TO THE GLOBAL that the causes and consequences of disease are The most obvious intrusion into national health no longer confined within national boundaries. complacency was the SARS episode of 2003, A first glimpse of the inherently global which claimed the lives of 774 people world- reality of our lives came with the lunar landing 207 Health Promotion 5/1/07 11:18 AM Page 208

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of 1969 and its compelling images of a lonely rebuild what World War II had destroyed and planet adrift in a massive universe. The phys- to prevent economic crises from precipitating icality of being one world (and, by extension, a Third—subsequently morphed into “watch- one people) became more prominent, and dog[s] for developing countries, to keep them arguably more powerful, than the cosmopol- on a policy track that would help them repay itan idea. The political significance of this most of their debts and to open their markets event, which had more to do with altering con- for international investors” (Junne, 2001, p. sciousness than behaviour, was quickly eclipsed 206). Their chosen policy track of structural by another, less visible force of interconnect- adjustment embodied the neo-liberal economic edness—the global recession of the early 1970s. orthodoxy and conservative politics of the This recession was partly caused by two major wealthier countries that (still) dominate deci- oil crises (shortages combined with cartels) that sions in both institutions: liberalization, pri- saw prices increase sharply. Many developing vatization, welfare minimalism, cost recovery, countries borrowed heavily from wealthier and making the country attractive to foreign nation lenders to sustain their oil-dependent investors (Milward, 2000). This orthodoxy growth. When the lending countries adopted became global gospel with the 1989 fall of the fiscal policies that quadrupled interest rates, Berlin Wall, which created a normative developing world debt escalated to a point vacuum for countries wishing to experiment where it threatened—through default on loan with “third way” blends of state centralism and payments—to collapse the global financial market capitalism. The result was not a fair system. Financial markets had become glob- one: rich countries—the home of foreign ally entwined. investors—became hugely wealthier while The World Bank and International poorer nations became stuck in health-debili- Monetary Fund (IMF)—originally set up to tating poverty (Figure 12.1).

FIGURE 12.1: GDP/CAPITA US$, 20 RICHEST/POOREST COUNTRIES

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BOX 12.1: FROM STRUCTURAL ADJUSTMENT TO AN HIV PANDEMIC

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MAPPING THE NEW all process of globalization” (Woodward et TERRITORY: THE DRIVERS al., 2001, p. 876). Changes in our global econ- OF CONTEMPORARY omy are the source of contemporary global- GLOBALIZATION ization’s intensification, bringing with it new The concept that has come to define the polit- challenges to health and its promotion. ical transformation of the past two decades Among these changes are: is globalization. Kelley Lee, a UK scholar and one of the early thinkers on the globaliza- 1. The scale of international private financial tion–health linkage, considers it broadly as a flows resulting from capital market liberal- function of technology, culture, and eco- ization: nomics leading to a compression of time Currency transactions worth between $1.8 (everything is faster), space (geographic and $2.2 trillion occur daily (Kahn & boundaries begin to blur), and cognition Yardley, 2004). These amounts dwarf the (awareness of the world as a whole) (Lee, total foreign exchange reserves of all gov- 2003). This is undoubtedly true, although ernments, reducing their ability to inter- these have been societal qualities for as long vene in foreign exchange markets to as there have been written records of soci- stabilize their currencies when specula- eties. The qualitative shift lies in the inten- tive investors decide to shift their hold- sity of these changes. Others have argued ings, thereby precipitating a currency (convincingly) that, “economic globalization crisis. Each country experiencing such a has been the driving force behind the over- crisis has seen increased poverty and Health Promotion 5/1/07 11:18 AM Page 210

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inequality, and decreased health and social the island of every last tree (Wright, 2004). spending (O’Brien, 2002). No trees, no birds, no insects, no mammals, 2. The establishment of binding trade rules, pri- no fresh water, no food. And by the time marily through the World Trade Organization the Europeans bumped into the island, (WTO): almost no people. The tragedy is that they With the birth of the WTO in 1995, trade likely knew what would happen even as agreements became more than simply they cut the last tree. Just as we know what lowering border barriers. They began to will likely happen as we continue to fish limit the policy flexibilities of national our oceans to extinction, eliminate our governments in ways that could imperil carbon sinks and biodiversity, contaminate public health. our sources of fresh water, grow our sup- 3. The reorganization of production across posedly healthy economies with a contin- national borders: ued addiction to toxic fossil fuels, and blind Multinational enterprises (MNEs) are cen- ourselves to the consequences with an ide- tral to this third and perhaps most signif- ological enslavement to growth as the only icant trend. The emergence of global marker of progress. production or commodity chains allows MNEs to locate labour intensive operations in low-wage countries (often in GLOBALIZATION AND exclusive export-processing zones that HEALTH: DISPUTED lack health, safety, or labour rights), carry TERRITORY out research and development in coun- If our aim is improving global health—with tries with high levels of publicly funded a particular emphasis on the poorer half of education and public investment in humanity facing the greatest burden of dis- research, and declare most of their prof- ease—we must attend to how contemporary its in low-tax countries. Good for business; globalization posits its health beneficent bad for public health. effects. These distill to a few key claims and 4. The crisis of climate change: counterclaims: Climate change is undoubtedly the most • Rapid diffusion of new health technolo- urgent global health issue. The scientific gies and innovation. This refers back to consensus is that we will experience some the impressive role played by several low- form of profound climatic change over the cost interventions (such as immunization next two decades—with annual death tolls and antibiotics) in raising life expectan- of 150,000 predicted to double within a cies in many poor countries (World Bank, matter of years—even assuming we achieve 1993). The problem is that collapsing and move well beyond the Kyoto require- health systems in many poor countries ments during that time (Plumb, 2003). can no longer deliver old technologies The apocryphal tale is that of the Easter (immunization coverage globally is Islanders, whose ideological enslavement to declining, and rapidly so in Africa), much a belief in the ancients led to the erection of less new ones. And those countries that huge stone monuments, whose movement did achieve high health gains in the past required skids of timber, which, as compe- did so by also providing potable water, tition among the families for more and sanitation, women’s education, state sub- bigger monuments accelerated, denuded sidization of necessities (such as food), and Health Promotion 5/1/07 11:18 AM Page 211

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equitable taxation and income redistrib- poverty at the abject less than $1 per day ution—interventions that are now level (an imperfect measure used by the beyond the fiscal means of many of the World Bank), it did not lift them very world’s poorest nations. far. Poverty at the less than $2 per day • Gender empowerment through increased level increased by almost the same employment opportunities for women. amount over the same period (Wade, There is some evidence supporting this, 2004). In every other region of the world, although such work is frequently in poverty rates increased. Economic unhealthy export-processing zones. growth has also given rise to escalating Women’s earnings are often channelled income inequalities within most nations, back to the control of male family mem- especially those that have grown the bers, and many women’s domestic respon- fastest (Cornia & Court, 2001), while sibilities remain unchanged, creating a trade liberalization has led to the double burden of work (Durano, 2002). increased marketing and adoption of • The growth-health-growth virtuous unhealthy Western lifestyles by larger circle, which is the mainstay globaliza- numbers of people, globalizing new pan- tion-is-good-for-health argument. Its demics of tobacco-related diseases, obe- proponents hold that liberalization (the sity, and diabetes. removal of border barriers on the flow of goods and capital) increases trade, which increases growth that decreases poverty; HEALTHY GLOBAL and any decline in poverty is good for PUBLIC POLICY: people’s health (Dollar, 2001). Economic A MODEST AGENDA growth also provides revenue for invest- The recent global economic changes ments in health care, education, women’s recounted in this chapter did not just happen. empowerment programs, and so on. They required policy decisions by govern- Improved health increases economic ments around the world, decisions from growth (World Health Organization which most affected citizens were often Commission on Macroeconomics and excluded. During the 1990s, the breadth and Health, 2001) and the circle closes virtu- depth of that exclusion generated a new ously upon itself. But the counterclaims global social movement that was, if not are many. Trade and financial liberaliza- actively hostile to the present form of glob- tion does not inevitably lead to increased alization, at least profoundly skeptical about trade or economic growth (Rodriguez & the “rising tide lifting all boats” claims made Rodrik, 2000). Those countries where lib- by its cheerleaders. This movement received eralization led to growth (primarily considerable media attention as a result of Southeast Asia and China) did so by pro- protests during meetings of the WTO, the tecting their domestic industries and G8,1 the World Bank and IMF, and the financial markets while subsidizing their World Economic Forum. However, its social exports (the same way today’s wealthy justice and environmental sustainability con- nations became so), and not by following cerns have long shaped grassroots campaigns the World Bank/IMF conditions and free in low- and middle-income countries, and trade rules (Chang, 2002). While their the quality of its research and advocacy have growth did lift many people out of compelled acceptance of such campaigns’ Health Promotion 5/1/07 11:18 AM Page 212

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legitimacy and even many of their conclu- of the new millennium) have not. sions. These conclusions—the leverage points Fulfilling aid commitments is one essen- for change—focus on globalization’s key eco- tial financing plank for global health pro- nomic drivers and counterbalances. motion. But it is insufficient in itself partly because, with the recent exception of sub- Saharan Africa, developing countries actu- Fair Financing ally send to wealthy nations far more money As the new millennium dawned, the global in debt repayments than they receive in aid community of countries imperfectly consti- (see Figure 12.2). Wealthy countries began a tuted as the United Nations consolidated a list program of debt relief in 1998 for some of the of Millennium Development Goals (MDGs) world’s poorest and most indebted countries, that it thought must be, and could be, achieved which has freed up some funding for health by the year 2015 (see Box 12.2). These and education services. But the program has MDGs—all concerning health or its deter- been inadequate and, even with more gen- minants—were endorsed by all nations, with erous debt cancellation announced at the G8 the wealthiest declaring that the poorest summit in the UK in 2005, will keep most should not lack for the resources necessary to developing countries trapped in a downward attain them. The rhetoric has not been spiral of debt. It also requires countries matched by action. Official development assis- receiving debt cancellation to follow the tance (ODA or simply “aid”) is the principal structural adjustment rules laid out by the form of public wealth transfers from rich to IMF and World Bank, essentially placing poor countries. For over 20 years, most of the their economies in the hands (and interests) world’s wealthier donor nations have pledged of the lending nations (Labonté & Schrecker, to contribute at least 0.7 percent of their GDP 2006). Effective cancellation of poor coun- to ODA. Very few have. Recent promises to tries’ debts without economic strings attached increase ODA are welcome; the European (though perhaps requiring good public Union countries have pledged to reach the 0.7 accountability for how the freed-up funds are percent target by 2015; the US, Japan, and used to improve health equity within a coun- Canada (the only donor country to post con- try’s borders) becomes another key element sistent budget surpluses in the first five years of fair financing for health.

BOX 12.2:THE MILLENNIUM DEVELOPMENT GOALS

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FIGURE 12.2: HOW DEBT SERVICE OBLIGATIONS DWARF DEVELOPMENT ASSISTANCE

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Inherently global health problems, how- the latter already being implemented by ever, demand inherently global solutions. France. The technically easiest tax (on cur- Three solutions have been suggested. The first rency exchange) could raise between $45 bil- urges greater funding for global public goods lion and $150 billion annually, depending on for health, such as cures for disease, control of the amount charged. Wealthier individuals air and water pollution, new health research, or institutions paying these taxes would and curbing epidemics. Because such goods scarcely notice the extra charge, while the directly or indirectly benefit all, funding them redistributive impacts on health in poorer should be based on ability to pay. The estab- countries would be substantial. lishment of the Global Fund to Fight AIDS, The third solution calls for closure of tax- Tuberculosis, and Malaria in 2000 is one exam- haven countries. Many of these tax havens ple of such a good. As with aid, however, sup- operate under UK or US protectorate status, port to the fund by those countries with the and increasingly are being used by MNEs and ability to pay has never matched estimates of their highly paid executives to hold their demand for its resources. As of September wealth exempt from taxation. Between $8 tril- 2005, commitments amounted to $3.7 billion lion and $13 trillion sit in such tax havens (the against minimal requirements of $7.1 billion low estimate comes from the IMF; the high (Global Fund, online statistics, 2005). estimate from the international Tax Justice The second solution—a more radical Network). Using the low estimate and assum- one—urges new forms of global taxation to ing a 5 percent return, taxed at 40 percent, fund health and human development on a this would raise $160 billion a year (UNRISD, global scale. Such taxes include small levies 2000)—about the estimated amount required on currency exchange, arms trade, carbon in extra financing for developing countries to emissions, and international travel/jet fuel, reach the MDG targets. Health Promotion 5/1/07 11:18 AM Page 214

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Fair Trade Fair Governance Economics, while dominating global policy This imbalance demands new forms of global in a particularly selfish form during “the governance. Global governance does not greediest decade in history,” as Nobel Prize imply global government. The difficulties of winner and former World Bank chief econ- even modest reform at the United Nations omist Joseph Stiglitz subtitled his recent book and the increasing unilateralism of the United The Roaring Nineties (Stiglitz, 2003), is States makes global government, for a fore- nonetheless important to global health. Trade seeable future, an impossible dream (or night- will remain a key component. At issue are the mare, depending on one’s point of view). But ecological and equity implications of the cur- global governance, a term describing the occa- rent terms of global trade. Developing coun- sional confluence of private, public, and civil try mobilizations—particularly among the society interests now shaping collective actions African nations—together with civil society at a global level, is occurring. Some of the analyses and campaigns helped to reveal the structures for this governance already exist in hypocrisy of the early generation of WTO the WTO, the World Bank, and the IMF, but agreements: the slow removal of rich world they are not yet fair or transparent. The WTO subsidies to economic sectors where develop- is nominally the most democratic (one coun- ing countries might have an advantage (such try, one vote) and is becoming more trans- as agriculture); the introduction of protec- parent, although in practice the sheer tionism (in the form of the TRIPS agree- economic weight of the wealthier nations still ment), which runs counter to the notion of predominates. The World Bank and IMF are free trade; the preponderance of rich world notorious for the secrecy of their decision delegates that dominate WTO negotiations making and their undemocratic governance, (given the ability of wealthier nations to afford in which the donor nations (those contribut- to do so); and enforcement rules (trade sanc- ing to the institutions’ funding) have voting tions) that poorer countries cannot afford to privileges commensurate to the amount they use, even if they win a trade dispute (a form give. A key reform plank long advocated by of cash penalty would be of much greater ben- developing countries and civil society groups efit) (Jawara & Kwa, 2003). Fair trade rules has been to shift the balance of power within require changes in all of these areas. these institutions toward developing countries. But an even greater requirement is that Other governance efforts are controver- poorer countries be extended exemptions to sial, such as the increase in “global public– trade rules until they are as comparatively private partnerships,” in which large MNEs developed as the already wealthy players. participate in policy making at the UN or its Equal rules for unequal players only produce agencies alongside member nations. The unequal results. There are some exemptions driving force behind these “3-Ps”—which to WTO agreements for developing coun- also exist and confound public policy making tries, referred to as “special and differential within national borders—is the simple need treatment.” Despite repeated promises and for more money to deliver programs, commitments to strengthen these in trade although fairer forms of taxation could also agreements, wealthier WTO member meet this need without ceding increased nations—including Canada—have not sup- influence or authority to the private sector ported actions to do so. (Deacon, 2003). The gradual incursion of peak civil society groups within these global Health Promotion 5/1/07 11:18 AM Page 215

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policy circles holds some hope for more bal- Feeding Action Coalition and its boycott anced discussions, though the risk that these of companies violating an internationally groups become another form of elites far agreed marketing code for infant formula, removed from the lives of those they claim and MSF’s Access to Essential Medicines to better is real, and not unfamiliar to health Campaign promoters well versed in the dynamics of • A new, integrating group, the People’s local community organizing. Health Movement (PHM), a growing There have been some successes in fair global coalition of health activists sup- global health governance, in which Canadians porting each other in national and inter- can take legitimate pride. One of these was national campaigns. The PHM, in its the creation of the Framework Convention on first five years, has convened two global Tobacco Control, described as the world’s first assemblies, created and lobbied several global public health treaty. The Convention declarations and charters, worked with is now in force, and requires countries to adopt the World Health Organization and its a number of measures on advertising, mar- 2005–2008 Commission on the Social keting, warning labels, and smoking restric- Determinants of Health, helped to pro- tions. The idea was instigated by Canadians duce Global Health Watch 2005–2006, an at the World Health Assembly, and strongly equity-oriented and activist-motivated supported by Canadian health activists during “alternative world health report,” and its lengthy negotiating phase. It is weaker than launched a global “right to health cam- activists wanted (the Convention, for exam- paign” in 2005 (see Box 12.3). ple, does not explicitly state that its protocols would trump trade rules)—and there are con- In sum, there is no absence of opportunity cerns over how it might be enforced (Fidler, for global health promotion activism. 2002). Whether the experience of the Convention can generalize to other global health governance issues is debatable, but it CONCLUSIONS does show that it is possible. But there are also only so many hours in a That possibility, in many ways, was cre- day, and a seemingly intractable morass of ated by and fuels the new global social global health problems. It would be nice to movements for health. I argued in 1994 that offer a simple prescription for transforming health promotion (then) was an embodiment what is toxic in contemporary globalization, of and response to the knowledge challenges allowing its healthful potential (the idealiza- of (then) progressive social movements tion of the global village) to flourish. But (Labonté, 1994). The nascent practice of there are no easy remedies, despite the abun- global health promotion is similarly a prod- dance of policy options and entry points. The uct of new civil society configurations: perennial difficulty is creating that ephemeral • The World Social Forum, the populist beast called “political will.” For better or and immensely popular alternative to worse, this “will” remains locked behind bor- the elite World Economic Forum ders. A curious irony in creating fairer forms • A multiplicity of international groups that of global governance is that it relies upon the have long campaigned on specific issues, choices of individual nation states. This irony such as Health Action International and nonetheless opens an opportunity for lobby- its anti-drug-monopoly work, the Infant ing and activism by health promoters within Health Promotion 5/1/07 11:18 AM Page 216

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BOX 12.3:THE RIGHT TO HEALTH

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their own countries, adopting actions or uti- eases. Many health promoters are skilled lizing strategies with which they are not in good “bottom-up” and more empow- unfamiliar. For instance: ering development approaches that can • We can align ourselves with the local be diffused through these global part- chapter or organizations of the larger nerships. Look for opportunities and global social movements for health and seize them. justice. Just as our advocacy has helped • We can enter the growing debates over to push local health issues into local polit- how globalization enhances or imperils ical arenas, it can help to prod global global health equity. We might do this as health issues into national ones, but not individuals, or by joining global social if we attempt it alone. movements, or by ensuring our profes- • We can build empowering health pro- sional associations take strong, evidence- motion partnerships that link poorer based positions on how globalization nations with wealthier ones. Many of should change to improve health out- these already exist, partly through the comes. Health promotion has developed funding mechanism of ODA, or some useful tools over the past years that through the new proliferation of inter- can be harnessed to issues central to con- national public–private partnerships for temporary globalization, such as apply- health, such as the Global Fund. Many ing the techniques of health impact of these new initiatives suffer the same assessment to trade or ODA policies, “top-down” problem of early health using capacity-building forms of evalua- promotion, with a focus on specific dis- tion to health projects funded through eases, treatments, or behaviour change ODA or the new global health partner- without sufficient attention to the social ships, or working with our national health and economic determinants of these dis- ministries to promote more international Health Promotion 5/1/07 11:18 AM Page 217

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BOX 12.4: CANADA’S GLOBAL HEALTH PROMOTION CONTRIBUTIONS PAST AND FUTURE

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health “laws” like the Framework is not “the end of history” in which Convention on Tobacco Control (the obe- Western economic liberalism settles in sity pandemic is a good next target). for an unmovable eternity (which, given • We need to inject this work with the ide- its environmental appetite, will not last alism that made the early days of the long, anyway). We need to rekindle an healthy cities/healthy communities pro- ethical social imaginary. grams so compelling. Visioning how we want to live is as important as analyzing As health promoters in a new millennium, why we are not yet doing so. We are not the most disturbing implication of global- living in “the best of all possible worlds.” ization may be that it forces us to confront TINA—There Is No Alternative—is the fundamental fallacy of our field: pro- simply disempowering propaganda. It moting the physical and mental health of Health Promotion 5/1/07 11:18 AM Page 218

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individuals whose well-being rests, in part, morally unacceptable and, from an inter- on economic practices that are today’s equiv- generational health vantage, indefensible. alent of logging the last Easter Island tree is What are we to say and to do about that?

NOTE 1 The group of eight leading industrialized nations: Canada, France, Germany, Italy, Japan, Russia, the US, and the UK (with special participation from the European Union). The G8 holds annual summits that formalize economic policies among themselves; by virtue of their combined economic size and dominance in multilateral organizations, these essentially become global economic policies for the rest of the world.

REFERENCES Canada Department of Finance. (2003). The Budget Plan 2003, Table A1.9. Ottawa: Department of Finance. Chang, H.J. (2002). Kicking away the ladder: Development strategy in historical perspective. London: Anthem Press. Cornia, G.A., & Court, J. (2001). Inequality, growth, and poverty in the era of liberalization and globalization. Helsinki: United Nations University World Institute for Development Economics Research (WIDER). Retrieved May 27, 2003, from www.wider.unu.edu/publications/policy-brief.htm. Deacon, B. (2003). Global social governance reform: From institutions and policies to networks, projects, and partnerships. In B. Deacon, E. Ollila, M. Koivusalo, & P. Stubbs (Eds.), Global social governance: Themes and prospects (pp. 11–35). Helsinki: Globalism and Social Policy Programme. Dollar, D. (2001). Globalization, inequality, and poverty since 1980. Washington: World Bank. Retrieved February 1, 2005, from http://econ.worldbank.org/files/2944_globalization-inequality-and- poverty.pdf. Durano, M. (2002). Foreign direct investment and its impact on gender relations: Women in development Europe (WIDE). Retrieved February 1, 2005, from www.eurosur.org/wide/Globalisation/ IS_Durano.htm. Fidler, D. (2002). Global health governance: Overview of the role of international law in protecting and promoting global public health. WHO Global Health Governance Discussion paper no. 3. Geneva: World Health Organization. Global Fund online statistics. Retrieved September 20, 2005, from www.theglobalfund.org/en. Jawara, F., & Kwa, E. (2003). Behind the scenes at the WTO: The real world of international trade negotiations. London: Zed Books. Junne, G.C.A. (2001). International organizations in a period of globalization: New (problems of) legitimacy. In J.M. Coicaud & V. Heiskanen (Eds.), The legitimacy of international organizations (pp. 189–220). Tokyo: United Nations University Press. Kahn, J., & Yardley, J. (2004, August 1). Amid China’s boom, no helping hand for young Qingming. New York Times Late Edition, p. 1. Labonté, R. (1994). Death of program, birth of metaphor: The development of health promotion in Canada. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 72–90). Toronto: W.B. Saunders. Labonté, R., & Schrecker, T. (2006). The G8 and global health: What now? What next? Canadian Journal of Public Health, 97(1), 32–34. Health Promotion 5/1/07 11:18 AM Page 219

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Labonté, R., Schrecker, T., & Sen Gupta, A. (2005). Health for some: Death, disease, and disparity in a globalizing era. Toronto: Centre for Social Justice. Lee, K. (2003). Globalization and health: An introduction. London: Palgrave Macmillan. Milward, B. (2000). What is structural adjustment? In G. Mohan, E. Brown, B. Milward, & A.B. Zack- Williams (Eds.), Structural adjustment: Theory, practice, and impacts (pp. 24–38). London & New York: Routledge. NewScientist.com. (2003). European heatwave caused 35,000 deaths. Retrieved March 16, 2006, from www.heatisonline.org/contentserver/objecthandlers/index.cfm?id=4485&method=full. O’Brien, R. (2002). Organizational politics, multilateral economic organizations, and social policy. Global Social Policy, 2, 141–162. OECD Development Assistance Committee. (2005). Development co-operation 2004 report. DAC Journal, 6(1). Plumb, C. (2003). Climate change death toll put at 150,000. December 11, 2003: Reuters. Retrieved June 16, 2005, from www.commondreams.org/headlines03/1211-13.htm. Rodriguez, F., & Rodrik, D. (2000). Trade policy and economic growth: A skeptic’s guide to the cross- national evidence. Discussion paper 2143. London: Centre for Economic Policy Research. Stiglitz, J. (2003). The roaring nineties. New York: Penguin Books. United Nations. (2005). The United Nations Millennium development goals. Retrieved June 27, 2006, from www.un.org/millenniumgoals. UNRISD. (2000). Visible hands: Taking responsibility for social development. Geneva: United Nations Research Institute for Social Development. Wade, R.H. (2004). Is globalization reducing poverty and inequality? World Development, 32(4), 567–589. Woodward, D., Drager, N., Beaglehole, R., & Lipson, D. (2001). Globalization and health: A framework for analysis and action. Bulletin of the World Health Organization, 79, 875–881. World Bank. (1993). World development report 1993: Investing in health. New York: Oxford University Press. World Health Organization. (2004). Summary of probable SARS cases with onset of illness from November 1, 2002 to July 31, 2003. Retrieved February 10, 2006, from www.who.int/csr/sars/country/ table2004_04_21/en/index.html. World Health Organization. (2005). The Bangkok Charter for health promotion. Retrieved March 16, 2006, from www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html. World Health Organization Commission on Macroeconomics and Health. (2001). Macroeconomics and health: Investing in health for economic development. Geneva: World Health Organization. Retrieved February 21, 2005, from www.cid.harvard.edu/cidcmh/CMHReport.pdf. Wright, R. (2004). A short history of progress. Toronto: House of Anansi Press.

CRITICAL THINKING QUESTIONS 1. What are some of the ways in which contemporary globalization might affect your own health? 2. Is a return to nationalism (a retreat from globalization) something that will be healthier for people? 3. Should we develop global rules for multinational enterprises—and the smaller companies from which they source their materials—to ensure healthier and fairer working conditions? Or are voluntary codes enough? 4. How can we promote the idea of global health equity? Health Promotion 5/1/07 11:18 AM Page 220

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5. Are there other steps Canadian health promoters can take to reduce global inequalities in health?

FURTHER READINGS Harris, R., & Seid, M. (Eds.). (2004). Globalization and health. Leiden & Boston: Brill Publications. Globalization has many different facets and multiple ways of influencing health. Twelve detailed chapters outline globalization’s health impacts in developed and developing nations, largely from a critical social science perspective.

Labonté, R., Schrecker, T., & Sen Gupta, A. (2005). Health for some: Death, disease, and disparity in a globalizing era. Toronto: Centre for Social Justice. This short book, a much expanded version of the authors’ contribution to the Global Health Watch 2005–2006, uses the stories of four people’s lives from around the world to unpack how contemporary globalization creates both health risks and opportunities. It concludes with a discussion of viable policy options for a healthier globalization. Online at www.socialjustice.org.

Lee, K. (2003). Globalization and health: An introduction. London: Palgrave Macmillan. As the title suggests, this short text provides an introductory overview of globalization and health. It is particularly useful for its focus on global health policy.

People’s Health Movement, Medact, Global Equity Gauge Alliance, UNISA Press, & Zed Books. (2005). Global health watch 2005–2006: An alternative world health report. London: Zed Books. The product of hundreds of health activists and organizations around the world, this book examines health in a globalizing world, with foci on health systems and vulnerable populations. An entire multi-chapter section is devoted to holding countries and multinational institutions accountable for improving global health. Online at www.ghwatch.org.

UNDP Human Development Report 2005. (2005). International cooperation at a crossroads: Aid, trade, and security in an unequal world. New York: Oxford University Press. Each year the UNDP issues its annual report, with its landmark Human Development Index. Its 2005 report became another landmark, by focusing on the major economic problems that create barriers to human (and hence health) development and what can be done about them. The report also includes up-to-date global statistics on health and its many determinants.

RELEVANT WEB SITES

Canadian Coalition on Global Health Research www.ccghr.ca Research is only one of many pathways to improving global health, but it is an important one. The Canadian Coalition was formed on the fateful day of 9/11 (quite by chance) and is committed to harnessing global health research evidence to policy action. Health Promotion 5/1/07 11:18 AM Page 221

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Canadian Society for International Health www.csih.org The CSIH is a non-governmental organization that undertakes international health promotion activities and other health development projects around the world. It also hosts an annual international health conference in the fall, one of the best ways for health promoters interested in global health to learn and network.

Global Health Watch www.ghwatch.org This site provides up-to-date information on global health campaigns, solicits inputs for future Global Health Watches, and offers useful advice and materials for global health promoting campaigners.

Globalization and Health www.globalizationandhealth.com This open access journal publishes important, peer-reviewed research and commentary.

People’s Health Movement www.phmovement.org The PHM is an activist group dedicated to the cause of “health for all” through a combination of national actions and international mobilizations. Its People’s Charter for Health is the most widely publicized, translated, and endorsed statement on international health since the Alma-Ata Declaration on Primary Health Care. Health Promotion 5/1/07 11:18 AM Page 222

CHAPTER 13 CANADA’S ROLE IN INTERNATIONAL HEALTH PROMOTION

Suzanne F. Jackson, Valéry Ridde, Helene Valentini, and Natalie Gierman

INTRODUCTION Cueto, & Fee, 2006; Scriven & Garman, 2005). anada plays a significant role at the Given the global interconnectedness of C international level in health promotion. the modern world, almost every individual In other chapters, we have already seen how and/or organization working in health pro- key documents produced by or within the motion in Canada has international ties. It country (such as the Lalonde Report and the was thus impossible for us to make an exten- Ottawa Charter) have had major impacts on sive account of all international Canadian the way the field has developed around the ventures since 1994, the period covered by this world since 1974 (Lalonde, 2002). We have book. We thus decided to select what seemed also seen that, after a period of decreased to us exemplary cases of international collab- international leadership since 1994 at the fed- oration that give a good idea of what is going eral level, there seems to be a certain revital- on and allow us to raise some of the key ization of interest for health promotion in dilemmas and issues. We searched for exam- Canada, as evidenced in part by the fact that ples keeping a few assumptions in mind. the 19th global conference on health promo- First, as most of us who have been work- tion will be in June 2007 in Vancouver. ing internationally know, Canada has a good In this chapter, we will focus more specif- international reputation. This has probably ically on what we will call international health to do with the fact that it has no international promotion activities, as compared to the colonial past, is not usually seen as having global perspective covered in the previous imperialistic ambitions, and employs two chapter. “International” refers to a relation- widely used international languages. We thus ship between nations or with others who are looked for examples of projects located in the outside the borders of one’s own country. It two linguistic universes of Canada. generally describes an approach within the Second, in the health promotion world, traditional ethnic, geographic, and political as reinforced in the rest of this book, Canada boundaries of nations (Brown, Cueto, & Fee, is perceived as promoting a more social than 2006) in a bilateral (between Canada and individual approach to the field, strongly another country) or multilateral (between grounded in a social justice, participatory, Canada and several other countries) way. In and empowerment set of principles (Potvin, contrast, “global,” as we have seen in the pre- 2003). As this reflects the position of the vious chapter, is a more holistic world view authors of this chapter, there was a tendency that is not limited by traditional national to search for projects with that type of ori- boundaries but uses an interdependent, inter- entation and consequently probably under- connected, and interrelated approach (Brown, estimates other types of international work 222 Health Promotion 5/1/07 11:18 AM Page 223

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operating with a different set of assumptions. INTERNATIONAL PROJECTS Finally, we restricted our search to our IN TRAINING AND academic research networks (Canadian CAPACITY BUILDING Consortium of Health Promotion Research One of the critical issues facing health pro- [CCHPR]) as well as certain key govern- fessionals in all countries is the availability mental and non-governmental organizations, and use of human resources. For developed which also affected our choice of projects and countries, there are specialized disciplines examples. Thus, other types of international and university and college training programs health promotion ventures led by Canadians, for health promotion workers, as well as edu- like the ones involving the private sector, are cation modules on health promotion for not represented here. other health professionals. In developing This being said, we nevertheless think countries or countries in transition, partly that the examples chosen here from the set of due to the brain drain (in Africa, see Labonté organizations described in Table 13.1 both et al., 2004), there are significantly fewer provide a good idea of the wide range of inter- health professional resources and training national activities and allow us to raise the programs. Most countries have a primary issues that we will address in the conclusion care workforce and some specialists (Labonté, of this chapter. These examples are organized 2003). Given the scope of health promotion in two broad categories: (1) training/capacity practice, which includes policy makers, com- building, and (2) knowledge development munity developers, and health professionals, and utilization in the area of evaluation. there is a need for training programs that

TABLE 13.1: MAJOR CANADIAN PLAYERS IN HEALTH PROMOTION ACTION AT THE INTERNATIONAL LEVEL

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provide the opportunity for people working Health, McMaster Research Centre for the in government, community, and primary care Promotion of Women’s Health, and the positions to learn about health promotion. Due Ministry of Health in Mozambique. The goal to Canada’s leadership role in health promo- of the project was to strengthen the capacities tion and its network of university-affiliated of education and training institutions to train health promotion education and research cen- health workers to create more egalitarian and tres, it is not surprising that Canada has been effective relationships with the communities able to make a significant contribution inter- they serve. The training style was rooted in nationally in training and capacity building. popular education, health promotion, and A central focus of Canadian work has community development theories. It included been to use a participatory style of education, critical inquiry, community participation, and train others in how to work with com- empowering, and discovery-based teaching munities and assess community needs; how to and learning methods, as well as sustainable plan, design, and evaluate health promotion institutional change approaches. Eleven programs; and how to introduce health pro- Mozambicans were trained as core facilitators motion concepts into clinical practice and pri- over 15-month periods in Canada in mary care, be it at the local or even in some 2000–2002. This training included a direct link instances at the national policy making levels. with community agencies in Saskatoon to get In the following pages, we give examples of a hands-on experience of community health Canadian training programs for different development in Canada. In Mozambique, the audiences: (a) trainers and educators in col- facilitators were part of the Centre for leges and universities; (b) community leaders, Continuing Education in Health at Massinga. administrators, and decision makers; (c) pri- The small nearby community of Tevele part- mary care and other health professionals; and nered as a pilot community for demonstrat- (d) indigenous peoples. We also (e) give two ing and implementing the teaching and examples of major integrated capacity-build- learning methods used at Massinga to train ing projects linking professional development workers. The community identified health to policy adoption and infrastructure imple- issues using a participatory action research mentation. approach. A second term of the Canadian International Development Agency (CIDA) funding is being used to integrate the Training for Educators in Universities Massinga Centre into national and provincial and Colleges health authorities and to strengthen its man- Training the trainers via direct provision of agement capacity. The main lesson of this pro- courses, session programs, etc., is one way gram was that the facilitative style of working Canadians have helped countless countries closely together led to enriched learning and abroad to develop their own capacity. Here experience on both sides of the world. are some examples. Latin America Mozambique The creation of networks and coalitions is an The Training for Health Renewal Program important health promotion strategy (De was a partnership between the Prairie Region Leeuw, 2001; Pluye, Potvin, & Pelletier, 2004) Health Promotion Research Centre at the and some of the key players in the creation of University of Saskatchewan, Saskatchewan international networks for capacity building Health Promotion 5/1/07 11:18 AM Page 225

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have been universities, as well illustrated by administration and development of health the Pan-American network described in the promotion for youth programs through a 30- Puerto Rico contribution for this book. An hour certificate program (1998–2001). The additional example was the creation in 2000 project participants commented that they of the Inter-American Network of Training liked the participatory Canadian style of on the Social Determinants of Health and the working and teaching, particularly with Management of Health Services. At the ini- youth, and participants were enthusiastic tiative of faculty at the University of Montreal, about expanding the project to other parts of and notably because of Quebec’s reputation Ukraine. The second phase of this Youth for in relation to the social determinants of health Health project (2002–2005) involved work- (Ridde, 2004), this network was set up with ing with teachers, municipal leaders, and university partners in Brazil, Peru, Costa other administrators in how to work with Rica, and Nicaragua. Built up over several youth using participatory methods. years through university-based exchanges and visits, the network developed written and France video teaching aids to introduce the topic of After a triggering event, the Forum on Social social determinants of health into university Development in April 1998 in Quebec, a set curricula. Seven modules were proposed in of exchanges were undertaken with the 2005, dealing with concepts and theories, National Federation of Family Benefit social movements, ethics, and situational Insurance Boards in France (CIF). This assessments. The REDET partners described organization was already using a social devel- the keys to success as flexible but constant ani- opment approach at the local level, helping mation, participative processes, engagement families deal with daily issues. What inter- of the participants, clear vision that a more ested the French in particular was that community-based approach to teaching Quebec linked social development and health would be more effective, and shared social at the governmental policy level, maintain- and human development values around social ing at the same time a focus on community inequalities (Valentini & Albert, 2005). The development and support at the local level lessons learned from this five-year project (Leroux & Ninacs, 2002). As a result, a three- were not to extend the size of the network too year partnership was signed between the quickly at the beginning, and that the cre- Institut national de santé publique du Québec ation of such a network takes a long time. (INSPQ) and the Centre national d’études de la sécurité sociale (France) (CNESSS), the organization responsible for training French Capacity Building for Community leaders in the field of social security; the goal Leaders, Administrators, and was to facilitate exchanges between networks Decision Makers of teachers, speakers, and lecturers in the fields of social security, public health, and Ukraine social development. The main lesson in this A CIDA-funded project led by the Canadian case is how a provincial government playing Society for International Health (CSIH) a leadership role in healthy public policy can requested the Centre for Health Promotion extend that leadership to work with policy at the University of Toronto (CHP) to help makers in another country and transfer skills enhance the Kyiv government’s capacity in and lessons learned. Health Promotion 5/1/07 11:18 AM Page 226

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Developing Health Promotion health promotion planning and evaluation Capacity in Primary Care Workers training during a two-week summer school and Other Health Professionals for 11 Croatian physicians from national and regional institutes of public health. Not only China did the Croatians develop plans on a variety The Yunan Mother and Child Project in of health promotion topics, which they then China of the Community Health Research implemented upon their return to Croatia, Unit (CHRU) in Ottawa, funded by CIDA they also adapted the course modules and and the Chinese government, used a partici- materials from the summer school to develop patory approach for teaching, monitoring, and a health promotion course of their own. At a evaluation in order to improve the quality, two-day training workshop in the fall of 2003 accessibility, and timely availability of essen- in Croatia, 70 people from various institutes tial services in ethnic minority counties in of public health were then trained and further Yunan province. The project also supported training took place at two other sites in 2004. maternal and child health staff and village This case is a classical illustration of the con- doctors in instituting and maintaining crete benefits of training the trainers where dynamic relationships and action with rural the latter build on what they have learned to women and village midwives and increased go beyond what was originally planned. the relevance and responsiveness of continuing education regarding the needs of women and children. The project trained over 4,000 Capacity Building for nurses, grassroots midwives, and physicians; Indigenous Peoples contributed to a 35 percent drop in maternal/neonatal/infant mortality rate; and the Chile counties involved in the project showed a In January 2005, the chair of the Aboriginal greater improvement in health status than the Planning Committee for the Ontario Health provincial average (Roelefs, 2005). These Promotion Summer School went to Santiago results convinced the provincial health bureau to be part of a week-long workshop on to replicate the model across all 128 counties indigenous people’s health. In exchange, four in Yunan and led the Ministry of Health to Chileans (including two Mapuche, indige- incorporate the approach into other national nous people of the Andes) came to Canada initiatives. As was the case in Ukraine, the to participate and present at the summer Chinese thought that the participatory style school in summer of 2005. The exchange of training, which was very different from between the indigenous peoples of Chile and their usual more authoritarian way, was very Canada was significant and both countries useful and adopted the approach across all of organized tours of indigenous communities Yunan. Due to the results achieved, this proj- and health centres for their visitors. Both ect is also an illustration of how education and countries looked to each other for examples support of grassroots health professionals can of ways to integrate traditional Aboriginal improve health outcomes. healing practices into community health centres and ways to ensure Aboriginal partici- Croatia pation and control over health issues and In 2003, the Centre for Health Promotion at organization of health care. The participa- the University of Toronto (CHP) conducted tory aspects of health promotion and the Health Promotion 5/1/07 11:18 AM Page 227

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focus on prevention of disease were impor- Chile tant components of these exchanges. From 1998–2001, the Centre for Health Promotion at the University of Toronto Mexico worked with the Chilean Ministry of Health Dr. Consuelo Garcia Andrade, a researcher at (Ministerio de Salud de Chile – MINSAL) to the Instituto Nacional de Psiquiatria Ramon support and strengthen (through the transfer de la Fuente Muniz in Mexico City, attended of Canadian expertise), the implementation the Ontario Health Promotion Summer of MINSAL’s National Health Promotion School in 2003 and saw the significance of Plan. Specific goals were to contribute to the using a health promotion participatory development and implementation of national approach and holistic understanding of the and regional health promotion strategies; to role of all aspects of the physical, social, and support the development and strengthening spiritual environment in working with indige- of infrastructures for health promotion; and nous communities in Mexico regarding issues to support the development of institutional of alcoholism. As a result of this connection, competencies for the implementation of people from the Aboriginal Health Services health promotion programs. The project, Unit of the Centre for Addiction and Mental funded by CIDA and PAHO, involved part- Health (CAMH) of Ontario and the nerships with government bodies, universi- University of Toronto Centre for Health ties, and NGOs in both countries. The main Promotion were invited to conduct workshops lessons learned were that Canadian teaching in mental health promotion and evaluation tools can be adapted to another country as and talk about Aboriginal health in Mexico long as the culturally affected components are City in 2004. Many of the participants in these modified, that partners need to take owner- workshops worked with indigenous peoples ship of the project in their country, and that in communities outside Mexico City and new multi-level support (national, regional, and ground was broken in using dance, drawing, local) was a key to success. and other arts to talk with people in these indigenous communities about their heritage, Brazil customs, and health. The main lesson we The “Health Promotion in Action” project retain from these two examples is the way in of the Canadian Public Health Association which more formal summer schools may lead (CPHA), funded for three years by CIDA, to a variety of other exchanges and capacity- was a partnership with the National School building activities, provided attention is of Public Health (ENSP) and the Brazilian devoted to capitalize on these formal encoun- association of graduates in collective health ters to generate other initiatives. (ABRASCO) The goal was to support the incorporation of health promotion into Brazilian public health policy and programs; Integrated Capacity-Building to enhance the academic health centre’s Initiatives capacity to develop, implement, and evalu- To conclude this section, two examples of ate health promotion strategies to the capacity building on a more ambitious level, Manguinhos community in Rio de Janeiro; involving support to policy makers, profes- and to strengthen health promotion in the sional development, and infrastructure con- graduate program of ENSP. This project solidation are presented. illustrates the value of collaboration between Health Promotion 5/1/07 11:18 AM Page 228

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NGOs and academic institutions as well as Consortium for Health Promotion Research the importance of connecting the commu- (CCHPR) sponsored a review of reviews to nity, university, and policy levels. determine whether the existing methods and criteria for synthesizing the literature did justice to health promotion requirements. The INTERNATIONAL WORK IN review identified some key points where EVALUATION THEORY, health promotion required a different RESEARCH, AND PRACTICE approach and suggested a model (Jackson et In addition to training and capacity building, al., 2001). This work drew on English-lan- one of the most significant international con- guage literature reviews from around the tributions of Canadians in the field of health world; it was of great interest to health pro- promotion has been in the area of evaluation. moters in Sweden and Germany and was at In order to improve health promotion practice the core of francophone debates on this topic in any country, it is important to have infor- in Switzerland (O’Neill, 2003) and France mation about best practices, evaluation tools (O’Neill & Arwidson, 2004). to communicate success and failures in prac- Also, in recognition of this lack of infor- tice, a policy culture that welcomes evidence- mation about effectiveness, the International based decision making, and lots of concrete Union for Health Promotion and Education evaluation projects. This section describes (IUHPE) initiated a Global Health Promotion Canadian international contributions to eval- Effectiveness Project in 2001 where each uation work in health promotion in three cat- region of the world was asked to gather infor- egories: (1) developing knowledge about health mation about best practices and effectiveness promotion effectiveness; (2) the development in health promotion based on literature writ- of evaluation tools; (3) recommendations for ten by or about people in their region (see policy makers. www.iuhpe.org). In the North American region of IUHPE, the focus of the work, co- chaired by Canadian and American scholars, Communicating Internationally Useful is on the effectiveness of community inter- Knowledge on Health Promotion ventions. Canadians, via the CCHPR, and Evaluation with some support of the Canadian govern- In 2001, the World Health Organization ment are playing a leading role in developing released a major book called Evaluation in a model for assessing the impact of commu- Health Promotion: Principles and Perspectives nity interventions (Hills, Carroll, & O’Neill, (Rootman et al., 2001), which is now consid- 2004). Progress on this project has been shared ered around the world as one of the founda- with the international community at the tional works in this domain. Of the IUHPE conferences in 2004 and 2007. seven-member editorial team, four were Canada has thus been at the forefront of Canadians as were also 12 authors of indi- international conceptual developments vidual chapters. around these issues, and the chapter by One of the significant issues in health Potvin and Goldberg illustrates how they promotion in all countries is the lack of infor- have been utilized in the Canadian context. mation about the effectiveness of health promotion programs. Building on expertise about the Canadian situation, the Canadian Health Promotion 5/1/07 11:18 AM Page 229

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Evaluation Tools nership between Quebec academics, two In order to increase the number of health Quebec NGOs, (the Centre de cooperation en promotion programs that are evaluated, work santé internationale et en development and needs to be done to develop user-friendly and Cooperative Tandem), and several francoph- culturally sensitive tools. This was identified one West African countries. The project was as a gap by the Latin American region of based on a formulation of theoretical propos- IUHPE and the Pan-American Health als about empowerment by academics (Bernier, Organization (WHO Regional Office for the Arteau, & Papin, 2005; Bossé et al, 2002; Americas) that led to a set of international ini- Ninacs, 2001), which were applied to work tiatives where Canada played a prominent with sex workers to give them the means and role. Several Canadians participated in a Pan- capacity to change their living and working American Health Organization (PAHO) conditions. The same framework and tools working group, which also included aca- were then used in a community nutrition proj- demics from the US and several countries in ect in Haiti (Ridde & Bailat, 2005). Latin America, to develop a Participatory In all of these initiatives to develop tools, Evaluation Resource Manual for health pro- the process was collaborative. This took time. moters (Pan-American Health Organization, It was challenging to adapt them to several 2003). Researchers from the University of linguistic cultures, but in all cases, the Victoria, the University of Toronto, Laval Canadian academics and NGOs demon- University, and the Institut national de santé strated their creativity in developing ways to publique du Québec played major roles in the evaluate at the community level, including development and the testing of this tool both evaluation with disenfranchised populations. in English and French. A second major initiative of PAHO to provide tools to health promoters of the Recommendations for Policy Makers Americas was in the area of economic evalu- When evaluation information is available, ation. Many decision makers involved in the it is important that decision makers and healthy municipality movement wanted to policy makers are made aware of it and know the economic effectiveness of adopting encouraged to act on evidence of effective- a health promotion approach. To address this, ness. A document called Health Promotion the Centre for Health Promotion at the Evaluation: Recommendations to Policy- University of Toronto partnered with the makers was produced by the WHO Europe University of Valle in Cali, Colombia, with Working Group on Health Promotion funding from the US Centers for Disease Evaluation in 1995–1996 (World Health Control, to develop a guide for economic eval- Organization, 1998). With less of a culture uation specifically for health promoters. of evaluation, Latin American policy Starting in 2002, the project involved health makers were seen by PAHO as an impor- economists and health promotion experts from tant target for information, but a different Canada, Colombia, Cuba, and PAHO. Again, slant was required than that of the Canada played a leading role in the develop- European approach. Using that first document of this forward-thinking document. ment, a PAHO-sponsored working group A third example of the development of developed a different version for use in internationally useful evaluation tools relates Latin America that was published in 2005 to empowerment. This initiative was a part- in English and Spanish as Healthy Health Promotion 5/1/07 11:18 AM Page 230

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Municipalities, Cities and Communities: ference in 2000, the Chile Forum in 2002, and Evaluation Recommendations for Policymakers the Bangkok conference in 2005. The in the Americas (Pan-American Health Canadian government provided case studies Organization, 2005). In these two operations, and models showing the successful imple- in Europe and then in Latin America, the mentation of health promotion programs in successive directors of the Centre of Health Canada as background documents to these Promotion at the University of Toronto conferences. At the provincial level, Quebec’s (Irving Rootman and Suzanne Jackson) National Public Health Program (Programme played a major role along with other national de santé publique – PNSP) Canadians. A third policy makers-oriented (2003–2012), (Gouvernement du Quebec, booklet synthesizing the evidence of health 2003) for instance, set out a health promotion promotion effectiveness for the European orientation that clearly guided its international Union (International Union for Health work and its significant leadership role in Promotion and Education, 1999) was also French-speaking countries. developed in 1999 with the assistance of And all this is in addition to the inter- Canadians. national support role that Canadian WHO Once again it is clear that information is Collaborating Centres in Health Promotion not immediately transferable from one cul- have played. tural context to another and work is required Other factors that have been critical to to prepare the adaptations. The European the success of Canadians in international documents were very popular in Canada and health promotion, at least if we look at the it is too soon to know how useful the Latin sample of projects presented in this chapter, American documents will be. are the presence of two official languages, a facilitation approach, cultural sensitivity, a focus on collaboration and capacity building, CONCLUSIONS and the ability to work with many partners In the period from 1994–2005, Canada con- in government, academia, communities, and tinued to develop an excellent reputation in NGOs. The active work of Quebec aca- its international health promotion ventures. demic, NGO, and government sectors has Its leadership role in training, evaluation, and enabled Canada to work in both French- and consultation around health promotion actions English-speaking countries and has the in other countries is well known. As illus- potential to lead to cross-cultural fertiliza- trated by the examples selected for this chap- tion. Unfortunately, this exchange of experi- ter, the role of Canadian governments ences is still limited within Canada because (federal, provincial, and regional) has been of the language barriers and has not yet key to providing credibility to governments reached its full potential. In the future, ways in other countries and support to WHO to increase the opportunity to exchange inter- health promotion discussions. national experiences more systematically At all recent World Health Organization need to be found. Secondly, work with many health promotion conferences, for instance, a immigrant cultures at home has also major Canadian player was the government increased Canadians’ sensitivity to, and abil- of Canada. Senior government staff headed ity to work with, many other cultures. Even the Canadian delegations that attended the then, Canadians need to maintain a sense of Jakarta conference in 1997, the Mexico con- humility in the face of the adaptations Health Promotion 5/1/07 11:18 AM Page 231

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BOX 13.1: ROLE OF WHO COLLABORATING CENTRES IN HEALTH PROMOTION IN CANADA

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required to transform Canadian experiences work that (1) is consistent with the definition into other cultural contexts, the risk of cul- of health promotion; (2) has been appreciated tural imperialism being always present. and copied by the countries Canadians work Thirdly, experience in collaboration between with; and (3) has led to reciprocal learning. academics, policy makers, and NGOs in The Canadian approach to evaluation, for Canada and abroad as well as active connec- instance, has regularly been to set the stage tions to these networks enrich many projects. for better projects by creating an evaluation- This ability to understand equity in part- positive policy culture and by creating guides nerships is a well-recognized strength of and tools for use by practitioners. In our view, Canadian health promotion work. It should it is probably this experience in building be noted, however, in line with the Bangkok healthy public policy; understanding the Charter reflections, that Canadian projects in socio-environmental determinants of health; the future would surely gain in engaging connecting the individual, the community, more with private sector partners, while and the policy levels; and understanding how maintaining the social justice and equity foci partnership and participation in decision that characterizes much of their work. making works that has been Canada’s great- Finally, and most significantly, Canadians est contribution to health promotion on the have used a facilitative approach in their international stage.

ACKNOWLEDGEMENTS The authors would like to acknowledge the assistance of Blair Johnston and Sharhyar Murshed at the Centre for Health Promotion, University of Toronto, in the preparation of this chapter. Health Promotion 5/1/07 11:18 AM Page 232

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REFERENCES Bernier, M., Arteau, M., & Papin, C. (2005). Palabres sur le pouvoir d’agir. Outil d’accompagnement sur l’empowerment. Quebec: CCSID. Bossé, Y., Gaudreau, L., Arteau, M., Deschamps, K., & Vandette, L. (2002). L’approche centrée sur le développement du pouvoir d’agir : aperçu de ses fondements et de son application. Canadian Journal of Counseling, 36(3), 180–193. Brown, T., Cueto, M., & Fee, E. (2006). The World Health Organization and the transition from international to global public health. American Journal of Public Health, 96(1), 62–73. De Leeuw, E. (2001). Investigating policy networks for health: Theory and method in a larger organizational perspective. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 185–206). Copenhagen: WHO Regional Publications. Gouvernement du Quéec. (2003). The Québec Public Health Program 2003-2012. Québec: Direction générale de la santé publique de la ministère de la santé et des services sociaux. Hills, M., Carroll, S., & O’Neill, M. (2004). Vers un modèle d’évaluation de l’efficacité des interventions communautaires en promotion de la santé: Compte-rendu de quelques développements nord-améri- cains récents. Promotion & Éducation, 11(Suppl. 1), 17–21. Hope Corbin, J. (2005). Pragmatic health promotion in a globalized world: Reflections on Bangkok from the next generation: Reviews of health promotion and education online. Retrieved February 31, 2006, from www.rhpeo.org/reviews/2005/32/index.htm. International Union for Health Promotion and Education. (1999). The evidence of health promotion effectiveness: Shaping public health in a new Europe. Part Two: Evidence book. Paris: IUHPE. Jackson, S., Edwards, R., Goodstadt, M., & Rootman, I. (1997). Review and evaluation of health promotion: Report of the International Health Promotion Indicators Project. Paper presented at the New Players for a New Era: Leadings Health Promotion into the 21st Century. Fourth International Conference on Health Promotion, Jakarta. Jackson, S., Edwards, R., Kahan, B., & Goodstadt, M. (2001). An assessment of the methods and concepts used to synthesize the evidence of effectiveness in health promotion: A review of 17 initiatives. Retrieved January 31, 2006, from www.utoronto.ca/chp/CCHPR/synthesisfinalreport.pdf. Jackson, S., Perkins, F., Khandor, E., & Cordwell, L. (2005). Integrated health promotion strategies: A contribution to tackling current and future health challenges. Presented at the Bangkok Charter for Health Promotion in a Globalized World: 6th Global conference on Health Promotion, Thailand. Labonté, R. (2003). Dying for trade: How globalization can be bad for our health. Toronto: Centre for Social Justice. Labonté, R., Schrecker, T., Sanders, D., & Meeus, W. (2004). Fatal indifference: The G8 and global health. Cape Town: University of Cape Town Press/IDRC Books. Lalonde, M. (2002). New perspectives on the health of Canadians: 28 years later. Pan-American Journal of Public Health, 12(3), 149–152. Leroux, R., & Ninacs, W.A. (2002). La santé des communautés: Perspectives pour la contribution de la santé publique au développement social et au développement des communautés. Quebec: Institut national de santé publique du Québec. Ninacs, W.A. (2001). Types et processus d’empowerment dans les initiatives de développement économique communautaire au Québec. Unpublished PhD thesis, Université Laval, Quebec. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? SPM International Journal of Public Health, 48(5), 317–326. Health Promotion 5/1/07 11:18 AM Page 233

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O’Neill, M., & Arwidson, P. (2004). L’efficacité de la promotion de la santé. Promotion & Éducation (numéro spécial), 11(Suppl. 1), 55 . Pan-American Health Organization. (2003). Participatory evaluation of healthy municipalities: A practical resource kit for action (Draft). Washington: Author. Pan-American Health Organization. (2005). Healthy municipalities, cities, and communities: Evaluation recommendations for policy makers in the Americas. Washington: Pan-American Health Organization, Area of Sustainable Development and Environmental Health, Healthy Settings Unit. Pluye, P., Potvin, L., & Pelletier, J. (2004). Community coalitions and health promotion: Is it that important to develop an inter-organisational network? Promotion and Education, 11(1), 17–23. Potvin, L. (2003). Implementing participatory intervention and research in communities: Lessons from the Kahnawake Schools Diabetes Prevention Project in Canada. Social Science & Medicine, 56(6), 1295–1305. Ridde, V. (2004). Une analyse comparative entre le Canada, le Québec et la France: L’importance des rap- ports sociaux et politiques eu égard aux déterminants et aux inégalités de la santé. Recherches Sociographiques, XLV(2), 343–364. Ridde, V., & Bailat, S. (2005). Rapport d’évaluation: Projet de lutte contre la malnutrition infantile dans le département du Sud 2003–2005. Quebec: Fondation Terre des hommes. Roelefs, S. (2005). International projects coordinator. Personal communication in October 2005, Faculty of Nursing, University of Ottawa. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (Eds.). (2001). Evaluation in health promotion: Principles and perspectives. Copenhagen: World Health Organization, Regional Publications, European Series. Scriven, A., & Garman, S. (Eds.). (2005). Promoting health: Global perspectives. London: Palgrave Macmillan. Valentini, H., & Albert, L. (2005). Institutionnaliser la coopération internationale dans le domaine de la santé: Nouveaux modes de partenariats pour une plus grande solidarité internationale. Paper presented at the Conférence luso-francophone de la santé (COLUFRAS). Montréal: USI-UdM, INSPQ. World Health Organization. (1986). The Ottawa Charter for Health Promotion: First international conference on health promotion. Ottawa: Author. World Health Organization. (1997). Jakarta Declaration on Leading Health Promotion into the 21st Century. Jakarta: The 4th International Conference on Health Promotion: New Players for New Era. World Health Organization. (1998). Health promotion evaluation: Recommendations to policy-makers: Report of the WHO European Working Group on Health Promotion Evaluation. World Health Organization, European working group. Retrieved January 31, 2006, from www.who.dk/document/ e60706.pdf. World Health Organization. (2000). Health promotion: Bridging the gap. Mexico City: 5th Global Conference on Health Promotion. World Health Organization. (2005). The Bangkok Charter for Health Promotion in a globalized world: 6th global conference on health promotion. Thailand: Author. Health Promotion 5/1/07 11:18 AM Page 234

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CRITICAL THINKING QUESTIONS 1. In what ways has Canada played a role in the development of health promotion internationally? 2. What is the difference between an “international” approach to health promotion as compared with a “global” approach? 3. What are the effects of adopting a capacity-building approach to international health promotion? What are the strengths and weaknesses of such an approach? 4. Why is evaluation a key concern within contemporary health promotion? Are there particular challenges in conducting evaluation in an international context? What is a “culture of evaluation” and why is it important? 5. What are the differences between the Ottawa Charter and the Bangkok Charter? What are the implications of these differences for how Canada might contribute to international health promotion?

FURTHER READINGS Brown, T., Cueto, M., & Fee, E. (2006). The World Health Organization and the transition from international to global public health. American Journal of Public Health, 96(1), 62–73. This article offers critical insights into the changing terminology of “global health” and “international health” as part of larger political and historical processes. Particular attention is paid to the changing role of the World Health Organization, its response to a transformed international political context, and emerging role as a leader of global health initiatives.

Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93(3), 383–388. This article outlines the developments of the concept of health promotion from 1980s policies of the World Health Organization. While the European Health for All targets and the settings approach have shifted public health strategies toward both addressing the determinants of health and empowering and supporting the participation of individuals, the focus of health policy still remains focused on expenditure rather than investment.

Labonté, R., & Togenson, R. (2003). Frameworks for analyzing the links between globalization and health. Geneva: World Health Organization. This article examines the complex relationship between globalization and health, arguing that research agendas must be expanded beyond a disease-specific focus to one that also examines the complexity of social, environmental, and economic contexts. An exhaustive review and critique of recent frameworks of globalization and health or health-determining contexts concludes that few comprehensive analytical frameworks currently exist. Key points are outlined that may be useful for the future development of analytical frameworks and how such frameworks might be used to improve research into the multiple pathways by which the process of globalization influences health.

Lalonde, M. (2002). New perspectives on the health of Canadians: 28 years later. Pan-American Journal of Public Health, 12(3), 149–152. Named one of the “Public Health Heroes of the the Americas” by the Pan-American Health Organization, Marc Lalonde traces both the local and global impacts of the concepts outlined in the Health Promotion 5/1/07 11:18 AM Page 235

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1974 Canadian government publication A new perspective on the health of Canadians and offers his insights into the future of the “health field” concept.

World Health Organization. (2005). Summary overview and background to health promotion: Globalization, health challenges, and the Bangkok Charter. Thailand: 6th Global Conference on Health Promotion in Bangkok. This short briefing paper offers an excellent outline of some of the key values, principles, and actions of health promotion since the inception of the Ottawa Charter of 1986, and outlines the challenges for health promotion in a rapidly changing world.

RELEVANT WEB SITES

Canadian Consortium for Health Promotion Research—International Projects www.utoronto.ca/chp/CCHPR/international.htm Individual members of the Canadian Consortium for Health Promotion Research work with academics, organizations and agencies, and communities and governments in many ways. This Web page tracks some of the projects underway and the individual centres that are affiliated with each project.

Canadian International Development Agency www.acdi-cida.gc.ca/index-e.htm The Canadian International Development Agency (CIDA) is Canada’s lead agency for development assistance. Funded by the federal government, it has a mandate to support sustainable development in developing countries in order to reduce poverty and to contribute to a more secure, equitable, and prosperous world. The site is bilingual.

Canadian Public Health Association www.cpha.ca/ The Canadian Public Health Association (CPHA) is a national, independent, not- for-profit, voluntary association representing public health in Canada with links to the international public health community.

Canadian Society for International Health www.csih.org/ This Web site is available in either English or French. CSIH manages projects funded bilaterally (CIDA), multilaterally (World Bank), and internationally (Pan- American Health Organization, the Department of Foreign Affairs and International Trade, and Industry Canada) in Latin America, Central and Eastern Europe, Africa, and Asia. Each of these projects contributes directly to an overall program that emphasizes capacity building for health systems reform. CSIH hosts an annual conference and tracks opportunities for internships, research, and advocacy internationally. Health Promotion 5/1/07 11:18 AM Page 236

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UN Millennium Development Goals www.un.org/millenniumgoals/ The eight Millennium Development Goals (MDGs) form a blueprint agreed to by all the world’s countries and all the world’s leading development institutions. The eight goals are: (1) eradicate extreme poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empower women; (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria, and other diseases; (7) ensure environmental sustainability; (8) develop a global partnership for development. Health Promotion 5/1/07 11:18 AM Page 237

CHAPTER 14 THE IMPACT OF CANADA ON THE GLOBAL INFRASTRUCTURE FOR HEALTH PROMOTION

Maurice B. Mittelmark,1,2 Maria Teresa Cerqueira,3 J. Hope Corbin,4 and Marie- Claude Lamarre5

INTRODUCTION to do with the flourishing of international he flourishing of any complex collabo- health promotion, not the least through its Trative enterprise requires appropriate strengthening of health promotion infra- infrastructure to nourish responsible growth structure. This chapter aims to illustrate how and quality improvement. In the case of this has happened, while accepting the hope- health promotion the key features of infra- lessness of doing full justice to Canadian structure include governmental and non-gov- influence. In other words, some Canadian fin- ernmental networks that plan and conduct gerprints are revealed, but most undoubtedly health promotion work. In the governmen- remain to be documented. tal arena, the World Health Organization (WHO) has established a network of health promotion expertise reaching every corner of INTERNATIONAL the globe, and its global conferences on health GOVERNMENTAL promotion have been sparkplugs of develop- INFRASTRUCTURE ment. On the non-governmental side, the Canada has positioned health promotion on International Union for Health Promotion political agendas as the leading public health and Education has long championed equity strategy for the improvement of the determi- in health and the pursuit of quality and effec- nants of health and quality of life. The first tiveness of health promotion work. Another international health promotion conference pro- key feature of infrastructure is the global net- duced the Ottawa Charter of 19866 and marked work of research facilities and collaborations a major milestone in public health thinking that provide the evidence on which solid and practice. Canada was a key advocate and health promotion work is founded. Equally partner in the implementation of the strategic important are the training facilities that pro- areas in the Ottawa Charter. The Canadian duce skilled practitioners and researchers to experience contributed to strengthening a replenish and expand the workforce. The broad policy focus in the promotion of health, “nerves” that keep all these elements in rela- rather than a narrow behaviour change tive synchrony are the communications facil- approach, including at the World Health ities provided by conferences, journals, and, Organization (WHO). The main contribu- more recently, the Internet. Health promo- tions of WHO at the global level have been tion today is a growing enterprise, and its twofold. The WHO’s continuation of the con- robust infrastructure has much credit for that. ference series started in Ottawa has been vital Canadian health promotion has, through its in keeping health promotion on the agendas good works at home and abroad, had much of governments. At each of the subsequent 237 Health Promotion 5/1/07 11:18 AM Page 238

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conferences (Adelaide in 1988, Sundsvall in Union for Health Promotion and Education 1991, Jakarta in 1997, Mexico in 2000, and (IUHPE), implementation of the aforemen- Bangkok in 2005), the Ottawa Charter has been tioned 51st WHA Resolution on health pro- reaffirmed as the defining document in the motion, and collaboration in the IUHPE-led health promotion arena. The Bangkok Charter Global Programme on Health Promotion for Health Promotion in a Globalized World,7 Effectiveness. which was proclaimed at the most recent However significant WHO action at the WHO conference in 2005, states among its global level has been, “WHO feet on the purposes to “…[complement and build] upon ground” in the regions have been equally crit- the values, principles and action strategies of ical to health promotion’s advancement at the health promotion established by the Ottawa country level. The experience in the (PAHO) Charter for Health Promotion and the recom- Region of WHO is of special interest, as sev- mendations of the subsequent global health eral chapters in this book testify (see Chapters promotion conferences….” 13 and 15).9 Here, just a few major highlights The other way in which WHO at the are mentioned. The Caribbean Charter (1993) global level has been influenced by Canada, adopted the Ottawa Charter and called for and has in turn used its influence to develop increased investment in promoting healthy health promotion across the globe, is via lifestyles. Of considerable significance to the debate at the World Health Assembly spread of health promotion in the Americas (WHA). The 51st WHA in 1998 explicitly was Canadian support at various stages to the acknowledged the 1986 Ottawa conference health promotion settings movement. The and Charter as sources of inspiration and Quebec Healthy Cities Network supported ideas for health promotion and many other widespread implementation of the healthy WHA resolutions have included elements municipality’s initiative, by advocating with urging the adoption of health promotion mayors for healthy public policies and local strategies. As the time of this writing, the plans of action to promote health. The WHO Executive Board has recommended University of Alberta contributed to devel- that the 59th WHA, scheduled to meet in oping the health promoting schools and uni- May 2006, adopt a resolution urging all versities initiatives, building a strong alliance member states to consider the need to increase between the health and education sectors. The investments in health promotion; establish Chilean Ministry of Health and the Centre mechanisms for involving all governments; for Health Promotion at the University of foster the engagement of civil society, moni- Toronto (CHP) with support from Pan- tor policies, programs, and infrastructure; and American Health Organization (PAHO), close the gap between evidence and practice.8 developed a project to strengthen health pro- With the legacy of Ottawa now stretch- motion capacity in Chile. The Canadian ing two decades, WHO at the global level has International Development Agency (CIDA) launched, or collaborated in, a series of con- financed the project (1999–2003), facilitating crete health promotion initiatives that would the exchange of knowledge and experiences hardly exist without the spark ignited in between Chilean and Canadian institutions, Ottawa. These include the Mega Country including the Chilean quality of life survey, Health Promotion Network, the Global adapted from the Canadian instrument. School Health Initiative, the co-sponsoring of As of this writing, Laval University and international conferences of the International the Universities of Victoria and Toronto par- Health Promotion 5/1/07 11:18 AM Page 239

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ticipate in the Working Group on Evaluation to promote global health and to contribute to convened by PAHO in 1999 to systematize, the achievement of equity in health between document, and evaluate the healthy settings and within countries of the world.10 The influ- initiatives in the region. The Division of ence of Canadian health promotion on the International Development at the University IUHPE is examined here, acknowledging that of Calgary strengthened healthy communities there is space to mention only a few highlights, in the improvement of maternal and infant and not nearly the full story. health in four countries: Bolivia, Honduras, At the turn of the 1990s, Canadian health Nicaragua, and Peru. CIDA also funded a local promoters, especially Lavada Pinder, helped development project in Manguinhos with the lead a transformation through which the school of public health (ENSP-Fio Cruz) in IUHPE took on a broader vision of health Rio de Janeiro, Brazil. In 2003–2004 a training and a broader concept of health promotion workshop was developed with the technical than before, emphasizing the importance of expertise from CHP to build and strengthen social, economic, and other environmental the capacity of several English-speaking determinants of health. It was in Canada that Caribbean countries in health promotion. the first IUHPE North American Regional This overview of Canadian contribu- Office (NARO) was established, in 1976, tions to the work of the WHO illustrates how immediately following the 9th World international governmental infrastructure Conference of the IUHPE, which took place has benefited from Canadian inspiration, in Ottawa during that year. As of this writ- assistance, and collaboration. The Canadian ing, Canadian leadership of IUHPE activi- approach has consistently been one of capac- ties in North America continues through the ity building, with respect for the experience work of the IUHPE regional office at the and expertise of health promoters in other University of Toronto. Canadian health pro- parts of the Americas. That Canadian health moters and organizations have played key promotion has operated in other parts of the roles in IUHPE advocacy work for many world solidly within the ethos of participa- years, a recent example of which is the work tion and empowerment can certainly be no of Ron Labonté.11 When the IUHPE wished surprise, but its documentation here serves to develop an advocacy position on the effects as a tribute to Canada’s long-time dedication of global trade on health, Labonté led the to develop health promotion globally in a effort, ensuring that the IUHPE played an health promoting way. active role in advocating at the World Trade Organization for an approach to globalization and trade that advances human, labour, IMPACT ON women’s, and children’s rights; increases envi- INTERNATIONAL ronmental protection and ecological sustain- NON-GOVERNMENTAL ability; and allows for democracies to INFRASTRUCTURE negotiate over how the wealth our economies Just as the WHO is the single global inter- create can be shared more equitably.12 governmental organization with the specific In fact, Canadian health promoters have mission to safeguard the public’s health, the taken significant responsibility for key International Union for Health Promotion and IUHPE work on many occasions. For exam- Education (IUHPE) is the only global non- ple, Canadians organized two IUHPE World governmental organization whose mission is Conferences on Health Promotion and Health Promotion 5/1/07 11:18 AM Page 240

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Health Education, the 9th one in Ottawa, in Besides contributions to IUHPE advo- 1976, and the 19th one during June 2007. cacy and to conferences, Canadian health IUHPE Conferences are open to all health promoters also play or have played impor- promotion and public health professionals, tant roles in these core IUHPE activities (see and aim to advance the scientific and profes- Box 14.1). sional development of the field. Considered together with WHO Global Conferences on Health Promotion, they ensure that forums IMPACT ON for health promotion dialogue are available INTERNATIONAL at regular intervals for all key partners in RESEARCH health promotion, including the governmen- COLLABORATION tal, non-governmental, and business sectors, Literally countless research collaborations and policy makers, practitioners, and involve Canadians with researchers in many researchers at all levels from international to parts of the world. The purpose here is to local. Hosting the 2007 conference provides highlight three Canadian activities that have an excellent opportunity for Canadian and all impacted international research infrastruc- other health promoters to commemorate and ture in significant ways. revisit the 1986 Ottawa Charter. Spanning the For many years, Canadian health pro- critical period of 20 years of health promo- moters have trekked regularly across the tion’s development, critical reflection on the Atlantic and participated as full partners with steps taken on the path from Ottawa in 1986 Europeans in building capacity for research to Vancouver in 2007 will undoubtedly be a and evaluation. A prime example comes from timely stimulus for creativity as we move into the WHO European Working Group on the third decade post-Ottawa. Health Promotion and Evaluation, whose

BOX 14.1: SUMMARY OF CANADIAN IMPACT ON IUHPE ACTIVITIES

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work began in 1995. A major product of the even as of this writing. Using resources and Working Group’s effort was the publication expertise from the national level, all 10 in 2001 of a work that has already attained the provinces, universities and communities, the status of being the international reference work Initiative showed that a health promotion in health promotion evaluation: Evaluation in approach to heart health could engage ordi- Health Promotion: Principles and Perspectives nary people in ways that made lasting differ- (Rootman et al., 2001). Remarkably, four of its ences in a community’s capacity to deal with editors are Canadians!13 Referred to familiarly public health issues. In the period 1994–2000, simply as “the yellow book,” this volume is the dissemination phase of the Initiative in today used in training programs and as a desk- nine provinces demonstrated that there was top reference work across the globe. Through a contribution not just to heart health, but also their long collaboration on the European to a strengthening of the public health system Working Group, Canadian colleagues brought in general (see Promotion and Education’s unique strengths and perspectives to this proj- Supplement 1, 2001, entirely devoted to this ect, helping to set a new standard for appro- Initiative). Taken in its entirety, the Initiative priateness in the planning and conduct of is a one-of-a-kind demonstration of how health promotion evaluation. policy can inform research that in turn can Related to the work just mentioned, inform practice in a way that makes a real dif- Canadian health promotion researchers have ference to public health. The publication of long been linked with one another in ways the dissemination phase of the Initiative in that have inspired tighter collaboration on a special issue of the IUHPE’s journal other continents. The unique Canadian Promotion and Education in 2001 brought this model that has had perhaps the most influ- success story to the rest of the world in an ence is the Canadian Consortium for Health inspiring manner. Promotion Research, which brings together researchers from all corners of the country in a highly participative network, in which IMPACT ON communities play critical roles alongside uni- INTERNATIONAL TEACHING versities. As Jackson has put it, one of the COLLABORATION main benefits of the Consortium is that it Students of health promotion in every corner serves as a “one-stop shopping” place for all of the globe are the future of health promo- health promoters worldwide who wish to tion, and if the growth in health promotion contact Canadian resource people regarding training programs is any indication, the not only research, but also education and future is bright. Training programs are not training (Jackson, 2003). only burgeoning; they are also connecting up A third resource for global health pro- in new ways to form international networks motion has been Canada’s long-term, sys- for training that truly produce synergy. tematic, and comprehensive approach to Canadian influence can be seen at every level, doing community-based research on public from what goes on in the classroom to how health problems that have yielded unique div- international training networks are organ- idends for Canadians and non-Canadians ized and operated. alike. Perhaps the most stellar example of this Health promotion students are strongly is the Canadian Heart Health Initiative, influenced by their teachers and by what they started in 1989 and ongoing in various forms read. An informal survey of 10 influential Health Promotion 5/1/07 11:18 AM Page 242

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health promotion texts reveals that all high- both in content and form, European health light Canadian centrality and significance to promotion educational infrastructure has the field of health promotion. For health pro- been influenced by Canadian scholarship motion students, the Ottawa Charter provides and practice. the most commonly cited definition of health Besides these important but indirect promotion (Seedhouse, 1997) and also pro- influences, Canadian health promoters are vides the framework for the delivery of health helping directly to build European health pro- promotion in a variety of settings (Bunton & motion education infrastructure. As but one Macdonald, 1992). One text uses the Ottawa example, the University of Toronto Centre Charter’s framework to explore success in for Health Promotion conducted a two-week health promotion since its inception as a way Croatian Health Promotion Summer School of concluding the book. Another text demon- for a group of 11 Croatian physicians from strates Canadian centrality by devoting an the National and Regional Institutes of Public entire chapter to criticizing the Charter Health in Toronto in 2003. Following this (Seedhouse, 1997). Yet another book sees the successful summer school, a two-day train- Charter as so indispensable that it includes ing workshop was conducted on health pro- the document in its entirety. motion for 70 people from various Institutes The building of international infrastruc- of Public Health in Croatia. Further training ture for health promotion training has been took place at other sites in 2004. one of the most important developments of the past decade. In this, too, Canadian influence is pervasive. In Europe, for example, European CONCLUSIONS Commission (EC) funding was used to estab- The recitation in this chapter summarizing lish the European Union Master’s in Health some of the ways Canada has influenced Promotion Consortium (EUMAHP) in 1998. global health promotion infrastructure has After its successful conclusion in 2004, it was been uniformly upbeat. However, there have succeeded by the EC-funded project Public been “downs” as well as “ups,” and it is Health Training in the Context of an important and instructive to examine how Enlarging Europe Project (PHETICE). Both swings in public policy in Canada have had EUMAHP and PHETICE provide the infra- negative as well as positive outcomes beyond structure for joint working among public national borders. In 1997, rumours swept the health trainers and educators across Europe, world of health promotion that ill winds of producing synergy (European added value) in change were aloft in Canada. A new health promotion training (Davies et al., 2000). approach to health in Canada was announced, A main aim has been to agree on a core cur- called population health, a strategy meant to riculum to be taught by all European health unify the entire range of health initiatives promotion training programs, and Canadian from prevention and promotion to treatment influence has been noteworthy. The founda- and care. The aims of the new approach were tion of the core curriculum is the ideology of laudable: to improve population health by the Ottawa Charter for Health Promotion and confronting the material and social inequities the methods of teaching and working with stu- that fostered health inequities. The strategy dents emphasize values that are foundational called for not only a sustainable and inte- to Canadian health promotion—participation, grated health system, but also for increased empowerment, and capacity building. Thus, national growth, heightened productivity, and Health Promotion 5/1/07 11:18 AM Page 243

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more citizen engagement in public and pri- and state bureaucracies, shrinking health vate life. All this meant more attention to so- budgets and conservative thinking had indeed called “upstream” factors, the fundamental contributed to a diminution of health pro- determinants of population health. motion compared to the heydays following While no health promoter could fault the Ottawa Charter. At the same time, they the logic of and the intention for the popu- saw evidence of a dynamic health promotion lation health approach, it seemed that with presence in the universities, in Eastern the new emphasis on upstream factors, Canada, and in several settings-based initia- Canada’s famous community-based approach tives, including the Healthy Communities to health promotion was threatened. The and Healthy Schools movements. Since the term “population health” quickly replaced publication of their paper, the tide appears to health promotion in public pronouncements have changed. Among the signs is the fact that coming from Canadian authorities. Many the Public Health Agency of Canada has observers outside Canada worried that the established health promotion as a competency people-centred spirit of Canadian health across the agency, and has established a promotion was threatened, if not by malig- Health Promotion Centre, which may replace nant forces, then by benign neglect. If health the Health Promotion Directorate of Health promotion was being abandoned in Canada, Canada that was missed since its elimination would not the ill winds spread globally, pre- in the mid-1990s. cisely because Canada—the home of health Thus, there is little doubt that the near promotion—must know best? future will see the world look to Canada again The purpose here is not to comment on for its health promotion inspiration. This is what actually happened in Canada in the inevitable, since the IUHPE 19th World period since then; there is much disagreement Conference on Health Promotion and Health on the facts because complex changes brew Education will take place in Vancouver in confusion from which many truths emerge. June 2007, with the theme “Health Promotion What we do know is that from 1997 onward, Comes of Age: Research, Policy and Practice the conversational agenda of health promot- for the 21st Century.” A particularly bright ers everywhere was suddenly taken up with spot is the fact that the Public Health Agency the question, “Is health promotion dying out of Canada and its top leadership have com- in Canada?” This came at a time when mitted to collaborate with the conference changes in public health in England also organizers, the inter-university Canadian seemed to de-emphasize health promotion as Consortium for Health Promotion Research, a public health strategy, while at the same to make the Vancouver conference a success. time health promotion policy, infrastructure, The many preparations leading to the con- and programs were beginning to flourish in ference, the conference itself, and the after- many parts of Latin America, Asia, and math will provide valuable opportunities to Africa. Confusion and concern ensued. strengthen the interplay of Canadian health O’Neill, Pederson, and Rootman’s (2000) promotion at all levels from national to local. analysis of the state of health promotion in This will be most welcome by health pro- Canada concluded that at the level of national moters everywhere. Health Promotion 5/1/07 11:18 AM Page 244

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NOTES 1 Department of Education and Health Promotion, University of Bergen, Norway. 2 Authors after the first are listed in alphabetical order. 3 Healthy Settings Unit, Area of Sustainable Development and Environmental Health, PAHO/WHO. 4 Department of Education and Health Promotion, University of Bergen, Norway. 5 International Union for Health Promotion and Education, Paris, France. 6 www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf 7 www.who.int/healthpromotion/conferences/6gchp/hpr_050829_%20BCHP.pdf 8 See www.who.int/nmh/eb117/en/index4.html for the full text of the recommendation. 9 In 1993 PAHO member states adopted Resolution DC 137.R14, a regional health promotion plan of action 1994–1998. 10 See www.iuhpe.org for details. 11 Then at the Saskatchewan Population Health and Evaluation Research Unit, Universities of Regina and Saskastchewan, Canada. 12 See www.ldb.org/iuhpe/Labonté.htm for the detailed report. 13 Irving Rootman, Michael Goodstadt, Brian Hyndman, and Louise Potvin.

REFERENCES Baum, F. (1998). The new public health: An Australian perspective. Melbourne: Oxford University Press. Bunton, R., & Macdonald, G. (1992). Health promotion: Disciplines and diversity. London: Routledge. Davies, J.K., Colmer, C., Lindstrom, B., Hospers, H., Tountas, Y., Modolo, M.A., et al. (2000). The EUMAHP project: The development of a European master’s programme in health promotion. Promotion and Education, VII(1), 15–18. Dines, A., & Cribb, A. (1993). Health promotion concepts and practice. London: Blackwell Science. Gorin, S.S., & Arnold, J. (1998). Health promotion handbook. St. Louis: Mosby. Jackson, S.F. (2003). The Canadian Consortium for Health Promotion Research: A network that adds value to governments and universities. Promotion and Education, 10(1), 16–19. Kemm, J., & Close, A. (1995). Health promotion: Theory and practice. London: Macmillan Press. Naidoo, J., & Wills, J. (1998). Practising health promotion dilemmas and challenges. London: Baillière Tindall. Naidoo, J., & Wills, J. (2000). Health promotion: Foundations for practice. Edinburgh: Harcourt Publishers. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (2001). Evaluation in health promotion: Principles and perspectives. Copenhagen: WHO Regional Office for Europe. Seedhouse, D. (1997). Health promotion, philosophy, prejudice, and practice. Chichester: John Wiley & Sons. Tones, K., & Green, J. (2004). Health promotion: Planning and strategies. London: Sage Publications Ltd. Tones, K., & Tilford, S. (2001). Health promotion: Effectiveness, efficiency, and equity (3rd ed.). Cheltenham: Nelson Thornes. World Health Organization. (2005). Bangkok Charter for Health Promotion in a Globalized World. Retrieved from www.who.int/healthpromotion/conferences/6gchp/hpr_050829_%20BCHP.pdf. Health Promotion 5/1/07 11:18 AM Page 245

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CRITICAL THINKING QUESTIONS 1. How might charters and declarations, such as the Ottawa Charter for Health Promotion, influence public health decision making at the national level? State level? Local level? 2. What are the complementary roles of international governmental organizations (e.g., the World Health Organization) and international non-governmental organizations (e.g., the International Union for Health Promotion and Education)? 3. How might Canadian influence on health promotion abroad in turn influence Canadian health promotion?

FURTHER READINGS Jackson, S.F. (2003). The Canadian Consortium for Health Promotion Research: A network that adds value to governments and universities. Promotion and Education, 10(1), 16–19. Mittelmark, M. (2005). Charters, declarations, world conferences: Practical significance for health promotion practitioners “on the ground.” Promotion and Education, 12(1), 6. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141.

RELEVANT WEB SITES

Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR/index.htm The role of the Canadian Consortium for Health Promotion Research is to support the work of its member centres, provide networking opportunities and information exchange, facilitate new opportunities for collaborative research, advocate for and promote health promotion research in Canada, and serve as a conduit to health promotion expertise and knowledge at a national level.

Health Promotion at the World Health Organization www.who.int/topics/health_promotion/en/ This page provides links to descriptions of activities, reports, news and events, as well as contacts and co-operating partners in the various WHO programs and offices working on this topic.

Health Promotion Links at the Public Health Agency of Canada www.phac-aspc.gc.ca/hp-ps/ This is the link to the main page of the PHAC Web site on health promotion. It contains links to dozens of health promotion topics and programs within Health Canada and the PHAC. Health Promotion 5/1/07 11:18 AM Page 246

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International Union for Health Promotion and Education www.iuhpe.org The IUHPE is a leading global network working to promote health worldwide and contribute to the achievement of equity in health among and within countries. It draws its strength and authority from the qualities and commitment of its diverse network of members, and it has an established track record in advancing the knowledge base and improving the quality and effectiveness of health promotion and health education practice. Members range from government bodies, to universities and institutes, to NGOs and individuals across all continents. Health Promotion 5/1/07 11:18 AM Page 247

CHAPTER 15 VIEWS ON THE INTERNATIONAL INFLUENCE OF CANADIAN HEALTH PROMOTION

Sophie Dupéré

INTRODUCTION States and New Zealand. Two other non- Canadians, Kickbusch (1994) and McQueen Intent of the Chapter (1994), also provided their viewpoints on the We are who we are only in the eyes of other influence of Canada globally and in Europe. people and their looks are what make us An important criticism of this approach in come to terms with ourselves as ourselves. the first edition was its narrowness, limited to a Western, Eurocentric, Anglo-Saxon —Jean-Paul Sartre, l’Être et le Néant view. We thus wanted to address this issue ur book aims to analyze the Canadian in the second edition and agreed that rather Ohealth promotion discourse and prac- than having a few long chapters, we would tice. Reflection on our practice and discourse look for shorter contributions, but from a necessarily implies reflexivity and self-cri- much wider range of countries. We were tique. This has been taken up in the other conscious that this would yield less substan- chapters mostly by “insiders,” Canadians who tial analyses for each country and more a col- have examined health promotion in different lection of selected sets of general observations. areas of the field and elicited reflections on Nevertheless, because of the diversity and the what we have learned and how to improve originality of the format, we believed that it our practice and research. As illustrated in had potential to enrich our reflection and the above quote, Jean-Paul Sartre neverthe- expose the reader to a wider panorama of the less reminds us that the judgment of others influence of Canadian health promotion. is essential to our existence and to the knowledge we have of ourselves. In this spirit and to add to our critical analysis of Canadian Process health promotion, we thought it would be We have tried to adopt as much as possible, important to have external observers share considering our time and technical con- their perceptions of Canada’s contribution (or straints, a participatory approach in the writ- not) to health promotion in their country in ing of this chapter. Every contributor was order to nourish our reflection and increase first asked to send a 500-word commentary our understanding of Canada’s role and influ- on if and how the health promotion move- ence internationally. ment in Canada had (or did not have) an In the first edition of the book, Green impact on health promotion as it existed (or (1994) and Raeburn (1994) commented on not) in their own country, be it in policy, proj- how Canadian health promotion develop- ects, capacity building, research, or otherwise. ment had an impact on the field in the United As editors of the book, we provided feedback 247 Health Promotion 5/1/07 11:18 AM Page 248

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on these first drafts and asked for clarifica- gathered, but rather to highlight certain gen- tions when necessary. As a third step, the eral elements that emerge from the contribu- coordinator of the chapter highlighted some tions. It is important to keep in mind that emerging issues/trends from the commen- those commentaries are just snapshots of very taries, posted them on a dedicated weblog, rich reflections. We therefore strongly encour- and invited the authors to react and engage age the interested reader to consult the refer- in a dialogue on this first analysis. A first final ences and additional resources provided by draft of the chapter, taking into account the our contributors to learn more about a par- comments and suggestions, was sent to the ticular country. Our comments below are publisher for its external review process and divided in three main sections: (1) the per- the feedback received was shared with the ceived influence of Canada on health promo- group of 32 contributors from 22 countries tion in other countries; (2) the status of health for final reactions. promotion in the different countries; and (3) As mentioned in the introduction to this the strengths and limits of the analysis. book, for this chapter as for the others, we wanted to include people involved in health promotion from a variety of backgrounds The Influence of Canada in and professional expertise. We also made a 22 Countries special effort to ensure the involvement of At least three sets of observations can be the younger generation, being at the same derived from the commentaries below: (1) the time privileged to count on the participation types of influences; (2) the types of interactions, of some of the most established voices in the collaborations, and partnerships developed; field. The commentaries are presented at the and (3) the levels of intensity and impacts. end of this chapter by country in alphabetical order (see Table 15.1 for a list of the coun- Diverse Types of Influences tries covered). In the next sections general We were able to identify seven major types analytical comments about what emerges of influences of Canada on health promotion from these contributions are presented as from the commentaries. Some were already well as a set of reflections about Canada’s role signalled in Chapters 13 and 14, but new ones and contribution on the global scene and a emerged as well. few considerations about the status of health The first, noted by most contributors, is promotion in the 22 countries for which a Canada’s influence through its contribution commentary was provided. to theoretical and conceptual knowledge in HP. Canada’s historical role in laying out important conceptual bases for the field has been OBSERVATIONS AND mentioned by many, notably through the REFLECTIONS BASED ON Lalonde Report and Canada’s influence on THE CONTRIBUTIONS the Ottawa Charter, although, as already men- The intent here is not to comment in a detailed tioned, the fact that the latter is an interna- manner on the state of health promotion (HP) tional rather than a Canadian document in the different countries nor to make an in- usually seems to be omitted. It is important depth analysis of the influence of Canada to mention, however, that these documents internationally, which is obviously an impos- were not perceived as having the same sible task given the nature of the material importance and influence in all countries for Health Promotion 5/1/07 11:18 AM Page 249

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TABLE 15.1: COUNTRY COMMENTARIES BY REGION

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various reasons such as the lack of participa- governmental). Capacity building and train- tion of developing countries in the meeting ing were indeed two of the main contributions that produced the Ottawa Charter (e.g., Latin and factors in the success of Canada’s work America, Senegal). internationally that Jackson and her colleagues Many commentaries have also high- identified in Chapter 13 and is certainly an lighted the academic contributions of important one to consolidate, considering that Canadians to HP knowledge. MacDonald, lack of human resources was mentioned as a from the UK, especially focused his com- barrier to HP development in certain coun- mentary on this topic and found that tries (e.g., Puerto Rico and Romania). Canadians have made a noticeable contri- A fourth type of influence highlighted bution to academic journals “which com- by some authors was Canada’s leadership role pares very favourably with countries of a in guiding healthy public policy, notably by similar stage in health promotion develop- stressing the leadership role of the federal ment” (see Macdonald’s commentary in this government at home (e.g., Australia), the chapter). Certain areas of the field have been work of Canada on the health impact of trade mentioned by more than one author as areas agreements (e.g., Mexico; PIC), or the influ- where Canadians have produced particularly ence of its legislative work (e.g., Switzerland, interesting academic contributions: partici- Israel). Again, this was identified in Chapter patory approaches; evaluation and effec- 13 as one of the greatest international con- tiveness in HP; globalization and its impact tributions of Canada in the last decade. on population health; multicultural and A fifth influence that emerged and that Aboriginal issues; health disparities and was discussed in Chapter 14 is Canada’s con- social determinants of health; healthy public tribution to global professional capacity (gov- policy and health literacy; dissemination and ernmental bodies, IUHPE, forums, chat media communication. lines) and to global infrastructure. Canada is A second important influence that was seen (see the Nordic countries commentary, highlighted by some authors was Canadians’ for instance) to have produced effective practical experience. Canada is perceived by internationalists who have been playing some as having made a difference by pro- important roles in various international gov- viding a distinctive model in certain areas ernmental bodies and NGOs. such as: (1) bottom-up experiences/commu- Another element mentioned by a few nity participatory experience (e.g., Japan); (2) contributors but nevertheless crucial is healthy cities (e.g., Brazil, Israel, Latin Canada’s influence as a donor country (e.g., America); (3) tobacco control (e.g., New PIC, Senegal), a role perhaps underestimated Zealand); (4) multi-ethnic society (e.g., Israel); and misunderstood in the health promotion (5) work with indigenous communities (e.g., community as noted in the PIC commentary. Australia); (6) evaluation and participatory Finally, an influence that was mentioned approaches (e.g., Afghanistan); (7) knowl- in the commentary from Australia is Canada’s edge dissemination and media communica- influence through the Canadian discourse and tion (e.g., France). practice, which is perceived to have distinct values A third influence of Canada on health such as equity, social justice, and participation. promotion in certain countries was seen This was seen as contributing to the rein- through its contribution to capacity building forcement of value-based HP in a country. of different sectors (health sector, academic sector, Considering the internal debates existing in Health Promotion 5/1/07 11:18 AM Page 251

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Canada on the role and importance of such Click4HP); meetings in international confer- a value base, as discussed in other chapters, ences or contacts through international agen- it is interesting to note the perceived inter- cies; short-term exchanges like visiting students national personality of Canada by some exter- and professors or visiting governmental offi- nal observers. cials, professionals, or activists; more intense Contributors were asked to identify, if and organized exchanges such as donor coun- they wished, Canadian resources that were try relationships, or collaborative projects of commonly consulted in their country. Seven all kinds (e.g., research, evaluation, training, out of 22 did so. This low participation was or capacity building as also shown in Chapters perhaps partly due to the confusion sur- 13 and 14). It is also interesting to note that rounding the request. What is a Canadian some contributors in the commentaries below resource? Is it defined by the origins of the have described how short meetings (interna- authors that have developed it? Also, as tional conferences, student and professional raised by some authors, many interesting exchanges during summer schools, etc.) gave resources or projects are not necessarily 100 birth to long-term projects. percent Canadian but may involve other One important issue for the global health countries as well. Table 15.2 summarizes the promotion community to reflect on is access results of this process. No major trend can be to these exchanges. Are health promoters from identified there, but it is interesting to see that different countries able to access them equally? electronic resources seem popular, probably Do Canadian health promoters have the same due to the capacity to access them easily even probability of meeting people from different in poorer countries and that Canadian gov- countries? Are some countries more present ernmental sites offer bilingual information than others? Are some countries absent? Why in two important international languages: is that so? Are there measures that could be French and English. taken in this respect to enlarge the international dialogue and collaboration in health pro- A Diversity of Types of Interactions, motion? Could this situation have an impact Collaborations, and Partnerships on Canada’s health promotion discourse, prac- Many contributors insisted on mutual influ- tice, and contribution internationally? ences rather than a one-way influence from Commentaries also show that collabora- Canada (e.g., Brazil, Nordic countries). tions between Canada and other countries Pederson, Rootman, and O’Neill (2005), who range from short-term and superficial con- have recently reflected on Canada’s global tacts to ongoing solid long-term partnerships. contribution to health promotion, have also Some of the contributors have expressed the highlighted this and stated that “Canada’s desire for more collaborative work with relationship to health promotion globally is Canadian health promoters (e.g., Israel, perhaps best understood as a reciprocal one Kuwait, Senegal) and suggested increasing in which all parties benefit” (p. 250). opportunities to exchange knowledge and This web of influences seems to take dif- expertise through translating key Canadian ferent forms and to be channelled through dif- health promotion documents in other lan- ferent mechanisms such as: academic guages (Spanish, for instance, as mentioned contributions and Canadian Web sites offer- by Mexico). Why has the Canadian health ing accessible bilingual material; virtual promotion community cultivated strong long- exchanges through electronic forums (e.g., term relationships with some countries and Health Promotion 5/1/07 11:18 AM Page 252

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TABLE 15.2

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less so with others? What guides our choices to allocate scarce resources for research, how to establish relationships with some countries to establish research priorities, and how to (personal affinities and interests; linguistic or have systemic and meaningful impacts on cultural affinities; professional affinities; health (Di Ruggiero et al., 2006; Kickbusch, demands from other countries; funding 2006; Labonté & Spiegel, 2001; Neufeld & opportunities)? Are there countries that would Spiegel, 2006). These reflections could inspire benefit more from collaboration than others? and nurture the Canadian health promotion Should we assign priority to collaboration community in its international work. For according to the countries that most need it? instance, Neufeld and Spiegel (2006) recom- Nixon (2006), who has reflected on some mend more coherent resource allocation, of the questions raised above, has recently aligned with consensually identified priori- argued that the conceptual perspectives under- ties in areas in which Canada has shown pinning projects lead to certain questions and strengths, which are many, as seen above. Di to the exclusion of others, which necessarily Ruggiero et al. (2006) argue that Canada can lead us to elaborate particular programs and best make research matter globally by ori- solutions. She suggests that “critical public enting the work on the “upstream” determi- health ethics,” an emerging field that is con- nants of health, a position that many in the cerned with global health equity and power Canadian health promotion community will relations between rich and poor countries, find quite familiar. becomes a crucial lens to guide international Finally, Louise Signal, in her commen- research endeavours. It is noteworthy to mentary about New Zealand, stresses the impor- tion two recent Canadian initiatives that are tance for the HP global community to find concerned with the disparities between the more effective ways to work internationally focus of health research investments and the by developing partnerships among nations, global burden of illnesses as they might be able working through international organizations, to nurture reflections on the issues raised in and building alliances with other sectors. this chapter. The first one is the Global Health Although there has been progress, the Research Initiative, which involves major inequality under which research has been car- Canadian federal agencies (CIDA, CIHR, ried out in the developing countries remains IDRC, HC) and seeks to coordinate Canada’s a challenge and models are needed to con- research response to global health challenges. solidate partnerships and strengthen research The second is the Canadian Coalition for capacity in global health (Forti, 2005). Global Health Research (CCGHR), a not-for- profit organization that promotes “better and A Diversity of Levels of Intensity and Impacts more equitable health worldwide” notably by The influence of Canada on other countries encouraging “greater Canadian investment in seems to have different levels of intensity, global health research” and “nurturing pro- ranging from no or subtle indirect influence ductive partnerships among Canadians and to distinct and significant impact. Influences people from low and middle income coun- reported were mainly positive, but ambigu- tries” and “translating research into action” ous ones were sometimes pointed out, the (CCGHR, 2006). most evident example of the latter being These initiatives, as well as authors in found in the commentary about Tunisia. This public health concerned with global health example reminds us that collaborative ven- and inequalities, are reflecting on how best tures and projects often take place in delicate Health Promotion 5/1/07 11:18 AM Page 254

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social and political contexts and can have uate the existence of health promotion insti- unexpected consequences. tutions within the public health system of The Tunisian example reminds us also their country, some spontaneously mention that international HP work requires as much its presence outside the health system and (if not more than) local work, a lot of reflex- even a few outside the governmental sector ivity on one’s practices (see Chapter 16). (e.g., the contributor from Romania identi- Elsewhere its author (Marzouki, 1994) illus- fies NGOs as key players in HP). trated well how HP concepts borrowed from Second, health promotion is clearly not countries of the North are often inappropri- operating in the same forms in all the coun- ate to countries of the South. It prompts us to tries. For example, some have mentioned that think about the validity of our assumptions, health education was the dominant approach the universality of our answers, as well as to HP (e.g., Kuwait, France). Some have also about our role and impact. What are the limits mentioned the existence of health promotion of Canadian HP models? Are they relevant interventions under other labels such as pri- for every other country? What are the neces- mary health care (e.g., Senegal) or something sary adaptations? Indeed, some commentaries else (e.g., Brazil, Afghanistan). below (Brazil and Ukraine notably) indicated Thirdly, we can observe many different that Canadian HP models need adaptation “health promotion trajectories” for countries. when transposed in other contexts if success Contemporary mainstream health promotion is to be attained. Ukraine has also underlined (as defined by the Ottawa Charter) has not that a key factor of success was the constant been adopted by certain countries and is just evaluation and research, which helped in the starting to gain currency in others whereas it monitoring of the project and facilitated effec- has been in place for variable periods (rang- tive adaptation of Canadian best practices. ing from 10 to 20 years), through an estab- This is certainly an example of a successful lished infrastructure, in a number of them. collaborative project that we can learn from. The evolution of health promotion is also Canada is generally known for its politics of influenced by the evolving social, cultural, dialogue and this reaffirms its importance. historic, and political context of each country as clearly seen for Tunisia, Afghanistan, and Brazil. It is interesting to observe in the 22 THE STATUS OF examples below the variety of experiences as HEALTH PROMOTION IN well as the various factors that have triggered 22 COUNTRIES the entry of HP in a country, from major social and political movements (as in Brazil) General Observations to significant personal encounters of senior Given the space the contributors had and the politicians (as in Iran). nature of the invitation, which focused on Despite these differences, however, there ways in which Canadian influence might be seem to be common and shared experiences reflected in their country, the information among many countries such as the struggle regarding HP in their respective country was with the biomedical and curative paradigm necessarily limited. Nevertheless, we have dominant in health systems all over the world, identified four sets of general observations as well as the quest for the demonstration of that can be derived from their commentaries. HP effectiveness and credibility (notably for First, whereas most authors seem to sit- policy makers); this will be discussed further Health Promotion 5/1/07 11:18 AM Page 255

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in our conclusion to the book. Health pro- HP community in Canada learn from the motion is not perceived as a recognized dis- mobilization experiences of civil movements cipline or legitimate field of practice in all such as the Landless Movement in Brazil to countries. Some contributors have underlined tackle increasing social health inequalities the importance of its recognition for the here? Hubley (2005), who has reviewed health development of public health policies and promotion activities in low- and middle- stronger multisectoral integration, whereas income countries, highlights the fact that they others stress the importance of its legitimiza- have received relatively little attention in the tion for an increased allocation of resources field. Some interesting work there remains for research and practice. largely undocumented because of the persistent inequalities under which research is carried out as well as the biases in the publication Additional Thoughts of knowledge and access to information These observations emerging from the con- mentioned by Forti (2005), among others. tributions below are quite similar to those Additionally, some health promotion initia- formulated by people who have recently tives that may be interesting to learn from are looked at health promotion internationally. excluded and ignored by the global HP com- Scriven and Garman (2005), for instance, munity because of insufficient evidence of who have dedicated a large part of their book effectiveness and impact due to lack of on global health promotion to case studies resources to assess them (Hubley, 2005) or to from different regions of the world, have also different definitions of effectiveness as pointed noted discrepancies in how health promotion out by the Global Programme on Health is conceived, valued, and approached in dif- Promotion Effectiveness (International Union ferent countries. for Health Promotion Education, 2006). This This a particularly interesting element to initiative, piloted by the IUHPE and WHO, reflect on as it has consequences for health pro- is an important one for the field as it aims to motion practices, especially if different labels share best practices from around the world and are used to designate them. An outsider may strengthen the capacity to develop evaluation find that a country has a “low level” of health of the effectiveness of health promotion in dif- promotion development based on the formal ferent parts of the planet. labelling of it whereas, in reality, there might Finally, and more generally, Canada as be more “health promoting interventions” than well as other countries would benefit by look- it might seem; this might have all sorts of ing at initiatives from other sectors that are repercussions. It may lead us, for example, to not labelled health promotion but aim to miss some important experiences that could improve the health of the population. As be learned from. For instance, health inequal- pointed out by Mittlemark (2005) or Ziglio, ities are emerging as an important concern in Hagard, and Griffiths (2000), intersectoral several Northern countries, as discussed by collaboration with partnerships beyond the Dennis Raphael in Chapter 7 of this book; con- traditional disciplines, groups, and profes- sequently, many people in these countries are sional alliances that define and shape current searching for possible interventions to reduce health promotion (such as social movements, them. Are we looking at all the pertinent expe- the corporate sector, and less usual academic riences in these matters? To take a concrete disciplines) is crucial to address the health example voiced in the commentaries, can the challenges of the world. Globally, health Health Promotion 5/1/07 11:18 AM Page 256

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promotion has tended to remain isolated in their hands. We have thus obtained, as seen its evolution and there is an urgent need to below, a great diversity in terms of styles and stimulate its development with new energy, content. Although this diversity is undoubt- alliances, and ideas (Mittlemark, 2005). edly a strength of the process, it also limits the Along with this quest for other alliances conclusions we can draw. The type of mate- outside of the orthodoxy of health promotion rial gathered does not permit us to make any there is a need to reflect on the essence of generalization; we cannot even pretend that health promotion, its unique scope, contri- this is a fair or a representative picture of bution, and benefits. As noted above and else- health promotion in the 22 countries, nor of where (Scriven & Garman, 2005), there seem the influence of Canada on them. to be common problems—such as the short- The selection of authors was made by age of HP resources and common struggles— the editors through their professional and notably with the dominant biomedical and personal networks and has certainly intro- curative paradigm, which call for continuing duced different biases. Although we have the evaluation of HP effectiveness and efforts certainly gathered a diversity of voices, many to develop its political and scientific credibil- important ones are missing. Notably, despite ity (Nutbeam, 1998, 1999; O’Neill, 2003, 2004; several trials, we were not able to get contri- Ziglio, Hagard, & Griffiths, 2000). butions from China or India, leaving unrep- resented a significant part of the world population, nor from Germany, Spain, or the CONCLUSION Netherlands, key European players in the global health promotion arena. Furthermore, Strengths and Weaknesses of although we encouraged the authors to adopt the Analysis a critical position, some may have held back The analysis presented above, even if it was and limited their criticisms because of past sent to and is using comments and reactions or ongoing relationships with us or because from the various contributors through the of the method we used to gather the infor- process described in the introduction to this mation. Finally, many authors have raised chapter, constitutes the conclusions of the the issue of the word count and the almost coordinating author of the chapter, which impossible task of writing a substantial crit- might not be shared by all the contributors ical reflection in such limited space. This has below. The idea was not to build a final con- provoked frustration and important cuts of sensus but to gather a variety of perspectives pertinent material to contextualize their and see what emerged from the harvest. statements or to add important elements. It The range of ways in which the contrib- is therefore important to keep in mind that utors interpreted their task, which was very those commentaries are just snapshots of broad, has its advantages and limits. The main richer reflections, and we hope that in read- advantage is perhaps the liberty that each took ing the chapter our contributors will find that in choosing what she or he wanted to high- their effort was worthwhile. light and how to do it. Contributors have This being said, we believe these short taken a particular stance and selected a set of commentaries are very useful in their con- observations about one or more elements of tribution to our understanding of Canada’s Canada’s contribution to health promotion in role internationally in the field of health pro- their country, a selection that was entirely in motion, as well as of the different forms and Health Promotion 5/1/07 11:18 AM Page 257

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colours health promotion takes in different By reading them we can certainly say that contexts. They offer a unique patchwork of Canada had global influence over the last the situation, allow several clear and signifi- 10–12 years, but we can wonder about the cant elements to emerge as well as some extent and the nature of its impact since health important questions and issues to be raised, promotion projects can have both intended which, as we have shown, are of the same type and unintended consequences. More evalua- as those noted by many global health scholars. tion should be conducted on Canadian international and global action. Only through more analysis can we ensure impact and effective- Final Thoughts ness when we intervene and create interven- Many have pointed out the historical leader- tions that are sustainable and effective. ship of Canada in the field of health promo- International work thus requires sus- tion notably through the Lalonde Report and tained reflection and informed debate in the Ottawa Charter, even though the latter as order to understand what is needed of the such is not a Canadian document any more Canadian health promotion community to than the Kyoto Protocol is a Japanese docu- understand Canada’s global responsibilities ment. Canada is still perceived today by and accountability in supporting a better inte- many as a leader in some areas of the field gration of the South into the global health and there is a remarkably consistent view on promotion community and to promote more Canada’s distinct and international profile as equitable North–South relationships in the well as on its degree of influence interna- context of globalization from which both tionally in the 22 contributions. parties can clearly benefit.

REFERENCES Canadian Coalition for Global Health Research (CCGHR). Vision and mission. Retrieved April 12, 2006, from www.ccghr.ca. Di Ruggiero E., Zarowsky, C., Frank, J., Mhatre, S., Aslanyan, G., Perry, A., et al. (2006). Coordinating Canada’s research response to global health challenges: The Global Health Research Initiative. Canadian Journal of Public Health, 97(1), 29–31. Forti, S. (2005). Building a partnership for research in global health: Analytical framework. Ottawa: Task Force on Building partnerships. Canadian Coalition for Global health research (CCGHR). Green, L.W. (1994). Canadian health promotion: An outsider’s view from the inside. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 314–326). Toronto: W.B. Saunders Canada. Hubley, J. (2005). Promoting health in low- and middle-income countries: Achievements and challenges. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 147–166). New York: Palgrave Mcmillan. International Union for Health Promotion and Education (IUHPE). (2006). Global programme on health promotion effectiveness. Retrieved April 12, 2006, from www.iuhpe.org/English/projects_project2. Kickbusch, I. (1994). Introduction: Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 350–374). Toronto: W.B. Saunders. Kickbusch, I. (2006). Mapping the future of public health: Action on global health. Canadian Journal of Public Health, 97(1), 6–8. Labonté, R., & Spiegel, J. (2001). Setting global health priorities for funding Canadian researchers. Health Promotion 5/1/07 11:18 AM Page 258

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A discussion paper prepared for the Institute on Population and public health. Retrieved April 12, 2006, from www.spheru.ca/PDF%20Files/GHpaper%20-%20PDF.pdf. Lalonde, M. (1974). Nouvelle perspective de la santé des canadiens. Ottawa: Gouvernement du Canada: Ministère des Approvisionnements et Services Canada. Marzouki, M. (1994). Promotion de la santé, une vision du Sud. In R. Bastien, L. Langevin, G. Larocque, & L. Renaud (Eds.), Promouvoir la santé: Réflexions sur les théories et les pratiques (pp. 3–38). Montréal: Partage. McQueen, D. (1994). Health promotion research in Canada: A European/British perspective. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 335–348). Toronto: W.B. Saunders. Mittlemark, M. (2005). Global health promotion: Challenges and opportunities. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 48–57). New York: Palgrave Mcmillan. Neufeld, V.R., & Spiegel, J. (2006). Canada and global health research: 2005 update. Canadian Journal of Public Health, 97(1), 39–41. Nixon, S.A. (2006). Critical public health ethics and Canada’s role in global health. Canadian Journal of Public Health, 97(1), 32–34. Nutbeam, D. (1998). Evaluating health promotion: Progress, problems, and solutions. Health Promotion International, 13(1), 27–44. Nutbeam, D. (1999). The challenge to provide “evidence” in health promotion. Health Promotion International, 14(2), 99–101. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? Sozial- und Praventivmedizin/Social and Preventive Medicine, 48(5), 317–326. O’Neill, M. (2004). Le débat international sur l’efficacité de la promotion de la santé: d’où vient-il et pourquoi est-il si important? Promotion et Education, Hors Série(1), 6–9. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future? In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). New York: Palgrave Mcmillan. Raeburn, J.M. (1994). The view from down under: The impact of Canadian health promotion on development in New Zealand. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 327–334). Toronto: W.B. Saunders. Sartre, J.-P. (1976). L’Être et le Néant. Paris: Gallimard. Scriven, A., & Garman, S. (2005). Promoting health: Global perspectives. New York: Palgrave Mcmillan. World Health Organization (WHO). (1986). Ottawa Charter for Health Promotion. Health Promotion International, 1(4), i–v. Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion development in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.

CRITICAL THINKING QUESTIONS 1. Describe the kind of influences Canada’s health promotion movement had or has on certain countries by providing concrete examples from five country commentaries below to illustrate your arguments. 2. Identify some factors that might explain Canada’s influence (or lack of) on health promotion in other countries by providing concrete examples from the country commentaries to illustrate your arguments. Health Promotion 5/1/07 11:18 AM Page 259

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3. How could Canada improve its HP international work and collaborations? 4. Of all the commentaries below, which ones strike you the most? Why? 5. Does the practice of health promotion vary from one country to another? Why?

HEALTH PROMOTION IN economic, ethnic, and gender disparities), AFGHANISTAN which require long-term and substantial tech- Valéry Ridde, Suraya Dalil, Shukrrullah Wahidi, nical and financial resources. Further recog- and Linda Bartlett nition and emphasis should be given to health promotion activities and policies to optimize How Health Promotion Is Embedded Afghanistan’s ability to build a sustainable, in the Recent Health Policies secure, and healthy society. In Afghanistan today, health promotion is largely unrecognized as a public health discipline. However, health programs in How Health Promotion Programs Afghanistan include health promotion activ- Are Evaluated ities. Afghanistan’s turbulent history has left Health promotion experts are advocating the health care and other infrastructures deci- use of participatory approaches to evaluate mated, and the population’s health indicators programs on which Canada has had signifi- are among the worst in the world, signalling cant influence through concrete tools or more a population struggling for survival and devel- academic contributions (Cousins & Whitmore, opment (Bartlett et al., 2005). In 2002, the 1998; Ridde et al., 2003). In addition to the rel- Afghan Ministry of Public Health established evance of this approach to evaluate NGOs key priorities called the Basic Package of health promotion programs, this Canadian Health Services (BPHS) to address the great- participatory way was adopted for the pro- est health problems of the population, includ- grams implemented by Aide Médicale ing those living in remote areas. The BPHS Internationale. In this context, between 2001 includes primary prevention and health pro- and 2003, three evaluations were conducted. motion services for maternal and newborn Thanks to the changing context (from con- care, immunization against communicable flict and the Taliban to a situation of post-con- diseases, nutrition, health education, and flict and rebuilding of the state) we were able supply of essential drugs. Additional health to use approaches closer to the ideal type of promotion activities, including those related the participatory model. One of the goals was to mental health and disability, are planned. to build capacity among the NGO stakehold- In addition, a settings approach is occasion- ers and was best exemplified in a 2003 evalu- ally utilized, as in the multisectoral Healthy ation, which adapted a method proposed by Schools Initiative. Afghanistan is currently in Aubel (1999). A final one-day workshop was a complex transitional phase, moving from a conducted, where a draft action plan regard- war and emergency situation toward one of ing the implementation of recommendations sustainable development. This requires con- was developed, based on the evaluation find- tinuation and expansion of multisectoral ings and lessons learned, and an evaluation efforts to address the multiple influences on steering committee was devised to follow up development identified in the health promo- on the action plan and implement it. tion approach (for instance health, education, The Afghanistan case is thus an excellent Health Promotion 5/1/07 11:18 AM Page 260

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example of a very complex international sit- essential but almost impossible to undertake uation of humanitarian aid where evaluation without through a participatory approach of health and health promotion ventures is (Ridde, 2003).

REFERENCES Aubel, J. (1999). Participatory program evaluation manual: Involving program stakeholders in the evaluation process. Calverton: Child Survival Technical Support Project and Catholic Relief Services. Bartlett, L.A., Mawji, S., Whitehead, S., Crouse, C., Dalil, S., Ionete, D., et al. (2005). Where giving birth is a forecast of death: Maternal mortality in four districts of Afghanistan, 1999–2002. Lancet, 365(9462), 864–870. Cousins, J.B., & Whitmore, E. (1998). Framing participatory evaluation. In E. Whitmore (Ed.), Understanding and practicing participatory evaluation (pp. 5–23). San Francisco: Jossey-Bass Publishers. Ridde, V. (2003). L’expérience d’une démarche pluraliste dans un pays en guerre: l’Afghanistan. Canadian Journal of Program Evaluation, 18(1), 25–48. Ridde, V., Baillargeon, J., Ouellet, P., & Roy, S. (2003). L’évaluation participative de type empowerment: Une stratégie pour le travail de rue. Service Social, 50, 263–279. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (2001). Evaluation in health promotion: Principles and perspectives. WHO Regional Publications, European Series, no. 92. Copenhagen: World Health Organization.

FURTHER READINGS Islamic Transitional Government of Afghanistan. Ministry of Health. (2003/1382). A basic package of health services for Afghanistan. From www.af/resources/aaca/cg+adf/health_nut_cg/ BPHS%20Final.pdf. In March 2002, the Afghan Ministry of Health began a process to determine its major priorities for rebuilding the national health system, and which health services were so important for addressing the greatest health problems that they should be available to all Afghans. It was decided to call these crucial services a Basic Package of Health Services (BPHS).

Ridde, V., & Shakir, S. (2005). Evaluation capacity building and humanitarian organization. Journal of MultiDisciplinary Evaluation, 3, 78–112. From http://evaluation.wmich.edu/jmde/ JMDE_Num003.html. This article documents a process of evaluation capacity building in a humanitarian organization in Afghanistan between 2001 and 2003. The authors carried out an annual evaluation and they under- took evaluation capacity-building activities.

Strong, L., Wali, A., & Sondorp, E. (2005). Health policy in Afghanistan: Two years of rapid change: A review of the process from 2001 to 2003. From www.lshtm.ac.uk/hpu/conflict/files/publications/file_33.pdf. This paper outlines policy developments in the reconstruction of Afghanistan’s health system between 2001 and 2003. A brief overview of the current health system and successes to date is presented together with an update on more recent developments. Health Promotion 5/1/07 11:18 AM Page 261

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RELEVANT WEB SITES Afghanistan Centre at Kabul University www.afghanresources.org/index.asp Afghanistan Centre at Kabul University (ACKU) provides the most comprehensive collection of materials related to Afghanistan in the region. A variety of Western and Afghan languages are represented.

Afghanistan Research and Evaluation Unit www.areu.org.af/ The Afghanistan Research and Evaluation Unit (AREU) is an independent research organization whose mission is to conduct and facilitate action-oriented research and learning that informs and influences policy and practice. AREU also actively promotes a culture of research and learning by strengthening analytical capacity in Afghanistan and creating opportunities for analysis, thought, and debate.

THE EVOLUTION OF health promotion practitioners, researchers, HEALTH PROMOTION: and policy makers to engage in the politics CANADA’S CONTRIBUTIONS of social decision making to define society’s TO POLICY,THEORY, goals and to pursue social justice, equitable RESEARCH, AND PRACTICE access to health care and health protection, IN AUSTRALIA and to enable all citizens to achieve optimal Marilyn Wise health status. From the time of the Lalonde Report in Australia invested in health education early 1974, characteristics of health promotion dis- in the 20th century and during the 1970s course and practice emerging from Canada began to undertake community-based health have reinforced the values that underpin promotion. Since then, the WHO Health for health promotion in Australia. All initiative, the Lalonde Report, the Alma- Beyond the focus on lifestyle, the Ata Declaration, and the Ottawa Charter (and Canadian approach has emphasized the sig- the subsequent WHO global documents) nificant role of the state in creating policy have stimulated the development of special- environments within which individuals, ized health promotion capacity within the communities, and organizations (including health sector, in the non-government and pri- the private sector) can make decisions that vate sectors, and in academia. The practice promote or maintain health and contribute of health promotion evolved to include the to equitable population health outcomes. application of the comprehensive range of Canadians have helped build the case and strategies that has been demonstrated to be have highlighted the need to work both effective in achieving significant, sustained with government and communities, partic- improvements in the health of populations. ularly indigenous and poorer communities. The 21st century is seeing persistent Canadians have also contributed to the con- inequalities in health and has challenged ceptual and theoretical frameworks that Health Promotion 5/1/07 11:18 AM Page 262

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underpin health promotion policy, practice, too. The investment in organizational infra- and research in Australia and to building evi- structure (for instance, the Canadian dence of effectiveness, combining method- Population Health Initiative, the appointment ological rigour in all aspects of practice, of a federal minister of state for public health, research, and evaluation. university-based research centres in health pro- Effective health promotion requires motion) has also been inspiring. strong, well-resourced organizational bases to Finally, Canada has contributed to conduct and disseminate research; to design, building evidence of the effects of globaliza- deliver, and evaluate local and national prac- tion on the health of populations, and on tice; and to establish and implement or con- some practical, evidence-based responses that tribute to public policy. Canada has contributed are helping us to address the issues “at to the identification of the structural compo- source” and to influence global practice. nents of such capacity, and to understanding In all, it is widely acknowledged in the need for specific investment to ensure that Australia that Canada has made significant the rights of all citizens to optimal health are contributions to building the scientific and included in policy, research, and practice. As political credibility of health promotion as a a result, Canada has demonstrated the rela- discipline and field of practice that has tionship between First Nations, Inuit, and proven to be effective in improving the health Métis land and political rights and their health, of populations. which is an issue of significance in Australia

REFERENCES Chandler, M., & Lalonde, C. (1998). Cultural continuity as a hedge against suicide in Canada’s First Nations. Transcultural Psychiatry, 35(2), 193–211. Jackson, S., Cleverly, S., Poland, B., Burman, D., Edwards, R., & Robertson, A. (2003). Working with Toronto neighborhoods toward developing indicators of community capacity. Health Promotion International, 18(4), 339–350. Labonté, R., Schrecker, T., & Amit Sen, G. (2003). Health for some: Death, disease, and disparity in a globalizing era. Toronto: Centre for Social Justice. Raphael, D. (2003). Barriers to addressing the societal determinants of health: Public health units and poverty in Ontario, Canada. Health Promotion International, 18(4), 397–405. Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D., Poitvin, L., Springett, J., et al. (Eds.). (2001). Evaluation in health promotion: Principles and perspectives. WHO Regional Publications, European Series, no. 92. Copenhagen: World Health Organization.

FURTHER READINGS Baum, F. (2002). The new public health: An Australian perspective (2nd ed.). Melbourne: Oxford University Press. This is a comprehensive overview of “the new public health” in Australia and includes strong chapters on health promotion or, as this author views it, on health development and empowerment, organizational development, public health policy, and healthy societies and environments. Baum’s work is distinguished by its clear focus on equity and social justice, themes that she develops Health Promotion 5/1/07 11:18 AM Page 263

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eloquently throughout the book, backed by evidence and guidance on means to bring about positive changes in society, as well as individuals.

Duckett, S.J. (2004). The Australian health care system (2nd ed.). Melbourne: Oxford University Press. A lucid overview of the Australian health care system that orients readers to the strengths and weaknesses of a complex health care system that has been described as “a strife of interests.” Duckett uses a systems approach to describe the inputs and processes of the system and the associated outputs and outcomes, including health outcomes. The book provides a context for the policy, design, and delivery of health promotion (and public health) interventions in Australia.

Hawe, P., Degeling, D., & Hall, J. (1990). Evaluating health promotion: A health workers’ guide. Sydney: MacLennan and Petty. Although published some time ago, this book has influenced all subsequent health promotion teaching, research, and practice in Australia. It continues to serve the field well, describing and illustrating a logical, evidence-based analytical approach to designing and evaluating programs.

Moodie, R., & Hulme A. (Eds.). (2004). Hands-on health promotion. Melbourne: IP Communications. The book focuses on contemporary health promotion practice, drawing together evidence of policy, structures, and processes, and examples of effective practice at local and global levels. It is a well- structured overview of the field in the early 21st century and offers insights into the “state of the art” in health promotion, with particular focus on priority populations and major public health issues.

THE CONTRIBUTION OF launched in 1994, health promotion is one of CANADIAN INITIATIVES TO its main components and in 2005, it was cov- BRAZILIAN HEALTH ering 43 percent of the Brazilian population, PROMOTION reaching almost 5,000 cities and 76.8 million Márcia Faria Westphal and people. Other examples of local health pro- Tatiana Pluciennik Dowbor motion projects include more than 40 healthy municipality and 19 healthy school initiatives. The Situation of Health Promotion Moreover, the Brazilian non-governmental in Brazil sector runs different initiatives aimed at In 1998, with the support of the Inter- impacting the social determinants of health as American Development Bank, the Brazilian is the case of the Landless Movement, a civil Ministry of Health launched a national health society movement aimed at narrowing the promotion program, but it never allocated the huge equity gap through rural reform. resources to make it work properly. However, On the academic front, Brazil has health without using a health promotion label, the promotion research centres (for instance at Brazilian federal government implemented the University of São Paulo, the Catholic diverse initiatives aimed at impacting the University of Parana, the Federal University social determinants of health. A current exam- of Pernambuco, and the Ceara School of ple is the Zero Hunger Program. Another Public Health), and several universities major initiative is the Family Health Program; include health promotion in their curricula. Health Promotion 5/1/07 11:18 AM Page 264

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Influences That Shaped Brazilian motion. The first Brazilian healthy munici- Health Promotion pality initiative was undertaken in São Paulo Brazil has a history of hard political conflicts in partnership with Toronto as sister cities. The and public health reform was part of a politi- Brazilian Family Health Program is some- cal fight that utilized the international public times described as being inspired by several health reform movements since the declara- international initiatives, including Canada’s tion of Alma-Alta to lead to the current situ- Family Doctors and Community Health ation; an important part of the Brazilian health Centres programs. Several Brazilian profes- promotion agenda was constructed through sionals got the opportunity to exchange expe- this internal fight. In this context Canada had riences with Canadian counterparts, Canadian its impact on how and how much health pro- professors regularly come to Brazil, and many motion would be disseminated in Brazil, but Brazilian students go to Canada for graduate more on the initiatives that are formally studies in health promotion. On coming back labelled health promotion than on the ones that to Brazil, many were able to critically recon- are not so. Canadian influence was also prob- textualize their knowledge and fruitfully con- ably more significant on initiatives that are tribute to local and national health promotion more consensus- and partnership-oriented developments. Finally, it is worth mentioning than on the ones that make social conflicts that Brazilians thinkers also had an impact on more explicit, such as the landless movement. the development of health promotion in There are several examples of the Canada, as is the case with Paulo Freire, whose Canadian influence on Brazilian health pro- work has been very influential.

REFERENCES Ferraz, S.T. (2000). Cidades Saudáveis: Uma urbanidade para 2000. Brasília: Paralelo 15. Westphal, M., et al. (2004). La Promoción de Salud en Brasil. In H. Arroyo-Acevedo (Ed.), La Promocion de la salud en America Latina: Modelos, estructuras y vision crítica. San Juan, Puerto Rico: División de Impresos Universitarios, Universidad de Puerto Rico.

RELEVANT WEB SITES Brazilian Collective Health Graduate Association www.abrasco.org.br

Collective Health Unit OPAS Brazil Healthy Municipalities Study, www.opas.org.br/coletiva Research, and Documentation Center Family Health Program www.cidadessaudaveis.org.br http://dtr2004.saude.gov.br/dab/ Zero Hunger Program Health Promotion Center www.fomezero.gov.br www.cedaps.org.br Health Promotion 5/1/07 11:18 AM Page 265

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THE CHILEAN NATIONAL local government and encourage them to act HEALTH PROMOTION PLAN in an intersectoral and collaborative way on Judith Salinas the social determinants of health. Health Promotion as a Public Policy The birth of health promotion in Chile began Canada’s Contribution in 1998 with the development of the country’s This process has counted on Canada’s ongo- first National Plan for Health Promotion. This ing and important contribution. At the plan created the VIDA CHILE Council, a beginning of 1999, representatives of gov- cross-sectoral coordination body chaired by the ernment and national and international Minister of Health and comprising 28 public organizations of both countries endorsed the and private institutions (Salinas, 2000, 2004; Collaboration Agreement for Development Salinas & Vio, 2002; Salinas et al., 2005). The of Health Promotion Canada–Chile. This role of this council is to help ministries estab- three-year agreement, funded by the lish healthy public policies and to support the Canadian International Development Agency implementation of local health promotion (CIDA), was implemented by the Centre for plans, conducted by all the municipalities Health Promotion at the University of throughout the country, with a wide social base Toronto and the Chilean Ministry of Health and support from the highest government with the support of CIDA, PAHO/WHO, authorities. and the collaboration of other partners in both The council has formulated five specific countries, including universities and govern- cross-sectoral targets for 2010. These have mental and non-governmental agencies. The become objectives in health reform to reduce University of Toronto team led this process, smoking, obesity, and sedentary lifestyles as facilitating a tremendous commitment of well as for increasing social participation and Canadian people and their experts and insti- healthy spaces. In 2005, nearly 18 percent of tutions who contributed time, resources, con- the population have participated in health sultations, technical assistance, and materials promotion activities through social organi- to support health promotion in Chile. zations, educational institutions, as well as This was achieved notably through many workplaces and primary care centres. numerous presentations in international con- In addition, the Ministry of Health has gresses, capacity-building workshops, eval- hosted three important national events: two uations, technical publications, workbooks, Chilean congresses for local and regional par- educational materials, as well as the devel- ticipants, and a Forum of the Americas with opment and operationalization of two aca- PAHO/WHO. demic resources centres in health promotion. Health promotion in Chile has faced dif- There have also been some other impor- ficulties in achieving cross-sectoral agreement tant contributions as different Canadian insti- with other actors and enforcing regulations. tutions have implemented collaborative projects VIDA CHILE suggests that participants must of research and support toward the Chilean consolidate what has been achieved and build process of health reform, with new partner- on best practices and scientific evidence. The ships and important effects and achievements. great challenge is to succeed in making health In conclusion, Canada has played a piv- promotion into a state policy that encompasses otal role in the development of health pro- all sectors and administrations of national and motion concepts, models, and strategies in Health Promotion 5/1/07 11:18 AM Page 266

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Chile. The contribution since the Ottawa operation among countries leading to the Charter and throughout several collaborative mobilization of necessary resources for eval- projects is widely recognized. It is an exem- uation, dissemination, and sharing knowl- plary case of leadership and technical co- edge for health promotion and equity.

REFERENCES Salinas, J. (2000). Health promotion in Chile: An evaluation of a national plan implementation. Promotion & Education, 4, 13–16. Salinas, J., & Vio, F. (2002). Promoción de la Salud en Chile. Revista Chilena de Nutrición, 29(S1), 164–173. Salinas, J. (2004). Vida Chile 1998–2003: Achievements & challenges of health promotion as a public policy. Health Targets: News & Views, 7(1), 8–9. Salinas, J., Castanedo, I., Harrison, D., & Vu, A.L. (2005). The whole of government approach to promoting health: The case of Chile, Cuba, United Kingdom, and Viet-Nam. Paper presented at the 6th Global Conference on Health Promotion, Bangkok, Thailand.

RELEVANT WEB SITES Institute of Nutrition and Food Technology (INTA),University of Chile www.inta.cl It describes the health promotion courses that the institute offers, scientific publications, healthy eating and physical activity programs, and educational materials in health promotion.

Ministry of Health,Vida Sana Section www.minsal.cl Description of the National Health Promotion Council Vida’s policies, strategies, technical orientations, handbooks, and educational materials. It also includes the health promotion congresses that have taken place, the annual public accountability report, and the Ministry of Health’s technical regulations regarding health promotion

Pontifical Catholic University of Chile, Initiative Healthy University www.puc.cl/ucsaludable Presentation of the Healthy University Program, news, healthy universities congresses, educational materials, and other resources for healthy universities.

Regional Resources Centre in Health Promotion “Promesa,” University of Concepción www2.udec.cl/promesa Virtual page presenting capacity-building programs, technical assistance, documentation, and educational material centre. Health Promotion 5/1/07 11:18 AM Page 267

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HEALTH PROMOTION IN has acquired significant experience in setting FRANCE: TRYING TO GO up actions in health education intervention. BEYOND THE BIOMEDICAL However, the French system remains WORLD centred on a biomedical approach, with Laurence Guillaumie funding devoted primarily to curative services (Henrard, 2005). Health promotion France is known for the efficiency of its structures lack the means, training, and health care system, but also for lagging methodology to reach professional excellence behind in the field of health promotion. In (Brodin et al., 2004). The actions set up are the background stand two opposing concep- jeopardized by unreliable funding, except in tions: on the one hand, a biomedical model a few regions that opted for massive invest- for which the health care system is a crucial ments to develop a strategic health promo- determinant, and on the other hand, a public tion capacity (Bourgueil, 2003). health system for which social, economic, Canada is recognized as a world leader in individual, and collective factors are to be health promotion. Since the end of the 1970s, taken into consideration (Joël, 2000). Canadian universities have been seriously During the past 10 years, with the mod- involved in research on the health determi- ernization of France’s health care system, the nants (the social ones notably) and have devel- practice of health promotion (still largely oped several multidisciplinary academic labelled health education) has been trans- programs accordingly (Giraud & Lorrain, formed. The importance given to prioritiz- 2004). This has had an impact on health pro- ing health actions according to specific motion practices in France, either through the objectives, to the health determinants, and to training of French students, researchers, and health education laid the foundations for sev- professionals, or by the way Canadian eral reforms. researchers and professionals get involved in In 2002, L’Institut national de prevention French projects. Another Canadian influence, et d’éducation pour la santé (National Institute mostly from French-speaking Canada, is also for Health Prevention and Education [the occurring via Internet through electronic access INPES]) was created. Its mission is to set up to a variety of innovative materials (descrip- public health programs for the state, and to tion of programs and pedagogical workshops). develop expertise in the field of health pro- In the end, even if interest in health promotion and develop health education. A net- motion increased in France over the last 10 work of 100 local committees for health years, which was greatly influenced by education initiated in the 1970s is the main Canada, it remains hindered by a system still field partner of the INPES. This network, very centred on curative care and a lack of whose work is inspired by the Ottawa Charter, political consideration for health determinants.

REFERENCES Bourgueil, Y. (2003). L’hôpital et la promotion de la santé: Un projet paradoxal? Revue hospitalière de France, 492, 17–22. Brodin, M., Chambaud, L., Dab, W., Jourdain, A., Lopez, A., & Mansour, Z. (2004). L’efficacité de la promotion de la santé en France: Commentaires d’une table ronde composée d’experts français. Promotion et Education, numéro spécial 1, 36–40. Giraud, F., & Lorrain, J.-L. (2004). Rapport relatif à la politique de santé publique (2 vols). Paris: Sénat. Health Promotion 5/1/07 11:18 AM Page 268

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Henrard, J.-C. (2005). Politiques et programmes nationaux de santé. Naissance et histoire des priorités et actions des politiques nationales de santé. Actualité et dossier en santé publique, 50, 18–28. Joël, M.-E. (2000). Des soins à la santé publique. Projet, 263, 35–42.

FURTHER READINGS Loriol, M. (2002). L’impossible politique de santé publique en France. Ramonville Saint-Agne: Eres. The French health care system is centred on curative health care. Therefore, facing economic and social interests, public health often lacks the legitimacy and the means to impose itself and promote long-term programs. The objective of this book is to report on shortcomings and weaknesses using an analysis of health services and relationships between the curative sector and authorities.

Sandier, S., Paris, V., & Polton, D. (2004). Health care systems in transition. Retrieved January 1, 2006, from http://euro.who.int/document/e83126.pdf. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies. This report provides an analytical description of the French health care system and of reform initiatives in progress or under development. It can be used to learn about the organization, financing, and delivery of health services and the process, content, and implementation of health care reform programs.

RELEVANT WEB SITES Banque de Données en Santé Publique (BDSP) www.bdsp.tm.fr The Banque de données en santé publique is a free databank that provides online public health information and resources for health and social workers.

Haut Comité de la Santé Publique (HCSP) www.hcsp.ensp.fr The Haut Comité de la Santé Publique, in close partnership with the Secretary of Heath and Human Services, participates in the decision making for the improvement of public health. It keeps track of the population’s health and contributes to set health policy goals. A triennial report, showing prospective indicators and analysis related to public health issues, is published to that effect.

Institut National de Prévention et d’Education pour la Santé (INPES) www.inpes.sante.fr/ The Institut National de Prévention et d’Education pour la Santé is a public health force in charge of implementing public health programs for the state and its public institutions. It also provides the development of health education for the whole country. Health Promotion 5/1/07 11:18 AM Page 269

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HEALTH PROMOTION Since the establishment of this new APPROACH IN IRAN department, a number of innovative activi- Iraj M. Poureslami ties and projects in community health pro- Iran is a middle-income country with a pop- motion have been planned and implemented ulation of approximately 73 million. There over the past five years. These include publi- has been significant improvement in the cation of many relevant books, reports, and health status of the population over the past documents; assembling different workshops three decades, primarily as a result of the and seminars across the country for establishment of a primary health care system researchers, health care professionals, policy targeted to communicable disease control. In makers, and community organizations; con- recent years, as result of rapid urbanization ducting comprehensive school health pro- and pervasive socio-economic and gender- motion project in central provinces; based inequities, Iran has experienced strik- developing participatory smoke-free schools ing changes in its serious health problems, in south-east provinces; addressing non-med- moving from an infectious disease to a ical determinants of cardiovascular disease chronic disease pattern. and emerging health issues such as road acci- In an effort to adapt to this situation, the dents and cancer in most provinces; per- Ministry of Health of Iran has reorganized forming school health-scouts project in its infrastructure and reformed the health selected districts; establishing health houses care system, notably in beginning to estab- in major manufactures across the country; lish a health promotion approach after par- and developing health literacy materials about ticipation of the minister, deputy minister of HIV/AIDS and other STDs among youth. health, and general director of health educa- In spite of these efforts, it seems the tion in the 5th international conference of future improvement of health of people in Health promotion in Mexico City in 2000. Iran will depend less on providing access to During the conference and thereafter there health services than on economic growth, were several meetings and mail exchanges empowerment, and establishment of health between the general director of health edu- promotion in the largest sense. As elsewhere, cation and the director of the Centre for it will depend on gradually building a fairer Health Promotion at the University of and more equitable society, as the most obvi- Toronto in order to initiate the new ous outcome of health promotion. Therefore, approach. Documents received in Mexico as the policy makers in the health ministry, with well as from the University of Toronto were their mandate to “improve the health of the later translated to Farsi by the Iranian health nation’s people,” need to work on building education department and turned out to be the political willingness and health officials’ very influential in the establishment of a new consciousness to gradually establish health health promotion department in the Ministry. promotion in the health care system.

REFERENCES Asadi-Lari, M., Sayyari, A.A., Akbari, M.E., & Gray, D. (2004). Public health improvement in Iran: Lessons from the last 20 years. Public Health, 118(6), 395–402. Eshraghi, E. (2001). Promotion of public health welfare through equity in access to education. Tehran: Payame-Noor University of Iran Press. Health Promotion 5/1/07 11:18 AM Page 270

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LeBaron, S., & Schultz, S. (2005). Family medicine in Iran: The birth of a new specialty. International Family Medicine, 37(7), 502–505. Shahraz, S., Sherafat, R., & Zalki, M. (2003). The boundaries of health system: A proposed model. Archives of Iranian Medicine, 6(4), 243–250. ShadPour, K. (2000). Primary health care networks in Iran. Eastern Mediterranean Health Journal, 6(4), 822–825.

FURTHER READINGS Hosseinpoor, A.R., Mohammad, K., Majdzadeh, R., Naghavi, M., Abolhassani, F., Sousa, A., et al. (2005). Socio-economic inequality in infant mortality in Iran and across its provinces. Bulletin of the WHO, 83(11), 837–844. United Nations Economic and Social Council. (2005). Economic and Social Commission for Asia and the Pacific: Health and Development: Selected Issues. Addressing emerging health risks: Strengthening health promotion. Retrieved January 2006 from www.unescap.org/esid/committee2005/English/CESI2_7E.pdf. Werner, D. (2002). The changing pattern of health in Iran. From www.healthwrights.org/static/HW- NL46.pdf.

CANADA’S INFLUENCE ON for the aforementioned transformation in HEALTH PROMOTION IN Israel. The Israel Ministry of Health trans- ISRAEL lated the Charter into Hebrew and made it Diane Levin-Zamir, Milka Donchin, Lilach available to all health promotion practition- Melville, and Irit Livne ers and students throughout Israel. Over the past decade, the principles of the OC have Health promotion in Israel has evolved over been applied to policy in Israel, as health pro- the past two decades from a focus on health motion practitioners are required to design education to that of population health, apply- programs according to its essence. Funding ing the five major areas delineated in the sources are encouraged to adopt the OC as Ottawa Charter for Health Promotion. The set- quality criteria in considering the candidates tings approach to health promotion has been that have applied for support. Canadian policy embraced, with specific investment made in for health has had very concrete influence on health-promoting cities, primary health care Israel, as the Israeli Knesset passed legislation facilities, schools, community centres, and regarding cigarette package design and hospitals. An inter-organizational Health hazard labels based on Canadian practice and Promotion National Council for promoting research. The principles of the OC are taught health promotion policy has also been estab- in courses on health promotion in institutes of lished under the auspices of the Ministry of higher education. The Healthy Cities move- Health (Fosse, Mittlemark, & Skogli, 2005). ment, born in Canada, has set the stage for the Canada’s influence on health promotion establishment of the Israel Network of in Israel has been profound. In hosting the Healthy Cities, which currently includes 40 meeting that produced the Ottawa Charter for cities and regional councils (World Health Health Promotion (OC), Canada set the stage Organization, 1997). The original model Health Promotion 5/1/07 11:18 AM Page 271

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demonstrated the importance of combining and practice from Canada (Shohet, 2002; viable environment, convivial community, and Rootman & Ronson, 2003) are providing a adequate economy for better health and sus- basis upon which they are being researched tainable development. In Israel, this model is and put into practice in health systems, in the interface between “Health for All” and community settings, and in the health media “Sustainable Development” principles. in Israel. Canadian research on globalization Health promotion in multicultural soci- and its influence on health determinants has eties and settings has been a challenge in Israel recently generated discussion in Israel, par- for decades, with recent work in reducing ticularly as it relates to its place in the Bangkok health disparities and promoting equity based Charter for Health Promotion. on the research of Canadian scholars. The In summary, we expect that Canada will work conducted in Canada that explored the continue to invest in the development of health and social needs of cultures in change theory, practice, and policy related to public contributed to the efforts made in Israel in health and health promotion, which has promoting health among the Arab popula- already had remarkable influence on these tion as well as among Israel’s diverse immi- fields in Israel. It is now hoped that more grant population, particularly among people reciprocal collaborative work between the with chronic illnesses. Health literacy research two countries can be established in the future.

REFERENCES Fosse, E., Mittelmark, M., & Skogli, K. (2005). European capacity for health promotion at the national level. Report retrieved from the HP-Source.net. HP-Source. (2005). Country profile (Israel). From www.hp-source.net. Rootman, I., & Ronson, B. (2003). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(2), S62–S77. Shohet, L. (2002). Health and literacy: Perspectives in 2002. From www.staff.vu.edu.au/alnarc/onlinefo- rum/AL_pap_shohet.htm. World Health Organization. (1997). City planning for health and sustainable development. WHO European Sustainable Development and Health Series, no. 2. Cophenhagen: WHO Regional Office for Europe.

FURTHER READING HP-Source. (2005). Country profile (Israel). From www.hp-source.net. Detailed description of health promotion policy, practice, and research in Israel according to settings and topic initiatives, including contact details for a wide range of organizations and professionals. Health Promotion 5/1/07 11:18 AM Page 272

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THE PUBLIC HEALTH Canadian Public Health Association NURSE AS A DRIVING (CPHA) in 1990. This booklet has been used FORCE FOR HEALTH as a practical guideline for health promotion PROMOTION IN JAPAN at the community level (Murashima et al., Masamine Jimba and Yuka Nomura 1999) in interaction in some cases with nurses Japan’s health promotion has been influenced from the Registered Nurses Association of both by the social focus of Canada and British Columbia (BC). European countries and the individual focus An interesting example to illustrate the of the US (Green, 1994). Integrating elements role of community nursing practice in health of both approaches, the Japanese Ministry of promotion in Japan is a case study from Health, Labour, and Welfare launched Kanagawa Prefecture. While the translation National Health Promotion in the 21st of CPHA’s document was being prepared, Century (Healthy Japan 21) in 2000 as a basic JNA members visited Canada and several national health policy for the coming 10 years. European countries to seek examples of In the guidelines of Healthy Japan 21, the PHNs playing active roles in health promo- famous health promotion PRECEDE-PRO- tion at the community level. After consider- CEED model, which we translated into ing various models, they decided to adopt Japanese, is introduced as one of the recom- BC’s Community Meeting model and tested mended health planning models. Healthy it in the city of Miura, Kanagawa Prefecture Japan 21 emphasizes quality of life, promotion (Japanese Nursing Association, 1997). In coor- of health throughout the life cycle, and indi- dination with the city of Miura and its citi- vidual choice; it also introduced goal-oriented zens, PHNs held a Community Meeting management strategies (Institute for Workshop in 1996 that was also attended by International Cooperation, Japan International guests from the Registered Nurses Cooperation Agency, 2005). Association of BC. During this event, the par- This policy adopted the concept of ticipants learned Community Meeting meth- health promotion as proposed in the Ottawa ods and heard about BC’s successes. After this Charter in 1986, but its implementation workshop, the PHNs created a manual-style remains controversial. One typical criticism booklet to use in community health promo- is that there is little community participation tion and Miura citizens are still to this day in its planning and that the process follows using this Community Meeting approach. the same top-down approach as other health The next step is to determine how to policies in Japan (Takahashi et al., 2002). expand this kind of community-level health In this respect, Canada’s practical expe- promotion activity to the country as a whole. rience can serve as a model for bottom-up Fortunately, Japan has over 39,000 PHNs health promotion. Among different types of who work closely with citizens all over the health workers, it is public health nurses country. Through their work, Japan will (PHN) who have the greatest potential to advance toward the kind of health promo- carry out this task in Japan. In 1997, the tion that the Ottawa Charter embraces, Japanese Nursing Association (JNA) pub- though how to bring it up to the national lished a Japanese translation of Community level remains a challenge. Health—Public Health Nursing in Canada: Preparation and Practice, issued by the Health Promotion 5/1/07 11:18 AM Page 273

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REFERENCES Green, L.W. (1994). Canadian health promotion: An outsider’s view from the inside. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 314–326). Toronto: W.B. Saunders Canada. Institute for International Cooperation, Japan International Cooperation Agency. (2005). Japan’s experiences in public health and medical systems: Towards improving public health and medical systems in developing countries (pp. 39–40). Tokyo: Research Group, Institute for International Cooperation, Japan International Cooperation Agency. Japanese Nursing Association. (1997). Community meeting (Miura workshop report). Tokyo: Author. (In Japanese.) Murashima, S., Hatono, Y., Whyte, N., & Asahara, K. (1999). Public health nursing in Japan: New opportunities for health promotion. Public Health Nursing, 16, 133–139. Takahashi, T., Baker, R., Sato, K., & Touma, A. (2002). An international comparison study on health promotion and medical care improvement for the aged, and its results. Health Research News, 30, 13–16. (In Japanese.)

FURTHER READINGS Japan Public Health Association. (2004). Public health of Japan. From www.jpha.or.jp/jpha/english/index.html This document shows the current situation of public health in Japan, which includes a brief summary of health promotion in Japan.

Yamashita, M., Miyaji, F., & Akimoto, R. (2005). The public health nursing role in rural Japan. Public Health Nursing, 22(2), 156–165. This article gives background information about public health nurses in Japan and addresses their expanded roles in community health.

HEALTH EDUCATION IN Evolution and Status of Health KUWAIT Education in Kuwait Layla Aljasem and Amal Hussain Jassem During the 1960s and 1970s, health education was practised in Kuwait by only a few physi- The state of Kuwait lies at the northwest cians until a health education department was corner of the Arabian Gulf. Due to oil rev- eventually established in the 1980s (Al- enues, it has a high standard of living Mash’an, 2003), whose main goal was to (Ministry of Information, 2001). The total increase health awareness (Planning and population is 2.5 million people and about Follow-up Department, 1986). Back then, one-third are Kuwaitis. Due to its fast-grow- most health education focused on improving ing economy, Kuwait’s exposure to Western health knowledge through lectures, printed civilization has been inevitable and its type materials, television, and radio. As the major- of lifestyles has raced ahead of the attitudes, ity of health educators were non-Kuwaiti with beliefs, traditions, and culture of the Kuwaiti different accents, culture, and minimum health population; chronic illnesses are now the education experience, the population was not major causes of death. very eager to participate in such activities. Health Promotion 5/1/07 11:18 AM Page 274

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However, in the last 15 years, scholar- public in co-operation with community ships to specialize in public health and health organizations; organization of workshops, education were allocated to Kuwaiti physi- exhibitions, and programs through the media; cians by the Ministry of Health. Currently, publication of articles in dailies and maga- there are about 20 Kuwaiti public health zines; marathons; and days for the public, physicians; two specialized in health educa- including consultation, exhibition, promotion (Department of Human Development, tions, competitions, and gifts. 2004). Moreover, a Council of Health However, there is very little funding for Education was established in 2002. Its mem- research in the field and lifestyle data are bers are physicians working in health educa- lacking. Consequently, no intervention is tion and others working in the preventive based on scientific data. medicine departments of the five health areas. The council helps improve the communication and cooperation between health educa- International Co-operation tion workers and the rest of the health sector. Currently, there is co-operation between In the past 10 years the Health Education Kuwait and the other Gulf countries through Department has focused on changing atti- a Health Education Gulf Committee, estab- tudes, beliefs, and behaviours detrimental to lished in 2001. It meets once a year to discuss health. As in most countries, Kuwait health issues of common interest, exchange field leaders are more concerned with curative experiences, share materials, and co-operate aspects of health rather than preventive ones, in organizing conferences, workshops, and and devote most of the health budget to cur- symposiums. ative services. Getting resources to improve Until now there is no direct collabora- healthy attitudes, beliefs, and behaviours has tion with Canada. A visit to Kuwait from a thus been a constant struggle, though many Canadian lecturer at the Women’s Health non-profit organizations contribute finan- Workshop in May 2005 may have put the cially to health education activities. These first brick for further collaboration in place, include: production of printed materials; lec- in co-operation with the World Health tures for students in schools and the general Organization.

REFERENCES Al-Mash’an, M. (2003). Mediator in Medicine and Law (Arabic). Kuwait City: Author. Department of Human Development, Sub-Department of Manpower Statistics, & Planning Division of Manpower Statistics. (2004). Manpower Statistics 2004. Kuwait: Ministry of Health. Ministry of Information. (2001). Kuwait Facts & Figures (8th ed.). Kuwait City: Author. Planning and Follow-up Department. (1986). Health of Kuwait. Kuwait: Ministry of General Health. Health Promotion 5/1/07 11:18 AM Page 275

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INFLUENCE OF CANADA countries of Latin America and the IN IMPLEMENTING Caribbean. This was encouraged by the fact HEALTH PROMOTION that the WHO office in Europe (EURO) was IN LATIN AMERICA developing HP programs using Canada as a Helena E. Restrepo model and with some conceptual and methodological frameworks developed with Background Canadian consultants. Over the years, The Lalonde Report (1974) was a key docu- Canada became a rich source of consultants ment for those interested in the role of public and information for technical co-operation: health versus medical care to improve the individuals like M. Gómez-Zamudio, L. health of populations. But in Latin America Gravel, R. Lacombe, T. Hancock, R. very few recognized its importance and its Labonté, M. O’Neill, L. Pinder, L. Renaud, profound worldwide repercussions in public or I. Rootman, to name but a few, have given health policies. Only those working at that support in many ways and on many topics. time in prevention of non-communicable dis- This can be exemplified using the Healthy eases (NCD) with a comprehensive commu- Municipalities movement. nity-based approach used it to justify actions At the end of 1980s and the beginning oriented to lifestyle changes. of 1990s the countries of Latin America and The participation of Latin American the Caribbean were strongly encouraged to countries in the Ottawa Conference on reform the structure of the state, following Health Promotion (HP) in 1986 was almost the recommendations of the International nil, since only a delegate from Uruguay was Monetary Fund, and to give more impor- present. In spite of that, the Pan-American tance to local levels through decentralization. Health Organization (PAHO) offered tech- In this context, PAHO presented the Healthy nical assistance in HP as of 1988. However, Municipalities initiative to member countries it is only in 1992, after the International in 1992, in order to advance in the applica- Conference on Health Promotion and tion of HP theories and practice at the local Equity and its Declaration of Santafe de level. After the pioneer twinning between Bogotá (Ministerio de Salud de Colombia, & Toronto and São Paolo, the Quebec move- Organización Panamericana de la Salud, ment, Villes et Villages en Santé, was con- 1992), that the principles and recommenda- sidered a very useful model to follow in the tions of the Ottawa Charter was more Latin American region; constant support has accepted by PAHO member countries. been provided over the years by the Quebec group ever since. A few other institutions (notably the University of Toronto and the Canada’s Leadership University of Victoria) were also heavily The leadership of Canada in HP is recog- involved in the evaluative dimension of this nized all over the world due notably to the venture, at the beginning of the 2000s. Lalonde Report (1974), the Ottawa Charter (1986), and the Epp Report (1986), as well as projects like Healthy Communities. It is why Conclusion PAHO looked toward Canada, searching for Canada is a recognized leader in HP devel- expertise to acquire and disseminate knowl- opment in Latin America and the Caribbean edge and experiences among developing regions. The understanding and sensitivity Health Promotion 5/1/07 11:18 AM Page 276

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of Canadians toward the social problems of continue to receive nurture from Canadians’ the people of the region has certainly been knowledge in HP and enjoying their friend- an important factor for such an extended col- ship. laboration and, hopefully our countries will

REFERENCES Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Minister of Supply and Services. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Information Canada. Ministerio de Salud de Colombia, & Organización Panamericana de la Salud. (1992). Promoción de la Salud y Equidad (Declaración de Santafé de Bogotá). Bogotá, Colombia. Organización Mundial de la Salud, Ministerio de Salud y Bienestar Social de Canadá, & Asociación Canadiense de Salud Pública. (1986). Carta de Ottawa para la Promoción de la Salud (versión en español). Ottawa, Canada.

FURTHER READINGS Arroyo, H.V. (Ed.). (2004). La promoción de la salud en América Latina: Modelos, estructuras y visión crítica. San Juan, Puerto Rico: División de Impresos Universitarios, Universidad de Puerto Rico. The book contains a chapter by country describing the development of health promotion in each one.

Interamericano de Universidades y Centros de Formación de Personal en Educación para la Salud y Promoción de la Salud (CIUEPS), Red Caribeña de Promoción de la Salud y Educación para la Salud de la Universidad de Puerto Rico. Proyecto Regional de Latinoamérica de Evaluación de la Efectividad de la Promoción de la Salud: [email protected]. This Project is a component of the Global Project of Effectiveness of Health Promotion of the International Union of Health Promotion and Education (IUHPE). Available at www.iuhpe.org.

Restrepo, E.H., et al. (1996). The PAHO/WHO experience: Healthy municipalities in Latin America. In Price, C., Tsouos, A. (Eds.) Our cities, our future: Policies and action plans for health and sustainable development (pp. 203–215). Madrid: WHO/EURO, Ayuntamiento de Madrid, OECD. It describes some of the projects of Healthy Municipalities in Latin America countries presented in Madrid, Spain, during the world meeting on Healthy Cities in 1995.

HEALTH PROMOTION: THE in changes in birth rate, life expectancy, and MEXICAN CASE migration patterns. The health sector now Dora Cardaci basically deals with two groups of health problems: (1) infectious diseases and malnu- Over the last 30 years, Mexico has undergone trition; and (2) cardiovascular diseases, cancer, a profound transformation in both its demo- mental disorders, and AIDS (Cardaci & Diaz, graphic and epidemiological profiles, as seen 2004). Health Promotion 5/1/07 11:18 AM Page 277

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Mexico’s health system is composed of programs have also been designed to prevent three broad segments: First, there are the addictions, accidents, and violence, particu- social security institutions, which include larly among teenagers and old people, two age IMSS (Mexican Institute of Social Security), groups with an increasing presence in the ISSSTE (Institute of Social Security for State overall population. Finally, efforts have con- Employees), and the medical services pro- centrated on protecting the health of migrants, vided by Pemex (the National Petroleum creating for their benefit the following pro- Company), as well as the defence and navy grams: Frontera saludable 2010 (Healthy ministries. The three types of institutions Border 2010) and Vete sano, regresa sano (Go look after 50–55 percent of the population. healthy, return healthy). Second, there are the health services for the Despite Canada’s diverse influences on uninsured, provided mainly by the health Mexican health promotion, there is space here secretary; and, third, the private health serv- to mention only three. Firstly, even before the ices. Health promotion activities are under- 1994 signing of the North American Free taken by the institutions that attend to the Trade Agreement (NAFTA), activists and population as a whole as well as by the social NGOs in both countries worked to lessen the security institutions, coordinated with other impact on health foreseen in operating the governmental sectors and a diversified set of treaty. Secondly, the Québécois movement, social actors, mainly NGOs. Villes et Villages en santé (Healthy Commu- The Secretary of Health, through its nities) became an important reference for a General Directorate of Health Promotion, network linking almost 1,500 Mexican used to enact laws concerning the promotion municipalities working to promote health. of health and to coordinate programs at Lastly, mention must be made of the role national, regional, and local levels. However, played by Canada’s International Develop- following the 5th World Conference on ment Research Centre (IDRC) in the dis- Health Promotion held in Mexico in 2000 semination and construction of new (OMS, 2000), greater prominence was given approaches in environmental health promo- to this field through the creation of an tion (Rodríguez, 2004). Under-Secretariat for Prevention and Health Links such as these with Canadian Promotion that coordinates the participation health professionals and activists are of the of all sectors and organizations with a pri- utmost importance to Mexico if we mean to mary commitment to health promotion. continue strengthening the field of health Examples of important health promotion promotion. Indeed, provision must be made initiatives in this context are, for instance, for even greater sharing of expertise in the Hospital amigo de la madre y el niño (baby- training of health personnel and for a wider friendly hospitals), actively promoting breast- distribution of the valuable publications feeding and joint mother-and-child hospital coming out of Canada, starting by having accommodation. Special health promotion them translated into Spanish.

REFERENCES Cardaci, D., & Díaz, B. (2004). ¿En un mar de ambigüedades? Políticas, programas y estrategias de for- mación en promoción y educación en salud en México. In H.V. Arroyo (Ed.), La la promoción de la salud en América Latina: Modelos, estructuras y visión crítica (pp. 343–365). San Juan, Puerto Rico: División de Impresos Universitanos, Universidad de Puerto Rico. Health Promotion 5/1/07 11:18 AM Page 278

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OMS. (2000, June 5). Declaración ministerial de México para la promoción de la salud. De las ideas a la acción. México City. Rodríguez, M. (2004). Importancia del ecosistema en el diseño de programas de promoción de la salud humana: malaria. México: ILCE.

RELEVANT WEB SITES La Fundación Mexicana para la Salus (FUNSALUD) www.funsalud.org.mx Secretan´a de Salud www.salud.gob.mx Instituto Nacional de Salud Pública www.insp.mx

HEALTH PROMOTION IN and tobacco control (Minister of Health, 2004; NEW ZEALAND: COMING Ministry of Transport, 2005). However, New INTO ITS OWN Zealand struggles with significant challenges, Louise Signal common internationally. Eliminating health inequalities poses one of the biggest chal- Health promotion has matured in New lenges, particularly inequalities for indige- Zealand over the past two decades into an nous Ma¯ori whose life expectancy at birth is accepted public health discipline. New Zealand nearly 10 years less than Ma¯ori (Ajwani et has adopted international concepts and al., 2003). Ongoing commitment to, and hon- approaches and added its own perspectives and ouring of, te Tiriti o Waitangi, a contract ways of working (Martin, 2002). There is a between Ma¯ori and the British Crown signed small but established health promotion infra- in 1840 in which Ma¯ori exchanged sover- structure of health promotion providers, and eignty for protection of their interests and the an increasingly experienced workforce, train- same citizenship rights as other British sub- ing programs, research groups, and provider jects, is thus necessary. networks for the development of health Increasing globalization means that promotion practice and advocacy, such as many health-related issues are increasingly the Health Promotion Forum and Te Reo influenced from outside New Zealand. Marama (Ma¯ ori Smokefree Coalition). Health promotion needs more effective ways Recently, the health promotion mandate of pri- to work internationally to address them, mary care has been strengthened, providing including developing partnerships between new opportunities if appropriate support and nations, working through international capacity building are forthcoming. organizations such as the World Health New Zealand has demonstrated that Organization (WHO) and the International comprehensive, sustained interventions can Union for Health Promotion and Education succeed in improving health status in areas (IUHPE), and building alliances with the such as road safety, heart disease prevention, many other sectors and interest groups with Health Promotion 5/1/07 11:18 AM Page 279

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shared values. There have been successes, in tobacco control (Studlar, 2005). People from such as the development of the Framework both countries study and work together, share Convention on Tobacco Control, in which learning at international conferences, and uti- New Zealand played a role. lize resources such as Click4HP. New New Zealand draws support for health Zealand’s relationship with Canada is due to promotion from a number of quarters, includ- many factors, including Canada’s leadership ing countries such as Canada, Australia, and in health promotion, the similar colonial his- Britain. Canada had a significant conceptual tory of both countries, and the links between influence on the foundations of current health Commonwealth nations. promotion practice in New Zealand. The In recent years New Zealand has “come Ottawa Charter is a cornerstone of New into its own” in relation to health promotion. Zealand health promotion. The concepts of However, in today’s global world, no nation healthy public policy and healthy cities can achieve health and equity without the emerged from Canada and are key aspects of support of others. The challenges facing the health promotion practice. New Zealand health of the peoples of the world require looks to Canada, as it does to other friends and vision, courage, and effective partnerships neighbours, for examples of good practice, e.g., for action.

REFERENCES Ajwani, S., Blakely, T., Robson, B., Tobias, M., & Bonne, M. (2003). Decades of disparity: Ethnic mortality trends in New Zealand 1980–1999. Wellington: Ministry of Health and University of Otago. Martin, H. (2002). TUHA-NZ a treaty understanding of Hauora in Aotearoa-New Zealand: An understanding about the application of te Tiriti o Waitangi in health promotion practice in Aotearoa-New Zealand. Auckland: Health Promotion Forum of New Zealand. Minister of Health. (2004). Implementing the New Zealand Health Strategy 2004: The minister of health’s fourth report on progress on the New Zealand Health Strategy, and her first report on actions to improve quality. Wellington: Ministry of Health. Ministry of Transport. (2005). Ministry of Transport: Brief to the minister of transport 2005. Wellington: Ministry of Transport. Studlar, D.T. (2005). The political dynamics of tobacco control in Australia and New Zealand: Explaining policy problems, instruments, and patterns of adoption. Australian Journal of Political Science, 40, 255–274.

RELEVANT WEB SITES Health Promotion Forum of Aotearoa–New Zealand (HPF) www.hpforum.org.nz The Health Promotion Forum is a national umbrella organization for health promotion in Aotearoa–New Zealand working for a healthier society. It provides national leadership and support for good health promotion practice consistent with the principles of Te Tiriti o Waitangi and the Ottawa Charter. More than 200 organizations nationwide are members. Health Promotion 5/1/07 11:18 AM Page 280

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Health Sponsorship Council www.healthsponsorship.org.nz The Health Sponsorship Council is an example of a New Zealand-based health promotion agency committed to social change and marketing health messages to New Zealanders. It uses a range of communication tools to promote health messages and its health brands, such as Smokefree/Auahi Kore.

Ministry of Health www.moh.govt.nz The Ministry of Health is the leading national government health agency in New Zealand. It has responsibility for policy development and funding of key health promotion action.

GO, CANADA, GO! THE years. All the countries have adopted the INTERPLAY OF CANADIAN Nordic welfare state model, some starting in AND NORDIC HEALTH the 1930s. The aim was to operate from a PROMOTION democratic foundation and universally pro- Bengt Lindstrom and Monica Eriksson vide for the basic needs of the populations. The welfare systems are very expensive, To compare the Nordic countries to Canada financed through high levels of income and is an interesting venture because this gives general taxes. Sweden and Denmark currently an opportunity to try to match us with one have the highest tax rates in the world. of the international leaders in health pro- Originally, it was thought to be very difficult motion. There are some similarities, such as to restructure the Nordic welfare systems to prosperity, population size, and geographic meet EU requirements, but they are among position, that make for an interesting com- the few who actually were able to do so prop- parison between Canada and the five coun- erly, as compared to what has been accom- tries of the Nordic Union as a whole (i.e., plished in some of the leading European Denmark, Iceland, Finland, Norway, and nations. However, it seems that for the time Sweden). being the states have come out of all of this more prosperous than ever, but it is difficult to know what impact these changes will have The Context: Some Historic, on the health of the population in the long run. Political, Socio-economic, and This long-term Nordic policy approach Demographic Facts has led to all kinds of generally very positive We believe that, at least in this part of the outcomes. GNP per capita is high—most of world, many of the contemporary achieve- the time, the five countries are among the top ments of health promotion actually are effects 10 globally. Canada held the world’s leading of a longer development and of certain kinds position for several years on the Human of political choices. The Nordic countries have Development Index (HDI) (that, in addition about 25 million inhabitants and historically to socio-economic and health indicators, also there have been strong political and socio-eco- includes human rights issues), but over the past nomic links among them over the past 1,000 three years Norway has taken over the lead. Health Promotion 5/1/07 11:18 AM Page 281

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The general health data of the Nordic At present, all the five countries have countries are among the best worldwide even national public health policies, including if less than 10 percent of the GNP is put into health promotion as a theme. Our general health. Infant and perinatal mortality rates are assessment is that among experts and policy the lowest in the world and the highest mean makers, health promotion is understood and life expectancy belongs to Iceland for men and accepted as an issue. However, many health to Sweden and Iceland, among other coun- care and education experts are still mixing tries, for women. Nevertheless, the Nordic up health promotion and prevention and the countries face the same health problems as the general population maintains a strong belief rest of the developed world: unstable family in the medical system. Thus we are far from structures, high divorce rates, high levels of a general understanding of health promotion alcohol and tobacco use notably among the and perhaps the Finnish initiative to include young, mental health problems (some of the health literacy as a school subject is the right highest suicide rates in the world), workload way to go to achieve long-term transforma- and everyday stress leading to exhaustion, tion of the vision of health in the young gen- long-term sick leaves, and early retirements. eration. Funding of health promotion The obesity epidemic is adding to the already remains very limited as compared to what is very high incidence of diabetes and cardio- given to the medical care system in general, vascular disease (NMK, 2001). a situation that does not seem much different than what we read about Canada. The Canada–Nordic Policy Connection Nordic Best Practices The Lalonde Report (Lalonde, 1974) was cer- A main conclusion of the evaluation of the tainly an eye opener and had a strong impact effectiveness of health promotion action after on the Nordic health policies, first through the 2005 Global Health Promotion actions within international and UN bodies Conference in Bangkok is that synergy and and later in the national implementation of coherence in action is the main road to suc- such policies. However, most of the time, the cess (Kickbusch, 2005). Much of this evidence Nordic influence on international health is based on the evaluation of Canadian pro- policy has also been strong and there have grams. As a consequence it would be imper- been Canadians on most of the international ative to find both theory-driven models and decision and development bodies, working practices that bring coherence between with Nordic colleagues, all the time since actions on the individual and societal levels Lalonde. The director general of WHO as well as synergy between programs and sec- behind the Health for All Policy was Danish tors. This has been said many times before, and a few of the WHO EURO directors have but again, frequently not followed through. been Nordics. Later, the IUHPE president The Nordic countries can nevertheless was Norwegian, the WHO-International be proud of several important health pro- Health Promotion director was Finnish, and motion achievements, among which the clas- a Finn was leading the EC health promotion sic one is the North Karelia project in program—almost at the same time. If one Finland; started in the early 1970s, it defi- looks at the Canadian input in such bodies, nitely had an impact all over the world it is just as impressive. (IUHPE, 2000). Another good example is the Health Promotion 5/1/07 11:18 AM Page 282

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accident-prevention programs of Sweden been influencing each other and working that have reduced accident rates to one of the together in health promotion over the last lowest in the world. Currently, there is a decades. A topic very dear to our hearts that common Nordic program for disability— could be an area of increased joint interest in Design for All—accepted by the Nordic the future is further developing the salutogenic Council of Ministers in October 2005, which framework originally proposed by medical takes coherent action to enable disabled sociologist Aaron Antonovsky ( Lindström & people to function fully in society. Another Eriksson, 2005). With its orientation on what important achievement is the anti-smoking produces health rather than disease (patho- program of Sweden, presently the only genic) and its concepts like sense of coherence nation in Europe to meet the aims of the (SOC) and general resistance resources, it has WHO/EC program on smoking reduction, a lot to offer in terms of a major conceptual despite the integration to EU where business advancement in health promotion (Eriksson and trade considerations have priority and & Lindström, 2005). often go against health promotion policies. So, go, Canada, go! and go, Nordics, go! In this area as in many others, we definitely have a lot in common beyond the snow, the The Future cold, and ice hockey on which we can jointly As we have seen, there are many ways in work in the future! which Canada and the Nordic countries have

REFERENCES Eriksson, M., & Lindström, B. (2005a). Antonovsky’s sense of coherence scale and the relationship with health—a systematic review. Journal of Epidemiological Community Health, Accepted 60(5), 376-381. Eriksson, M., & Lindström, B. (2005b). Validity of Antonovsky’s sense of coherence scale—a systematic review. Journal of Epidemiology Community Health, 59, 460–466. IUHPE. (2000). The evidence of health promotion effectiveness. Shaping public health in a new Europe. A report for the European Commission. Brussels: ECSC-EC-EAEC. Kickbusch, I. (2005). Policy for health promotion addressing global health governance challenges. Paper presented at the 6th Global Conference on Health Promotion, Bangkok. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Minister of Supply and Services. Lindström, B., & Eriksson, M. (2005a). Professor Aaron Antonovsky (1923–1994)—the father of the salutogenesis. Journal of Epidemiology Community Health, 59, 506–511. Lindström, B., & Eriksson, M. (2005b). Salutogenesis. Journal of Epidemiology Community Health, 59, 440–442. NMK. (2001). Health statistics in the Nordic Countries 1999. Copenhagen: Nordisk Medicinalstatistisk Komité.

RELEVANT WEB SITE Nordic Medico-Statistical Committee www.nom-nos.dk/ Health Promotion 5/1/07 11:18 AM Page 283

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ON BEING A DONOR children since it is clear that smoking uptake COUNTRY: CANADA’S ROLE is reduced with higher cigarette costs. Other IN HEALTH PROMOTION IN health promoting support includes that from PACIFIC ISLAND NATIONS the Canada Fund, run directly by the Jan Ritchie Canadian High Commissions in New Zealand and Australia, which provides finan- The Pacific Ocean is home to 22 nation-states cial support for PIC’s small-scale local ini- (often designated as Pacific island countries, tiatives, including some community health or PICs), primarily concentrated in the south- promotion projects (www.dfait-maeci.gc.ca/ western quarter of this vast stretch of water. newzealand/cdafund-en.asp). These island countries are home to less than 9 In 1995, the World Health Organization million people overall; however, they have hosted a meeting of Pacific island health min- unusual strategic importance both because of isters where the ministers determined not their location just east of Asia, and because the only to improve their countries’ health care United Nations and its agencies give votes to but also seek to place equal importance on member states on an individual membership health promotion for their citizens. The basis regardless of population size, thus lead- Yanuca Island Declaration arising from this ing to these Pacific votes being influential polit- meeting has been the frontrunner of a decade ically in international affairs. Although most of regional commitments to maintain a focus island countries have thrown off their colonial on health promotion across the Pacific status, they have gained political autonomy but through a settings approach, following the little in the way of economic independence, principles of the Healthy Cities movement and it is here that donor countries, including (Galea, Powis, & Tamplin, 2000). Again, Canada, have had an influence. Canada has been instrumental in taking this As already discussed in an earlier chap- forward through supporting the work of the ter by Labonté, the health promotion com- SPC in acting as a resource base for Pacific munity within Canada has taken a island countries, working in the two official forward-looking perspective on the health languages of the Pacific, French and English. impacts of global trade agreements, and this The bilingual nature of the print and Web- influence has recently penetrated the Pacific. based health promotion resources emanating Canada has funded a policy document pro- from Canada has meant these materials are duced by the Secretariat of the Pacific particularly valued by SPC for dissemination Community (SPC), taking forward the across the region, and bilingual Canadians Framework Convention on Tobacco Control, with health promotion expertise have played and related issues in alcohol control as rec- an important part in conducting workshops ommended by the 2004 World Health for health promotion personnel on Healthy Assembly, with the document reporting on Islands’ policy and practice. the negative aspects of reducing tobacco and It is thus mainly through its donor capac- alcohol tariffs within the recent regional ity that Canada has influenced the develop- trade agreements (SPC, 2005). Its recom- ment of health promotion in PICs, a role often mendations, if implemented, will have a underestimated and misunderstood. marked impact on the health of Pacific island Health Promotion 5/1/07 11:18 AM Page 284

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REFERENCES Galea, G., Powis, B., & Tamplin, S.A. (2000). Healthy islands in the Western Pacific-international settings development. Health Promotion International, 15(2), 169–178. SPC. (2005). Tobacco and alcohol in the Pacific Island Countries Trade Agreement: Impacts on population health. Retrieved December 12, 2005 from www.spc.int/AC/Tobacco/ tobacco_trade_agreement_in_the_region.html.

RELEVANT WEB SITES Fiji School of Medicine (FSM) www.fsm.ac.fj FSM has a strong health promotion stream in both its undergraduate and post-graduate training relevant to PICs.

Secretariat of the Pacific Community (SPC) www.spc.org.nc SPC has developed many health promotion-related resources relevant to PICs.

United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) www.unescap.org UNESCAP similarly has produced relevant resources for the Pacific region.

THE PUERTO-RICO health promotion initiatives that can be eval- CANADA LINKAGE uated to assess their effectiveness. Hiram V.Arroyo Currently, the Puerto Rican health promotion community strongly values and uti- Canadian Influence on Puerto Rican lizes Canadian models in public health and Health Promotion health promotion. We see the Canadian The publication of the Ottawa Charter for public health system as a dynamic policy Health Promotion in 1986 helped consolidate maker, capable of promoting crucial social and legitimize the global movement for and structural system changes. In that sense, health promotion in our country. Since then, Canada has been and continues to be a cen- the Canadian commitment and hands-on tral reference for Latin American countries. experience have been constant guides and sources of academic, professional, and technical references, helping the development of Canadian Links to Puerto Rico– health promotion ideas and values as well as Driven Pan-American Initiatives the development of institutional structures. The Canadian presence is also strong in the Still needed, however, is the development of ongoing work of the Latin American academic stronger multisectoral integration and insti- and professional network. For example, many tutional policy. If these steps are taken, they Canadian organizations and prominent indi- may lead to the implementation of stable viduals partake in initiatives developed by the Health Promotion 5/1/07 11:18 AM Page 285

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Latin American Regional Office (Oficina training of health promotion human resources Regional Lation-Americana – ORLA) of the was included (Hills, 2001) in a Pan-American International Union for Health Promotion and book published by the CIUEPS on this topic Health Education (IUHPE), whose head- (Arroyo, 2000). quarters are in Puerto Rico. In a different area, the Canadian presence We have also collaborated with Canada has been constant in the planning and devel- in the training of human resources in the opment of regional, national, and international health promotion field. Various Canadian public health education and health promotion institutions, including Laval University in events held in Puerto Rico during the last Quebec and the University of Toronto, were decade. Some that deserve a special mention founding members of the Inter-American are: the IUHPE 16th World Conference on Consortium of Universities and Training Health Promotion and Health Education Centers for the Formation of Public Health (June 1998), the 2nd Puerto Rican Conference Education and Health Promotion Personnel on Public Health (September 2004), and the (Consorcio Interamericano de Universidades Health Promotion Effectiveness Projects y Centos de Formación de personal en Synergy Meeting between IUHPE/NARO Educación para la Salud y Promoción de la and IUHPE/ORLA (December 2004). Salud – CIUEPS) launched in 1996 under the There is no doubt that collaborative leadership of the Pan-American Health partnerships with the Canadian academic- Organization and the University of Puerto professional community will continue, Rico (Arroyo, 1996). In addition, the CIUEPS notably to partake in the organization and collaborated with the Université de Montréal insure a strong Puerto Rican and Latin in the development of a guide for media com- American participation in the IUHPE 19th munication (Renaud & Caron-Bouchard, World Conference to be held in Vancouver, 1999). Finally, the Canadian experience in the Canada in 2007.

REFERENCES Arroyo, H.V. (1996, April 17–19). Memorias I Asamblea General del Consorcio Interamericano de Universidades y Centros de Formación de Personal en Educación para la Salud y Promoción de la Salud. San Juan, Puerto Rico. Arroyo, H.V. (2000, June). Memorias III Asamblea General del Consorcio Interamericano de Universidades y Centros de Formación de Personal en Educación para la Salud y Promoción de la Salud, Mexico City, D.F., Mexico. Hills, M. (2001). Health promotion courses and programs in Canadian universities: A survey. In H. Arroyo (Ed.), Formación de Recursos Humanos en Educación para la Salud y Promoción de la Salud. San Juan, Puerto Rico: University Printers, University of Puerto Rico. Renaud, L., & Caron-Bouchard. (1999). Guía Práctica Comunicaciones Mediáticas para la Promoción de la Salud. Edited in Spanish by Mauricio Gómez-Zamudio. Montreal-Centro Public Health Directory. Montreal (Quebec).

FURTHER READINGS Arroyo, H.V. (Ed.). (2001). Formación de Recursos Humanos en Educación para la Salud y Promoción de la Salud: Modelos y Prácticas en las Américas. San Juan: División de Impresos Universitarios, Universidad de Puerto Rico. Health Promotion 5/1/07 11:18 AM Page 286

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The book describes the contribution of many higher education institutions from the Pan-American region in the topic of human resources development and training in the field of health promotion and health education.

Arroyo, H.V. (Ed.). (2004). La Promoción de la Salud en América Latina: Modelos, Estructuras y Visión Crítica. División de Impresos Universitarios. San Juan: Universidad de Puerto Rico. This book offers a collection of articles written by expert contributors representing 12 Latin American countries. The articles presents a profile of the national situation of health promotion in Puerto Rico and the following countries: Argentina, Brazil, Chile, Colombia, Cuba, Ecuador, México, Panamá, Perú, Dominican Republic, and Uruguay.

Government of Commonwealth of Puerto Rico. (2005). Final report of the National Commission for the study of health system in Puerto Rico. This official report presents a comprehensive analysis of the situation of public health and health promotion in Puerto Rico. From www.rcm.upr.edu. and www.salud.gov.pr.

RELEVANT WEB SITES Government of Commonwealth of Puerto Rico, Department of Health, Auxiliary Secretary for Health Promotion www.salud.gov.pr The Auxiliary Secretary for Health Promotion is the structure of the Puerto Rico Health Department responsible for developing and evaluating the island-wide Health Promotion National Plan.

Inter-American Consortium of Universities and Training Centres for the Formation of Health Education and Health Promotion Personnel www.rcm.upr.edu. The consortium is an initiative of the Pan-American Health Organization, the University of Puerto Rico, and others institutions of higher education with the purpose of promoting training, research, and special projects in the fields of health education and health promotion. The Consortium Coordination Office is located in the Department of Social Sciences, School of Public Health, Medical Sciences Campus, University of Puerto Rico.

Latin American Regional Office (ORLA) of the International Union on Health Promotion and Education (IUHPE) www.iuhpe.org The IUHPE headquarters of the Latin American Regional Office (ORLA) are located in the Department of Social Sciences, School of Public Health, University of Puerto Rico. This office provides information, contacts, and relevant reports of the IUHPE/ORLA initiatives. Health Promotion 5/1/07 11:18 AM Page 287

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School of Public Health, Medical Sciences Campus, University of Puerto Rico www.rcm.upr.edu The School of Public Health is the academic unit of the Medical Sciences Campus with the responsibility for offering direct training, services, and research in public health and health promotion.

ROMANIA: AN EASTERN- ing for Romanian staff abroad became key EUROPEAN APPROACH TO elements in insuring the change in theoreti- HEALTH PROMOTION cal approaches. In 1993, Romania joined the Irina Dinca European Network of Health Promoting Schools, and then the European Committee Health promotion is a quite new concept in for Health Promotion Development. It also Romania. Before 1990 this concept was gen- benefited from an Investment for Health erally known as sanitary/ hygiene education. audit in 1998. Romania has established part- The roots of hygiene education in Romania nerships with, among other institutions, the date back to 1948, and in 1951 a national net- Canadian Public Health Association (which work was set up, with a national centre based mentored and offered funding to the at the Institute of Public Health in Bucharest. Romanian Public Health Association, includ- Health care in communist Romania was free ing a component in health promotion) and and universal for the population, but based on the Université de Montréal (through the very tight measures. Some of these measures, summer schools organized in Switzerland in the maternal and child health sector, led in through Swiss Development Cooperation fact to disastrous consequences in terms of [SDC] funding). maternal mortality and abandoned children. In addition to these successes at the gov- Consequently, after the political changes ernment level, the newly emerging sector of in December 1989, the first law that was abol- non-governmental organizations in civil soci- ished was the one forbidding abortion. ety, which was non-existent during the com- Health reform has since started, with many munist regime, has become a key player in advances and retreats, and this complex health promotion; it is able to attract excel- process has not yet ended. The major change lent staff (salaries are much higher than in the impacting all sectors of life was Romania’s public sector) and significant funding from new openness to the world. In the public international donors, while the public sector health field, concepts like non-communica- didn’t fund such organizations until 1997. ble disease prevention, health promotion, However, in spite of all of these pro- advocacy, or empowerment were among the found changes at a theoretical level by an elite first providing renewal of old-fashioned of health promotion professionals, few Soviet-influenced social medicine. changes occurred in everyday practice and The Ottawa Charter became one of the the governmental network is still very frag- main documents studied during post-gradu- ile. National priorities have been established ate training in health promotion that all staff in health promotion (reproductive and family employed at local (district) and national levels health, sexually transmitted disease preven- in the hygiene network had to go through. tion, healthy lifestyle including tobacco con- International technical assistance and train- trol, moderate use of alcohol, drug abuse Health Promotion 5/1/07 11:18 AM Page 288

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prevention, cancer prevention, and tubercu- international donors (USAID, UN agencies, losis prevention), but local priorities are left SDC). Thus, although some progress has to the decisions of district teams (e.g., iodine been made in health promotion in Romania, deficiency, etc.). Funds from the Ministry of stimulated in part by Canadian experience, Health budget became available, but remain there is still much to be done. scarce, and have to be complemented by

RELEVANT WEB SITES

National Institute for Research and Development www.incds.ro Romanian Ministry of Health www.ms.ro United Nations Development Programme: Romania www.undp.ro United Nations Population Fund: Romania www.unfpa.ro

HEALTH PROMOTION IN and sanitation, intersectoral collaboration, SENEGAL: SIMILARITIES home care, and community staff training AND DIFFERENCES WITH (Mbacké, 1997). These are components of PRIMARY HEALTH CARE PHC, but also belong to what would be later Awa Seck called health promotion. Consequently, there are similarities between PHC and health pro- Since the adoption of the Ottawa Charter, the motion since the Ottawa Charter was certainly concept of health promotion evolved with influenced by the Alma-Ata Declaration, but strong differences worldwide. They are espe- health promotion has a broader perspective cially evident between developed and devel- than PHC and its application goes beyond the oping countries, as health promotion was local level of health system. During a initially conceived for the industrialized Senegalese National Health Conference held countries. in 2000, the participants further recognized that to achieve “health for all,” health promotion offered more possibilities than PHC. Primary Health Care (PHC) and Thus, it was decided to integrate it into the Health Promotion in Senegal national health policy (Ministère de la santé, After the Alma-Ata Conference (World 2000). However, this integration requires Health Organization, 1978), the Senegalese health promotion specialists, who are government based its health policy on PHC. extremely rare in Senegal. To help fill this gap, Among the reforms undertaken were the a study was conducted (Seck, Morin, & O’ front-line health services to include activities Neill, 2003), but, unfortunately, its recom- such as health education, community organ- mendations have not yet been applied and the ization, interpersonal communication, hygiene need for qualified personnel is still abysmal. Health Promotion 5/1/07 11:18 AM Page 289

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Canada’s Contribution to PHC and These contributions support the “fight Health Promotion in Senegal against poverty” strategy whereby Senegal, Canada has traditionally been one of Senegal’s in line with the spirit of the Millennium main partners in development projects. In Development Goals, aims for a 50 percent PHC and health promotion, it has notably reduction by 2015. taken the form of strengthening the peda- Canada is considered as a major, if not gogical skills of nurse and midwife teachers, the, world leader in health promotion. We of working to reduce maternal and infant thus think that it could help Senegal even mortality, of participating in the fight against more in supporting the development of a HIV/AIDS, of developing community-based public health promotion policy and its imple- health insurance, and, more recently, of mentation. Support in health promotion taking charge of anti-personnel mines victims training and education could be another very in the Ziguinchor area (Gouvernement du important contribution. Finally, helping to Canada, 2005). build capacity in health promotion research Moreover, Canada contributes to would allow for better health service reori- improving the determinants of health by, entation and utilization. among other things, fostering basic educa- Even if it has done a lot in the past, tion, promoting women’s rights, strengthen- Canada still has a lot to bring to the Senegalese ing grassroots economy in rural areas, as well people! as stimulating decentralization and community participation in local decisions.

REFERENCES Gouvernement du Canada. (2005). La coopération canadienne au Sénégal. Sénégal: Bureau d’appui à la coopération canadienne au Sénégal, Agence canadienne de développement international. Retrieved January 2, 2005, from www.dfait-maeci.gc.ca/dakar/devel-fr.asp. Mbacké, M.A. (1997). Historique du poste de santé. Saly Mbour: Document préparatoire de la Conférence Nationale sur le poste de santé au Sénégal. Saly Mbour: Ministère de la santé et de l’action sociale. Ministère de la santé. (2000). Assises nationales sur la santé (travaux des commissions, thèmes des tables rondes et des sous-commissions). Dakar: Le Présidium. Seck, A., Morin, D., & O’Neill, M. (2003). L’étude des besoins de formation continue en promotion de la santé pour les infirmières et infirmiers chefs de postes de santé au Sénégal. International Journal of Health Promotion and Education, X(2), 81–86. World Health Organization (WHO). (1978). Declaration of Alma-Ata. Geneva: International Conference on Primary Health Care. Alma-Ata, USSR.

RELEVANT WEB SITES Health Promotion WHO Afro www.afro.who.int/healthpromotion/index.html In this Web site, there is information about health promotion for the African area. The mission, functions, and strategies to implement health promotion are described for all the African countries. Health Promotion 5/1/07 11:18 AM Page 290

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International Union for Health Promotion and Education www.iuhpe.org This Web site is a WHO reference in health promotion and health education. This resource supports continuing education throughout the world because it publishes several reviews and gives recent information on these two interest fields.

Réseau Francophone International Pour la Promotion de la Santé www.refips.org The REFIPS is an important French network, very utilized by the French African people. It helps health promotion professionals by offering many possibilities to exchange knowledge and experience in relation to health promotion.

PROMOTING HEALTH IN proper training, notably with respect to theo- SWITZERLAND: A FEDERAL– ries in health promotion, can also partly CANTONAL INTERPLAY explain the relative weakness of health pro- Jean Simos motion in our country. By its contribution to capacity building It’s only since the middle of the 1990s that the in health promotion, Canada has gained concept of “health promotion” was progres- great visibility in Switzerland. The numer- sively utilized in Switzerland. The term was ous interventions of Canadian experts in a introduced in the federal Medicare legislation variety of contexts (e.g., the summer univer- of 1996, which triggered the creation of an sity in Ascona, which has been running for institution whose goal would be “to stimulate, more than a decade) have influenced several coordinate, and evaluate measures intended key figures in Switzerland’s health promo- to promote health and prevent illnesses.” The tion community. The exchanges taking place financing of Health Promotion Switzerland, during seminars organized by universities or which was then created, is assured by an some of the cantons were beneficial and the annual subscription collected from each citi- implementation of concrete projects enabled zen through Medicare, which is mandatory Canadian experts to share their experience for every person residing in Switzerland. with their Swiss colleagues as in the case of In the Swiss confederation, as in Canada Geneva’s plan on injury prevention. The can- but with a much smaller population of about tons where universities are implemented ben- 7 million, most of the health sector belongs efit more directly from these contributions constitutionally to the 26 cantons, which are although other cantons can also be innova- the states of the federal state of Switzerland. tive. For instance, it is tiny Jura (70,000 pop.) Hence, Switzerland doesn’t have a national that introduced in Switzerland Quebec’s health promotion policy. In order to alleviate “Operation Nez Rouge,” designed to prevent this situation, inter-canton collaborations, as drunk driving during the winter holidays. well as with the Confederation, have been International networks such as Villes- developed, but mostly for the French and Santé OMS and Villes et Villages en Santé for Italian parts of the country, which are a minor- healthy cities, or the Réseau francophone de ity as compared to the German majority. The prévention des traumatismes et de promotion absence of a critical mass of professionals with de la sécurité of the RÉFIPS for injury pre- Health Promotion 5/1/07 11:18 AM Page 291

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vention, have also been very useful especially The influences of Canada and specifi- on the lobbying and advocacy side of things. cally of Quebec on Swiss health promotion Finally, Canadian legislative work was a have thus been numerous and diversified and source of inspiration for Switzerland. For we are convinced that exchanges will con- instance Article 54 of Quebec’s recent public tinue in the future between our countries. health law, which requires a health impact assessment for every new legislation, has inspired elements of Geneva’s new health law.

FURTHER READINGS Bourdages, J., et al. (2005). L’intégration de la prévention et de la promotion dans les systèmes de santé: Quatre réalités, plusieurs similitudes. Promotion & Education (Suppl. 3), 62–64. Paris: Ed. Union Internationale de Promotion de la Santé et d’Education à la Santé. Synthesis of the work carried out during the forum Dialogue sur les systèmes nationaux de santé that was held in margin of the 2nd international symposium on the local and regional health programs. It also gave place to a compared analysis of four countries (Brazil, France, Switzerland, Canada).

Secrétariat du Grand Conseil. (2003). Rapport du Conseil d’Etat au Grand Conseil concernant le bilan de la planification sanitaire qualitative. From www.geneve.ch/grandconseil/data/texte/RD00490.pdf. This report relates the experience of a four-year health promotion pilot program. The program was conducted from 1998–2002 in the Geneva district. It can be consulted at www.geneve.ch/grandconseil/data/texte/RD00490.pdf.

Simos, J. (2006). Introducing health impact assessment (HIA) in Switzerland. Social and Preventive Medicine 51(3), 130-132. A forum dedicated to the health impact evaluation problematic and its premises in Switzerland.

RELEVANT WEB SITES Promotion Santé Suisse www.promotionsante.ch/fr/default.asp This Web site of Promotion Santé Suisse (Swiss Health Promotion) gives access to information and other resources related to health promotion in Switzerland.

Réseau Francophone des Villes-Santé de l’O.M.S. www.villes-sante.fr/datas/doc_pdf/presentation_RfVS.pdf. Presentation of WHO’s francophone network Villes-Santé, hosted on the francophone network’s Web site. Also, there are links to other networks and organizations connected to Villes-Santé, which, on another note, was born during the Ottawa Charter epoch. Health Promotion 5/1/07 11:18 AM Page 292

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THE CANADIAN APPROACH ulties of Tunis and Sfax, which were still AND ITS IMPACT IN operating with an outdated public health TUNISIA vision of hygiene and immunization. Moncef Marzouki Unfortunately, the adventure ended somewhat bitterly. Accused of being a com- At the beginning of the 1980s, I took over as munist medicine service, Sousse’s department the first Tunisian director of the Community was dismantled in 1992. I was myself banned Medicine Department at the Faculty of from the university in 2000 because of my Medicine of the University of Sousse, situ- activities as a human rights activist. Even ated in the centre of Tunisia. It was a fact worse, the dispensaries that we had begun to then that ambitious and talented Tunisian transform into community health centres fos- physicians were not going into public health, tering community participation quickly a field mainly occupied by political activists reverted to their old function: to give mini- (my case) or individuals who had failed on mum health care at the lowest possible cost so the clinical front. that a dominated population stood quietly in The job entailed teaching duties but, its everyday misery. All decision making foremost, preventive medicine activities in became concentrated in the hands of the Party. dispensaries spread out in the suburbs and The limit of the Canadian model then countryside of the area. As the team I led was struck me: It was the child of democracy and composed of almost all Canadians, it was my could not function properly in a dictatorial first encounter with the know-how and the state. The concepts and techniques originat- typical Quebec accent. It was an intense time ing from the shores of the St. Lawrence River of discovery and fascination about the tech- were highly subversive. That is why a step niques, concepts, and ethical approaches con- backward took place in the middle of the veyed by my new friends, a radical departure 1990s; why today I live in exile; and why my from the outdated French public health con- old colleagues trained in Montreal re-spe- ception that was previously predominant. cialized in other areas while being very care- The Canadian co-operation program, ful not to irritate the system. So then, was this which had triggered the implementation of a complete failure? Yes and no. The fight for the Community Medicine Department in a democratic state, a necessary condition for 1978, continued during the 1980s and a good the establishment of health promotion, car- part of the 1990s, which enabled systematic ries on slowly but surely. As for the ideas and exchanges with our friends and colleagues ideals related to a public-minded health serv- from Montreal and Quebec City. It facilitated ice, chances are that as sturdy seeds, they will the training of the Tunisians, who would emerge out of the arid ground when the then staff the department, and the organiza- proper rainfall, called freedom, comes. tion of three international symposiums at Sousse University. For more than 20 years then, the Tunisian faculty disseminated FROM YOUTH HEALTH TO A Canadian knowledge revolving around the NATIONAL HEALTH analysis of health determinants, health pro- PROMOTION PLAN: motion planning, and community participa- CANADA’S PARTNERSHIP tion. Sousse’s progressive department was WITH UKRAINE then influencing, for better or worse, the fac- Nadiya Komarova and Maryna Murashova Health Promotion 5/1/07 11:18 AM Page 293

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From 1998–2005, a model of intersectoral as in providing advice to youth and profes- multi-level collaboration was introduced in sionals on the development of youth health several regions of Ukraine within the Youth promotion materials and resources. Study for Health (YFH) Project. The project was tours organized by the Canadian partners managed by the Canadian Society for played a special role in the process of devel- International Health and funded by the opment of local capacity and in educating Canadian International Development Ukrainian decision makers in the develop- Agency. The model was developed by the ment of healthy public policies. Ukrainian Institute for Social Research, the Hands-on and scientific results of the project’s Ukrainian partner, in collaboration YFH project implementation in Ukraine is with a number of state and non-govern- an exemplary case of a country (Canada) play- mental Ukrainian and Canadian organiza- ing a fundamental role in supporting the tions based on the front-line Canadian development of a specific area of activity experience in health promotion. The goal of (youth health promotion) in another country the model was to promote healthier lifestyles (Ukraine). The intersectoral multi-level YFH among Ukrainian children and youth. model was presented and discussed at the It was critical to correctly select the ways Verkhovna Rada (the Parliament) of Ukraine of achieving the project’s goal and determine during parliamentary hearings in 2003, which the criteria of its success. Evaluation and gave an impetus to the development of the research have been significant components of National Health Promotion Program for the all activities, which have helped in monitor- Ukrainian population. The Verkhovna Rada ing the project’s responsiveness and facilitated of Ukraine then made a decision to create the the effective adaptation of Canadian best prac- National Centre of Youth Health Promotion, tices to the Ukrainian context and conditions. originally established within the YFH II While the project’s overall management was Project and later transferred to the State effectively carried out by the Canadian organ- Institute of Family and Youth Problems ization, a large role was played by Ukrainian under the Ministry of Ukraine for Family, project participants, who took part in the deci- Youth, and Sports; it is now a fully operational sion-making process using advice and rec- and effectively working structure that will ommendations provided by a number of continue to utilize Canadian expertise to fur- project advisory bodies, experts, and consult- ther promote healthy lifestyles among ants from both Ukraine and Canada. Ukrainian children and youth and to facili- The development of an effective mech- tate the policy-development processes at the anism of collaboration between Canada and local and national levels. Ukraine to maintain the exchange of information and effective coordination of partners’ actions was among the most crucial prereq- REFERENCING CANADA: A uisites of success. Contributions from the COMMENTARY ON Canadian partners were extremely valuable CANADIAN ACADEMIC at all stages of the development, piloting, and PUBLICATIONS FROM THE delivery of the YFH model. The expertise of UK Canadian consultants was particularly useful Gordon Macdonald in organizing and conducting project training, conferences, and special sessions, as well Internationally, but especially in the UK, the Health Promotion 5/1/07 11:18 AM Page 294

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world of academic health promotion has come motion development and similar population. of age in the 21st century. From slow embry- A paper was considered to be Canadian when onic beginnings in the 1970s, academia began at least one (but more normally all) the authors embracing health promotion in the 1980s, sup- were based in Canada when the article was ported its mushrooming in the 1990s, and is written. The content ranges from original witnessing its maturation in the first decade of research (Vahabi & Ferris, 1995 or Vossen et this century (Bunton & Macdonald, 2002). al., 2004 for instance) to editorials (e.g., Academic health promotion includes the Labonté, 1996), as well as whole issues dedi- teaching of the subject at undergraduate and cated to Canadian heart health (P&E, 2001) or post-graduate levels, research in all its forms, edited by Canadians (e.g., Potvin et al., 2005). and, of course, publication in books, periodi- HPI has carried an article from Canada cals, reports, and journals. In the 1970s few in virtually every other issue between 1995 and universities offered any form of study or award 2005. Some of these articles have been truly in health promotion; today it is truly an inter- seminal. Discussions on evaluating commu- national discipline with teaching and research nity health initiatives have been conducted on opportunities worldwide. In the 1970s there a worldwide basis, but Canada’s contribution were barely a handful of dedicated books avail- is significant (e.g., Judd et al., 2001); Poland’s able to any student of health promotion; today (1996) two-part debate on the principles and we have access to well over 100 texts content to evaluate healthy communities ini- (Mittelmark et al., 2000). In the 1970s very few tiatives was also influential. Robertson (1998) journals were dedicated to health promotion kicked off a debate on the shift from health as an independent discipline. Today we have promotion to population health, which was in excess of 50. This is a truly remarkable story, followed by a response from Raphael and and Canada’s contribution to these develop- Bryant (2002) on the limitations of population ments has been very noticeable. health. Raphael, Bryant, and Curry-Steven’s I know this because of my time over the work on poverty reduction and public health last 15 years as an editor or member of the edi- policy (2003, 2004) builds on the work by torial board of four academic journals: Journal Marmot and others in the UK on the social of Contemporary Health (JCH) (now, sadly, no determinants of ill health and disease and has longer published), The Health Education received worldwide attention. Journal (HEJ) (the longest-running domestic With the Ottawa conference some 20 journal in the UK); Promotion and Education years ago and Vancouver’s coming up in 2007, (P&E) (one of the official journals of the Canada’s influence on UK health promotion International Union for Health Promotion and developments continues to impress, and not Education), and, finally, Health Promotion only at the academic level. Evidence of the sig- International (HPI) (now published for over 20 nificance of Canada’s contribution to health years). Together these four journals have pub- promotion is to be found in UK policy docu- lished at least 49 articles by Canadian authors ments and in the four individual UK country since 1995, which compares very favourably members’ public health policies and strategies with countries of a similar stage in health pro- for the first decade of the 21st century. Health Promotion 5/1/07 11:18 AM Page 295

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REFERENCES Canadian Heart Health Dissemination Research. (2001). Promotion & Education, (Suppl. 1). Bunton, R., & Macdonald, G. (Eds.). (2002). Health promotion: Disciplines, diversity and developments (2nd ed.). London: Routledge. Judd, J., Frankish, C.J., & Moulton, G. (2001). Setting standards in the evaluation of community-based health promotion programmes—a unifying approach. Health Promotion International, 16(4), 367–380. Labonté, R. (1996). Community and its health—its power and its problems. Journal of Contemporary Health, 4, 2-3. Mittelmark, M.B., Kvernevik, A.M., Kannas, L., & Davies, J.K. (2000). Health promotion curricula; cross-national comparisons of essential reading. Promotion & Education, 7(1), 27–32. Poland, B.D. (1996). Knowledge development and evaluation in, of, and for healthy community initiatives. Part I: Guiding principles. Health Promotion International, 11(3), 237–247. Poland, B.D. (1996). Knowledge development and evaluation in, of, and for healthy community initiatives. Part II: Potential content foci. Health Promotion International, 11(4), 341–349. Potvin, L., Avargues, M.-C., Berghmans, L., Bilodeau, A., Bourdages, J., Brunelle, Y., et al. (2005). L’intégration de la promotion et de la prévention dans les systèmes de santé. Promotion & Education, 12, Supp. 3, 94. Raphael, D. (2003). Barriers to addressing the societal determinants of health: Public health units and poverty in Ontario, Canada. Health Promotion International, 18(4), 397–405. Raphael, D., & Bryant, T. (2002). The limitations of population health as a model for a new public health. Health Promotion International, 17(2), 189-199. Raphael, D., Bryant, T., & Curry-Stevens, A. (2004). Toronto charter outlines future health policy directions for Canada and elsewhere. Health Promotion International, 19(2), 269–274. Robertson, A. (1998). Shifting discourse on health in Canada: From health promotion to population health. Health Promotion International, 13(2), 155–166. Vahabi, M., & Ferris, L. (1995). Improving written patient education materials: A review of the evidence. Health Education Journal, 54(1), 99–106. Vossen, D., McArel, H., Vossen, J., & Thompson, A. (2004). Physical activity and the common cold in undergraduate university students; implications for health professionals. Health Education Journal, 63(2), 145–157.

FURTHER READINGS Cribb, A., & Duncan, P. (2002). Health promotion and professional ethics. Oxford: Blackwell Publishing. Marmot, M., & Wilkinson, R.G. (Eds.). (1999). Social determinants of health. Oxford: Oxford University Press. Tones, K., & Tilford, S. (2001). Health promotion: Effectiveness, efficiency, and equity (3rd ed.). Cheltenham: Nelson Thornes.

RELEVANT WEB SITES NHS Centre for Reviews and Dissemination www.york.ac.uk/inst/crd.dissem.htm This is is the well-established academic centre at York University specializing in systematic reviews of evidence. Health Promotion 5/1/07 11:18 AM Page 296

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UK Government’s Department of Health www.doh.gov.uk This gives a wealth of information on public health policy.

UK’s National Institute for Clinical Excellence www.nice.org.uk This incorporates the health promotion/public health evidence into practice agenda (NICE now includes the defunct Health Development Agency).

CANADA’S INFLUENCE ON These early initiatives predated the HEALTH PROMOTION IN Ottawa Charter and aligned the official poli- THE UNITED STATES OF cies and documents of the two countries. AMERICA Political resistance, however, too often derails Lawrence W. Green and Robert A. Hiatt the philosophical commitments of health promotion professionals in both countries. The Canada influences the United States in subtle commitment to more sweeping policies of ways. The influences are real, sometimes pro- socio-environmental changes recommended found, but often disavowed. Canada’s uni- by the Ottawa Charter to “make the health- versal health insurance, for example, inspired ier choices the easier choices” (Milio, 1986) reformers in the US health care system, but have been limited in the US largely to tobacco they always disclaimed Canadian-style uni- control. versality and uniformity. The Canadian Task A central concept of the Ottawa Charter Force on the Periodic Health Examination was participation. Canada led the way again (1979) influenced the US’s first Guide to in compiling the North American experience Clinical Preventive Services (1989), wherein in participatory research, and in supporting, over half of the 169 interventions recom- through the Royal Society of Canada, a mended were patient counselling for health review of the experience of participatory promotion and self-care. research in health promotion across Canada Medicine aside, the US has a very sub- to derive a set of guidelines for participatory stantial commitment within its public health research (www.lwgreen.net/guidelines.html). system to health promotion, thanks, in part, Sadly, this has been another good idea having to the Lalonde Report (more so even than the difficulty gaining traction as official policy Ottawa Charter), which influenced the pri- in Canada, but the guidelines have been orities on the environment, lifestyle, and widely applied by grant-making organiza- health services in the first US Surgeon tions in the US. General’s Report on Health Promotion and Recent interaction between leadership Disease Prevention (1979). Bilateral discus- of the National Cancer Institute of Canada sions in 1980 contributed to comparable ques- (NCIC) and that of the US NCI has created tions in Canada’s first Health Promotion a dynamic framework for cancer control Survey and the first comprehensive set of research. A model developed by Canadians social and behavioural measures in the US in the mid-1990s (Advisory Committee on National Health Interview Survey (Green, Cancer Control, 1994) formulated new strate- Wilson, & Bauer, 1983). gies for cancer control research adopted in Health Promotion 5/1/07 11:18 AM Page 297

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the US at the turn of the century (Hiatt & In return, these interactions have pro- Rimer, 1999). This synergistic interaction vided Canadians at least the opportunity to continues as health promotion evolves in both observe American false starts and failures countries (Best et al., 2003) toward greater first hand, and then to reshape them in more emphasis on dissemination and implemen- socially responsible and politically palatable tation of research and practice with leader- forms up north. ship from the Canadian Institute for Health Services Research, NCIC, and the Canadian Heart Foundation (see Johnson et al., 1996).

REFERENCES Advisory Committee on Cancer Control. National Cancer Institute of Canada. (1994). Bridging research to action: A framework and decision-making process for cancer control. Canadian Medical Association Journal, 151(8), 1141–1146. Best, A., Stokels, D., Green, L.W., Leischow, S., Holmes, B., & Buckholz, K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion, 18(2), 168–176. Canadian Task Force on the Periodic Health Examination. (1979). The periodic health examination. Canadian Medical Association Journal 121, 1193–1254. Green, L.W., Wilson, R.W., & Bauer, K.G. (1983). Data required to measure progress on the objectives for the nation in disease prevention and health promotion. American Journal of Public Health, 73, 18–24. Hiatt, R.A., & Rimer, B.K. (1999). A new strategy for cancer control research. Cancer Epidemiology Biomarkers and Prevention, 8(11), 957–964. Johnson, J.L., Green, L.W., Frankish, C.J., MacLean, D.R., & Stachenko, S.A. (1996). Dissemination research agenda to strengthen health promotion and disease prevention. Canadian Journal of Public Health, (Suppl. 2), S5–S10. Milio, N. (1986). Promoting health through public policy. Ottawa: Canadian Public Health Association. US Department of Health Education and Welfare. (1979). Healthy people: Surgeon general’s report on health promotion and disease prevention. DHEW-PHS-79-55071. Washington: Public Health Service. US Preventive Services Task Force. (1989). Guide to clinical preventive services: An assessment of the effectiveness of 169 interventions. Baltimore: William & Wilkens.

FURTHER READINGS Best, A., Stokels, D., Green, L.W., Leischow, S., Holmes, B., & Buckholz, K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion, 18(2), 168–176. Reviews extant and emerging health promotion models, their Canadian and American roots, and ways to integrate them toward a more systems-oriented health promotion practice.

Green, L.W., Wilson, R.W., & Bauer, K.G. (1983). Data required to measure progress on the objectives for the nation in disease prevention and health promotion. American Journal of Public Health, 73, 18–24. Health Promotion 5/1/07 11:18 AM Page 298

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Based partly on bilateral talks between Health Canada, Statistics Canada, and the US Department of Health and Human Services, the first National Health Interview Survey was planned to track health behaviour changes associated with the health promotion objectives in the now three decades of the US Healthy People initiative, with data that could be compared with Canada’s experience.

Johnson, J.L., Green, L.W., Frankish, C.J., MacLean, D.R., & Stachenko, S.A. (1996). Dissemination research agenda to strengthen health promotion and disease prevention. Canadian Journal of Public Health, (Suppl. 2), S5–S10. Reviews the initiatives of Health Canada, NCIC, the Canadian Heart Foundation, and others to propose a research agenda for dissemination of research to policy and practice.

RELEVANT WEB SITES

A Resource for Instructors, Students, Health Practitioners, and Researchers www.lgreen.net The banner for this Web site declares, “If we want more evidence-based practice, we need more practice-based evidence.” It contains the Guidelines for Participatory Research in Health Promotion based on a review and consultation across Canada. These guidelines have been widely adopted in US federal and foundation grant making. Published applications are cited in www.lgreen.net/guidelines.html.

“From Research to ‘Best Practices’ in Other Settings and Populations” by Lawrence W.Green www.ajhb.org/2001/25-3-2.pdf A reflection by an American on lessons from eight years of work in Canadian health promotion, and the implications of efforts in Canada and the US to build evidence- based practice from research that is often conducted under circumstances that do not generalize to the conditions of most communities in which they would be applied.

Johns Hopkins University Press: Journals www.press.jhu.edu/journals/progress_in_community_health_partnerships/ A new journal founded at Johns Hopkins University, illustrating the extent of influence on participatory research in the US since the publication of Participatory Research in Health Promotion by the Royal Society of Canada. Health Promotion 5/1/07 11:18 AM Page 299

PART V

PRACTICAL PERSPECTIVES

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s we noted at the outset of this book, we believe that a sound conceptual base is the Afoundation of sound practice. We also think that understanding how the field of health promotion has developed within Canada and abroad has practical relevance because it facilitates practitioners’ understanding of the vagaries of funding, policy, and international action. Most importantly, however, we believe that being or becoming a reflexive practitioner increases the likelihood of one’s work being relevant and useful. Reflexivity is another tool for enhancing practice—whether one’s practice is one’s personal health practices, research, policy making, program planning and implementation, management, consulting, or activism. We have thus introduced themes in this section that we think are significant for the practice of health promotion, beginning with the concept of the reflexive practitioner. Chapter 16 opens this section with a critical analysis of the notion of reflexive practitioner by Boutilier and Mason. Drawing on the literature on the reflexive practitioner from several fields, they derive implications for people working in health promotion in various capacities. In Chapter 17, concrete examples of programs run across Canada in the last decade, in a variety of settings, with various populations and on different issues are presented by Richard and Gauvin. They argue for the use of an ecological approach to develop interventions and derive lessons for others from the programs they analyze. There is often a gap between the clinical practice of various health care professionals (nurses, physicians, etc.) and the discourse of health promotion to the point that many of these professionals do not identify with the health promotion field. In Chapter 18, Hills, Carroll, and Vollman explore how this dilemma has been addressed in Canada over the last decade and the challenges of creating a shared vision of health promotion acceptable to clinicians and other types of health promotion practitioners. Over the past 10 years or so, the evaluation of health promotion programs has generated a substantial international debate, notably over issues of defining and measuring effectiveness and, in an evidence-based era, of the nature of evidence required to properly evaluate 299 Health Promotion 5/1/07 11:18 AM Page 300

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health promotion interventions. In Chapter 19, the theoretical and practical contribution of Canadian scholars and practitioners to this debate is presented and illustrated through specific examples by Potvin and Goldberg. At the end of this section, the reader will understand the major issues related to the practice of health promotion in Canada and will be able, in a reflexive manner, to analyze and eventually transform his or her practice accordingly. Health Promotion 5/1/07 11:18 AM Page 301

CHAPTER 16 THE REFLEXIVE PRACTITIONER IN HEALTH PROMOTION: FROM REFLECTION TO REFLEXIVITY

Marie Boutilier and Robin Mason1 reflections shed light on the reflective process for others?

INTRODUCTION hen we were invited to write this REFLECTIVE PRACTICE IN W chapter on reflective practice in HEALTH PROMOTION: health promotion, we expected to draw heav- CONTEXTUAL ELEMENTS ily upon on our previous experience and writ- ings to distill lessons and guidelines for Health Promotion Practice others. Now, as we finish, we are once again The broadly accepted definition of profes- reminded of how risky it is to act on assump- sional practice is the application of knowl- tions at a project’s beginnings. Upon reflec- edge (theoretical and/or technical) in tion, we have found that we brought specialized professional work. Health pro- different disciplines, questions, and writing motion as practised in Canada, however, is a styles to this project and it has led us to exam- multidisciplinary endeavour, usually draw- ine reflexivity in health promotion as both a ing on the values and strategies of the Ottawa solitary and collaborative process. In this Charter rather than a rigorously defined dis- chapter, we thus explore reflective practice cipline. While health promotion is practised in health promotion by examining the con- by professionals, it is not a profession per se cepts and the process of reflexivity and reflec- in that it has no standardized education tive practice with implications for people requirements, and no licensing, professional working in health promotion in a variety of college, or governing body. So while the indi- capacities. First, we outline some under- vidual health promoter may well have standings of health promotion practice and another professional identity (e.g., nurse), health promoters, and some basic character- health promoters as a group bring a multi- istics of professional practice with implica- disciplinary values-based training to their pro- tions for health promotion professionals. fessional role. Canadian training programs Second, we situate the terms “reflective” and expect that “health promoters” will practise “reflexive” in their philosophical and histor- in a range of organizations, including gov- ical contexts and, third, identify foci of reflec- ernments, private corporations, public health tions in health promotion. Finally, we look units, hospitals, community-based networks, at the “how to” of reflective practice in health research organizations, and international aid promotion, including addressing a question agencies (University of Toronto, 2004) in the that emerged for us: How might our own delivery of services, policy, and research. 301 Health Promotion 5/1/07 11:18 AM Page 302

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Professionals and Reflective Health into power struggles (Reuschemeyer, 1986). Promotion Practice This is an important point for health promo- Our reflective practice literature review (Web tion. First, health promoters may find them- of Science, Sociofile, Medline, Google Scholar, selves in a dilemma of accountability and Google) revealed that “reflection” is applied power, especially when projects take commu- to occupations as diverse as coaching nity development or capacity-building (Knowles, Borrie, & Telfer, 2005), social work approaches (Hawe et al., 1998). In examining (Riemann, 2005), software development their own power and status vis-à-vis the part- (Hazzan & Tomaykoz, 2003), and medicine ner community, health promoters may be (Mamede & Schmidt, 2004). Reflection is seen caught in a position of “dual accountability”— as integral to core competencies in specific accountable to both the community and to professions, e.g., nursing, (College of Nurses their employing organization with multiple, of Ontario, 2007), and in interprofessional possibly conflicting, goals (Mason, 1997; Poland practice (Barker, Bosco, & Oandasan, 2005). et al., 2001). When health promoters commit Yet little has been written about reflective to strategies of community “empowerment,” practice specific to professionals who practise they can feel torn between their employing health promotion (Boutilier, Mason, & organization and the community they serve, Rootman, 1997; Health Promotion Resource under the critical eye of managers and employ- System, 2006; Labonté & Feather, 1996). ers (Hawe et al., 1998; Poland et al., 2000). Broadly, professions perform knowl- Second, the project-by-project nature of edge-based services that require specialized many health promotion initiatives also means training, and professional work is marked by that health promotion initiatives may feel some common features, generally applicable tenuous and risky because they often com- to health promotion. Professionals solve pete for funding with more easily measured, problems for others and are therefore, by def- biomedically focused health issues (Raphael, inition, agents of change (Schön, 1983); the 2000), acute care (Poland et al., 2001), or focus on problem solving in professional immunization in public health (Boutilier et work necessitates consideration of risk al., 2001). In addition, there is a trend to indi- (Evetts, 2006); professional knowledge is a viduals working from their homes as con- source of power because it accords the power sultants rather than salaried employees to frame the problem at hand (Schön, 1983); (Hughes, 1999), creating professional vul- professional work is underpinned by an nerability in new ways. Finally, the manage- “ethic of service” to clients and/or patients ment of resources, including the time (Friedson, 2001), which translates to profes- required to build trusted relationships, col- sionalism, requiring professionals to be laboration, and reflection, can be a source of worthy of trust (Evetts, 2006). tension between the professional and his or As professionals often practise in large her employer/manager/funder. organizations, their work becomes standard- All these circumstances make the reflec- ized according to institutional policies; in this tion on health promotion work both relevant context, the discipline-based problem solving, and necessary. knowledge-based power, autonomy, “ethic of service,” and role as change agent can lead to a tension between professionals and their employing institutions, with tensions erupting Health Promotion 5/1/07 11:18 AM Page 303

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CYCLES AND SPIRALS: THE “welfare state,” and post-secondary education ORIGINS OF “REFLECTION,” following World War II. Schön’s ground- “REFLECTIVE PRACTICE,” breaking contribution was the recognition that AND “REFLEXIVITY” in the action of real-life problem solving, pro- The terms “reflective” and “reflexive” are fessionals must “reflect in action” when the sometimes used interchangeably, but it is catalogue of known theories and strategies important to outline differences when apply- prove overly simplistic and only marginally ing them to professional practice. relevant. Faced with complex problems, when discipline-based knowledge proves inadequate, thoughtful experimentation becomes “Reflection” part of the process of problem solving—a form Reflection can be thought of as a learning of “research”—occurring in an iterative and process and was first given attention by edu- cyclical process akin to action research. cational theorists and researchers such as The act of questioning and experiment- Dewey, Lewin, Freire, and Schön. Reflection ing with strategies occurs in an ongoing cycli- was initially defined as the “active persistent cal process until the question is reframed and careful consideration of any belief or sup- (often in collaboration with others) and posed form of knowledge in the light of the change occurs. Not only does reflection grounds which support it” (Dewey, 1933, p. expand the professional’s tacit knowledge 118), emerging from a state of doubt and toolkit for problem solving, it can contribute involving “the kind of thinking that consists to theory development, self-development (as in turning a subject over in the mind and a professional and individual), decision giving it serious thought” (Moon, 1999). In making, empowerment, and other outcomes this model, reflection was conceptualized as that are unexpected, as new ideas or images individualistic, goal-directed, and solution- can be applied in practice (Moon, 1999). In focused, a cycle that concludes with the test- addition, it serves as a preventive process in ing or evaluation of a determined action and being drawn into repetitive and routine then begins all over again. This was the inspi- thinking and solutions, missed opportunities, ration for Lewin’s (1946) spiral of action and boredom or burnout (Schön, 1983). For research. Educational theory later took on an health promoters, the challenges for reflec- explicit values base and a political agenda tion are found in the combination of collab- with Paolo Freire’s vision of education as dia- oration, multidisciplinary strategies, and logue with no dichotomy between “true values (which generally include an ethic of reflection and action” (Freire, 1998, p. 64). service to communities), all practised within the context of their employing organizations. “Reflective Practice” In the reflective practice literature Donald “Reflexive” and Reflexivity Schön’s The Reflective Practitioner: How The term “reflexive” is now so widely used Professionals Think in Action (1983) was piv- that “it has … become a sin to not be reflex- otal. It was published at a time when profes- ive” (Maton, 2003, p. 54; original emphasis). sionals were increasingly employed by large Although the term carries different mean- organizations, following the growth of multi- ings, it is generally rooted in Bourdieu’s national corporations, the bureaucracy of the (1990) “epistemic reflexivity” or Giddens’s Health Promotion 5/1/07 11:18 AM Page 304

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notion of the “reflexive project of the self” in plain language, the risk is that our reflexive a modern “detraditionalized” “risk society” undertakings will focus on our personal emo- (Giddens, 1991). Lupton (1997) summarizes tions and psyches rather than being accom- reflexivity as: panied by critical analysis of our practice and its context. Haggerty points out that the [Drawing] upon the assumption that in … assumption of self-awareness requisite to modern Western societies individuals constantly reflexivity sidesteps the truism (following seek to reflect upon the practices constituting Freud) that we cannot be fully aware of our the self and the body and to maximize … the assumptions and, in reflexivity, we may benefits for the self.… Life, in this formulation, unwittingly “rationaliz[e] unconscious moti- is carried out as an enterprise, demanding a con- vations and prejudices” (2003, p. 159). For this tinual search for knowledge to engage in self- reason, we offer the caveat that reflexivity is improvement … continually mak[ing] decisions meant to focus largely on professional prac- from a variety of options as part of everyday tice, with some boundaries drawn by the indi- life.… [I]ndividuals experience the self, the body vidual between personal and professional and the social and physical worlds with a high issues. This is integral to “professionalism” degree of reflection, questioning, evaluation and for most people and becomes more or less uncertainty…. [E]xpert knowledges … are no intuitive, but is a point that bears articulation. longer … accepted on face value [but] are now To summarize, Canadian health pro- open to skepticism and to challenge on the part motion practice, integrating values of of lay people.… (p. 374) empowerment and participation, crosses professional boundaries and disciplines and is Reflexivity is also said to be “a perform- inextricably linked to the context within ance that positions the author in relationship which it occurs. Collaboration and reflection to the field … [and] is demonstrated in the (both individual and collaborative) underlie act of writing” (Haggerty, 2003). Reflexivity health promotion practice. As professionals, complements standpoint epistemology (Smith, health promoters are agents of change who 1987) and participatory research (Park et al., focus on solving problems with individuals 1993) in that both hold that the enquiry is and communities, but as such, they may shaped by the researcher’s social identity based experience tensions in dual accountability, on gender, race, class, and ability. and risk vulnerability in their positions. We There is the risk that reflexivity may now turn to foci for reflection in health pro- become too inward-looking, self-absorbed, motion practice. and over individualized in “hermeneutic nar- cissism” (Maton, 2003), losing its intent of transformative knowledge development. It FOCI FOR REFLECTION can “become a disembodied process because IN HEALTH PROMOTION: it involves turning ourselves into objects of POWER AND study” (Cunliffe & Easterby-Smith, 2003, p. COLLABORATION 34). Or, “the often lofty theoretical justifica- In order to avoid narcissistic self-scrutiny in tions for greater reflexivity can manifest their reflections, health promoters need to themselves as a license to write about our most remain thoughtful, critical, and focused on the beloved topic—ourselves … shad[ing] into context of practice. Health promotion prac- personal therapy” (Haggerty, 2003, p. 159). In tice, however, often requires the “messiness” Health Promotion 5/1/07 11:18 AM Page 305

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of collaboration. Collaboration involves work- when the same words (e.g., time, practice, ing across differences, whether these are dis- commitment) signify different things to those cipline-based, characteristics of diverse in the partnership (Bogo et al., 1992; Boutilier communities, or of practice settings. On each & Mason, 1994; Buckeridge et al., 2002; side (community and institutional organiza- Gilling, 1994; Gondolf, Yllo, & Campbell, tion) there are power networks, structures, 1997; Nyden & Wiewel, 1992; Peterson, 1993). including some formal and informal hierar- Collaborations can also shift with dis- chies, and different notions of knowledge and crepancies in resources, both tangible (e.g., expertise. The most readily identified chal- funding or personnel) or less visible (e.g., lenges relate to issues of power, expertise, and intellectual capacity of partners, time, prior control (Gondolf, Yllo, & Campbell 1997; community linkages). Developing effective Peterson 1993; Rovegno & Bandhauer, 1998). working collaborations requires significant In addition, there are challenges related to dif- investments, often in short measure at the ferences in work cultures, language of prac- start: time, trust, and energy (Bevilacqua, tice or discipline, time constraints, and Morris, & Pumariega, 1996; Buckeridge et al., outcome expectations (Buckeridge et al., 2002). 2002). Individual and collective engagement Collaborations are forced to confront in the process of reflection can help bring these and, usually, negotiate issues of power. Power issues to light, while honest commitment to and the perception of who has power may the process also supports the development of derive from differences in status, knowledge trust in the individuals and organizations par- (and kinds of knowledge), resources, skills, ticipating in the collaboration. and commitment to the collaboration itself In reflective practice, individuals delib- (Buckeridge et al., 2002). It can be addressed erately examine their situations, behaviour, with different strategies in health promotion practices, and effectiveness within specific sit- initiatives; for example, participants can use uations after the fact, so they become wiser at others’ power to their own ends, redirect their working within the complex and dynamic strategies, withdraw altogether, or (less often) world of practice. Experienced professionals become confrontational (Boutilier, Cleverly, also engage in reflection during action, form- & Labonté, 2000). ing judgments, acting and reacting in the Communication difficulties in collabo- moment on the basis of past experience and ration can stem from differing bases and learning: Schon’s “reflection-in-action.” sources of knowledge, work cultures, and When decisions are made on the basis of expe- professional practices (Mason & Boutilier, rience and the aims, means and context are 1996). For example, in one instance where considered against the actual situation and the process of collaboration itself was the probable outcomes; however, reflection may focus of a health project, distinct work cul- be considered to have begun before the action tures with attendant differences in expecta- (Van Manen, 1991, in Clarke, James, & Kelly, tions, values, outcomes, reward systems, and 1996). This kind of reflection also builds on work styles emerged; early misunderstand- reflections from previous projects, merging ings resulting from these issues coloured the with reflection-on-action. Not to be taken collaboration and impacted the development lightly are the resources needed for both kinds of real understanding (Buckeridge et al., of reflective practice: the time and space to 2002). Added to these perhaps predictable ask questions and speculate upon the answers. misunderstandings are problems that emerge Health Promotion 5/1/07 11:18 AM Page 306

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BOX 16.1: “WHAT IF?” QUESTIONS FOR INDIVIDUAL AND COLLABORATIVE REFLECTION

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MOVING BEYOND audiotaping practice sessions, utilizing client PROJECTS: BECOMING A feedback, and working with peer or mentor REFLECTIVE HEALTH supervision (Evans, 1997; Ferraro, 2000; PROMOTION Kottkamp, 1990). There are also resources in PRACTITIONER participatory research evaluations that will also often apply to health promotion. These include Writing,Writing,Writing … group reflections and storytelling (Ellis, Reid, In this section we will explore some of the tools & Barnsley, 1990; Labonté & Feather, 1996). that can assist in becoming a reflexive practi- However, the most frequently used and easily tioner. The literature offers some examples of accessible tool for health promoters is writing how to begin, including: role playing, video or (Health Promotion Resource System, 2006). Health Promotion 5/1/07 11:18 AM Page 307

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Writing is a powerful tool for learning factual description of an event is written in from and reflecting upon experience. First, one column and later reflections in a second the act of writing itself engages both hand and column (Moon, 1999), to reflection on action. brain, integrating the right and left hemi- Journal writing shares features in common spheres in the action. Second, the physical act with case records, but expands the scope of of converting thoughts into words upon a reflection beyond problematic situations. page demands the slowing down of thought; A journal contains the ongoing consid- it allows for moving back into the past and eration of the individual in relation to others, invites musing about the future. While writ- the emotions evoked, values in harmony or ing, we can pause the action, go back and collision, and skills possessed or wanting, in revisit a thought, consider options, and refor- addition to questions about specific situations, mulate a sentence; in this way writing is itself actions taken, alternatives considered, and often a reflective process (Kottkamp, 1990). hoped-for outcomes. A journal may contain There are different forms that writing conversations, poetry, drawings, or songs that can take, including diaries, case records, or assist in making thoughts or feelings clear. journals. While a diary is a list of daily activ- A journal, therefore, is both an ongoing ities with little space set aside for review of catalogue of activities plus the repository of those activities, a case record contains detailed a critical appraisal of those activities with description of specific situations or projects. associated thoughts and feelings. It is the Kottkamp (1990) describes a case record as record of a critical and constructive internal being based on a problematic situation that dialogue one holds with oneself and as such, includes responses to basic questions about the journal is deeply personal. In addition to the nature of the situation, the action taken, the descriptive documentation of situations alternatives considered, and hoped-for out- and events, alternatives considered and pos- comes. Also useful is a document in which a sible outcomes had these been followed, the

BOX 16.2: AIDS TO WRITTEN REFLECTION

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journal includes a critical analysis of the polit- frequently found journalling a useful way of ical context in which actions unfold, one’s organizing my thoughts and experiences. In knowledge, skills, expertise, values, and the excerpts below, taken from some early assumptions. It becomes the means by which work on trying to integrate education on inti- observing, questioning, critiquing, synthe- mate partner violence (IPV) into a hospital sizing, and acting are integrated into daily setting, I consider the “place” and “owner- practice, or reflection-in-action. From reflect- ship” of education in the larger hospital envi- ing on the specifics of a project or problem- ronment. At the time, I was the facilitator of atic situation and in the midst of making a group of front-line practitioners who met choices in daily practice, one shifts into reflec- monthly to discuss IPV and health care prac- tion as a way of encountering the world. tices. We had collaborated on the develop- To begin journalling, one should set ment of a curriculum on IPV relevant to aside a block of time. Begin the entry with hospital practitioners and had begun deliv- the date, place, and a summary of a specific ering the training to different programs in situation, activity, or focus of reflection. The the hospital. I represented this ad hoc group conversation begins most easily by consider- at meetings with hospital administrators, ing issues and questions such as the “What department chiefs, and program managers. if” ones noted above. Once the present real- Our group felt vulnerable within the hospi- ity has been documented, consider the emo- tal system—beyond my salary, there was no tional reactions to that reality. If reflecting funding for the group or the education pro- on a specific event or situation, consider the gram we had developed, no clear lines for emotions related to entry, during the situa- reporting or accountability, and our group tion, and now, upon reflection. did not appear on any organizational chart. One advantage we did have was an organizational policy we had developed, and which Reflections Past and Present: Journals had been approved and ratified, that made and Diagrams responding to IPV part of everyone’s prac- In writing this chapter we have inevitably tice. In addition, education on the issue was reflected on our own reflective processes. One ensconced within this policy. So our group, of us (RM) is a fairly consistent journal writer and especially myself as the group’s facilita- while the other (MB) uses journals more selec- tor, operated in a grey area both within and tively and more often engages in diagrams outside the traditional professional hierar- that map out relationships and ideas, leading chies and structures. At one and the same to decisions and strategies. We offer below time, there was a mandate to ensure that staff examples drawn from our own reflections. were educated as outlined by the policy, but no clear indication or infrastructure to sup- Journal Reflections (RM) port our claim that our group should be ful- My career path has taken me to work in com- filling that mandate. munity social service settings, research centres, In order to preserve the anonymity of and a hospital. I have worked collaboratively those to whom I refer in the journal, names on projects to address local hunger, youth and other identifiers have been removed. The unemployment, newcomer settlement issues, original entries are in Box 16.3. an organizational policy on intimate partner In rereading these two excerpts I am violence, and curriculum development. I have aware now of how vulnerable I felt my Health Promotion 5/1/07 11:18 AM Page 309

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BOX 16.3: CASE STUDY: REFLECTIONS ON A PRACTICAL SITUATION

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position was at that time and in that organ- power was held by physicians and hospital ization. I felt responsible for ensuring our administrators. As an insider/outsider (a little group’s collaborative way of working status achieved by default because the lines was upheld in the face of a sometimes over- of reporting were unclear) I was also whelming bureaucracy and hierarchy. I also afforded a certain power in that I attended felt an enormous trust had been placed in the same meetings as those who made key me to represent and speak out for the group; decisions and could contribute to the orga- it was as their representative that I found nization’s strategic goals and priorities. Yet my power and courage. Representing the I had no resources or infrastructure to help group also meant, however, that as an indi- our group achieve its goals. I recall trying vidual I was visible in the hospital organi- to figure out if it was safer to be silent and zation and thus vulnerable whereas other overlooked or wiser to be outspoken and members of the group were not. I became noticed so that the project and my position highly attuned to and preoccupied by the could not “disappear” without comment. organizational politics; I was continuously Now, I wonder whether my anxieties jockeying for power where the bulk of were accurate reflections of dire possibilities Health Promotion 5/1/07 11:18 AM Page 310

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within the organization or merely my own of labour in research (McQueen, 1994). This personal demons. I remember how the con- contingent nature of formal written reflec- flicts with my community partners added to tions may hold for many people—it may be my general sense of tension, conflict, and frus- that decision moments trigger the need to tration. As the first line of the second excerpt reflect rather than when work processes can shows, I was exasperated by the politicking be more or less routine. The irony of this is that seemed to govern every aspect of my that it is at these moments of possible crises daily work life. In rereading this excerpt now, that the time needed for reflection is in I recognize how reconciled I have become to short supply. the politics surrounding practice. The issue itself (IPV) is a politically sensitive one and those who work on it, particularly in hospi- CONCLUSIONS tal environments, are not usually accorded We have examined health promotion prac- the support or recognition afforded those who tice, collaboration, reflection, reflexivity, how specialize in other health issues. On the com- to reflect, and considered how the process of munity side, the tension between compara- reflection can illuminate relationships, power, tively well-resourced hospitals and poorly hierarchies, and improve practice. Reflection resourced community partners has contin- is integral to the repertoire of knowledge and ued, although ways of collaborating and sup- understanding of what it means to promote porting each other’s work have been found health in a context of multiple interests. It and respect for the constraints within which becomes a key resource for health promoters we each practise are better understood. as they develop expertise over time, becoming Finally, rereading this entry has allowed me a part of one’s professional identity and way to recognize the continuity between the values of being a reflexive practitioner. that made the work important to me then On reflection, the writing of this chap- (helping and providing services to women) ter itself has shaped our representation of and today. reflexivity. While emphasizing the principles and values outlined in the Ottawa Charter, Diagrams as Reflection (MB) we are mindful of the practice of health pro- Rather than the traditional path of doctorate motion as lived experience for professionals to academic post, my career has focused solely committed to the health of the communities on research in different capacities and in a they serve. Reflection requires resources and range of organizations and working arrange- facilitators, not the least of which is time. ments. My written professional reflections We have focused on reflexivity for have been somewhat sporadic and I have health promoters, but the processes of reflec- moved in and out of practice reflections tive practice described here will apply to pro- depending on the projects I work on, stages fessional work in general. In health of the projects, whether I am employed or promotion, the importance of collaboration working in a volunteer capacity, and the begs the question of whether processes and urgency of other dimensions of my life. My foci of reflection and reflexivity may differ reflections have thus incorporated the logis- across disciplines and professions as influ- tics and “political economy of research,” i.e., enced by their respective assumptions and how the structures of the university mesh values. While we see collaborative reflection with research funding models and the division as part of the health promotion reflective Health Promotion 5/1/07 11:18 AM Page 311

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process, each individual and health promo- diversity of individuals, interests, organization initiative will be unique according to the tions, values, personalities, and goals involved.

NOTE 1 The authors acknowledge their equal contributions to this chapter.

REFERENCES Barker, K.K., Bosco, C., & Oandasan, I.F. (2005). Factors in implementing interprofessional education and collaborative practice initiatives: Findings from key informant interviews. Journal of Interprofessional Care, S1, 166–176. Bevilacqua, J., Morris, J., & Pumariega, A. (1996). State services research capacity: Building a state infrastructure for mental health services research. Community Mental Health Journal, 32(6), 519–533. Bogo, M., Wells, L., Abbey, S., Bergman, A., Chandler, V., Embleton, L., et al. (1992). Advancing social work practice in the health field: A collaborative research partnership. Health and Social Work, 17(3), 223–235. Bourdieu, P. (1990). The logic of practice. Palo Alto: Stanford University Press. Boutilier, M., Badgley, R.F., Poland, B., & Tobin, S. (2001). “Playing on shifting sand”: Reflections on the impact of political shifts on community action and public health. Canadian Journal of Public Health, 92(2), 87–89. Boutilier, M., Cleverly, S., & Labonté, R. (2000). Community as a setting for health promotion. In B. Poland, I. Rootman, & L. Green (Eds.), Settings for health promotion (pp. 250–279). Thousand Oaks: Sage Publications. Boutilier, M., & Mason, R. (1994). Action research in the community: Issues in collaboration. Kingston: Health and Behaviour Conference Proceedings. Boutilier, M., Mason, R., & Rootman, I. (1997). Community action and reflective practice in health promotion research. Health Promotion International, 12(1), 69–78. Boutilier, M., Mason, R., Rootman, I., Robertson, A., Bresolin, L., Panhuysen, N., et al. (1995). Can the 2- step become a square dance?: Participatory action research with community residents, agencies, public health, and the university. Annual meetings of the Ontario Public Health Association, 1995. Buckeridge, D., Mason, R., Robertson, A., Frank, J., Glazier, R., Purdon, L., et al. (2002). Making health data maps: A case study of a community/university research collaboration. Social Science & Medicine, 55(7), 1189–1206. Clarke, B., James, C., & Kelly, J. (1996). Reflective practice: Reviewing the issues and refocusing the debate. International Journal of Nursing Studies, 33(2), 171–180. College of Nurses of Ontario, Quality Assurance Program. Retrieved January 15, 2007, from www.cno. org/qa/index.htm. Cunliffe, A., & Easterby-Smith, M. (2003). From reflection to practical reflexivity: Experiential learning as lived experience. In M. Reynolds & R. Vince (Eds.), Organizing reflection (pp. 30–46). Burlington: Ashgate Publishing Co. Dewey, J. (1933). How we think. Boston: Heath & Co. Ellis, D., Reid, G., & Barnsley, J. (1990). Keeping on track: An evaluation guide for community groups. Vancouver: The Women’s Research Centre. Health Promotion 5/1/07 11:18 AM Page 312

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Evans, D. (1997). Reflective learning through practice-based assignments. Paper presented at the British Educational Research Association Annual Conference, September 11–14. From www.leeds.ac.uk/educol/documents/000000468.htm. Evetts, J. (2006). Short note: The sociology of professional groups. New Directions Current Sociology, 54(1), 133–143. Ferraro, J. (2000). Reflective practice and professional development. ERIC clearinghouse on teaching and teacher education. ED449120. Retrieved June 30, 2006, from http://eric.ed.gov/ERICDocs/data/ ericdocs2/content_storage_01/0000000b/80/2a/32/84.pdf. Freire, P. (1998). Pedagogy of the oppressed (New revised 20th anniversary ed.). New York: Continuum Publishing Company. Friedson, E. (2001). Professionalism: The Third Logic. London: Polity Press. Giddens, A. (1991). Modernity and self-identity: Self and society in the late modern age. Cambridge: Polity Press. Gilling, D.J. (1994). Multi-agency crime prevention: Some barriers to collaboration. Howard Journal of Criminal Justice, 33(3), 246–257. Gondolf, E.W., Yllo, K., & Campbell, J. (1997). Collaboration between researchers and advocates. In G.K. Kantor & J.L. Jasinski (Eds.), Out of the darkness: Contemporary perspectives on family violence (pp. 255–267). Thousand Oaks: Sage. Haggerty, K. (2003). Ruminations on reflexivity. Current Sociology, 51(2), 153–162. Hawe, P., King, L., Noort, M., Gifford, S., & Lloyd, B. (1998). Working invisibly: Health workers talk about capacity-building in health promotion. Health Promotion International, 13(4), 285–295. Hazzan, I., & Tomaykoz, J. (2003). The reflective practitioner perspective in eXtreme programming. XP/agile universe 2003 lecture notes in computer science, 2753, 51–61. Health Promotion Resource System. HP-101, Health promotion online course. Retrieved March 7, 2006, from www.ohprs.ca/hp101/main.htm. Hughes, K. (1999). Gender and self-employment in Canada: Assessing trends and policy implications: CPRN study no. W|04: Changing employment relationships series. Ottawa: Canadian Policy Research Networks. Knowles, Z., Borrie, A., & Telfer, H. (2005). Towards the reflective sports coach: Issues of context, education, and application. Ergonomics, 48(11–14), 1711–1720. Kottkamp. (1990). Means for facilitating reflection. Education and Urban Society, 22(2), 182–203. Labonté, R., & Feather, J. (1996). Handbook on using stories in health promotion practice. Cat. no. H39- 378/1996E. Ottawa: Minister of Supply and Services. Lewin, K. (1946). Action research and minority problems. Journal of Social Issues, 2, 34–46. Lupton, D. (1997). Consumerism, reflectivity, and the medical encounter. Social Science and Medicine, 45(3), 373–381. Mamede, S., & Schmidt, H.G. (2004). The structure of reflective practice in medicine. Medical Education, 38(12), 1302–1308. Mason, R. (1997). “Total responsibility and absolutely no control”: Participatory research as a health promotion strategy. Unpublished PhD thesis, OISE, University of Toronto. Mason, R., & Boutilier, M. (1996). The challenge of genuine power sharing in participatory research: The gap between theory and practice. The Canadian Journal of Community Mental Health, 15(2), 145–152. Maton, K. (2003). Reflexivity, relationism, & research: Pierre Bourdieu and the epistemic conditions of social scientific knowledge. Space & Culture, 6(1), 52–65. McQueen, D. (1994, June 16). Visions of health promotion research. Keynote address, 3rd Conference on Health Promotion Research, Calgary, Alberta. Health Promotion 5/1/07 11:18 AM Page 313

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Moon, J. (1999). Reflection in learning & professional development: Theory & practice. London: Kogan Page. Nyden, P., & Wiewel, W. (1992). Collaborative research: Harnessing the tensions between researcher and practitioner. The American Sociologist, 23(4), 43–55. Park, P., Brydon-Miller, M., Hall, B., & Jackson, T. (Eds.). (1993). Voices of change: Participatory research in the United States and Canada. Toronto: OISE Press. Peterson, P.D. (1993). Merging cultures: Challenges and opportunities in public academic liaison. Administration and Policy in Mental Health, 20(6), 411–419. Poland, B., Boutilier, M., Tobin, S., & Badgley, R.F. (2000). The policy context for community development practice in public health: A Canadian case study. Journal of Public Health Policy, 21(1), 5–19. Poland, B., Fell, L., Graham, H., Lum, J., Walsh, E., Williams, A.P., et al. (2001). “We’re hired by the hospital, but we work for the community”: Examining hospital involvement in community action. Hospital Quarterly, 4(3), 52–59. Raphael, D. (2000). The question of evidence in health promotion. Health Promotion International, 15(4), 355–367. Reuschemeyer, D. (1986). Power and the division of labour. Cambridge: Polity Press. Riemann, G. (2005). Ethnographics of practice-practising ethnography: Resources for self-reflective social work. Journal of Social Work Practice, 19(1), 87–101. Roth, R. (1989). Preparing the reflective practitioner: Transforming the apprentice through the dialectic. Journal of Teacher Education, 40(2), 31–35. Rovegno, I., & Bandhauer, D. (1998). A study of the collaborative research process: Shared privilege and shared empowerment. Journal of Teaching in Physical Education, 17, 357–375. Schön, D. (1983). The reflective practitioner: How professionals think in action. Boston: Basic Books. Smith, D. (1987). The everyday world as problematic: A feminist sociology. Toronto: University of Toronto Press. Taggar, R., & Clarke, B. (2001). Reflective practice gets new tool. Retrieved June 29, 2006, from College of Nurses of Ontario, www.cno.org/qa/refprac/rp_rpnewtool.html. University of Toronto. (2004). MHSc health promotion grad whereabouts. Unpublished report. Centre for Health Promotion, University of Toronto.

CRITICAL THINKING QUESTIONS 1. What are the underlying disciplines that form the bases of the knowledge and theoretical frameworks with which you frame questions and issues in health promotion? 2. What is the difference between reflecting on an issue and becoming a reflexive professional? 3. If you were to organize a collaborative reflection process, who would you involve? How would it happen? What questions would you start with? 4. What values are important to you in your work/professional life? Can you imagine a situation in which these are challenged in your work? What would be your first steps in working it through? 5. If you were designing a Type 2 diabetes educational initiative for an urban hospital setting, which stakeholders representing which interests would you consider as you developed your program? Who would be the target audience for the program? If you were designing a similar program for a low-income housing complex, which stakeholders Health Promotion 5/1/07 11:18 AM Page 314

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representing which interests would you need to consider? In what ways would the program change depending upon where it was being delivered?

FURTHER READINGS Gould, J., & Nelson, J. (2005). Researchers reflect from the cancer precipice. Reflective Practice, 6(2), 277–284. Nelson, J., & Gould, J. (2005). Hidden in the mirror: A reflective conversation about research with marginalized communities. Reflective Practice, 6(3), 327–339. These two articles present the reflections of two researchers employed at a cancer research unit. They often reflect together about the difficult emotional issues involved in working with cancer patients, power relations, and privilege, as well as facets of identity that come into play in their work, including race, class, gender, cultural capital, and personal life histories. To formalize these conversations, they audiotaped and transcribed four dialogue sessions during which they asked themselves what they were learning about themselves as both social scientists and as individuals through their work.

Hernández-Ramos, P. (2004). Web logs and online discussions as tools to promote reflective practice. Retrieved July 3, 2006, from The Journal of Interactive Online Learning, 3(1), Summer 2004 ISSN: 1541-4914. From www.ncolr.org/jiol/issues/PDF/3.1.4.pdf. Blogs are increasingly appearing as a means of reflection for both personal and professional communities; this article cites over 500,000 blogs available on the Internet. They are seen as an accessible tool to promote collaborative reflection and to alter individuals’ perceptions of themselves and their practice in testing their ideas with an audience of peers or other professionals, privately or anonymously, depending on the parameters of the blog. The article describes how a teacher education course required 56 students to blog for weekly reflection. Few students intended to incorporate blog- ging into their professional practice, but it allowed for an examination of the issues in a format that was challenging to everyday practice.

Journal of Reflective Practice This journal focuses on reflective practice as applied to various practices, including nursing, occupational therapy, research, art, and social work. It is an interesting and useful source for readings on reflections and how to develop these into a manuscript.

Kahan, B., & Goodstadt, M. (2001). The interactive domain model of best practices in health promotion: Developing and implementing a best practices approach to health promotion. Health Promotion Practice, 2(1), 43–67. This article discusses issues associated with taking a best practices approach to health promotion, including determining factors, implementation, and implications for practitioners and policy makers. The authors suggest that health promotion effectiveness will be increased through adoption of a systematic and critically reflective approach to practice—one that considers all major factors affecting practice and is consciously guided by health promotion values and goals, theories and beliefs, evidence, and understanding of the environment. To help practitioners develop and implement best practices, they outline a model, the Inter-active Domain Model of Best Practices in Health Promotion, and a set of best practices criteria. Health Promotion 5/1/07 11:18 AM Page 315

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Labonté, R., & Feather, J. (1996). Handbook on using stories in health promotion practice. Cat. No. H39- 378/1996E. Ottawa: Minister of Supply and Services. This booklet is directed at health promotion practitioners and walks the reader through a process that includes individual and collaborative reflection. It provides questions to initiate reflection, tips for problem solving, and synthesis.

Moon, J. (1999). Reflection in learning & professional development: Theory & practice. London: Kogan Page. The first part of this book provides an overview of reflection and its application to different disciplines, professions, and practices. The second part is a study of learning, in particular higher level learning and the role of reflection in learning. The last section applies reflection to the improvement of learning and practice.

Reynolds, M., & Vince, R. (Eds.). (2004). Organizing reflection. Aldershot: Ashgate Publishing Ltd. This collection is based on the idea that reflection has a utility beyond individual self-improvement, that it can, in fact, be a key factor in organizational development. The individual chapters further both theory and the practice of reflection. They discuss reflection as applied to communities of practice, collective reflection, critical reflection, and reflexivity. Included also are discussions of power and power relations, experience, and the role and place of emotions.

Schön, D. (1983). The reflective practitioner: How professionals think in action. Boston: Basic Books. This seminal work in the literature on reflective practice provides a “sociology of knowledge” approach to expertise and expert power. It rests on case studies of how professionals learn and hone their intellectual crafts, with implications for individual professionals, and for mentors and learners. Meticulous in its case study analyses, it is easy to read and provides insights into reflexivity applicable across professions. While the discussion chapter on the move away from technical rationality may be somewhat dated, its historical perspective maintains it as a paradigm-shaping work and a continuing resource for professionals, their teachers, and managers.

RELEVANT WEB SITES

Case Study: Partners in Practice Port Colbourne, Ontario www.partnersinpractice.org/orgtale.html Partners in Practice examines the mentoring relationship and ways to support, enrich, and encourage that relationship in early childhood practice. Includes a workbook approach.

College of Education, University of North Texas www.coe.unt.edu/teachertools/research/aboutresearch.htm Includes a description of collaborative action research for teachers and learners, whatever the setting. Also provides tips on getting started, and a framework for action. Health Promotion 5/1/07 11:18 AM Page 316

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Learning and Teaching Unit,Manchester Metropolitan University Adult Education Web Site www.ltu.mmu.ac.uk/ltia/issue11/index.shtml Aims at widening participation in higher education (HE) through “activities and interventions aimed at creating an HE system that includes all who can benefit from it—people who might not otherwise view learning as an option, or who may be discouraged by social, cultural, economic, or institutional barriers.”

International Journal of Education & the Arts, 4(1) January 30, 2003 http://ijea.asu.edu/index.html I, Me, Mine: Soliloquizing as Reflective Practice Monica Prendergast University of Victoria “Examines soliloquies as forms of reflective practice through an understanding of this dramatic voice applied to qualitative research writing, …[e.g.,] data poems, dialogues of symbolic interactions (between “I” in practice and “Me” in reflection), as autobiography (talking to myself about myself), and autoethnography (talking to the group within which I place myself). Soliloquy writing offers myriad ways to engage in reflective practice and qualitative interpretive inquiry.”

ItsLife www.itslifejimbutnotasweknowit.org.uk/RefPractice.htm UK teacher education site; extensive bibliography on reflective practice.

Journal Writing www.journal-writing.com/index.html This Web site was developed by Gerry Starnes and explores journal writing as a vehicle for personal growth. Health Promotion 5/1/07 11:18 AM Page 317

CHAPTER 17 BUILDING AND IMPLEMENTING ECOLOGICAL HEALTH PROMOTION INTERVENTIONS

Lucie Richard and Lise Gauvin some emerging challenges to the design, implementation, and evaluation of such innovative initiatives. INTRODUCTION he main goal of this chapter is to pro- T vide examples of innovative, contem- THE ECOLOGICAL porary health promotion programs that APPROACH effectively translate social ecological concep- Derived from ecology, a subfield of biology, tions into tangible health promotion inter- the ecological approach offers a research and ventions. Given that a full description of the action framework that emphasizes the com- complexity inherent in these programs would plex transactions between people, groups, and exceed what can realistically be accomplished their environments. Contrary to traditional within the purview of a single chapter, we ecology, which highlighted the physical fea- centre the presentation on one key dimen- tures of environment, the ecological approach sion of health promotion intervention: the used in health promotion is more social eco- degree of integration of an ecological logical in nature and focuses more centrally approach. The ecological approach is cur- on the social, organizational, and cultural rently generating much enthusiasm among components of the environment. Within such theorists, planners, and practitioners in health a vision, planners and practitioners are urged promotion and public health. However, to design interventions and programs that despite this high level of interest, proponents will integrate people-focused efforts to continue to lament its poor level of integra- modify health behaviours with environment- tion into programming efforts. Given this focused interventions to enhance physical, paradox and the potential of the approach, social, and cultural surroundings. Such com- we believe it is a useful exercise to describe plex intervention packages are touted as programs deemed as exemplary in terms of having the potential for greater success than their degree of integration of such an traditional single-focused health education approach. Accordingly, after having briefly interventions (Sallis et al., 2006; Smedley & described the ecological approach and the Syme, 2000; Stokols, 1992). historical context of its emergence in public health, we illustrate some applications by describing three highly ecological health pro- The Rise of the Ecological Perspective motion initiatives drawn from the contem- Ecological thinking has a long history in dis- porary Canadian context. Finally, we identify ciplines such as biology and psychology. An 317 Health Promotion 5/1/07 11:18 AM Page 318

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emphasis on socio-environmental determi- (2001) and of Canadian authors (Best et al., nants of health was also at the root of public 2003; Edwards, Mill, & Kothari, 2004). health at the turn of the 19th century. Applications of the approach to a wide vari- However, the ecological discourse re-emerged ety of health and disease problems have also only very recently in public health. In fact, the been published over the years (Gauvin, World Health Organization European Lévesque, & Richard, 2001; Glasgow et al., Regional Office (World Health Organization, 1999; Richard, 1996; Sallis et al., 2006). 1984) presented its new conceptualization of Despite all these efforts, a low level of health issues as recently as the mid-1980s. This integration of the ecological approach in conceptualization reiterated the importance health promotion practice is still observed of environmental determinants of health and overall (Beaglehole & Bonita, 2004; Merzel & of ecological approaches to promote the health D’Afflitti, 2003; Orleans et al., 1999; Richard of populations. Besides WHO, several et al., in review; Smedley & Syme, 2000). Yet, Canadian organizations played a leadership the health promotion literature, reports from role in the emergence of the ecological the field, and testimonials of dozens of plan- approach and of the health promotion dis- ners and practitioners indicate that descrip- course and practice (Epp, 1986; Kickbusch, tions of innovative programs aimed at a 1994, 2003; World Health Organization, variety of health determinants are available Health and Welfare Canada, & the Canadian as exemplars. In a quest to contribute to a Public Health Association, 1986). greater integration of the ecological approach Oddly enough, because of its emphasis into professional practices, our strategy is to on complexity and wide-scale system influ- describe examples of best practices in this ences, the ecological approach has often been regard by spotlighting selected examples of seen as intimidating and difficult to opera- successful Canadian applications of the eco- tionalize (Green, Richard, & Potvin, 1996). logical approach in health promotion pro- One way to address this problem has been to grams. Our selection was strategic, covering stratify the environment as, for example, psy- a variety of target populations, intervention chologists have done: Bronfenbrenner (1979) areas, and geographical regions. We now turn stratified the environment into micro-, meso, to a description of these three success stories. exo-, and macrosystems whereas Moos (1979) proposed a four-strata classification revolving around physical settings, organizational THREE EXAMPLES OF factors, human aggregate factors, and social PROGRAMS climate. In public health, similar efforts have Promoting Healthy Living and Health Sup- been undertaken as demonstrated in the eco- portive Environments: Inception of a “Pos- logical framework of McLeroy and col- sibility Framework” through the Promoting leagues (McLeroy et al., 1988), the MATCH Action toward Health (PATH) Project is a model (Simons-Morton, et al., 1988), or in five-year federally funded health promotion Stokols’s (1992) seminal paper. Later, appli- research project. It has been implemented in cation of the ecological approach for the a relatively disadvantaged area of a medium- planning of interventions was undertaken by sized city in Western Canada. It involves a Green and Kreuter (1999) and Stokols (1996). partnership between a community centre, a More recent efforts include those of regional health authority, and a university. Bartholomew, Parcel, Kok, and Gottlieb PATH was initially aimed at preventing Health Promotion 5/1/07 11:18 AM Page 319

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Type 2 diabetes among the midlife popula- (Chappell et al., 2006, p. 11). Obviously, the tion (35–64 years) of the target area. How- list of initiatives shown in Table 17.1 is not ever, in acknowledging that many medical exhaustive (non-listed initiatives such as and non-medical causes of diabetes (e.g., obe- health fairs, community gardens, and history sity, poverty) are also at the root of several and heritage activities are also mentioned in other chronic diseases, the need to include Chappell et al., 2006), but the information other age groups and to adopt a population illustrates the strong ecological dimension of health approach were recognized (Chappell the PATH Project. et al., 2006). It was also evident at the start of As seen in Table 17.1, the set of initia- the project that involvement of the broader tives implemented has potential for reaching community would be desirable for the proj- the target population in a variety of settings. ect to facilitate community development and In addition, PATH includes a variety of health goals (Carson, Chappell, & Knight, in intervention targets and strategies. Good press). Gradually, a stronger emphasis on examples of this diversity are the establish- reducing inequities related to social determi- ment of interorganizational networks and nants of health has become apparent: linkages as well as various strategies to develop and reinforce personal competen- PATH’s goal is to support healthy living cies. A final strength to be highlighted is cer- through addressing social determinants; that is, tainly the strong emphasis put on capacity the focus is on barriers and obstacles, and building and community participation in the making the healthy choices the easy choices. PATH Project (Carson et al., in press; Recognizing the difficulties if not impossibility Chappell et al., 2006). For example, consis- of changing root socioeconomic conditions in a tent with a community activation or com- time-limited research project, PATH seeks to munity action strategy, community residents promote healthy living and health supportive and local organizations were involved in the environments via initiatives at multiple levels planning, design, and management of activ- that identify and respond to resident concerns. ities. Accordingly, it was believed that ini- (Chappell et al., 2006, p. 4) tiatives ought to emanate from residents rather than professionals and researchers. For In line with the ecological approach that this reason, the project started at the indi- the promoters explicitly adopted as a theo- vidual level; “this strategy […] helped avoid retical underpinning (Chappell et al., 2006), a potential paralysis of action due to multi- a central criterion guiding the choice of ini- ple simultaneous commitment” (Chappell et tiatives for the project was the capacity to al., 2006, p. 4). As discussed below, there is address one or more determinants of health often a tension between the comprehensive and to effect change at multiple levels. To focus of an ecological approach and the ideal help ensure this multi-level focus, a planning of participation inherent in health promotion tool allowing for the charting of project activ- (Chappell et al., 2006; Stokols, 1996). The ities by level of change was used. Labelled PATH Project is a good demonstration of the “Possibility Framework” (see Table 17.1), how such a large-scale approach can thrive this tool “lists specific initiatives in the proj- with an agenda permeated by community ect by their current level of focus, and participation and capacity building. includes ‘possible’ examples of initiatives and activities at other levels of intervention” Health Promotion 5/1/07 11:18 AM Page 320

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TABLE 17.1: MULTI-LEVEL “POSSIBILITY FRAMEWORK” FOR INITIATIVES

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Getting Kids on the Move and Eating specific information with the schools. A third Well: Stunning Impact of the set of activities consisted of developing a busi- Annapolis Valley Health Promoting ness plan for healthy food and physical activ- Schools Project ity in each participating school that was Another interesting example of the applica- directly in line with an ecological approach. tion of the ecological approach is found in The fourth aimed at implementing a healthy the Annapolis Valley Health Promoting eating strategy: changes were made in food Schools Project (AVHPSP, 2004). It is one of offerings as well as in presentation of new the few initiatives that has been evaluated types of food. The fifth strategy was the extensively in terms of behaviour and health implementation of physical activity on a daily outcomes (Veugelers & Fitzgerald, 2005). basis through non-competitive running, play- Similarly to the PATH project, the ground games, “kids teaching kids” coach- AVHPSP revolved around the theme of ing clinics, equipment loan, etc. The final making the healthy choice the easy choice, strategy included creating links between but focused more specifically on promoting schools and the community through build- healthy eating and daily physical activity to ing partnerships with local stakeholders. fight overweight and obesity among ele- An effectiveness evaluation of the mentary schoolchildren in Nova Scotia. The AVHPSP showed that children attending program promoters believed that “multiple AVHPSP schools had significantly lower strategies occurring simultaneously to pro- rates of obesity and overweight, had health- mote healthy eating and physical activity ier diets, and reported more physical activi- enhances the acceptance and ability to deliver ties (Veugelers & Fitzgerald, 2005). The the programmes at the school, school board, AVHPSP is an example where successful and community level. These strategies include integration of ecological principles led to policy, education, awareness, leadership measurable changes in indicators of popula- development, programme development, pro- tion health. gramme implementation, and advocacy” (AVHPSP, 2004). The activities were organized in six sets. First, the project aimed at Moving toward Tobacco Control: shifting the focus from a “profit” framework Shaping the Web of Environmental toward a “prophet” framework by mobiliz- Determinants in a Quebec Regional ing people around the idea of changing envi- Public Health Department ronments and policies to effect change. This Our third example is the tobacco control pro- was achieved through a number of means: gram of one regional public health department identification of a program champion, cre- (Breton et al., 2004). In 1994, the Quebec ating links with the community, and devel- Ministry of Health and Social Services oping leadership among school staff. The launched an ambitious action plan to tackle the second set of activities involved conducting high prevalence and incidence of smoking in school surveys. This was done by developing the province (Ministère de la santé et des serv- an evaluation framework and developing dif- ices sociaux, 1994). Supported by a budget of ferent data collection activities, including a $20 million, this plan included four compo- student preference survey, activity logs, and nents—prevention, health protection, cessa- school physical activity and menu snapshots. tion, and surveillance/evaluation—and targeted A plan was also developed to share school- youth and low-income populations. In addi- Health Promotion 5/1/07 11:18 AM Page 322

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tion to encouraging collaboration with com- program: schools, health organizations, the munity partners in the development and imple- community, and the society. A variety of mentation of interventions, the plan also called intervention targets were also included. for the adoption of a global, ecological approach Organizational elements (ORG) were by far to tobacco control, including action on a vari- the most frequently targeted by the inter- ety of environmental and personal determi- ventions like, for instance, school tobacco- nants of smoking initiation and maintenance. control policy or increase of tobacco-control The ministry mandated the regional public skills of key actors in organizations (e.g., health departments to implement the plan. In physicians, nurses, teachers, administrators). the following paragraphs, we describe how one Organizational targets were also involved in specific public health department responded to strategies aimed at networking organizations. this mandate. In line with the ministerial plan, An example here is the creation and main- this particular program included a variety of tenance of a network of CLSCs1 involved in initiatives (see Box 17.1) covering a variety of tobacco control in various organizations in intervention settings and targets. their territory. As shown in Table 17.2, four types of set- Three other types of targets were also tings emerged as the most dominant in the aimed at. For example, one initiative (“La

BOX 17.1: SELECTED EXAMPLES OF INITIATIVES IDENTIFIED IN THE TOBACCO-CONTROL PROGRAMMING OF A REGIONAL PUBLIC HEALTH DIRECTORATE

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Gang Allumée”—“The Enlightened Gang”) the intervention (IND). Finally, one initiative involved networking of various actors inter- aimed at a political target. At the same time ested in tobacco control in high school set- that these local and regional activities took tings, including student representatives seen place, the Quebec tobacco-control commu- as key players in the interpersonal environ- nity was actively working toward the adop- ment (INT) of the target population. A self- tion of a new provincial law (Breton, 2005); help cessation guide was distributed in the thus, many of the regional activists were also population through various channels; in this provincially involved in a strategic coalition example, the individual is the direct target of aimed at lobbying elected officials (POL). Health Promotion 5/1/07 11:18 AM Page 323

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TABLE 17.2: FREQUENCY OF INITIATIVES (N = 14) ACCORDING TO DIFFERENT TYPES OF INTERVENTION SETTINGS AND TARGETS

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This tobacco program for youth is an WHERE TO FROM HERE? excellent example of an ecological intervention In sum, we view the ecological approach as (Richard et al., 1996). First, it integrated envi- a contemporary and practicable framework ronmental and individual targets across a vari- within which to orient health promotion ety of settings. Second, these targets translated interventions. However, we also note several into a diversity of strategies of which at least challenges that threaten the reach it might one was aimed directly toward the target pop- have for future practice and research. ulation itself and others at the environment. It The first challenge is conceptual and is noteworthy to mention that smoking was pertains to the role of community participa- among the first contemporary public health tion in the development and implementation issues to be redefined in a broader social per- of programs. Although we highlighted the spective that extended well beyond personal fact that ecological health promotion pro- behaviour (Brownson et al., 1997) thus calling gramming is founded on a broad conception for a comprehensive, ecological response from of health determinants, we also note that less the public health community. The tobacco- emphasis has been devoted to the role of com- control programming described above is a munity participation even though it is seen good example of such a response. as pivotal in health promotion and population health (Rootman et al., 2001; Schwab & Syme, 1997). The reasons for this situation Health Promotion 5/1/07 11:18 AM Page 324

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are likely associated with the inherent chal- A third challenge pertains to the evalu- lenge of reconciling objectives related to ation of the complex and multi-level health multi-level community outcomes on the one promotion programs that integrate the eco- hand, and maximizing community partici- logical approach. First, there is a need for pation, which is often fuelled by more prox- appropriate methods to establish the efficacy imal preoccupations, on the other hand. For and effectiveness of interventions. In this example, Chappell et al. (2006) indicate that, regard, we noted that AVHPSP promoters “residents may be seen to want their kitchens deployed unusual efforts to produce evidence to remain at the individual and group level of the impact of the program in preventing of intervention, whereas PATH may seek obesity and changing eating and activity pat- expansion to more macro levels. This demon- terns (Veugelers & Fitzgerald, 2005). As noted strates potential conflicting priorities for by several authors, though, randomized clin- PATH facilitators between being responsive ical trials, which still represent the gold stan- to community desires on the one hand while dard for evidence, are difficult to apply in on the other hand seeking changes at broader evaluating complex community programs levels” (p. 13). (Victora, Habicht, & Bryce, 2004). Numerous A second and related challenge pertains interesting alternatives have been identified, to the unwillingness of practitioners to advo- though: clustered randomized trials, quasi- cate for legislative and policy changes partly experimentation, and case studies. Yet, effi- because they find themselves in the awkward cacy/effectiveness is not the only focus of position of trying to influence the very people evaluation. As noted by Glasgow and his col- who employ them. Similarly, they are in the leagues (Dzewaltowski, Estabrooks, Klesges, difficult position of interfering with the daily Bull, & Glasgow, 2004; Dzewaltowski, business of very powerful corporations (e.g., Glasgow, Klesges, Estabrooks, & Brock, 2004; the tobacco or fast-food industries). As a result, Glasgow, Klesges, Dzewaltowski, Bull, & existing health promotion programs under- Estabrooks, 2004), evaluations of health pro- standably display timid efforts to influence the motion efforts must also address reach, adop- political sphere. Nevertheless, in the examples tion, implementation, and maintenance. We described above actions at the political level note with some concern that these evaluation were actually undertaken. For example, at the issues will become even more acute as prac- regional public health department, one way of titioners get more involved in stimulating facilitating political action was to support coali- community participation and political action. tions and other collaborative networks that then acted as leaders in terms of political action and advocacy. Similarly, in the “Possibility CONCLUSIONS Framework” of the PATH Project, activities As demonstrated in the three programs were aimed at co-operative interorganizational described above, integrating ecological prin- efforts to change policy affecting local resi- ciples in practice is possible. We anticipate dents. Significant results in health promotion that further advances will occur at an accel- programming are likely to be achieved only if erated pace if researchers and practitioners practitioners, in addition to working at the devote continued efforts to comprehensive individual level, are able to influence political evaluation of ecological programs and to targets (O’Neill, 1989; O’Neill, Gosselin, & knowledge transfer activities. Research on Boyer, 1997). the identification of factors associated with Health Promotion 5/1/07 11:18 AM Page 325

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greater levels of integration of the ecological approach in actual programming is also a promising avenue.

NOTE 1 CLSC: Centre local de services communautaires (local community health centres)

REFERENCES AVHPSP. (2004). Annapolis Valley Health Promoting Schools Project: Making the healthy choice the easy choice. Retrieved March 20, 2006, from www.hpclearinghouse.ca/features/AVHPSP.pdf. Bartholomew, K.L., Parcel, G.S., Kok, G., & Gottlieb, N.H. Intervention mapping: Designing theory- and evidence-based health promotion programs. Mountain View: Mayfield Publishing Company. Beaglehole, R., & Bonita, R. (2004). Public health at the crossroads: Achievements and prospects (2nd ed.). Cambridge: Cambridge University Press. Best, A., Stokols, D., Green, L.W., Leischow, S., Holmes, B., & Buchholz, K. (2003). An integrative framework for community partnering to translate theory into effective health promotion strategy. American Journal of Health Promotion, 18, 168–176. Breton, E. (2005). Promouvoir des mesures législatives en vue de réduire le tabagisme: Une analyse de la contribution du système de santé publique à l’adoption de la loi sur le tabac du Québec [Promoting legislative measures toward tobacco control: An analysis of the contribution of the public health system to the adoption of the Québec tobacco law]. Unpublished doctoral dissertation, Université de Montréal, Montréal, Quebec. Breton, E., Richard, L., Lehoux, P., Labrie, L., & Léonard, C. (2004). Analyser le degré d’intégration de l’approche écologique dans les programmes de promotion de la santé: Le cas des programmations de réduc- tion du tabagisme de deux directions de santé publique québécoises [An analysis of the level of integration of the ecological approach in health promotion programmes: The tobacco control programming of two Québec public health directorates]. Revue canadienne d’évaluation de programme, 19(1), 97–123. Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge: Harvard University Press. Brownson, R.C., Eriksen, M.P., Davis, R.M., & Warner, K.A. (1997). Environmental tobacco smoke: Health effects and policies to reduce exposure. Annual Review of Public Health, 18, 163–185. Carson, A., Chappell, N.L., & Knight, C.J. (in press). Promoting health and innovative health promotion practice through a community arts centre. Health Promotion Practice. Chappell, N., Funk, L., Carson, A., MacKenzie, P., & Stanwick, R. (2006). Multilevel community health promotion: How can we make it work? Community Development Journal, 41(3), 352–366. Dzewaltowski, D.A., Estabrooks, P.A., Klesges, L.M., Bull, S.S., & Glasgow, R.E. (2004). Behavior change intervention research in community settings: How generalizable are the results? Health Promotion International, 19, 235–245. Dzewaltowski, D.A., Glasgow, R.E., Klesges, L.M., Estabrooks, P.A., & Brock, E. (2004). Re-aim: Evidence-based standards and a web-resource to improve translation of research into practice. Annals of Behavioral Medicine, 28, 75–80. Edwards, N., Mill, J., & Kothari, A.R. (2004). Multiple intervention research programs in community health. Canadian Journal of Nursing Research, 36, 40–54. Health Promotion 5/1/07 11:18 AM Page 326

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Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Health and Welfare Canada. Gauvin, L., Lévesque, L., & Richard, L. (2001). Helping people initiate and maintain a more active lifestyle: A public health framework for studies of physical activity promotion. In R.N. Singer, H. Hausemblas, & C. Janelle (Eds.), Handbook of sport psychology (2nd ed., pp. 718–739). New York: Wiley. Glasgow, R.E., Klesges, L.M., Dzewaltowski, D.A., Bull, S.S., & Estabrooks, P. (2004). The future of health behavior change research: What is needed to improve translation of research into health promotion practice? Annals of Behavioral Medicine, 27, 3–12. Glasgow, R.E., Wagner, E.H., Kaplan, R.M., Vinicor, F., Smith, L., & Norman, J. (1999). If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness. Annals of Behavioral Medicine, 21, 159–170. Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach. Mountain View: Mayfield Publishing Company. Green, L.W., Richard, L., & Potvin, L. (1996). Ecological foundation of health promotion. American Journal of Health Promotion, 10(4), 270–281. Kickbusch, I. (1994). Introduction: Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, & international perspectives. Toronto: W.B. Saunders Canada. Kickbusch, I. (2003). The contribution of the World Health Organization to a new public health and health promotion. American Journal of Public Health, 93(3), 383–387. McLeroy, K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351–377. Merzel, C., & D’Afflitti, J. (2003). Reconsidering community-based health promotion: Promise, performance, and potential. American Journal of Public Health, 93(4), 557–574. Ministère de la santé et des services sociaux. (1994). Plan d’action de lutte au tabagisme [Anti-tobacco action plan]. Quebec: Gouvernement du Québec. Moos, R.H. (1979). Social-ecological perspectives on health. In G. Stone, F. Cohen, & N. Alder (Eds.), Health psychology—a handbook: Theories, applications, and challenges of a psychological approach to the health care system (pp. 523–547). San Francisco: Jossey-Bass. O’Neill, M. (1989). The political dimension of health promotion work. In C. Martin & D.V. McQueen (Eds.), Reading for a new public health (pp. 222–234). Edinburgh: Edinburgh University Press. O’Neill, M., Gosselin, P., & Boyer, M. (1997). La santé politique: Petit manuel d’analyse et d’intervention politique dans le domaine de la santé (Monographie du Centre québécois collaborateur de l’OMS pour le développement de Villes et villages en santé). Beauport: Réseau québécois des villes et villages en santé. Orleans, C.T., Gruman, G., Umer, C., Emont, S.L., & Hollendonner, K.K. (1999). Rating our progress in population health promotion: Report card on six behaviors. American Journal of Health Promotion, 14, 75–81. Richard, L. (1996). Pour une approche écologique en promotion de la santé: Le cas des programmes de lutte contre le tabagisme [For an ecological approach in health promotion intervention: The case of tobacco control programmes]. Ruptures: Revue transdiciplinaire en santé, 3(1), 52–67. Richard, L., Gauvin, L., Gosselin, C., Ducharme, F., Sapinski, J.P., & Trudel, M. (in review). Integration of the ecological approach in health promotion and disease prevention programs for older adults. Richard, L., Lehoux, P., Breton, E., Denis, J.L., Labrie, L., & Léonard, C. (2004). Implementing the ecological approach in tobacco control programs: Results of a case study. Evaluation and Program Planning, 27, 409–421. Health Promotion 5/1/07 11:18 AM Page 327

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Richard, L., Potvin, L., Kishchuk, N., Prlic, H., & Green, L.W. (1996). Assessment of the integration of the ecological approach in health promotion programs. American Journal of Health Promotion, 10(4), 318–328. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). Copenhagen: Organisation mondiale de la santé. Sallis, J.F., Cervero, R.B., Ascher, W., Henderson, K.A., Kraft, M.K., & Kerr, J., K. (2006). An ecological approach to creating active living communities. Annual Review of Public Health, 27, 297–322. Schwab, M., & Syme, S.L. (1997). On paradigms, community participation, and the future of public health. American Journal of Public Health, 87, 2049–2051. Simons-Morton, D.-G., Simons-Morton, B.G., Parcel, G.S., & Bunker, J.F. (1988). Influencing personal and environmental conditions for community health: A multilevel intervention model. Family and Community Health, 11(2), 25–35. Smedley, B.D., & Syme, S.L. (Eds.). (2000). Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press. Stokols, D. (1992). Establishing and maintaining healthy environments: Toward a social ecology of health promotion. American Psychologist, 47(1), 6–22. Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10, 282–298. Veugelers, P.J., & Fitzgerald, A.L. (2005). Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. American Journal of Public Health, 95(3), 432–435. Victora, C.G., Habicht, J.P., & Bryce, J. (2004). Evidence-based public health: Moving beyond randomized trials. American Journal of Public Health, 94, 400–405. World Health Organization. (1984). Health promotion: A discussion document on the concept and principles. Copenhagen: World Health Organization, Regional Office for Europe. World Health Organization, Health and Welfare Canada, & the Canadian Public Health Association. (1986). Ottawa Charter for Health Promotion. Canadian Journal of Public Health, 77, 425–430.

CRITICAL THINKING QUESTIONS 1. How can the ideal of increased community participation in the health promotion process be reconciled with action on a variety of determinants of health (e.g., the community and the socio-political environment)? 2. How can public health interventionists further integrate advocacy and legislative action into their repertoire of action? 3. What are the most appropriate research designs for evaluating health promotion interventions that are characterized by a high degree of integration of the ecological approach? 4. Why is the ecological approach often qualified as intimidating and difficult to operationalize? What would you suggest in order to facilitate its integration into programs? 5. Could you think of other examples of programs and interventions that have successfully integrated the ecological approach? Health Promotion 5/1/07 11:18 AM Page 328

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FURTHER READINGS Baker, E.A., Metzler, M.M., & Galeo, S. (2005). Addressing social determinants of health inequalities: Learning from doing. American Journal of Public Health, 95, 553–556. Provides a novel perspective on how to develop interventions aimed at dealing with the challenging issue of health inequalities. Paper has a significant focus on studying activities implemented by actors in the field.

Bauman, A. (2005). The physical environment and physical activity: Moving from ecological associations to intervention evidence. Journal of Epidemiology and Community Health, 59, 535–536. This editorial provides a provocative view on how evidence can be translated into interventions.

Cohen, D.A., Scribner, R.A., & Farley, T.A. (2000). A structural model of health behavior: A pragmatic approach to explain and influence health behaviors at the population level. Preventive Medicine, 30, 146–154. Provides a conceptual model that describes features of the physical and social environment that could be modified to promote the adoption and maintenance of health behaviours.

Smedley, B.D., & Syme, S.L. (Eds.). (2000). Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press. A report from the Institute of Medicine Committee on Capitalizing on Social Science and Behavioural Research to Improve the Public Health. It emphasizes the role of social and behavioural factors in influencing health and disease at different stage of life. Many chapters are devoted to public health intervention, including health promotion.

Task Force on Community Preventive Services, Zaza, S., Briss, P.A., & Harris, K.W. (Eds.). (2005). The guide to community preventive services: What works to promote health? Oxford & New York: Oxford University Press. Developed in the United States by the Task Force on Community Preventive Services, the Guide provides recommendations for interventions that promote health and prevent disease in communities and health care systems. It is based on systematic review methods for evaluating population-oriented health.

RELEVANT WEB SITES

BC Coalition for Health Promotion www.vcn.bc.ca/bchpc Health in Action: On-line Access to Health Promotion and Injury Prevention Information in Alberta www.health-in-action.org Health Promotion Clearinghouse (Nova Scotia) www.hpclearinghouse.ca Ontario Health Promotion Resource System www.ohprs.ca Health Promotion 5/1/07 11:18 AM Page 329

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Ontario Prevention Clearinghouse www.opc.on.ca A sample of provincial resource systems generally aimed at supporting health promotion organizations and interventionists with community resources and expertise. Several examples of programs appear on these Web sites.

Institut national de santé publique du Québec www.inspq.qc.ca/english The mandate of the Institut is to support the minister and regional agencies in fulfilling their public health mission. The Institut’s mission includes, among other goals, development, updating, dissemination, and implementation of knowledge. Its Web site provides information and resources related to a variety of health issues and interventions.

Public Health Agency of Canada www.phac-aspc.gc.ca With the mandate of promoting and protecting the health of Canadians, the agency is involved in various activities such as program delivery, research and knowledge development, and public and professional education. Its Web site includes information and resources related to key health issues and interventions in Canada.

RE-AIM www.re-aim.org RE-AIM provides an explanatory framework to systematically evaluate health behaviour interventions. The acronym stands for Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance. The Web site provides links to several resources useful to researchers and interventionists (data sources, reporting guidelines, examples of questions to investigate when evaluating health promotion program and policies, etc.). Health Promotion 5/1/07 11:18 AM Page 330

CHAPTER 18 HEALTH PROMOTION AND HEALTH PROFESSIONS IN CANADA: TOWARD A SHARED VISION

Marcia Hills, Simon Carroll, and Ardene Vollman

INTRODUCTION environmental and economic conditions so as efore we begin to discuss the complex to alleviate their impact on public and indi- Brelations between the health professions vidual health. Health promotion is the process and the field of health promotion, it is neces- of enabling people to increase control over the sary to consider the definition of health pro- determinants of health and thereby improve motion. In this we are in agreement with their health. Participation is essential to sus- O’Neill (1997) in his comment on health pro- tain health promotion action” (Nutbeam, motion and nursing when he says that the 1998). This definition links the “how” and “main issue at hand is to agree on a definition “why” ideology to the “what” of the determi- of health promotion, as this has a direct impact nants of health (World Health Organization, on related research, funding, teaching and 1998). We believe this is crucial because if practice” (p. 72). This is particularly true with health promotion is about anything, it is about regard to the role of the two dominant health action taken across the broad spectrum of professions, physicians and nurses. While health determinants, particularly directed there has been much progress in health pro- toward the social, environmental, and eco- motion as a field of research and practice, it is nomic conditions that support health. still unfortunately true that the “ambiguity of While this does not in any way denigrate the discourse in health promotion” (p. 73) is the important work of developing personal pervasive, and, as will be shown, this ambi- skills and capabilities, notably through indi- guity continues to have a direct impact on how vidual counselling strategies in the clinical physicians and nurses understand their roles setting, it makes the strong point that we in relation to the concept. cannot consider this type of individually In this chapter, we will follow the Ottawa focused, “lifestyles counselling” as constitut- Charter definition of health promotion as “the ing health promotion in toto. Thus, an eval- process of enabling people to increase control uation of whether physicians and nurses are over, and to improve their health” (World integrating health promotion into their edu- Health Organization, 1986). However, we cation and practice must consider this will also draw upon the expanded definition broader definition of health promotion.1 It in the updated Health Promotion Glossary: must consider health promotion to be the “Health promotion represents a comprehen- combination of concerted, integrated strate- sive social and political process, it not only gies of action on the broad determinants of embraces actions directed at strengthening health through the values-based process of the skills and capabilities of individuals, but enabling and empowering people to have also action directed towards changing social, control over these determinants. While we 330 Health Promotion 5/1/07 11:18 AM Page 331

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are not quite ready to give up the “ideology” It will use a two-dimensional mapping strat- dimension of the health promotion concept egy for locating where on the health promo- (as this would entail junking the values and tion spectrum doctors and nurses find moral substance of health promotion), we themselves when attempting to teach and agree with O’Neill’s general sentiment, as practise health promotion. also voiced in Chapter 3 of this book, that Finally, the chapter will offer a theoreti- clearer agreement on what health promotion cal argument for primary health care as the entails would be very helpful as not all people key locus for new efforts in the future, to inte- currently practising “health promotion” grate the Ottawa Charter vision of health pro- share this ideology and value base. motion into the heart of our health systems. The chapter will focus exclusively on the roles of physicians and nurses in health promotion. This somewhat narrow focus (there TRENDS IN HEALTH are many other health professionals who are PROMOTION ENGAGEMENT relevant to health promotion—including BY PHYSICIANS AND nutritionists, dentists, physiotherapists, chiro- NURSES practors, mental health professionals, etc.)— Over the past two decades or more, many is taken for two reasons. First is the simple changes have taken place in Canada within matter of space: We wanted to focus critically these two health professions regarding their on some very specific issues rather than pro- engagement in health promotion activities. duce a more superficial survey of all the rele- Health promotion as a concept (however var- vant professions. Second, and more complex, iously defined) has become a standard refer- is the desire to bring into relief the crucial chal- ence point in medical and nursing education. lenge health promotion still faces in con- However, the particular understanding and fronting the Sisyphean task of reorienting health working definition (explicit or implicit) that services or “health systems,” which is the more dominates is very different for medicine and frequently used term now. This requires going nursing. In this section, we will explore some back to health promotion’s roots in the Alma- of the reasons for this divergence and some Ata Declaration (World Health Organization, solutions for moving both professions toward 1978) and linking its prospects for tackling the a more consistent approach to teaching about great mountain of health systems reform health promotion from a broader perspec- through the strategy of primary health care. tive. In addition, it is also the case that there Physicians and nurses are the key strategic pro- is a vast diversity of attitudes and practices fessions to mobilize for health systems change, to health promotion once one ventures to the and primary health care, if implemented in its clinical settings, where health professionals fullest sense, is the basic fulcrum for leverag- have to implement their educational experi- ing this desperately needed change. ence when they start to work in communi- The chapter will first look at some of the ties or in acute care settings. recent trends in how physicians and nurses have engaged in health promotion, and will critically analyze the barriers to fully incor- Health Promotion in Medical and porating a broad definition of health promo- Nursing Education tion into their everyday reflective practice, It is very clear that across the spectrum of both as educators and as clinical practitioners. medical and nursing undergraduate course Health Promotion 5/1/07 11:18 AM Page 332

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offerings, health promotion has made a sig- drawn out of the analysis of the core curric- nificant imprint, albeit at very different levels ula and regular electives offered internally and with a very different impact for nurses by each medical program. and doctors respectively. We start our analy- Almost invariably, health promotion is sis with a brief review of undergraduate cur- linked with, if not conflated with, disease ricula in both the nursing and medical prevention and epidemiology, and is usually schools across Canada. Although there is cer- subsumed under the broader labels of “pop- tainly a diversity of perspectives within each ulation health” or “community health.” The profession, the focus of this analysis will be overall focus is on health promotion as a on the overall contrast between how nursing “function” with a related set of technical and medicine have approached integrating intervention strategies. Several programs health promotion into their core curriculum. (e.g., Queen’s University and the University of Toronto) now offer placements for med- Health Promotion within the Medical Curriculum ical students in “community health settings” We conducted a brief review of all 16 of the to apply their learning in community medi- medical curricula in Canada, with the course cine broadly interpreted. contents as available on university Web sites Despite the move toward a “community” for the current year. The information avail- focus in many of the programs, we could find able on each Web site varied in the amount little or no mention of the values-based orien- of detail provided. Despite these variations, tation of health promotion as outlined in the we were able to ascertain which programs Ottawa Charter, leaving the concepts of partic- contained health promotion content. No ipation, empowerment, and equity noticeably interviews or other data collection methods missing. Wherever health promotion is men- were used; thus, the analysis is obviously lim- tioned, it is thus strongly associated with epi- ited. For the purposes of the broad contrasts demiology, population health, and community we want to make, the course descriptions— medicine. For example, at McGill, health pro- wherein the curricula health promotion is sit- motion is mentioned as one part of the uated and the prominence given to health “Epidemiology, Biostatistics, and Occupational promotion overall—provided the required Health” course, and at the University of information we needed to allow us to reach Manitoba, it fits under “Population Health and our conclusions. These conclusions are based Medicine.” This orientation, many health on the words “health promotion” appearing promoters have pointed out, tends to leave in specific courses and in the broad learning the emphasis on values out of the equation objectives of the programs. (Raphael & Bryant, 2000). The term “health promotion” appears This is curious because there are strong in almost all (14 out of 16) of the program movements within family medicine such as and course descriptions of the medical cur- “patient-centred medicine” (Stewart et al., ricula across Canada. Some of the medical 1995), and “relationship-centred care” (Pew- programs—for example, at the University of Fetzer Task Force, 1994, 2000) that emphasize Alberta—collaborate closely to offer courses many of the values that are compatible with a with their respective public health and health broader interpretation of health promotion, promotion programs, which can be located yet these areas of curriculum development are in the same school or in other related schools not usually associated with health promotion. or faculties; however, our conclusions are This is probably due, as found in our analysis Health Promotion 5/1/07 11:18 AM Page 333

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of curricula, to the fact that health promotion promotion to impact medical education is still has often tried to impact medicine through the largely unfulfilled and the effort to broaden back doors of disease prevention or social and the understanding of health promotion within preventive medicine and has not well con- medicine means paying much more attention nected health promotion’s value base with the to its value base and less to its technical com- more general value base several medical pro- ponent in connection to epidemiology and dis- grams seem to encourage and promote. This ease prevention. represents a major missed opportunity as building alliances with innovations in the core Health Promotion within the Nursing Curriculum of clinical teaching in family medicine could There are 138 nursing programs in Canada, be a more effective strategy for changing med- with 40 of these offering diplomas only (mostly icine’s view of health promotion. Specifically, in Quebec). Of the remaining 98 programs, health promotion could make the connection most are university–college collaborations, between everyday clinical realities and the resulting in only 32 distinct baccalaureate focus on equity, participation, and empower- degree programs. Only two of these are uni- ment that are foundational to health promo- versity programs without college partners. tion’s philosophy and quite compatible with One rationale for choosing to focus only family medicine orientations in many univer- on programs offering a baccalaureate degree sities, with the most notable and long running is because after 2005, baccalaureate educa- being the McMaster program, along with tion became mandatory for nursing pro- University of Western Ontario, Laval, and, grams in most provinces in Canada. This more recently, UBC, with its innovative “dis- position is supported by the Canadian Nurses tributed” medical programs strongly empha- Association (2004). sizing family medicine. Over the last two decades, there have What we found in our analysis of medical been major changes in nursing curricula in curricula is quite in line with a report by the Canada. The major impetus for these changes Steering Committee on Social Accountability was what our American colleagues called “the of Medical Schools, which recently recom- curriculum revolution” (Bevis & Watson, mended that medical education should adopt 1989; National League of Nursing, 1988, “a philosophy that values health promotion 1991). In Canada, this movement had a pro- and disease prevention as components of med- found impact by recognizing the connections ical care and an assumption that physicians between health promotion and nurses “lived” have a responsibility in health promotion and domain of practice, based on a philosophy of disease prevention” (Health Canada, 2001b). caring and a focus on people’s experiences of This movement is strongly linked to many of health and healing (Bevis, 1989; Duncan, 1996; health promotion’s broader goals of commu- Hartrick, Lindsay, & Hills, 1994; Stewart, nity involvement, international health, and 1990; Watson, 1988). As these ideas took hold, addressing health inequities (Parboosingh, they were eventually transformed into con- 2003). Here we again see the twinning of crete actions for curriculum change and health promotion with disease prevention, but development (Hills et al., 1994; Rush, 1997; with a more direct link to some basic ethical Smillie, 1992). During this period, there was, premises and a broader social focus. Such serendipitously, a national movement, which statements, which are becoming more fre- evolved at a variable speed in the different quent, demonstrate that the potential for health provinces and territories, to push forward Health Promotion 5/1/07 11:18 AM Page 334

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baccalaureate degrees for nurses as the basic University of Calgary), while in other curric- credential for entry to practise in the profes- ula a health promotion perspective is fully inte- sion. Before these changes, nursing education grated across their entire program (University was dominated by a technical orientation to of Victoria, University of Western Ontario, biomedical practice and a strong emphasis on Laurentian University, and University of individual patient care in acute care settings. Alberta) (Hills & Lindsey, 1994). Unlike med- It had neglected to embrace its roots in an eth- icine, the tension is not between health pro- ical orientation to patient empowerment and motion and disease prevention, but more caring (Benner & Wrubel, 1989; Bevis & between a broad ecological approach and one Watson, 1989; Watson, 1988). more restricted to traditional health education In this context, an important decision was interventions. In addition, there continues to made across Canada to integrate and articu- be a tension between a focus on individual late pre-existing diploma programs with the patients and the families and communities they emerging university-centred baccalaureate live in and with; this tension complicates and degrees. This serendipity provided a unique creates barriers for encouraging nurses to inter- opportunity for a change in orientation because vene on the broader determinants of health of the necessity for a total reorganization of (Purkis, 1997; Hartrick, 2000). nursing programs in Canada (Hills et al., 1994). We can thus conclude this subsection by Even if it remains unclear how this formal suggesting, as indicated in Figure 18.1 below, inclusion of health promotion rhetoric is trans- that probably the most important distinction lated into actual teaching practices, we can now between medicine’s and nursing’s inclusion of say that in many nursing programs, health health promotion in their respective curricula promotion is at least nominally recognized as is that nursing has adopted more readily the a core aspect of nursing education. Of the value-based aspects of health promotion phi- selected nursing programs, we conducted a losophy, notably because it was already close to review of each of the university calendars, sup- its generally dominant value base, whereas plemented by Internet searches for specific medicine has concentrated more on its instru- courses, to determine the number of the mental aspects. We can see a progressive shift selected nursing programs that had courses or in nursing education toward a broader con- content within courses that named health pro- ceptualization of health promotion with motion as a component. While there are cer- much variation in the extent of this shift. tainly large variations in the orientation and Unfortunately, as we will see, the disjunction focus that each program gives to health pro- between education and practice in nursing has motion, the fact that the language of health a profound effect on how well this new edu- promotion is gaining a strong foothold is a cational philosophy is transformed into health promising development and potential base for promotion practice where nurses actually work. expanding the scope and depth of health promotion in nursing in Canada. However, there are still important variations in the definition Health Promotion in Health and conceptualization of health promotion. Professional Practice For example, some programs name health pro- For both physicians and nurses, as well as for motion as a component of a particular course, most professions, integrating their education usually under “primary health care” or “com- with the “reality shock” of entering real world munity health” (McGill, University of Toronto, practice is a major issue (Kramer, 1974, 1985; Health Promotion 5/1/07 11:18 AM Page 335

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Rafferty, Allcock, & Lathlean, 1996). For a Arguably, this shift toward “hospitalists” is difficult and complex area such as health pro- unfavourable to the more natural continuity motion, this can be even more difficult to between the patient, his or her family, and the retain and integrate, especially given the lack community they live in that family practi- of systemic supports for this area of practice. tioners often provide and a less favourable This latter issue is particularly true for acute environment in which health promotion prac- care settings, such as hospitals. Nevertheless, tices can flourish. there are particular issues that distinguish the In primary care, family practitioners in challenges faced by physicians and nurses Canada have typically integrated health pro- based on the settings in which they work. motion on a very superficial level, if at all. Unfortunately, partly due to education and Health Promotion within Physician policy developments, family practitioners asso- Clinical Practice ciate health promotion with the battery of As we have been able to observe in several demands on them to provide a series of pre- research projects recently (Hills & Mullett, ventive screening and other measures (Pimlott, 2005a, 2005b), for physicians, there are major 2005). This interpretation is reinforced by the challenges to integrating health promotion into bias toward individual “lifestyles” counselling their clinical practice. In the acute care setting, prevalent in the literature on primary care the obstacles are more obvious. Physicians in health promotion (Beaulieu et al., 1999; Gillam, hospitals are often restricted to episodic care McCartney, & Thorogood, 1996; Guthrie, 2001; encounters, dominated by a technical routine Hudon, Beaulieu, & Roberge, 2004; Narayan, of rapid diagnosis and treatment schedules; in Bowman, & Engelgau, 2001). The difficulties fact, “objectifying” the patient is an under- involved in shifting family physicians to a focus standable course of action in many basic situ- on health promotion beyond the limited strat- ational encounters between doctor and patient egy of “lifestyles” and health education strate- in a hospital setting (some surgical procedures gies are many (Green, Cargo, & Ottoson, 1994; offer an extreme example of this) (Moreira, Herbert, 1995), yet there are some good exam- 2004). Without a more sophisticated view of ples of a move toward greater involvement for health promotion than what is generally taught physicians in a “settings” approach (Mackie & in medical curricula, specifically an approach Oickle, 1997). that looks at system level and policy change in This is complicated by the public percep- hospitals, incorporating health promotion tion that physicians deal only with acute, bio- becomes close to impossible. These latter issues medical concerns. This latter phenomenon was have been best addressed by the health-pro- emphasized in a study investigating adoles- moting hospitals movement (Haddock & cents’ perceptions of family physicians in health Burrows, 1997; Hancock, 1999; Korn, 1997; promotion and disease prevention (Malik, Pineault, Baskerville, & Letouze, 1990; World Oandasan, & Yang, 2002). Paradoxically, the Health Organization, 1997). In most provinces, main users of primary care medicine (women, there have been some important changes in mothers with young children, and seniors) are relation to the access family practitioners have fully aware that physicians are there for more had to hospitals in recent years, replacing in- than acute episodic health issues (Hills & patient care by the patient’s regular doctor with Mullett, 2005a). As clearly observed in our full-time “hospitalists” (Sullivan, 2000; van research, the normal situation for the primary Walraven et al., 2004; Wilson et al., 2001). care physician is as an isolated individual Health Promotion 5/1/07 11:18 AM Page 336

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managing an impossible range of needs with care” (p. 66). With the advent of the curricu- little or no support, and even less time or lum revolution there was a glimmer of hope patience for people advocating that they take that nurses would finally address the power on more. As health promoters, we need to issues inherent in interprofessional, intra-pro- recognize that there are better ways of engag- fessional, and structural relationships (Benner, ing family practitioners in the health promo- Tanner, & Chesla, 1996; Robinson, 1995). It tion approach than extending preventive was assumed that teaching nurses differently medicine to an enlarged series of technical could impact and dramatically change nurs- interventions. A different approach might be ing practice even in hospital settings. Although to support the basic philosophy of helping there were some gains in the 1990s, the recent physicians empower their patients, the fam- literature suggests that this dominant subju- ilies that support them, and the communities gated culture continues to exist in many in which they live. This can be done in a vari- Canadian hospitals (Daiski, 2004; Fletcher, ety of ways that are more related to how 2000; Roberts, 2000). physicians can engage in a broader social and Even in situations where hospital admin- political engagement in advocacy and lead- istrators have been active in presenting oppor- ership on the full spectrum of health deter- tunities for health promoting activities, nurses minants affecting their patients health than have not always been as active as they could to very specific and limited, individually be to support the political will necessary for focused interventions. these changes (Whitehead, 2004). However, nursing practice varies considerably in the Health Promotion within Nursing acute care setting and some nursing units are Clinical Practice able to do more health promotion than others. Nursing is in the unenviable position of being Nursing students who have been trained with largely confined to the relatively impermeable a health promotion curriculum report that institution of the hospital, with all the trap- although they are able to integrate health pro- pings associated with its militaristic past and motion into their clinical practice (Hills, 1998, its hierarchical present. In 2003, the percent- 2000), this is often discouraged by the hege- age of nurses working in the hospital sector mony of the hospital system and its diagnose- was 62.4 percent, compared to 12.9 percent in treat-cure triad. the community sector (Canadian Nurses The most disappointing to date and yet Association, 2004). Historically, in acute care most promising potential for health promo- settings, nurses have had a long and often tion practice in nursing lies in the community unrewarding struggle with basic workplace setting. In Canada, the main categories of oppression and a lingering subordinate men- nurses working in the community setting are tality, reinforced often by the medical profes- public health nurses (sometimes called com- sion and systematically backed up by hospital munity health nurses) and the emerging and administrators and policy makers (Ashley, growing group of nurse practitioners. For 1976; Roberts, 1983). As Robinson (1995) public health nurses, there is a further irony explains: “The extent of our oppression means in relation to health promotion. Many of the that we often relate to each other through most dedicated and aware health promotion processes characterised by horizontal violence, practitioners in Canada are public health where we attack each other in response to our nurses, yet they are often hamstrung by two subjugated positioning in the culture of health issues: first, they are quite marginalized and Health Promotion 5/1/07 11:18 AM Page 337

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on the periphery of the health system; second, Summarizing the Differences between they tend to rely heavily on a technical ori- Medicine and Nursing in Relation to entation to epidemiological surveys to predict Health Promotion what programs and interventions to offer We propose here a two-dimensional matrix, (Chalmers & Bramadat, 1995). with a continuum on the x-axis running from These two issues are connected because a “technical” orientation to health promotion the lack of resources available often lead public to a “values-based” orientation, and a con- health nurses to focus on identifying problems tinuum on the y-axis, running from an “indi- at the community level, but their professional vidual” focus to a broad “community” focus control over knowledge of community health on health promotion. Using this matrix, we needs (Chalmers & Bramadat, 1995) leave can now situate the two dominant health pro- them less able to enlist community participa- fessions in term of their educational and prac- tion to support health promotion activities. As tice-based foci as well as their orientation to nurse practitioners are only really starting to health promotion. This simple representa- become a regular part of everyday commu- tional tool allows us to explore visually how nity practice, and have a strong connection to various definitions of health promotion have the effort at primary health care renewal, we been incorporated in the everyday education will mention them in the next section of the and practice of physicians and nurses in chapter as probably having the pivotal role in Canada (see Figure 18.1) introducing health promotion in primary care Physician education has moved signifi- clinical professional practices. cantly toward a broader population focus on health promotion, yet has retained a fairly

FIGURE 18.1: FOCUS AND ORIENTATION ON HEALTH PROMOTION

Image not available Health Promotion 5/1/07 11:18 AM Page 338

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technical orientation toward its type of health Health Services). While health promotion in promotion intervention strategies. Physician Canada has been attempting to address the practice is still mainly based on a very narrow first four action areas (whatever the actual use and interpretation of health promotion, concrete successes), until recently, there has limited to individual counselling, and only been a reluctance to tackle the difficult area where feasible, given the wider systemic dis- of reorienting health services. There have incentives (i.e., no remuneration) to imple- been a variety of reasons for this situation, ment such limited strategies. Nursing but the key factor has been the political dom- education, though uneven, has made a sig- inance of curative techno-medicine and nificant move toward a broader focus on health promoters’ fear of squandering its community health and a more explicit value- energies and being co-opted by medicine and based approach, while still having a way to its prerogatives (Frankish et al., 2000). go toward meeting the Ottawa Charter Over the last decade, some health pro- approach. Finally, nursing practice still faces motion researchers have started to realize that many barriers to converting improved edu- a renewal of primary health care (PHC), par- cation in health promotion philosophy into ticularly one oriented to the original Alma-Ata a strong focus on community and a more Declaration (World Health Organization, determined orientation to basic health pro- 1978) principles (Birse & Rootman,1999; motion values. While the figure offers only Frankish et al., 2000), presents a unique oppor- a crude representation of the placement of tunity for health promotion to fulfill its man- these four aspects of health professional date described in the Ottawa Charter’s claim engagement in health promotion, we argue that health promotion could play a significant it can be used profitably as a thinking tool to role in reorienting health services. What fol- interrogate the landscape of health promo- lows is a brief outline of how this opportunity tion as it currently stands for nurses and can overcome some of the barriers and chal- physicians in Canada. lenges identified earlier in the chapter. As the history of health promotion is inti- mately linked with the Alma-Ata Declaration PRIMARY HEALTH CARE AS (see Chapter 1), we can see that many of the THE KEY STRATEGY FOR challenges that technically oriented, individ- REORIENTING HEALTH ually focused illness care present are addressed SYSTEMS AND INTRODUCING there and supplanted by a strong orientation HEALTH PROMOTION IN to participation, empowerment, and equity, PROFESSIONAL PRACTICE and a very radical focus on community as the key setting for implementing primary health The Primary Health Care/ care. There is also an important advocacy in Health Promotion Alliance: PHC for multidisciplinary teams and a shift A Missed Opportunity from a system dominated by the priorities of The Ottawa Charter outlined five action areas illness care to one driven by primary health where health promoters should focus their care and public health priorities (MacDonald, collective energies (Building Healthy Public 1993; Starfield, 1998). Policy; Creating Supportive Environments; Many of the elements of primary health Strengthening Community Action; Devel- care are also the key ingredients for success- oping Personal Skills; and Reorienting ful reorientation of the health system toward Health Promotion 5/1/07 11:18 AM Page 339

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a health promotion focus. While many of focused, participatory health promotion the originators of health promotion would requires a variety of disciplines to work recognize this commonality between the two together to help identify with the community approaches, this important political alliance what its needs and strengths are, and to has often been ignored, forgotten, or delib- develop initiatives aimed at improving health erately avoided due to the perceived risk of and reducing health inequities. Physicians collaborating with the dominant medical and nurses just happen to be the more pow- profession (Sindall, 2001). This self-defeat- erful (with nurses’ power based more on pure ing strategy has borne little fruit and, in many quantity) disciplines in the health sector. ways, has allowed health promotion to be There is a strong argument that if we further marginalized and excluded from the could get physicians and nurses to work and core of the health system. While many have be educated together, we would be able to advocated for an intersectoral focus and a make a major shift toward the goal of mul- move away from relying on the health sector tiple disciplines practising together as a team. to promote health, we believe that the most Not only that, we can learn much from the important allies for health promotion still difficulties and challenges posed by the past reside in the health sector. attempts to get these two professional groups to drop their defensive armour and build true collaboration. In education, we know that The Promising Future of Health there is a growing willingness to integrate Promotion in Primary Health Care significant parts of the health curriculum so Now we outline a few concrete strategies for that at least physicians and nurses can be using primary health care renewal, reform, taught together (Pringle et al., 2000). and revitalization as a fulcrum for leveraging Nevertheless, despite these exhortations, change in the health system and advancing the this has been an exceedingly difficult pro- aims and vision of health promotion. We will gram of change to implement. Health pro- focus on how primary health care could affect moters must get involved and support this physician and nursing education and practice. movement as strongly as possible. There are However, rather than separate the two pro- many opportunities for academics involved fessions as was done above, we now present an in health promotion to use their now estab- integrated approach we think is crucial to over- lished positions in academe to advocate for coming the dualisms and counterproductive this change in health professionals’ curricula. dichotomies that nursing and medicine have Arguing that this change is a necessity for perpetuated as primary defence mechanisms primary health care reform and the integra- in the interest of professional advancement. tion of health promotion can provide addi- The first and most obvious aspect asso- tional elements for such advocacy. ciated with primary health care that would The second obvious place for enabling encourage physicians and nurses to work the reorientation of health systems through together to provide a more health promoting primary health care is the organizational set- team approach, along with other disciplines, ting of community health care practices. is the long wished for, but seldom practised, These already come in a variety of shapes and move toward interdisciplinary education. The sizes in Canada (Lamarche, Chauvette, & movement for primary health care has long Larouche, 2003; Richard et al., 2005), with recognized that supporting community- Quebec probably having the longest systemic Health Promotion 5/1/07 11:18 AM Page 340

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experimentation since the beginning of the Charter for Health Promotion. The litany of CLSCs in the early 1970s, but they all share barriers and obstacles, real and imaginary, the common goal of bringing many different that prevent the health professions from lift- professions together to provide integrated ing their eyes above the din of system chaos health and social services, so that the needs of and crisis is interminable. The rationale for communities are met and individuals and optimism is tenuous at best. However, as families can navigate the systems seamlessly Gramsci (1971) recommended, “pessimism of and be empowered to take control of their the spirit, optimism of the will.” own health. Health promoters need to find Thus, the real and awaiting opportunities ways of supporting the move toward these are also legion, and for health promotion to types of models and philosophical approaches. drop the ball, so to speak, at this crucial time, Most importantly, they need to ensure that as would be unconscionable. We have outlined the system evolves, it does not slide back into some of the problems that health profession- a technical and individual focus on illness care. als create for themselves, but the real message A final aspect is the emerging role and here is how health promoters can be more prominence of nurse practitioners (NPs) in strategic and more understanding of the prob- Canada. While some NPs will work as lems and complexities that confront physicians advanced practice nurses in hospital settings, and nurses in their day-to-day realities in edu- many will be engaged in the community in cation and practice. We have for too long relied hopes of enhancing primary health care and on the meek role of being the “etcetera” after health promotion. While this represents a preventive medicine, the underling of chronic great opportunity, health promotion-minded disease management, and the hopeful face of people have a role in making sure that NPs population health. It is time for health pro- don’t become “mini doctors.” NPs face a par- moters to be proud of their heritage in an ticular challenge as they try to legitimize their unabashed commitment to the values and expanded scope of practice in a medically principles and ethics of health promotion. dominated sector. If NPs are to be truly effec- The next time we talk to physicians or tive in advancing their role in PHC, a strong nurses about health promotion who are work- health promotion element must be incorpo- ing at the “coal face” or in “the trenches,” we, rated into their practice. Although such vicis- as health promoters, need to emphasize par- situdes may seem remote from the day-to-day ticipation, empowerment, and equity, linking concerns of many health promoters, this is a them to the long-standing value base of nurs- key strategic area in the overall struggle to ing and the emerging one in family medicine. reorient health systems and should be a major In this way, we can create a common vision of focus of advocacy efforts. the landscape of health promotion, getting behind the technocratic curtain, to the shared core values that cultivate caring, commitment, CONCLUSIONS and collaboration to improve people’s health. As we have suggested in this chapter, health The key challenge still remains to develop promotion has had a significant impact on the strategies that enable physicians and nurses to two main health professions in Canada over be actively involved in health promotion activ- the last 12 years. Yet, there are still great chal- ities that go beyond individual behavioural lenges to overcome if we are to realize, even interventions to broader community develop- partially, the vision outlined in the Ottawa ment, advocacy, and intersectoral collabora- Health Promotion 5/1/07 11:18 AM Page 341

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tions for health, but together, we can imagine and implement them.

NOTE 1 In this chapter we do not focus on health promotion research carried out by health professionals. Although there is a significant level of involvement by many health professionals in such endeavours (especially by nurses), we have chosen to limit our analysis to the basic training and practice elements in order to gain an overall perspective on how most physicians and nurse are educated and carry out their practice.

REFERENCES Ashley, I. (1979). Hospitals, paternalism and the role of the nurse. New York: Teachers College Press, Columbia University. Beaulieu, M.-D., Hudon, E., Roberge, D., Pineault, R., Forte, D., & Legare, J. (1999). Practice guidelines for clinical prevention: Do patients, physicians, and experts share common ground? Canadian Medical Association Journal, 161(5), 519–523. Benner, P., Tanner, C., & Chesla, C. (1996). The nurse-physician relationship: Negotiating clinical knowledge. In P. Benner, C. Tanner, & C. Chesla (Eds.), Expertise in nursing practice: Caring, clinical judgment, and ethics (pp. 280–306). New York: Springer Publishing Co. Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping in health and illness. Los Angeles: Addison-Wesley. Bevis, E. (1989). Organizing for and evaluating change. In E.O. Bevis, curriculum building in nursing: A process (3rd ed.). New York: National League for Nursing. Bevis, E.O., & Watson, J. (1989). Toward a caring curriculum: A newpedagogy for nursing. New York: National League for Nursing. Birse, E., & Rootman, I. (1999). Implications of health promotion for integrated health systems. International Journal of Health Care Quality Assurance Incorporating Leadership in Health Services, 12(1), i–v. British Medical Journal. (2006). From http://bmj.bmjjournals.com/. Canadian Nurses Association. (2004). Canadian Nurses Association: 2003 annual report. Ottawa: Author. Center for the Health Professions. (2006). Future of the health professions, 2006. From www.futurehealth.ucsf.edu/summaries/challenges.html. Chalmers, K., & Bramadat, I. (1995). Community development: Theoretical and practical issues for community health nursing in Canada. Journal of Advanced Nursing, 24, 719–726. Daiski, I. (2004). Issues and innovations in nursing practice: Changing nurses’ dis-empowering relationship patterns. Journal of Advanced Nursing, 48(1), 43–50. Duncan, S.M. (1996). Empowerment strategies in nursing education: A foundation for population- focused clinical studies. Public Health Nursing, 13(5), 311–317. Fletcher, M. (2000) Handmaidens no more. Canadian Nurse, 96(5), 18–22. Frankish, C.J., et al. (2000). Health promotion in primary health care settings: A suggested approach to establishing criteria, submitted to Health Canada (pp. 1–79). Prepared by the Institute of Health Promotion Research, UBC. Gillam, S., McCartney, P., & Thorogood, M. (1996). Health promotion in primary care. British Medical Journal, 312, 324–325. Health Promotion 5/1/07 11:18 AM Page 342

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Gramsci, A. 1971. Selections from the prison notebooks of Antonio Gramsci. London: Lawrence and Wishart. Green, L.W., Cargo, M., & Ottoson, J.M. (1994). The role of physicians in supporting lifestyle changes. Medicine, Exercise, Nutrition, and Health, 3, 119–130. Also in Proceedings of the twenty-ninth annual meeting of the Society of Prospective Medicine (pp. 89–129), St. Louis, Missouri, April 15–17, 1993. Indianapolis: Society of Prospective Medicine, Publishers. Guthrie, C. (2001). Prevention of type 2 diabetes: Health promotion helps no one. British Medical Journal, 323, 997. Haddock, J., & Burrows, C. (1997). The role of the nurse in health promotion: An evaluation of a smoking cessation programme in surgical pre-admission clinics. Journal of Advanced Nursing, 26(6), 1098–1110. Hancock, T. (1999). Creating health and health promoting hospitals: A worthy challenge for the twenty- first century. Leadership in Health Services, 12(2), viii–xix. Hartrick G. (2000). Developing health-promoting practice with families: One pedagogical experience. Journal of Advanced Nursing, 31, 27–34. Hartrick, G., Lindsey, A.E., & Hills, M. (1994). Family nursing assessment: Meeting the challenge of health promotion. Journal of Advanced Nursing, 20(1), 85–91. Health Canada. (2001a). Health Canada community action program (CAPC)—national program profile (NPP) Cycle 1 summary report: Final. Available at http://www.phac-aspc.gc.ca/dca-dea/publication/ capc-pace_cycle1_e.html. Health Canada. (2001b). Social Accountability: A Vision for Canadian Medical Schools. Ottawa: Author. Available from http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgbs/pdf/pubs/2001-social-vision-med/ 2001-socila-vision-med_e.pdf. Herbert, C.P. (1995). Clinical health promotion and family physicians: A Canadian perspective. Patient Education and Counseling, 25, 277–282. Hills, M. (1998). Student experiences of nursing health promotion practice in hospital settings. Nursing Inquiry, 5, 164–173. Hills, M. (2000). Perspectives on learning and practicing health promotion in hospitals: Nursing students’ stories. In L. Young & J. Hayes (Eds.), Transforming health promotion practice: Concepts, issues, applications, 229–240. Philadelphia: F.A. Davis. Hills, M.D., & Lindsey, E. (1994). Health promotion: A viable curriculum framework for nursing education. Nursing Outlook, 42(4), 158–162. Hills, M.D., Lindsey, A.E., Chisamore, M., Bassett-Smith, J., Abbott, K., & Fournier-Chalmers, J. (1994). University-college collaboration: Rethinking curriculum development in nursing education. Journal of Nursing Education, 33(5), 220–225. Hills, M., & Mullett, J. (2005a). Primary health care: A preferred service delivery option for women. Health Care for Women International, 26(4), 325–339. Hills, M. & Mullett, J. (2005b). Community-based research: A catalyst for transforming primary health care rhetoric into practice. Primary Health Care Research & Development, 4, 279–290. Hudon, E., Beaulieu, M.-D. & Roberge, D. (2004). Integration of the recommendations of the Canadian Task Force on Preventive Health Care: Obstacles perceived by a group of family physicians. Family Practice, 21(1), 11–17. Korn, D. (1997, April 16–19). Health promoting hospitals in Canada. Paper presented at the Feasibility, Effectiveness, Quality, and Sustainability of Health Promoting Hospital Projects, 5th International Conference on Health Promoting Hospitals, Vienna, Austria. Health Promotion 5/1/07 11:18 AM Page 343

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Kramer, M. (1974). Reality shock: Why nurses leave nursing. St. Louis: C.V. Mosby. Kramer, M. (1985). Why does reality shock continue? In J.C. McCloskey & H. K. Grace ( Eds.), Current issues in nursing (2nd ed., pp. 891–903). Boston: Blackwell. Lamarche, P., Chauvette, M., & Larouche, D. (2003). Choices for change: The path for restructuring primary healthcare services in Canada. Ottawa: Canadian Health Services Research Foundation. Macdonald, J.J. (1993). Primary health care: Medicine in its place. London: Earthscan Publications Limited. Mackie, J.W., & Oickle, P. (1997). School-based health promotion: The physician as advocate. Canadian Medical Association Journal, 156(9), 1301–1305. Malik, R., & Oandasan, I., & Yang, M. (2002). Health promotion, the family physician, and youth: Improving the connection. Family Practice 19(5), 523–528. Mead, N., & Bower, P. (2000). Patient-centredness: A conceptual framework and review of empirical literature. Social Science & Medicine, 51, 1087–1110. Moreira, T. (2004). Coordination and embodiment in the operating room. Body & Society 10(1), 109–129. Narayan, K.M., Bowman, B.A., & Engelgau, M.M. (2001). Prevention of type 2 diabetes. British Medical Journal 323, 63–64. National League of Nursing. (1988). Curriculum revolution: Mandate for change. New York: National League of Nursing Press. National League of Nursing. (1991). Curriculum revolution: Community building and Activism. New York: National League of Nursing Press. Nursing Standard Journal. (2006). Primary health care. From www.nursing-standard.co.uk/primaryhealthcare/. O’Neill, M. (1997). Health promotion: Issues for the year 2000. Canadian Journal of Nursing Research, 29(1), 63–70. Parboosingh, J., & Association of the Canadian Medical Colleges’ Working Group on Social Accountability. (2003). Medical schools’ social contract: More than just education and research. Canadian Medical Association Journal, 168(7), 852–853. Pew-Fetzer Task Force. (1994). Health professions education and relationship-centred care. (Report of the Pew-Fetzer Task Force on advancing psychosocial education. Reprinted January 2000). San Francisco: Pew Health Profession Commission. Pimlott, Nicholas. (2005). Preventive care: So many recommendations, so little time. Canadian Medical Association Journal, 173(11), 1345–1346. Pineault, R., Baskerville, B., & Letouze, D. (1990). Health promoting activities in Quebec hospitals: A comparison of Dsc and non-Dsc hospitals. Canadian Journal of Public Health, 81, 199–203. Pringle, D., Levitt, C., Horsburgh, M.E., Wilson, R., & Whittaker, M.-K. (2000). Interdisciplinary collaboration and primary health care reform. Canadian Family Physician, 46, 763–765. Purkis, M.E. (1997). The “social determinants” of practice? A critical analysis of the discourse of health promotion. Canadian Journal of Nursing Research, 29(1), 47–62. Rafferty, A.M., Allcock, N., & Lathlean, J. (1996). The theory/practice “gap”: Taking issue with the issue. Journal of Advanced Nursing, 23(4), 426–427. Raphael, D., & Bryant, T. (2000). Putting the population into population health. Canadian Journal of Public Health, 91, 9–12. Richard, L., Pineault, R., D’Amour, d., Brodeur, J.M., Sequin, L., Latour, R., & Labadie, J.F. (2005). The diversity of prevention and health promotion services offered by Quebec Community Health Centres: A study of infant and toddler programmes. Health & Social Care in the Community, 13(5), 399–408. Health Promotion 5/1/07 11:18 AM Page 344

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Roberts, S. (1983). Oppressed group behaviour: Implications for nursing. Advances in Nursing Science, 5(4), 21–30. Roberts, S. (2000). Development of a positive professional identity: Liberating oneself from the oppressor within. Advanced Nursing Science, 22(4), 71–82. Robinson, A. (1995). Transformative “cultural shifts” in nursing: Participatory action research and the “project of possibility.” Nursing Inquiry, 2, 65–74. Rush, K.L. (1997). Health promotion ideology and nursing education. Journal of Advanced Nursing, 25, 1292–1298. Sindall, C. (2001). Health promotion and chronic disease: Building on the Ottawa Charter, not betraying it? Health Promotion, 16(3), 215–217. Smillie, C. (1992). Preparing health professionals for a collaborative health promotion role. Canadian Journal of Public Health, 83(4), 279–282. Starfield, B. (1998). Primary care: Balancing health needs, services, and technology. New York & Oxford: Oxford University Press. Stewart, M.J. (1990). From provider to partner: A conceptual framework for nursing education based on primary health care premises. Advances in Nursing Science, 12(2), 9–27. Stewart, M., Brown, J., Weston, W., McWhinney, I., McWilliam, C., & Freeman, T. (1995). Patient-centred medicine: Transforming the clinical method. London: Sage. Sullivan, P. (2000). Enter the hospitalist: New type of patient creating a new type of specialist. Canadian Medical Association Journal, 162(9), 1345–1346. Tresolini, C.P., & Pew-Fetzer Task Force. (1994). Health professions education and relationship-centered care: Report of the Pew-Fetzer Task Force on advancing psychosocial education. Reprinted January 2000. San Francisco: Pew Health Professions Commission. van Walraven, C., Mamdani, M., Fang, J., & Austin, P.C. (2004). Continuity of care and patient outcomes: After hospital discharge. Journal of General Internal Medicine, 19, 624–631. Watson, J. (1988). Nursing: Human science and human: A theory of nursing. New York: National League for Nursing. Whitehead, D. (2004). Health promotion and health education: Advancing the concepts. Journal of Advanced Nursing, 47(3), 311–320. Wilson, S., Ruscoe, W., Chapman, M., & Miller, R. (2001). General practitioner—hospital communications: A review of discharge summaries. Journal of Quality in Clinical Practice, 21(4), 104. World Health Organization. (1978). Primary health care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR, September 6–12. Geneva: Author. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Author. World Health Organization. (1997). The Vienna recommendations on health promoting hospitals. Copenhagen: Author. World Health Organization. (1998). Health promotion glossary. Geneva: Author.

CRITICAL THINKING QUESTIONS 1. What would it take to increase the engagement of the health care professions in health promotion? Health Promotion 5/1/07 11:18 AM Page 345

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2. In what ways can general practitioners contribute to action on the broader determinants of health, particularly the social, economic, and cultural determinants of population health in their own communities? 3. In what ways can hospital-based nurses challenge the hegemony of individually focused, exclusively curative approaches to patient care and help institutionalize health promotion in hospitals? 4. What are some key changes that could be made to the curricula of physicians and nurses that would strengthen the understanding of health promotion? 5. Is it really possible for primary health care to be the catalyst for radical changes to the health system?

FURTHER READINGS Hills, M., & Mullett, J. (2005). Primary health care: A preferred service delivery option for women. Health Care for Women International, 26(4), 325–339. This article traces the similarities between primary health care and women-centred care from their overlapping philosophical foundations to the similar health, social, and economic benefits of both approaches. It is argued that investments in primary health care positively impact women’s health and, as such, should be a preferred option for the delivery of women’s community health services. Several models of health service delivery that operate in accordance with principles of primary health care and that also address the key tenets of women’s-centred care are examined and their merits are compared. The article also identifies the major impediments to the adoption of both primary health care and women’s-centred care approaches.

Malik, R., & Oandasan, I., & Yang, M. (2002). Health promotion, the family physician, and youth: Improving the connection. Family Practice, 19(5), 523–528. This article reports on a qualitative study of young people’s use of family physicians and their readi- ness to see them as health promotion resources. The full text of this article is available online through the journal’s Web site at http://fampra.oxfordjournals.org/.

Pew Health Professions Commission. (1995). Critical challenges: Revitalizing the health professions for the twenty-first century. The Third Report of the Pew Health Commission. Available from the Centre for the Health Professions, University of California, San Francisco at www.futurehealth.ucsf.edu/summaries/challenges.html. This report outlines transformations underway in the American health care system in the mid-1990s. It suggests that the emerging health care system include the following characteristics: orientation toward health; constrained resources; coordination of services; intensive use of information; reconsid- eration of human values; focus on the consumer; expectations of accountability; knowledge of treatment outcomes; and growing interdependence. It is interesting to consider the implications of this document for health professionals in Canada and whether the vision of the future predicted has been fulfilled. Health Promotion 5/1/07 11:18 AM Page 346

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RELEVANT WEB SITES

British Medical Journal http://bmj.bmjjournals.com/ The British Medical Journal is a leading world authority on medical topics, including health care systems. This site will enable readers to monitor developments in the British medical system as it undergoes health reforms.

Canadian Health Services Research Foundation—Primary Health Care Theme www.chsrf.ca/research_themes/ph_e.php This site is available in both English and French. This particular page addresses a variety of initiatives of CHSRF that relate to primary health care reform and research.

Canadian Medical Association Journal www.cmaj.ca/ This is the link to Canada’s foremost medical journal; it links readers to the journal itself as well as offering numerous online editorials and commentaries.

Centre for the Health Professions, University of California, San Francisco www.futurehealth.ucsf.edu/home.html This Web site addresses innovations in health care professions in the context of the American health care system. Specifically, the Center for the Health Professions at the University of California, San Francisco, focuses its efforts on understanding the challenges faced by the health care workforce and developing programs and resources that assist in making successful transitions to the emergent health care systems

Primary Health Care—a Nursing Standard Journal www.nursing-standard.co.uk/primaryhealthcare/ This is the Web site for a British journal on primary health care in the context of nursing. Primary Health Care aims to inform and encourage critical reflection among people in the primary care and community health field by publishing articles that have clear implications for practice. Health Promotion 5/1/07 11:18 AM Page 347

CHAPTER 19 TWO ROLES OF EVALUATION IN TRANSFORMING HEALTH PROMOTION PRACTICE

Louise Potvin and Carmelle Goldberg

INTRODUCTION and ultimately the health of hundreds of his chapter is about the meanings and thousands of people. T roles of evaluation in the context of The evaluation of the North Karelia health promotion. More precisely, we argue Project provides a good illustration of a com- that an important role for evaluation is to plex and successful evaluation research support the transformation of practices in endeavour. The project spans over three health promotion. To do so, we consider def- decades1: data on several cardiovascular risk initions of evaluation, the particularities of factors were collected in three Finnish evaluation in the context of health promo- provinces over two decades. The knowledge tion interventions, and the importance of produced in the several hundreds of docu- evaluation for health promotion practice. ments it generated2 has been integrated into Using Canadian examples, we then explore public health training throughout the world. two major reasons why health promotion While there are debates about the validity of should be evaluated: (1) to increase the effec- certain evaluation conclusions, one thing is tiveness of health promotion intervention; certain—if the North Karelia intervention and (2) to support innovative practices. had not been coupled with evaluation research that has produced and disseminated all this knowledge, public health and health promo- WHAT IS EVALUATION? tion practices today would be different. There are many definitions of evaluation. Mark, Henry, and Julnes (2000) provide In its simplest form, evaluation is the crit- one of the most encompassing definitions of ical appraisal of human actions in context. evaluation: “Evaluation assists sense making It is a value-laden feedback response to about policies and programs through the con- action. In its most sophisticated form, eval- duct of systematic inquiry that describes and uation research: (1) spans over several years, explains the policies’ and programs’ opera- if not decades; (2) mobilizes a large amount tions, effects, justifications, and social impli- of human and material resources to design cations” (p. 3). Compared to most, this and implement a complex system of activi- definition avoids falling into the trap of pit- ties to define, gather, analyze, and interpret ting against one another various forms of a huge quantity of data; and, finally, (3) pro- evaluations based on either their object, pur- duces knowledge about numerous aspects pose, or method. Indeed, we think that eval- of interventions. The knowledge produced uation typologies or classification systems, by such evaluations potentially influences whichever criteria they use, are of limited the practice of thousands of professionals usefulness. Especially in health promotion, 347 Health Promotion 5/1/07 11:18 AM Page 348

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evaluations often deploy a variety of methods Health Promotion Interventions: to address a number of stakeholders’ issues Targeting Individuals or Collectivities? regarding various program components. As seen throughout this book, there are many Following a similar argument, the definitions of health promotion and they all, WHO-EURO task force on health promo- as Rootman et al. (2001) pointed out, “involve tion evaluation also proposed a very broad a set of actions, focused on the individual or definition: “evaluation is the systematic environment, which through increasing con- examination and assessment of features of a trol, ultimately leads to improved health or programme or other intervention in order to well-being” (p. 13). Clearly at the core of produce knowledge that different stake- health promotion lays the idea of intervention. holders can use in a variety of purposes” As also seen in several chapters of this (Rootman et al., p. 26). Thus, whenever the book, the field of health promotion is char- object of inquiry is an intervention’s feature, acterized by a tension between definitions whenever the method of enquiry is system- that emphasize changes in individuals, and atic, and whenever the purpose is to produce those that target environmental changes in information that can be used by a variety of social conditions as the main purpose of social actors, we think it is proper to identify health promotion. According to Rootman et such activity as evaluation. al. (2001), this tension is the main divider between existing definitions of health promotion. The implications of this divide in WHAT IS EVALUATED IN terms of approach and forms of interventions HEALTH PROMOTION? are seldom discussed. Evaluation is about interventions. It is thus In the rest of this chapter, we will con- important to have a clear understanding of centrate our discussion on the evaluation of what is an intervention in the context of complex multi-level health promotion inter- health promotion. The verb “to intervene” ventions that involve actions planned and contains the Latin verb venire, which means implemented at a collective level for two rea- to come, and the prefix inter-, which means sons. First, the prominent evaluation tradition “in between.” Literally, to intervene is to in the health sector represented by clinical epi- come in between, to disturb the natural order demiology is well equipped to address evalu- of things. An intervention implies an action ation issues of interventions targeting from external actors who have the power to individual changes, but its usefulness and rel- mobilize and deploy resources in the pursuit evance for evaluating health promotion strate- of specific results (Couturier, 2005). gies that call for collective action is much more Interventions are planned actions to achieve limited (Potvin & Chabot, 2002). Second, as projected changes. They form the core of a Potvin, Gendron, Bilodeau, and Chabot (2005) practice, understood as skills learned, repro- indicate, defining a practice that advocates col- duced, and improved by professionals lective strategies of actions represents a major through their actions. “Intervention” is a innovation of the Ottawa Charter for the health generic term that encompasses diverse sector. This issue has been seldom discussed modalities of planned actions. with regard to evaluation. Health Promotion 5/1/07 11:18 AM Page 349

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Program as the Core Type Gendron, & Bilodeau, in press). Interventions of Intervention in Health and programs are not things in themselves, Promotion Practice but they are always defined from a specific At this point it is important to make a dis- perspective. Judging whether something or tinction between policy development and someone belongs to a program greatly other forms of collective interventions. depends on the particular viewpoint of the Building healthy public policy is one of the individual making the judgment. five strategies of the Ottawa Charter (World In a school program aimed at increasing Health Organization, 1986). Broadly defined, children’s resilience, for example, a teacher “public policy is a guide to government action trained and deeply involved in leading class- to alter what would otherwise occur” (Milio, room resilience enhancement activities may 2001, p. 367). Policy is the intervention modal- perceive that many elements in her school and ity of a governing body, of an organization her broader environment are parts of the pro- entrusted with legitimate power to regulate gram such as the school social worker who exchanges in the public domain. Policies are runs teacher’s resilience workshops, the local specialized forms of interventions and their health centre that provides documentation, evaluation requires different sets of skills, and the school physical activity teacher who designs, and apparatus (Milio, 2001). For this develops “feel good with your body” activi- reason, this chapter will restrict its focus to the ties. This view contrasts with that of children’s most common form of health promotion parents who know about the program only interventions: programs. Although programs through their child, and who may include only can be designed for a variety of purposes, the teacher and the documents they receive including developing individual skills, we will periodically as composing the program. So focus our attention on those programs that what is to be considered as being part of a pro- imply a composite and multifaceted package gram needs to be defined and agreed upon. of activities as promoted in three of the Ottawa The structure of multifaceted projects is Charter strategies of action: creating support- another dimension of programs that lends ive environment, strengthening community itself to confusion among program stake- actions, and reorienting health systems. holders. Within complex interventions, activities can be grouped according to various What Is a Program? dimensions such as specific objectives, actors Although health promotion literature is involved, resources mobilized, context, and replete with terms such as “programs,” “proj- so on, leading to various degrees of organi- ects,” “initiatives,” “activities,” and “inter- zation. For example, in their study of the pub- ventions,” there have been very few attempts lished documents from the North Karelia to identify common and unique characteris- Project, Levesque et al. (2000) needed as many tics of the realities defined by those terms. as five hierarchical levels of organization to Very often these labels are used interchange- account for this program’s complex structure. ably or they are used in reference to various Their detailed analysis provides a compelling levels of organization of actions in composite example of the constructed nature of pro- interventions. One reason for this confusion grams and their structure. Programs are not is that the reality circumscribed by these terms a given; they are the product of social activ- is necessarily complex and its delineation nec- ity. Their structure is defined according to essarily related to a specific context (Potvin, which aspects of the program one wants to Health Promotion 5/1/07 11:18 AM Page 350

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emphasize. It is only through a representa- that health promotion programs germinate tion that programs gain some reality (Potvin, and come to life. Gendron, & Bilodeau, in press).3 Contrary to more technical innovations Most often, programs are represented by like new drugs, health promotion programs the problematic situation they address, the based on those values involve a strong inte- objectives pursued, the resources mobilized, gration into local context, and therefore can the services and activities produced, the hardly be elaborated outside of this context expected results, and the chain of events nec- and then imported and tested.4 Such pro- essary for the program to yield those results grams need to evolve within their social con- (Potvin, Haddad, & Frohlich, 2001). It is very text, constantly adapting and negotiating rare that the existing relationships between practices imported from effective programs. relevant program actors are represented as Through this process it is not only the social part of the program. As in program logic context and life trajectories of those who models (Cooksy, Gill, & Kelly, 2001), most interact with the program that get trans- representations portray programs as techni- formed, but also the program itself (Potvin, cal procedures, independent of the social iden- Haddad, & Frohlich, 2001). Values underly- tity of people involved. It is as if programs are ing health promotion are at odds with a con- a kind of transplant creating totally new social ception of program participants as passive entities in an existing environment. If this subjects who need to be intervened on may be true for some programs that are pack- through programs that come from elsewhere. aged and encapsulated in ready-to-use solu- On the contrary, these values imply that pro- tions that necessitate no local adaptation, this grams are better conceptualized as reconfig- is at odds with most of the innovative prac- urations of existing contextual elements to tices advocated for by the health promotion adapt to new practices suggested by pro- rhetoric. grams, practices that are themselves adapted to fit better the characteristics of the context. The Nature of Programs Implied by the “Documenting the events that marked the Ottawa Charter of Health Promotion evolution of this relational system and con- In addition to a comprehensive definition of structing a coherent narrative to interpret the health and its determinants and to the five system’s dynamism is as crucial for under- well-known strategies of action, the Ottawa standing health promotion intervention as is Charter (1986) also identifies key values and the ‘evidence’ about its efficacy” (Potvin & principles forming the core of the health pro- Chabot, 2002). motion agenda (McQueen, 2001). Many of these values and principles of action call for a strong integration of programs into the WHY EVALUATE HEALTH social reality of the milieu in which they are PROMOTION PROGRAMS? implemented. Furthermore, values such as Following Mark, Henry, and Julnes, (2000) participation, empowerment, and intersec- above, evaluation is thus about making sense toral collaboration at the core of the health of what happens in programs. Since programs promotion rhetoric can only be actualized by are a defining modality for health promotion positioning programs, program participants, practice, it follows that evaluation is central and program context in a network of recip- for the transformation of health promotion rocal relationships. It is within such networks practice. In this section we discuss two crucial Health Promotion 5/1/07 11:18 AM Page 351

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roles for evaluation with regard to health pro- The first is the subjects’ assignment to motion practices. One is to increase the effec- treatment conditions. As experimental treat- tiveness of interventions; this role has been ments are usually available only in the context widely advocated by professional associations of evaluation research, patients’ freedom is in attempts to increase the relevance of health thus limited to consenting to participate to a promotion for policy makers (International study. The more absolute the control of eval- Union for Health Promotion & Education, uators over the treatment assignment process, 1999; Zaza, Briss, & Harris, 2005). The other the more it is possible to ensure that the role is to support the development and diffu- observed relationship between treatments and sion of innovative practices (Bilodeau, outcomes is not explained by some unique Chamberland, & White, 2002). individual features. Having accepted these conditions, study subjects can then be treated as equivalent and interchangeable objects. The Evaluation to Increase the second aspect of the experimental situation Effectiveness of Health Promotion the clinical setting greatly facilitates is the Interventions integrity and fidelity of the intervention. To play this role, evaluation tries to attribute Indeed, in the somewhat closed clinical envi- a result to an intervention, i.e., establish causal ronment, contextual features not directly rel- links between program and outcomes. Causal evant to the treatment under study can be claims are usually achieved by holding every- controlled or held constant, reducing greatly thing constant (the famous “ceteris paribus” variations in the implementation conditions. condition of the experimental method) but These two features of clinical setting are para- the intervention under study in an effort to mount for evaluation to play its alleged role isolate the causal mechanism of interest in providing evidence of a causal relationship (Campbell, 1984). Because this can never be “when everything else is held constant” (effi- totally achieved outside of the laboratory, eval- cacy trials) or under controlled implementa- uation researchers use strategies and meth- tion conditions (effectiveness trials). ods that emulate laboratory conditions. This Because most of the early evaluation experimentalist approach to evaluation found studies of prevention interventions were two main traditions in health promotion eval- developed in clinical settings, patients’ uation: clinical epidemiology and social sci- random assignment and treatment stan- ences quasi-experimental designs. dardization rapidly became customary features for quality evaluation. The limitations Clinical Epidemiology of the experimentalist tradition for evaluat- Strongly anchored in experimental medicine, ing prevention interventions, however, were clinical epidemiology is associated with a soon experienced. strong stream of experimental evaluation As early as the 1970s the Multiple Risk research facilitated by the fact that medical Factor Intervention Trial (MRFIT) study clinics and hospitals are highly institutional- assigned 12,866 healthy male volunteers to ized settings where power and decisions are three modalities of clinical preventive serv- concentrated among clinicians. Because of ices. Randomization worked and study groups this, clinicians and evaluators can and do exer- ended up being statistically equivalent. The cise a high level of control over two funda- three preventive treatments were successfully mental aspects of the experimental situation. implemented in 20 clinics throughout the US. Health Promotion 5/1/07 11:18 AM Page 352

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Interestingly, though, the power of this trial lies within the evaluation paradigm itself. was greatly diminished by the fact that many People entertain unrealistic expectations given subjects who had been randomly assigned to the inherent limitations of evaluation, which either the low-intensity prevention interven- has to operate outside of the well-controlled tion or to the usual care groups sought and were world of laboratories. The complexity of real- given high-intensity preventive interventions life situations in which programs are imple- outside of trial clinics (Ockene et al., 1991). So, mented interferes with the evaluator’s even in clinical settings where randomization capacity to control the experimental situation, can be implemented, conclusions from efficacy thus threatening studies’ internal validity trials are limited by the availability of inter- (capacity to infer a causal link between treat- ventions obtained through other means. ments and observed outcomes). Furthermore, because programs are social products neces- Social Science Quasi-experimental Designs sarily embedded into their social contexts, The quasi-experimentalist stream of evalu- external validity (the capacity to generalize ation developed by Campbell, Cook, and results of a single evaluation to other program their students (Shadish, Cook, & Leviton, instantiations) is also greatly reduced. It is thus 1991) has also been very influential for defin- impossible for any single evaluation study to ing a paradigm for the evaluation of health establish clearly a program causal effect. education and health promotion programs. Taking the randomized control trial as the The Difficulties for Experimentalists to gold standard for establishing causal relations Evaluate Health Promotion Programs between treatments and observed effects, The experimentalist tradition does not accom- quasi-experimentalists characterize alterna- modate well approximations and uncertain- tive weaker research designs in terms of their ties in evaluating interventions. Because such capacity to control for plausible rival hypoth- uncertainties are often inherent in health pro- esis and advocated for their proper use in motion programs, there is much debate on the evaluation research.5 appropriateness of the experimental paradigm Unfortunately, very early in the devel- for evaluating health promotion (McQueen, opment of the field of evaluation, numerous 2001; Rychetnik et al., 2002). quasi-experimental evaluation projects failed In the rare cases where practices have to produce the expected straightforward evolved into well-packaged and well-defined results that would fuel rational decisions programs, they could be suitable to experi- (Pawson & Tilley, 1997). In the field of public mental evaluations. We agree with Hawe, health, quasi-experimental evaluations of very Shiell, and Riley (2004) that it is not so much important projects such as the Minnesota procedural aspects that should be used to create Heart Health (Luepker et al., 1994) or the the intervention and control groups to be com- COMMIT Trial produced very disappoint- pared in experimental evaluations but the func- ing results (COMMIT Research Group, tions that are thought to be related to the 1995). Although both projects showed sig- intended effects. But even in randomized trials nificant reductions of risk factor prevalence of program functions, the complex interactions in exposed populations, those reductions were between programs and contextual factors fur- not significantly different from those observed ther complicate the role of experimental eval- in non-equivalent control communities. uation. Because all trials are subjected to such For Campbell (1984, 1987) the problem interactions with contextual factors, and Health Promotion 5/1/07 11:18 AM Page 353

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because as we all learn in introductory statis- local circumstances. Unfortunately, very few tics, main effects are not interpretable in the studies document those partnerships’ roles presence of interaction effects, it follows that and contributions to programs’ effectiveness. causal interpretations from single experimen- Third, identifying a problem locally even tal trials are dubious. The only solution is to when its causes are scientifically known does pool and synthesize several experimental eval- not mean that interventions can be readily uations of similar programs (however simi- available or designed in that context. Indeed, larity is defined), and to estimate program program components are always strongly effectiveness by taking into account imple- intertwined into the broader social context mentation variations as possible interaction through a dense network of partnerships. For effects. This solution obviously requires that a many, thus, the social context is thought to be great number of experimental evaluation stud- at least as important (if not even more impor- ies be conducted in a wide variety of imple- tant) than technical aspects of program deliv- mentation conditions. In terms of the ery (Bilodeau, Chamberland, & White, 2002). transformation of practices, what comes out of The case study in Box 19.1 illustrates this. existing syntheses is that programs with doc- In real-life contexts of health promotion umented effectiveness are usually simple and programs, the selection and implementation not very well integrated within local networks of program interventions is not simply a by- of actors (Zaza, Briss, & Harris., 2005). product of rational choices informed by scientific knowledge. It is strongly influenced by a continuous negotiation and adjustment Evaluation to Support process. The aim of such a process is to find Innovative Practices convergence between: (1) scientific theoretical This is a much less developed but potentially and empirical knowledge about the identified much more important role for evaluation in problem and about effective interventions; (2) health promotion. people’s subjective knowledge about the problem, its causes, its impact on their lives, and Why Is Supporting Innovation through about their own community and its strengths; Evaluation Important? and (3) the local values and norms relevant to There are at least three reasons why it is so. the situation.6 The outcome of this process is First, well-defined programs form only a a socially constructed innovation where prac- small part of health promotion practice, and tices are continuously transformed by a dense these well-defined programs are usually not network of social interactions constitutive of well aligned with the innovative practices the program. This, as developed in Chapter advocated for in the Ottawa Charter (Potvin 17, clearly requires the evaluation to serve a et al., 2005). Second, to go the participatory reflexive function that fosters program stake- route advocated for by health promotion, holders’ capacity to incorporate and act upon practitioners have to start from the preoccu- the knowledge provided to them (Potvin et al., pations and possibilities of the local milieus 2005). One of the crucial roles of evaluation is (Israel et al., 1998). In those cases, at best, well- thus to systematize and facilitate the reflexive tested programs with a demonstrated effec- function of programs in order to illuminate tiveness constitute only a good starting point the process by which programs become local for designing interventions that can go in innovations and support their transformative totally different directions to accommodate practices. Health Promotion 5/1/07 11:18 AM Page 354

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BOX 19.1: SCIENTIFIC AND CONTEXTUAL ELEMENTS FOR PROGRAM PLANNING: THE CASE OF THE KANAWAKHE SCHOOL DIABETES PREVENTION PROJECT

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The Example of the Canadian Heart ects with evaluation studies was a compul- Health Initiative sory feature of the project. The evaluation of Although there are few reports about evalu- the CHHI was thus a built-in component of ations deliberately designed to fulfill this role, the 10 provincial heart health programs and we think that in many instances, when eval- the 311 local and regional demonstration uation studies were implemented to accom- projects. All were designed to accompany the pany programs from their developmental intervention project rather to than prescribe stages, they have played exactly this role. This the content and form of the intervention, as is the case with the Canadian Heart Health shown in the Ontarian case study in Box 19.2. Initiative (CHHI), established in 1988 as a national program for cardiovascular disease prevention based on intersectoral partner- CONCLUSIONS ships. Although its aim would characterize In this chapter we proposed that there are this initiative as prevention, its main operat- mainly two ways in which evaluation can ing principle is consistent with those of the support changes in health promotion prac- Ottawa Charter. The project was based on a tice. The first is to attempt to direct health collaborative infrastructure to establish part- promotion practice to specific interventions nerships, which makes the initiative unique found effective in controlled experiments as a means of delivering a national health through evidence-based procedures. It is program using a web of networks, coalitions, grounded within the experimentalist tradi- and opinion leaders that diffuse information tion, where innovations are derived from sci- and resources through formal and informal entific knowledge and tested in controlled channels (Stachenko, 1996). conditions. The viability of this evaluation The demonstration phase, initiated from approach to inform practice is, however, chal- 1990–2000, was comprised of 10 provincial lenged by the assumptions underlying heart health programs. The aim of this phase methodologies that systematically remove was to experiment with implementation context from the evaluation inquiry. methods for heart health at provincial and The second way evaluation can support community levels; linking intervention proj- changes in health promotion practice is by Health Promotion 5/1/07 11:18 AM Page 355

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BOX 19.2: EVALUATING THE ONTARIO HEART HEALTH INITIATIVE

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facilitating social innovation. This approach that limits evaluations to the collection of rou- is grounded in social science theory where tine data regarding program operations and innovation is created by systematizing and resources. We strongly believe that this putting in place reflexive processes respon- accountability approach is of limited utility to sive to local project implementation. This informing practice and orienting program approach engages practitioners in a contin- transformation because no attention is devoted uous dialogue on the performance and mean- to the actions that are actually performed ing of program actions, and their interactions within the social space of the program. This is with the local context. The dynamic rela- so mostly because we are conceptually and tionship fostered by this approach allows methodologically ill equipped to observe and practitioners to consciously reinforce certain analyze the unfolding of social processes that actions while reorienting others. This facili- involve a diversity of actors implicated in tates programs’ adaptation by strengthening dynamic relationships at the heart of health its reflexive and innovative capacity. promotion programs. This, we think, consti- These are two opposite perspectives on tutes a priority for future evaluation research, evaluation. Both are laden with enormous in order to better understand how health pro- methodological challenges that somehow motion operates and therefore effectively impede on their capacity to fulfill these roles, induce changes in the social determinants of leading many stakeholders toward a narrow health. accountability perspective on evaluation, one

NOTES 1 The first evaluation article was published in 1973 (Puska, 1973) whereas studies of the cohort assembled for this evaluation are still published periodically. 2 Searching for “North Karelia Project” in Google Scholar resulted in 855 entries. 3 For Guba and Lincoln (1989), the main purpose of evaluation is to lead program stakeholders toward a consensual program representation. Although we agree that this is part of program evaluation (Thurston & Potvin, 2003), we think that evaluation can produce much more diverse knowledge. 4 Even “hard” technologies cannot be conceived and evaluated outside of the social web in which they were developed and in relation to which they evolve (Lehoux, 2006). Health Promotion 5/1/07 11:18 AM Page 356

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5 The proper use of a weaker research design means that researchers generate and design ways to control for hypotheses, other than the treatment, which could also explain observed outcomes (Cook & Campbell 1979). 6 The sociologist Jurgen Habermas (1987) developed the idea that communicative actions—i.e., actions that involve social actors trying to agree on a common course of action—always put in play arguments from three spheres that composed the experienced world. These arguments come from: (1) the objective world as described by scientific knowledge; (2) the normative world that prescribes legitimate forms of interactions in specific contexts; and (3) the subjective world made of the actors’ desires, emotions, and projects not directly accessible for outsiders. Although the idea that programs could be conceived as a form of communicative action is interesting, it is well beyond the scope of this chapter. We think, however, that the three forms of the experienced world that Habermas reconciled in his theory of communicative action are relevant for modelling health promotion programs.

REFERENCES Bilodeau, A., Chamberland, C., & White, D. (2002). L’innovation sociale, une condition pour accroître la qualité de l’action en partenariat dans le champ de la santé publique. Revue canadienne d’évaluation de programme, 17(2), 59–88. Bisset, S.L., Cargo, M., Delormier, T., Macaulay, A.C., & Potvin, L. (2004). Legitimizing diabetes as a community health issue: A case analysis of the Kahnawake schools diabetes prevention project. Health Promotion International, 19, 317–326. Campbell, D.T. (1984). Can we be scientific in applied social science? Evaluation Studies Review Annual, 9, 26–48. Campbell, D.T. (1987). Guidelines for monitoring the scientific competence of the preventive intervention research centers: An exercise in the sociology of scientific validity. Knowledge—Creation, Diffusion, Utilization, 8, 389–430. Cargo, M., Levesque, L., Macaulay, A.C., McComber, A., Desrosiers, S., Delormier, T., et al. (2003). Kahnawake schools diabetes prevention project (KSDPP) community advisory board. Community governance of the Kahnawake schools diabetes prevention project, Kahnawake Territory, Mohawk Nation, Canada. Health Promotion International, 18, 177–187. COMMIT Research Group. (1995). Community intervention trial for smoking cessation (COMMIT). I. Cohort results from a four-year community intervention. American Journal of Public Health, 85, 183–192. Cook, T.D., & Campbell, D.T. (1979). Quasi experimentation: Design and analysis issues for field settings. Boston: Houghton Mifflin. Cooksy, L.J., Gill, P., & Kelly, A. (2001). The program logic model as an integrative framework for a multimethod evaluation. Program Planning and Evaluation, 24, 119–128. Couturier, Y. (2005). La collaboration entre travailleuses sociales et infirmières. Éléments d’une théorie de l’intervention interdisciplinaire. Paris: l’Harmattan. Elliot, J., Taylor, M., Cameron, R., & Schabas, R. (1998). Assessing public health capacity to support community-based heart health promotion: The Canadian heart health promotion. The Canadian Heart Health Initiative, Ontario project. Health Education Research, 13, 607–622. Guba, E.G., & Lincoln, Y.S. (1989). Fourth generation evaluation. Newbury Park: Sage. Habermas, J. (1987). Théorie de l’agir communicationnel. Tome 1. Rationalité de l’agir et rationalisation de la société. Paris: Fayard. Hawe, P., Shiell, A., & Riley, T. (2004). Complex interventions: How “out of control” can a randomized control trial be? British Medical Journal, 328, 1561–1563. Health Promotion 5/1/07 11:18 AM Page 357

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International Union for Health Promotion & Education. (1999). The evidence of health promotion effectiveness. Shaping public health in a new Europe. Part two, evidence book. Brussels: ECSC-EC-EAEC. Israel, B.A., Schulz, A.J., Parker, E.A., & Becker, A.B. (1998). Review of community-based research: Assessing partnership approaches to improve public health. Annual Review of Public Health, 19, 173–202. Lehoux, P. (2006). The problem of health technology. London: Routledge. Levesque, L., Richard, L., Duplantie, J., Gauvin, L., Cargo, M., Renaud, L., et al. (2000). Vers une description et une évaluation du caractère écologique des interventions en promotion de la santé: Le cas du Programme de la Carélie du nord. Rupture, revue transdisciplinaire en santé, 7, 114–129. Luepker, R.V., Murray, D.M., Jacobs, D.R. Jr., et al. (1994). Community education for cardiovascular disease prevention: Risk factor changes in the Minnesota Heart Health Program. American Journal of Public Health, 84(9), 1383–1393. Mark, M., Henry, G.T., & Julnes, G. (2000). Evaluation: An integrated framework for understanding, guiding, and improving public and non-profit policies and programs. San Francisco: Jossey Bass. McQueen, D.V. (2001). Strengthening the evidence base for health promotion. Health Promotion International, 11, 261–268. Milio, N. (2001). Evaluation of health promotion policy: Tracking a moving target. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 365–385). European series no. 92. Copenhagen: WHO regional publications. Ockene, J.K., Hymowitz, N., Lagus, J., & Shaten, B.J. (1991). Comparison of smoking behavior change for SI and UC study groups. MRFIT Research Group. Preventive Medicine, 20, 564–573. Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage. Potvin, L., & Chabot, P. (2002). Splendour and misery of epidemiology for evaluation of health promotion. Revista Brasileira de Epidemiologia, 5(Suppl. 1), 91–103. Potvin, L., Gendron, S., & Bilodeau, A. (in press). Três posturas ontológicas concernentes à natureza dos programas de saúde: implicações para a avaliação. In M.L.M. Bosi & F.J. Mercado (Eds.), Avaliação qualitativa de programas de saúde. Enfoques emergentes. Petropolis. Brazil: Vozes Editoria. Potvin, L., Gendron, S., Bilodeau, A., & Chabot, P. (2005). Integrating social science theory into public health practice. American Journal of Public Health, 95, 591–595. Potvin, L., Haddad, S., & Frohlich, K.L. (2001). Beyond process and outcome evaluation: A comprehensive approach for evaluating health promotion programmes. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 45–62). European series, no. 92. Copenhagen: WHO Regional Publications. Puska, P. (1973). The North Karelia project: An attempt at community prevention of cardiovascular disease. WHO Chronicle, 27, 55–58. Riley, B., Taylor, M., & Elliot, S. (2003). Organizational capacity and implementation change: A comparative case study of heart health promotion in Ontario public health agencies. Health Education Research, 18, 754–769. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D.V. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). European Series, no. 92. Copenhagen: WHO Regional Publications. Rychetnik, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence on public health interventions. Journal of Epidemiology & Community Health, 56, 119–127. Health Promotion 5/1/07 11:18 AM Page 358

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Shadish, W.R., Cook, T.D., & Leviton, L.C. (1991). Foundations of program evaluation: Theories of practice. Newbury Park: Sage. Stachenko, S. (1996). The Canadian Heart Health Initiative: A countrywide cardiovascular disease prevention strategy. Journal of Human Hypertension, 10(Suppl. 1), S5–S8. Taylor, M., Elliot, S., & Riley, B. (1998). Heart health promotion: Predisposition, capacity, and implementation in Ontario public health units, 1994–96. Revue Canadienne de Santé Publique, 89, 410–414. Thurston, W.E., & Potvin, L. (2003). Evaluability assessment: A tool for incorporating evaluation in social change programs. Evaluation, 9, 453–469. World Health Organization. (1986). The Ottawa Charter for Health Promotion. Retrieved March 2006 from www.phac-aspc.gc.ca/ph-sp/phdd/pdf/charter.pdf. Zaza, S., Briss, P.A., & Harris, K.W. (2005). The guide to community preventive services: What works to promote health. New York: Oxford University Press.

CRITICAL THINKING QUESTIONS 1. How are evaluated programs different from non-evaluated programs? 2. Who is implicated in conceptualizing and implementing the evaluation? How are the various actors represented in this process? 3. Whose interests are being served by the evaluation? 4. Who is defining evaluation questions? How are the evaluation questions contributing to social betterment? 5. How are evaluation recommendations translated into practice? Whose interests are or are not being served by this process?

FURTHER READINGS Mark, M.M., & Henry, G.T. (2004). The mechanism and outcomes of evaluation influence. Evaluation, 10(1), 35–57. This article describes a framework designed to capture change mechanisms through which evaluations may affect practice and decisions. By discussing mechanisms underlying evaluation’s influence, they hope to move the field forward in relation to its understanding and facilitation of evaluation’s role in the service of social betterment.

Mark, M., Henry, G.T., & Julnes, G. (2000). Evaluation: An integrated framework for understanding, guiding, and improving public and non-profit policies and programs. San Francisco: Jossey Bass. This book offers a new approach to evaluation, one that will encourage organizations or agencies to improve their contribution to social betterment. The authors draw from three decades of evaluation practice and theory to present a framework for conceptualizing evaluation and pragmatically assessing social policies and programs.

Pawson, R., & Tilley, N. (1997). Realistic evaluation. London: Sage. The authors present a critique of traditional evaluation practice for its inability to produce straightforward results that would fuel rational decisions. They articulate a new evaluation paradigm that requires a careful blend of theory and method to understand causality in terms of underlying causal Health Promotion 5/1/07 11:18 AM Page 359

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mechanisms. It is concerned with understanding causal mechanisms and the conditions under which they are activated to produce intended outcomes.

Potvin, L., Gendron, S., Bilodeau, A., & Chabot, P. (2005). Integrating social science theory into public health practice. American Journal of Public Health, 95, 591–595. This article discusses the challenges inherent in public health programming and evaluation in light of the Ottawa Charter for Health Promotion. It illustrates the need to formulate program theory that embraces social determinants of health and local actors mobilization, social change, and a theory of evaluation that fosters reflexive understanding of public health programs engaged in social change.

Rootman, I., Goodstadt, M., Hyndman, B., McQueen, D.V., Potvin, L., Springett, J., et al. (Eds.). (2001). Evaluation in health promotion: Principles and perspectives. European series, no. 92. Copenhagen: WHO Regional Publications. This book is one product resulting from the five-year work of the WHO-EURO Working Group on Health Promotion Evaluation that was led by Irving Rootman and David McQueen. With contributors from Europe and North America, the book provides a broad overview of the challenges and opportunities for evaluation associated with health promotion.

RELEVANT WEB SITES

American Evaluation Association www.eval.org/ The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. They publish the American Journal of Evaluation, New Directions for Evaluation, and Guiding Principles for Evaluators. Their activities include an annual conference, training opportunities, career opportunities, and much more.

Canadian Evaluation Society www.evaluationcanada.ca/ The Canadian Evaluation Society is a Canada-wide, non-profit bilingual association dedicated to the advancement of evaluation theory and practice. The society promotes leadership, knowledge, advocacy, and professional development. It does this through diverse activities, including the publication of the Canadian Journal of Program Evaluation, annual conferences, diverse professional development events, notification of employment and contact opportunities, and much more.

CDC Evaluation Working Group www.cdc.gov/eval/index.htm The CDC Evaluation Working Group was charged by the US Centers for Disease Control and Prevention with developing a framework that summarizes and organizes Health Promotion 5/1/07 11:18 AM Page 360

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the basic elements of program evaluation. The working group develops resources and linkages to evaluation of health programs.

Evaluation Center, Western Michigan University www.wmich.edu/evalctr/ The Evaluation Center, Western Michigan University, offers links to evaluation tools and resources, publications, and other important Web sites in the field of evaluation. It is also the site of The Journal of Multi Disciplinary Evaluation, edited by Michael Scriven and E. Jane Davidson, with a mission of providing news and thinking of the profession and discipline of evaluation in the world.

Health Communication Unit, Centre for Health Promotion, University of Toronto www.thcu.ca/index.htm The Health Communication Unit at the Centre for Health Promotion, University of Toronto, is one of 22 members of the Ontario Health Promotion Resource System funded by the Ontario Ministry of Health and Long-Term Care. Their goal is to increase the capacity of community and public health agencies to plan for, conduct, and evaluate a wide range of health programs. Health Promotion 5/1/07 11:18 AM Page 361

PART VI

CONCLUDING THOUGHTS

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he final section of this book offers three perspectives that address the implications of T the developments described throughout the book. Chapter 20 opens the section with a commentary prepared by Ilona Kickbusch, originally framed as a foreword, but in the end moved here because it provides an overall assessment of the health promotion field over the past decade and positions many of the outcomes of the Ottawa Charter within the context of international and global health. In her commentary, Kickbusch introduces a pair of alternative analogies for considering the development of health promotion—the rhizome and the tree—and illustrates the continuing development of health promotion worldwide as if the field were a person growing up. The second chapter in this section, Chapter 21, was solicited after most of the manuscript was compiled. In a moment of critical reflection, the editors recognized that overall the book reflected a particular slant on health promotion in Canada that could be called the “social” approach, despite material that clearly tells us that health promotion, as practised, continues to focus primarily on individual risk factors and fostering better health-related behaviours. We therefore asked Gaston Godin to comment on the status of the “individual” approach within health promotion in Canada to remind the reader of the roots of this approach and its important intellectual and practical contributions to health promotion. The final chapter of the book, Chapter 22, provides an overall commentary on the book itself and what it says about the status of health promotion in Canada halfway through the first decade of the 21st century. In addition to providing a summary of the key themes developed throughout the book, such as the continuing marginalization of health promotion in the health field, the call for health promotion to demonstrate its effectiveness, and the challenge of building an appropriate theoretical base for the field, this final chapter describes var- 361 Health Promotion 5/1/07 11:18 AM Page 362

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ious current tensions in the field. In particular, the chapter debates the ways in which health promotion relates to the intellectual and political currents of modernism and post-modernism, linking these to Kickbusch’s opening imagery of the rhizome and the tree. Health Promotion 5/1/07 11:18 AM Page 363

CHAPTER 20 HEALTH PROMOTION: NOT A TREE BUT A RHIZOME

Ilona Kickbusch

hen asked to write this chapter I was being its ultimate expression. Health promo- W also asked to refer back to the anal- tion, I would argue, is a rhizome. ogy I had made in the earlier book about the Looking back is essential in order to “growing up” of health promotion as a child. understand the present and look into the Now if one were to take the adoption of the future. How big and strong or how wide- Ottawa Charter in November 1986 as its birth spread is health promotion? Are the World date, she would be 20 this year, but one could Health Organization and Canada, which also argue that given all the preparatory work, were so present at its birth, still around to she is more like 25. My own son was born support and nurture it? Has it overcome its right in the middle of this process—1983— adolescent problems when it was challenged and he was present at many of the global by every new view of health that came along? health promotion conferences. When he Are the other kids still more popular, par- joined me at the Bangkok Conference in ticularly those with medical parents? Has it August 2005, now a student of international found its identity as a grown-up? Where will relations and about 2 metres tall, the most it go next? common comment he heard was the usual: Every mother, of course, sees her child “I remember you when you were so small”— as very special and I believe the Ottawa and a hand would stop somewhere in his Charter was a very unique child. It was the present navel region. It frustrated him no end. first and so far still is the only document to We tend to see growing up as growing set the health agenda of the late 20th and 21st taller. And the most usual analogy is the tree. centuries. Its key assumptions are continu- In general we have a mind frame that under- ously being reinforced by research. It framed stands power to be reflected in strong visible the third public health revolution with institutions. Yet I would argue that the power empowerment at its centre and there is no and influence of health promotion have been going back. Key health policy documents of another kind that exists in nature and has such as the International Tobacco Framework been adapted as a principle of knowledge Convention and many others reflect its strate- organization by the French philosophers Gilles gic premise: focus on policies and environ- Deleuze and Felix Guttari (1976): a rhizome. ments as much as on people. And “making It is a system that has many roots, that is con- the healthy choice the easier choice” is now nected and heterogenic; it does not respect ter- the marketing premise of many a consumer ritory but expands continuously, thus creating goods company. The Charter set the stage for its own plateaus. Modern knowledge systems many of the developments in health policy are rhizomes—with the World Wide Web that are now considered key innovations as, 363 Health Promotion 5/1/07 11:18 AM Page 364

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for example, the “whole government” health promotion organizations, WHO dis- approach of the Swedish health policy or the mantled its program. And Canada, from the new German legislation that wants to put mid-1990s on, dismissed it for a population health promotion and prevention on a par health approach. The kid was too bound to with the other components of the health a social concept of health, and that was a hard system. And it pre-shadowed the work being sell in the traditional health world. But due done in the World Health Organization to a wide range of initiatives and settings, the Commission on Social Determinants and rhizome expanded its territory: for example, Health. The rhizome has spread. thousands of municipalities, workplaces and There were things the child was not schools around the world are working to really prepared for. The Charter had built on implement health promotion. the responsibility of the public sector to take The kid was headstrong, and started seriously its commitments to health, but fell playing with what many considered to be the right into two decades of neo-liberalism and wrong playmates. In the 1990s it had become the weakening of the state due to global clear that better health could be achieved only developments. It was accused—despite the if there was a willingness by the private sector major modernization underway globally— to show social responsibility for health—and, that it was relevant only for the developed for example, not produce and market goods countries and therefore had no validity for harmful to health, particularly to children and poor countries. It was considered icing on the the developing countries. The Jakarta cake of health care reform, dispensable in the Conference in 1997 set out to explore this face of more challenging issues such as minefield and became the venue for a major financing medical care. It was challenged that health promotion family row, demanding that it could not provide evidence for its effec- health promotion refrain from such contacts. tiveness—despite decades and libraries full Today WHO has meetings with major fast- of research on the interface between social food and soft drink manufacturers to discuss factors and health. It was attacked as leftist the global strategy on obesity, diet, and exer- ideology because it insisted on addressing cise; the United Nations has developed the inequalities and structural health determi- Global Compact; and many agencies at coun- nants. Not an easy schoolyard to be in. try level have developed partnerships with Even worse, the child could not always the private sector to promote health. rely on its parents and guardians. It never The past 20 years have seen tremendous became a priority in the work of the World changes in the context for health promotion, Health Organization, and despite its suc- and perhaps the most astounding factor is the cesses was frequently subject to the “not extent to which health has become an inte- invented here” syndrome. WHO felt more gral part of modern society. The child was at home starting a set of new initiatives based born when many issues that are matter of fact on a medical view of chronic diseases, but in public health today were not taken seri- applying health promotion strategies. Not ously or not even thought of. Many of today’s only does the health sector continue to think energetic health promotion professionals were “disease” and structure itself accordingly, also children or adolescents when the Charter was in a media-driven world it is easier to get written, and yet they were already trained attention for problems and risks. Even as its under its influence because it was dissemi- member states started to build and strengthen nated with great speed to teaching institutions Health Promotion 5/1/07 11:18 AM Page 365

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and curricula. Health promotion argued that is different from a process of medicalization; health was a sound investment and today it rather, it constitutes a new mix of privatiza- is a major social, political, and economic driv- tion and commodification, empowerment ing force. In developed countries the com- and participation, social inclusion and exclu- bined expenditures on health care and sion, public and private. The dimensions of personal wellness can be as much as 15 per- personal health, public health, medical health, cent of GNP or more. Food and soft drink and the health market interface in new ways companies are restructuring, the tobacco com- in a pattern that I call the health society. At panies have been reigned in, marketing for this point there are very few policy mecha- ill health is under attack, wellness is one of nisms that allow an adequate response to the fastest-growing sectors of private enter- these new kinds of deterritorialized “health- prise, and health information receives more scapes.” Indeed, I believe that the governance hits on the Internet than pornography. of what is called the “health system” (but For me the most important sentence in rarely deals with health) is due for a revolu- the Ottawa Charter remains the positioning tionary overhaul. of health within society: Health is created in It is time therefore for the young man to the context of everyday life—where people live, seek new qualifications in health promotion— love, work, and play. Today one might add maybe he needs to become a health entrepre- where we travel, shop, and Google. This neur or a litigation lawyer. Maybe he will head simple sentence in the Ottawa Charter is the the new line of healthy snacks in a major food expression of the significant social process of company, be an equity funds manager who the de-territorialization of health out of the invests in the health market, or creates a new health care system into the social arena and health portal on the Web. If in the past the the market. Health promotion has both been original focus of health promotion programs a response to and has considerably con- was the individual with the “unhealthy” tributed to this changing nature of health in behaviour and if it evolved toward govern- society. The young man (let me this time mental policy interventions over the environ- associate the gender with my own son) now ment, today the big health debate is directed has to move in many different arenas in new at the producers of unhealthy products, at those kinds of “healthscapes” because we now live who market them (particularly to children and in a society where health is present in every young people), and at the arenas of everyday dimension of life; indeed, where lifestyles life where they are consumed. The supermar- have become health styles. ket has become a key “health facility” of the This has significant consequences for 21st century. Health, it turns out, really is how we (re)define each and every action area everybody’s business in a symbolic, virtual, and of the Ottawa Charter and where we assign real sense: owners of bars and restaurants, responsibilities for health in society. For exam- retailers, the management of airports and rail- ple, the European Commission has proposed way lines, to name but a few, all need to be con- combining the public health program with the cerned with health. Settings of everyday life consumer protection program because the become “healthy” settings through a commit- synergies are so critical. If health is every- ment to norms and standards and patterns of where, every place or setting in society can appropriate behaviour, with laws and regula- support or endanger health and every deci- tions sometimes promoting, in other cases fol- sion is potentially also a health decision. This lowing, cultural shifts. Health Promotion 5/1/07 11:18 AM Page 366

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Finally, there will be central ethical ques- a debate on the values that will ultimately tions for the young man to consider. In the drive the health society. It is the strength of health society, personal health returns in a health promotion as codified in the Ottawa new form: autonomy, individualization, and Charter that its vision of health under condi- choice come in tandem with increasing tions of modernity is deeply democratic and inequalities. Individuals do not only have an participatory. It is the role of citizens in health increased interest in health, they also have an that becomes the most critical component of increased responsibility for their own health. health governance in the 21st century. The expansion of rights ensures, for exam- “I remember you when you were so ple, the rights of non-smokers, but it also leads small.” When the Charter was adopted, we to debates about higher premiums for people knew we had achieved something important, with unhealthy lifestyles. What extent of but we could, of course, not gauge the broad exclusion and inequality will be politically range of impacts it would have. I see health accepted in health? What social, political, and promotion as a network or as a rhizome that financial price are we willing to pay for better has made its way through the health arena and health both individually and as a community, society not by creating massive infrastructures, both at the local and at the global level? While but by changing minds. Maybe that is all we it seems unfair that some parts of society can need to continue to do. Not deplore the fact buy better health in the marketplace, where that there are no great health promotion are the limits set? While it seems appropriate palaces, but continue to work on the process to strive for more health, should we not also of spreading out and taking root, a process to critically consider the limits of this quest? which many Canadians have centrally con- These questions cannot be resolved without tributed and will no doubt continue to do so.

REFERENCE Deleuze, G., & Guattari, F. (1976). Rhizome. Paris : Les Éditions de Minuit. Health Promotion 5/1/07 11:18 AM Page 367

CHAPTER 21 HAS THE INDIVIDUAL VANISHED FROM CANADIAN HEALTH PROMOTION?

Gaston Godin

s seen in several chapters of this book, tion was that the goals targeting behavioural ACanadian health promotion since the changes instilled guilty feelings and victim Ottawa Charter (World Health Organization, blaming because concerned individuals have 1986) is mainly perceived here and abroad as only limited control over their lifestyle having put an emphasis on the “social” deter- choices. Indeed, according to this thesis, minants of health. Given our interest in par- people fail to eat properly essentially because ticipating in the debate on crucial issues for they do not have access to healthy foods at health promotion, we wish to draw attention reasonable cost. Likewise, the primary cause to contradictions emerging as a result of the of a sedentary lifestyle is low family income. way in which the Ottawa Charter has been used It was then suggested that in order to to determine public health intervention prior- intervene more appropriately in health pro- ities. Most health professionals, researchers, motion, the emphasis should not be placed and stakeholders eagerly welcomed the pub- on individual decision making in connection lication of this Charter. Enthusiasm was almost with behavioural change, but rather on the palpable because this document called for a role played by the social, cultural, and eco- broad and thorough approach to health pro- nomic environment—that is, socio-structural motion. However, we believe that the way the factors. There was a progressive swing away Charter has been used by a number of parties from studies and interventions targeting the in Canada is far removed from the initial dec- individual and toward consideration of the laration of intent. social, cultural, and economic environment, Health promotion as interpreted from with these factors now deemed the most 1986 on quickly turned into a reassessment important health determinants. This even of health education interventions primarily led some specialists to suggest defining health targeting individuals and changes in their promotion as the study of “social” health behaviour (e.g., unhealthy lifestyles) that determinants. The end result of this trend is were current since the 1950s and, in Canada, obvious: the individual was progressively even after the Lalonde Report of 1974 had excluded from health promotion activities. opened up much wider areas of possibilities. Yet contrary to this interpretation of the To some extent, doubts were raised con- Ottawa Charter so popular since the 1980s, sev- cerning not only the effectiveness of educa- eral meta-analyses have confirmed that edu- tional and preventive measures to improve cation is also an efficient strategy encouraging the health of individuals, but also on the per- the adoption of healthy behaviour (Kalichman, tinence of their use. One argument against Carey, & Johnson, 1996; Kok, Van Den Borne, the appropriateness of this type of interven- & Dolan Mullen, 1997). This is even truer 367 Health Promotion 5/1/07 11:18 AM Page 368

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when planned under appropriate conditions for our state; the “system” around us is. We of implementation (Bartholomew, Parcel, & eat badly because of McDonald’s and other Kok, 1998). Among other things, one of the fast-food restaurants. Our children are obese winning conditions in health education because of the soft drink machines in schools. involves the development of interventions We have become sedentary because of the based on recognized theoretical premises irrational way the environment around us is (Bartholomew, Parcel, & Kok, 1998; Rakowski, mapped out: lack of sidewalks, overdevel- 1999; Webb & Sheeran, in press). opment of the road network, etc. However, despite a demonstration based This thesis is compellingly supported in on solid data, several stakeholders in health the 2004 movie by Morgan Spurlock entitled promotion continue to refuse to acknowledge Super Size Me. The pervasive societal message the merits of the educational approach and in this documentary is clearly the following: insist on abandoning interventions aimed at “We are victims of the system.” It is up to gov- changing an individual’s behaviour (e.g., Joffe, ernment and public health agencies to control 1996). In their opinion, only social and cul- these “polluters” in our physical, economic, tural conditions are important. In fact, even if and social environment through appropriate it is true that these factors are important, one laws and regulations. No one has yet ques- notes, unfortunately, that arguments voiced tioned the behaviour or individual responsi- in the debate seem to be based more on ideo- bility of the actor- author of Super Size Me. The logical conviction rather than on scientific rea- solution resides in the pure and simple eradi- soning (Abraham, Sheeran, & Orbell, 1998). cation of McDonald’s restaurants. Although The contemporary approach to the obe- this way of thinking might seem comforting, sity epidemic provides a prime example of it removes all sense of responsibility from the this approach to health promotion. To fight individual, making “It’s not my fault, I have this important health problem, several public done nothing wrong” the winner here—a health specialists advocate adopting a narrow somewhat simplistic approach to dealing with view, recommending action that might the situation! “directly change living conditions at the root However, one would have to be naïve to of certain kinds of behaviour. Thus, the focus surmise that this miracle recipe will uncon- would be on behaviour without necessarily sciously force us to adopt good behaviour and broaching education. […] since people are lead to improved health among the popula- exposed passively, they will benefit from pre- tion at large. One should harbour doubt; even ventive measures without having to think in a supportive environment, lack of moti- about them” (ASPQ, 2003, p. 14; free trans- vation has harmful repercussions. Motivation lation). This is an endorsement of the theory is an unavoidable companion along the road of operant conditioning in which an indi- to changing a bad habit. Every ex-smoker vidual responds to a specific external stimu- has begun the long rite of passage to a smoke- lus without being prompted. According to free existence with the intention to stop this theory, X need only be changed in order smoking. We are, in fact, tributaries not only that Y adopt the correct behaviour. From this of the environment and context surrounding standpoint, why worry about the person, us, but also of the decisions we make. It is since his or her motivation is unimportant? difficult, even impossible, to contemplate sig- If one is to believe advocates of this approach nificantly changing the behaviour of a person to health promotion, we are not responsible who is not motivated. Health Promotion 5/1/07 11:18 AM Page 369

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One of our recent studies reviewed the Temporal stability might be defined as “the role of cognition versus that of the immedi- extent to which intention remains unchanged ate social environment in the adoption of a over time regardless of whether or not it is particular behaviour, namely, regular phys- challenged” (Sheeran, Orbell, & Trafimow, ical activity. A subgroup of 1,749 people, 1999, p. 722). Therefore, in this example, in a chosen at random from 22,702 respondents favourable or unfavourable social environ- to the 1998 Quebec Health and Social Survey, ment, when an individual has an unstable was monitored for three months. There were intention of engaging in physical activity on a three measured categories of variables avail- regular basis, the intention–behaviour rela- able at the beginning of the study to predict tionship is not only weak, but null for all behaviour over the next three months: cog- intents and purposes. In summary, if a person nition (i.e., intention, attitude, perception of has an unstable intention, the social environ- control); personal variables in the immediate ment has no effect. Likewise, the social envi- social environment (e.g., family income, job ronment encourages a move from intention status, perceived social support); and the same to action when the person has a stable inten- socio-structural variables measured at the tion. Consequently, these results clearly regional level irrespective of respondent demonstrate the importance in health pro- background. The results were rather elo- motion of attributing similar importance to quent (Godin et al., in preparation). A first- the individual (i.e., his or her motivation) and level analysis showed that no variable of the the social environment (i.e., its quality). social environment contributed significantly Ignoring one or the other is tantamount to to behaviour prediction (i.e., regular practice being cut off from a significant part of reality. of leisure time physical activity); the best What does the future hold for us in determinants were intention and perception terms of health promotion activities? It is of control. A second-level analysis identified hard to say, but one thing is certain: We must some intention–behaviour relationship mod- stop relegating the individual to the sidelines erators, meaning variables affecting the in our approaches and interventions. It is strength of the relationship between inten- time to reinstate the individual to the place tion and behaviour. Among these modera- he or she should take in health promotion, a tors, some were associated with the personal place that many have never forgotten in social environment (e.g., level of education) Canada over the last 10–12 years despite an and others with the regional social environ- unfavourable environment. By following the ment (e.g., regional family income, regional global approach advocated in the Ottawa level of education). However, a third-level Charter, individual responsibility in the adop- analysis showed that social structural vari- tion of healthy behaviour will once again find ables (personal and regional) exert influence renewed legitimacy. only when the individual has a stable intention of adopting a particular course of action.

REFERENCES Abraham, C., Sheeran, P., &1, Orbell, S. (1998). Can social cognitive models contribute to the effectiveness of HIV-preventive behavioural interventions? A brief review of the literature and a reply to Joffe (1996, 1997) and Five-Schaw (1997). British Journal of Medical Psychology, 71, 297–310. Health Promotion 5/1/07 11:18 AM Page 370

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ASPQ (Association pour la sante publique du Québec). (2003). Les problèmes reliés au poids au Québec: Un appel à la mobilisation. Rapport du Groupe de travail provincial sur la problématique du poids (GTPPP). Montreal: ASPQ Éditions. Bartholomew, L.W., Parcel, S.G., & Kok, G. (1998). Intervention mapping: A process for developing theory- and evidence-based health education programs. Health Education and Behaviour, 25, 545–563. Godin, G., Gallini, M.C., Conner, M., & Sheeran, P. (in preparation). Individual and socio-structural moderators of the intention-behaviour relationship. Joffe, H. (1996). AIDS research and prevention: A social representation approach. British Journal of Medical Psychology, 69, 169–190. Kalichman, S.C., Carey, M.P., & Johnson, B.T. (1996). Prevention of sexually transmitted HIV infection: A meta-analysis review of the behavioral outcome literature. American Behavioral Medicine, 18, 6–15. Kok, G., Van Den Borne, B., & Dolan Mullen, P. (1997). Effectiveness of health education and health promotion: Meta-analyses of effect studies and determinants of effectiveness. Patient Education and Counseling, 30, 19–27. Rakowski, W. (1999). The potential variances of tailoring in health behavior interventions. Annals of Behavioral Medicine, 21, 284–289. Sheeran, P., Orbell, S., & Trafimow, D. (1999). Does the temporal stability of behavioral intentions moderate intention-behavior and past behavior-future behavior relations? Personality and Social Psychology Bulletin, 25(6), 724–734. Webb, T., & Sheeran, P. (in press). Does changing behavioral intentions engender behavior change? A meta-analysis of the experimental evidence. Psychological Bulletin. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. Health Promotion 5/1/07 11:18 AM Page 371

CHAPTER 22 CONCLUSION: THE RHIZOME AND THE TREE

Sophie Dupéré, Valéry Ridde, Simon Carroll, Michel O’Neill, Irving Rootman, and Ann Pederson

INTRODUCTION returns to, and critically reflects upon, the his book has provided a broad yet modern/post-modern distinction that was T detailed scan of developments within made in the conclusion to the first edition. health promotion in Canada since the mid- These concluding thoughts thus build 1990s. These developments have been docu- upon the different chapters of this book, as mented from both inside and outside of well as additional literature and dialogue Canada, and from the perspectives of active among the authors, a team put together health promotion practitioners, researchers, explicitly for the purpose of writing this final advocates, educators, and program evalua- chapter.1 We also refer to the predictions and tors. A range of theoretical perspectives has analytical remarks that were made in the first been put forward and activities have been dis- edition, as we recognize that this new edition cussed from macro to micro perspectives, as is both an update of the first book and a well as from the perspective of various juris- broadening of the perspectives from which dictions. Given these many varied contribu- we reflect upon the development of health tions, what can we conclude about health promotion in Canada and its influence promotion in Canada and how has it influ- abroad. One issue that challenged us as we enced the field globally from 1994–2006? And wrote these final thoughts is an old one, given what we have found, what does it inti- namely, the relationship between science, ide- mate for the future? ology, and health promotion. After extensive In this chapter we try to answer these discussion, we concluded that this complex questions by reflecting on developments in topic warrants a fuller treatment than is pos- health promotion that continue earlier trends sible in the short space available. We there- as well as those that have evolved signifi- fore intend to return to this particular cantly or emerged during this period. We discussion in a future article, although we rec- conclude by referring to the analogy Ilona ognize that in so doing this ongoing discus- Kickbusch draws in her commentary about sion—and our analysis of it—remains one of health promotion being a rhizome rather the possibly unsatisfying elements of the book. than a tree (see Chapter 20). Linking this metaphor to the distinction made between health promotion and the promotion of OLD ISSUES REMAIN VALID health in Chapter 3 and to the arguments we develop throughout this chapter allows us to Health Promotion: Still Marginal propose a way to think about the develop- But Resilient ment of health promotion over the years that As clearly shown throughout the book, but 371 Health Promotion 5/1/07 11:18 AM Page 372

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particularly in the chapter about the provin- opposed to the ones pertaining to the social and cial and territorial situations, health promo- economic context. Thus, despite a decade in tion continues to be marginal in the overall Canada of a discourse of the social determi- Canadian health care system. As is evident nants of health that recognizes the importance throughout the world, health promotion in of an ecological approach to interventions, Canada continues to struggle to locate itself in Canadian health promotion in its day-to-day relation to the biomedical and curative para- practice remains largely lifestyle-oriented and digms that still dominate health care, research, focused on individual behavioural change. and policy. The health care constituencies (pro- This probably can be explained by a lack of fessionals, especially physicians, hospital well-articulated and supported social theories boards, etc.) are well organized as well as very to guide practice, in contrast to the array of influential and powerful, notably by having better-known psychosocial theories of health the public opinion on their side as we were behaviour (Potvin et al., 2005) that continue to reminded in Chapter 10. In the last decade we inform the training of practitioners (see have witnessed the health sector’s increasing Chapter 18). That policy and funding struc- focus on reducing costs in an economically tures remain linked with specific diseases, driven, neo-liberal context, leaving little fund- behavioural risk factors, or at-risk populations ing for public health and/or health promotion, also creates barriers to the facilitation of the although we note a certain renewed interest intersectoral work and the holistic view and additional funding since the establishment deemed necessary to act within a broader of the Public Health Agency of Canada in vision of health promotion (Kickbusch, 2003; September 2004. Even within the public health Ziglio, Hagard, & Griffiths, 2000). budget and programs, however, health pro- Moreover, as argued by Hills and her col- motion is still marginal and governmental leagues in Chapter 18, Canada continues to budgets dedicated to its practice in Canada be challenged to reorient its health system remain extremely modest. Bujold (2004) toward a primary health care focus (and in described this situation by saying that health turn to establish the role of health promotion promotion has always been—and indeed has within primary health care). One of the main remained so over the last 12 years—“l’humble reasons they mention for the limited progress Cendrillon” (the humble Cinderella) in the pro- on this issue, namely, the resistance of health motion/prevention/protection triad. promotion to building alliances with the med- As argued by Hancock (1994) in the first ical sector, was identified in the first edition edition of this book, and more recently by sev- of this book (O’Neill, Pederson, & Rootman, eral scholars (Bengel, Strittmatter, & Willmann, 1994) and likely reflects a fear of giving the 1999; Frolich & Potvin, 1999; McKinlay, 1998; powerful constituencies of biomedicine the Ziglio, Hagard, & Griffiths, 2000), public opportunity to redefine the field of health pro- health and health promotion practice remain motion. Rather than a broad health promo- largely anchored in a pathogenic paradigm, tion vision, what has been emerging in the oriented toward illness in its manifestations, medical sector over the last decade is a dis- both in Canada and around the world. As seen course on clinical preventive practices. In in Chapter 4, public health programs are still Quebec, for instance, the Clair Commission primarily developed on the basis of epidemi- (Quebec Ministère de la Santé et des Services ological models of risk factors (Breslow, 1999), sociaux, 2001) observed that public health with an emphasis on individual risks as resources lacked coordination and were Health Promotion 5/1/07 11:18 AM Page 373

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badly used; it also identified the need to very present in a paradoxical way in Canada. better inform health professionals on the As mentioned above, the contributors to this preventive practices that could be employed book have made it clear that the practice of in their clinical encounters (Lévesque & health promotion in all jurisdictions has still Bergeron, 2003). As highlighted in Chapter largely been based on individual lifestyle 18, clinical preventive practices tend to focus change related to the main illnesses plaguing on lifestyle counselling and individual pre- the population. On the other hand, as also ventive practices. Broader health promotion seen throughout the book, the discourse on continues to be absent or only minimally the social determinants of health was also present in the training and practice of most heavily emphasized and became, at home nurses, physicians, and other clinically ori- and abroad, a trademark of Canadian health ented health professionals. promotion. Indeed, many authors now sug- It is thus interesting to observe that gest (see Chapters 4 and 7, for instance) that despite very little funding, the current empha- health promotion’s work should be more (if sis on downsizing the health care system, the not entirely) devoted to social change. This rise of clinical preventive practices, and the somewhat contradictory tension between predominance of the population health dis- most of the practice and the dominant discourse, health promotion has been sufficiently course has created significant discomfort for resilient to survive. To adopt once more one many practitioners as well as for Canadian of Kickbusch’s analogies, the teenager learned researchers who have been working on indi- to elbow his way in a difficult schoolyard. vidual change over the last decade. We have This can probably be partly explained by the asked one of them, Gaston Godin, who holds dedication and motivation of people work- a Canadian research chair on health-related ing in the field. More structurally, in her com- behaviour, to comment on this situation and parison between three provinces, Bernier his contribution is included in the conclud- argues in Chapter 10 that elements like state ing section of this book. We support Godin’s legitimacy and a neo-liberal social investment position that health promotion practice perspective explain this resilience. Finally, the should be based on sound science and note fact that at the international level health pro- that research has clearly shown that both indi- motion never vanished and Canada contin- vidual and social factors are crucial to the ued to be singled out as a model to emulate, adoption and the maintenance of healthy as all the chapters of the international section lifestyles and healthy life conditions. of the book have shown, surely helped sustain health promotion in Canada. Professionals, Bureaucrats, and Academics in the Canadian Health Structural versus Individual Change Promotion Movement As thoroughly discussed in the introduction In the conclusion of the first edition (O’Neill, to this book, the evolution from health edu- Pederson, & Rootman, 1994), it was observed cation to health promotion in the mid-1980s that the key actors who had influenced the was largely in reaction to the strong empha- development of the field from 1974–1994 sis on individual change that characterized were a group of health professionals, policy the field from its inception in the 1950s. makers, and academics. The point made then Between 1994 and 2006, this issue was still was that health promotion was not a wide- Health Promotion 5/1/07 11:18 AM Page 374

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spread social movement but rather a profes- Two sets of actors who were involved sional movement that had successfully earlier but which were given little attention advanced a discourse about health and the in the first edition are the private and the vol- production of health. It was also suggested untary sectors. The role of the private sector that local communities, notably through the has been pointed out by many in this book, healthy cities movement, could become more including Kickbusch and Labonté, as one of important in the future, but that they were the key emerging elements of the last decade. not then the leaders in health promotion. We will return to this point later. The other What is clear in the national and provin- set of actors we did not talk much about in cial sections of this second edition is that the the first edition—and which remains under- key actors have essentially remained the same explored in this volume as well—is the vol- from 1994–2006. The main difference is that untary sector. Our sense is that this sector has academics might have played a larger role than always been important to health promotion, in the previous period, bureaucrats a less impor- but that perhaps this role has increased in the tant one, and that practitioners have probably past 10–12 years. We have therefore asked maintained a relatively constant level of Elinor Wilson, chief executive officer of one involvement. Moreover, as they were struggling of the key Canadian non-governmental asso- as well with structural reorganization, local ciations in relation to health promotion, the communities, whether through the healthy Canadian Public Health Association, to write communities movement or other mechanisms, about this issue (see Box 22.1). have not taken the much more active role that Hancock (1994) and others had envisioned.

BOX 22.1:THE ROLE OF THE VOLUNTARY SECTOR IN HEALTH PROMOTION IN CANADA

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The International Leadership on how to establish research priorities, as well of Canada as on how to have systemic and meaningful In the first edition, the editors predicted that impact on health (Kickbusch, 2006; Labonté Canada would continue to play an important & Spiegel, 2001; Neufeld & Spiegel, 2006). role in health promotion on the international The role of Canada as a donor country or as scene. Indeed, and despite always possible part of powerful political structures like the biases in the selection of our contributors, it G8 alluded to in chapters 12 and 15 should is obvious from all the chapters of our inter- also be recognized. national section that Canada continues to have a good international reputation and has contributed in many different ways to the Not Yet a Worldwide Presence global development of the field in the last In 1994, the editors predicted that health pro- decade. And this is the case despite the mar- motion would continue to be primarily a phe- ginalization of health promotion in Canada nomenon of developed countries and a luxury during this period discussed previously. that few developing countries would be able Although there are definitely reasons to cel- to afford. After a decade, we can certainly ebrate this reputation and these contribu- affirm that many countries, be they developed tions, much reflection and work remain to or developing if we use this vocabulary, have be done in order to improve Canada’s effec- not yet adopted the Ottawa Charter version of tiveness in its international and global actions. health promotion discourse. As seen in the As argued in Chapter 15, many individuals various country examples of Chapter 15, and groups of scholars (such as the Canadian health promotion is gaining currency in some Coalition on Global Health Research) con- countries whereas it has been in place for vari- cerned with global health and inequalities in able periods for others, even through an estab- Canada and abroad are reflecting on how lished infrastructure in a few of them. best to allocate scarce resources for research The adoption of health promotion is in the context of the 10/90 gap (see Box 22.2), clearly influenced by various social, cultural,

BOX 22.2:THE 10/90 GAP IN GLOBAL HEALTH RESEARCH

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historic, and political factors. For instance, emerge over the last decade has been the speed as argued by Ridde and Seck (in press) with at which the processes of globalization have respect to francophone African countries, been unfolding. Globalization has had an some countries may prefer to adopt the impact on countries from the South (De Alma-Alta discourse of primary health care Leeuw, 2001; Kim, 2000) as well as from the than the discourse of health promotion. This North, including Canada (Romanow, 2002). preference can probably be partly explained As Labonté observes, many voices are rising by the historical relation between those coun- to affirm (Feachem, 2001) or deny (Bezruchka, tries and France (e.g., aid, training) where, 2000) a positive link between globalization and as also seen in Chapter 15, health promotion health. Yet, the “globalization of health” is has very little currency even today. less recent than many think (Yach & Bettcher, It is also interesting to note from Chapter 1998): it could be argued that it began five 15 that health promotion clearly does not centuries ago when Europe’s conquest com- operate in the same forms in all countries and pleted the microbial unification of the world that similar activities may exist but be labelled (Berlinguer, 1999). Co-operation among differently. O’Neill and Cardinal (1994) made countries on health issues is also an old phe- the same type of observation in the first edi- nomenon, as the first international health- tion, but with respect to a provincial juris- related meeting was held in Paris, France, in diction: they observed that in Quebec the 1851 (Walt, 1998). However, despite this his- adoption of the health promotion discourse tory, the magnitude of recent globalizing in the mid-1980s was slow; they argued that activities is unprecedented and forces us to there were many practices then, as there prob- reflect anew on its link to health promotion ably still are, that were consistent with health practice and research. promotion, but not labelled as such. This First, it is important to differentiate appears to be the case for many countries, par- actions in international health from global ticularly those of the South. Consequently, health issues, as argued by Brown, Cueto, and there is a lot of interesting work for the global Fee (2006) and Jackson et al. in Chapter 13. health promotion community that is largely Some have even argued that we are now unknown, notably because of publication facing the “globalization of international biases and persistent inequalities under which health” (Walt, 1998). According to Labonté research is carried out. This calls for meas- (2006), talking about global instead of inter- ures to make these practices more visible as national health completely reframes the the Global Effectiveness Project (Jones, 2004) research agenda, as many local or national and the Equity for Publication Project of the health situations can no longer be resolved by International Union for Health Promotion local or bilateral action but in fact require and Health Education try to do (see IUHPE global responses. This was the case for SARS Web site below). and has been true of the HIV/AIDS epidemic, and is currently a feature of diverse issues ranging from avian flu, to BSE, to bioterror- MAIN EMERGING ISSUES ism. Furthermore, local actions and policies undertaken in Canada can have unintended Globalization consequences in different corners of the world As Labonté suggests in Chapter 12, the earli- (e.g., brain drain: see the 2006 annual report est and probably most significant issue to of the World Health Organization). Health Promotion 5/1/07 11:18 AM Page 377

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Second, the economic dimension of glob- national agencies such as the World Trade alization has led to global institutional Organization have also had major health- changes. Whereas WHO and its member related effects around the world over recent states were still very important global health years, not only among countries of the South. actors during the writing of this book’s first As Labonté notes in Chapter 12, in par- edition, in recent years there are those who allel with the increasing role of these insti- argue that the leadership of many United tutions, many debates are emerging with Nation’s agencies has been supplanted by the respect to global governance and the “watch- World Bank and other economically driven dog” role of public health and heath pro- global institutions such as the World Trade motion practitioners and organizations. The Organization. Indeed, a collection of articles emergence of initiatives such as the People’s on this subject published at the end of the Health Movement (see Web site in the list at 1990s in the British Medical Journal led a senior the end of this chapter) or the drafting of a WHO official to say: “The World Bank is the counter report to WHO’s by Global Health new 800 lb gorilla in world health care” Watch (see Web site below) are indications (Abbasi, 1999, p. 3). Through the publication that mechanisms are becoming organized for of its famous report on health (Banque mon- this new global governance to function. It diale, 1993) and its Health, Nutrition, and will be interesting to see whether the WHO’s Population Strategy (World Bank, 1997), the Commission on the Social Determinants of World Bank has had a dramatic influence Health (see Web site below) has significant with its “investment in health” approach. impact and what arises from work on the Although this strategy significantly mobilized UN Millennium Development Goals. It new funds toward health, the results of this remains to be seen if the UN organizations mobilization were questioned by many as are able to balance the impact of these other early as 1993 and similar issues have been emerging organizations or whether we have raised with respect to malaria by a Canadian- entered a new world order, as Kickbusch run research team (Attaran, et al., 2006). suggests in her commentary. Two additional issues need to be raised here. First, it is well known that for the World Bank, health is not considered a right but The Evidence Base of rather a means of leveraging economic devel- Health Promotion opment, especially in poorer countries (Buse An important development since 1994 has & Walt, 2000; de Beyer, Preker, & Feacham, been the need for health promotion to 2000), though this outcome has never fully strengthen its scientific evidence base. This materialized, as acknowledged by one of the has been triggered both from outside the World Bank’s former directors (Stigliz, 2005). field, by the need to prove to governments Second, the Bank tends to ignore the impor- and other funding bodies that health pro- tance of countries’ legitimate political pref- motion interventions are effective during a erences (Hibou, 1998). The World Bank decade of major downsizing in publicly concept of governance is associated in their funded health systems (O’Neill, 2004), and publications and their discourse with a lim- from within through important work to ited (or indeed minimalist) role for the state establish and assess the theoretical bases of (Attaran et al., 2006; Hibou, 1998). In this con- health promotion activities. Contributors text, many other economically driven inter- throughout this book have continued this Health Promotion 5/1/07 11:18 AM Page 378

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trend and have tried to elaborate how theory and decision makers might well need to recon- could enhance health promotion practice and sider the very concept of effectiveness, which research in particular. is not as universal as it might seem, as Jullien (2005) eloquently showed in a recent compar- The Effectiveness Movement and ison of European and Chinese perspectives Realistic Evaluation toward effectiveness. Health promotion has been struggling with two important questions when it comes to The Need for Theory assessing its evidence base: Which types of Despite the still unsolved debates about evidence are required to assess the effective- whether the individual or the social is the ness of health promotion? How should we most important focus for health promotion evaluate health promotion interventions? As interventions, researchers and practitioners Potvin and Goldberg discuss in Chapter 19, in both camps believe that better theory is a whole area of knowledge development needed to inform practice. This view has arose in the 1990s around these questions, sharpened since 1994. with fundamental consequences for the evo- On the individual side, psychosocial lution of the field. International work has models aimed at understanding, predicting, been conducted by IUHPE (1999), WHO- and influencing health-related behaviour EURO (Rootman et al., 2001), and many have been around for decades since the first others (Cloetta et al., 2005; Nutbeam, 1998), formulations of the Health Belief Model in within which Canadian scholars have been the early 1960s. The centrality of intention central. This work has been summarized by as a key predictor of behaviour has been Jackson and her colleagues (2001) of the demonstrated repeatedly through genera- Canadian Consortium on Health Promotion tions of theoretical models building on one Research, who note the key scientific and another by authors such as Azjen, Fishbein, political dilemmas involved. Triandis, Bandura, Prochaska, and di Despite the importance of this evolution, Clemente, to name the best known (Godin, a paradigmatic dead end remains. Experts in 1991). Several sets of variables have been health promotion evaluation have to come to introduced to understand what makes inten- realize the difficulty—and possible irrele- tion evolve, and in general, even if they vance—of adopting positivist research meth- remain uncommon because of the complex- ods and experimental designs to evaluate ities involved, interventions based on these health promotion practice, especially at the theoretical advances are much more success- community level. They are thus now turning ful than those not so informed. An attempt to an important recent theoretical development has recently been made by a scholar from in program evaluation, the realistic approach Canada to assemble all these developments (Pawson & Tilley, 1997), and exploring its use in one “integrated model” (see Godin, 2002). within the field of health promotion program On the social side, and notwithstanding evaluation (Hills, Carroll, & O’Neill, 2004; Kickbusch’s claims in this book about Potvin, Gendron, & Bilodeau, in press). One “decades and libraries full of research on the of the biggest challenges in the years to come interface between social factors and health,” will be whether this promising approach to efforts to explicitly link social theory and evaluation can actually demonstrate health health promotion have come later and have promotion’s effectiveness. Moreover, scholars been less systematic and well articulated than Health Promotion 5/1/07 11:18 AM Page 379

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on the individual side. In this respect, two more complex if the construct involved is one recent undertakings to link social theory and as broad and difficult to define as health pro- health promotion, one primarily international motion (see Chapter 3). Clearly, the last decade and one largely Canadian, are worth men- has demonstrated that for both practical and tioning. The international effort is the publi- political reasons, the field of health promotion cation by some leading voices in the field of a needs to articulate and refine its scientific base; book, entitled Health and Modernity: The Role failure to do so runs the risk of health promo- of Theory in Health Promotion (McQueen et tion being discredited as simply one of many al., forthcoming). The Canadian one, which competing ideological discourses rather than has had significant international impact, is a sound framework for action. the development of the collective lifestyles concept presented in Chapter 4. To date, whether building on the sociology of Weber, Habermas, Addressing Social Health Inequalities Bourdieu, or Giddens, these efforts have gen- Health promotion has always focused on erally produced less integrated and less robust action on health determinants in order to models of the relationships between social fac- improve the overall health of the whole pop- tors and health than the ones on individual ulation. This was relatively new at the time change, but there is clearly commitment and of the Ottawa Charter, but since then much capacity to extend this line of theorizing and substantive knowledge on the determinants we should continue to expect important the- of health has been accumulated. Many ana- oretical advances. lytic frameworks have been developed to Moreover, health promotion should describe and analyze the different determi- expand academic alliances to enrich its the- nants of health, one of which, published at oretical base. For example, the authors of the same time as the first edition of this book, Chapter 6 call for more dialogue with the raised much interest and critique, both from field of women’s studies and present inter- those who identified themselves as part of the sectionality as a relevant theory to guide health promotion field and those who did not health promotion research and practice. And (Coburn et al., 2003; Poland et al., 1998). we note that Canadians have been involved Over the last decade a double evolution seems in efforts to integrate the individual and the to have taken place in discussions on the social elements in a single framework (see determinants of health. Best et al., 2003). These efforts are still pre- On the one hand, researchers are begin- liminary, but we think that the ecological ning to move beyond the description of model discussed in Chapter 17 shows determinants of health and look into their tremendous promise in this regard and interactions and social processes over time in appreciate that Richard and Gauvin used it order to account for differential exposure and to examine some examples of health promo- vulnerability over the life course. The con- tion programs in Canada. ceptual contribution of the “collective lifestyle” Finally, this book illustrates (through the concept presented in Chapter 4 or the devel- example of health literacy described in Chapter opments of the “ecological health promotion” 5) that the various steps to scientifically define, discussed by Richard and Gauvin in Chapter operationalize, and measure a concept in order 17 are salient examples of the Canadian con- to move from theory to program planning are tribution to knowledge development in this numerous and complex. This process is even area. More recently, some Canadian researchers Health Promotion 5/1/07 11:18 AM Page 380

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have suggested thinking of the determinants interest, and a resurgence of interest in cre- as “contributors to disease causation, rather dentialing (see Hyndman, 2006). As the first than as determining factors” (Lock, Nguyen, two have been already abundantly discussed, & Zarowsky, 2005, p. 58). we will briefly comment on the issue of cre- On the other hand, the problem of social dentialing because of its implications for the inequalities in health is beginning (albeit still conclusion of this chapter. timidly) to interest researchers. A core chal- As we complete the manuscript for this lenge in this analysis is to not only link social book, credentialing is once more emerging as inequalities to population health but, more an issue with the creation of a College of importantly, to understand the social and polit- Health Promoters in one province, with pos- ical processes that produce them (Coburn et al., sible implications for the rest of the country. 2003; Navarro, 1998)—understanding that can This is something that many Canadians work- only be realized through an interdisciplinary ing in the field had resisted because of the science of health inequalities (Graham, 2004). underlying egalitarianism of health promo- In terms of actions to reduce social tion expressed in the Ottawa Charter. But inequalities in health, Canada is still in its internationally, credentialing has always been infancy (Mackenbach & Bakker, 2002).Very a hot topic (O’Neill & Hills, 2000), reflected, few countries have implemented global and for example, by IUHPE’s creation of a new coordinated policies in this respect, including vice-presidency on capacity building, train- Canada (see Raphael in Chapter 7) and, in ing, and education in 2004. The first vice-pres- Canada, not even Quebec, which is often a ident is Alyson Taub, a well-known American leader in policy reforms, has taken such action. scholar who has worked for most of her career Should health promotion actors become social on credentialing and certification issues, and and political entrepreneurs to put the elimi- key elements of her mandate include address- nation of health inequalities on the Canadian ing credentialing at the global level. policy agenda? In contrast to the field of public Despite this tradition of reluctance in health, which, according to former WHO Canada with respect to credentialing, pres- Director General Gustaf Mahler, “has lost its sure appears to be mounting from two con- original link to social justice, social change and stituencies to move in the direction of social reform,” health promotion has put the formalizing professional recognition of health reduction of disparities that have an impact promoters. The first group includes practi- on health at the heart of its dominant value tioners working in the field, particularly those base, included it in the Ottawa Charter, and employed in public health, who are concerned has espoused the importance of such work that they lack credibility and protection from over the last decade, even if this concern does a college or licensing body that others such as not rally all the health promotion community. nurses and dieticians enjoy. The other constituency encouraging credentialing is the community college sector; those offering The Growth of the Tree diploma programs in health promotion are If we look at the development of health pro- concerned about the recognition of the train- motion as a specialized field in Canada, there ing and skills of their graduates. In their view, have been significant developments over the this would be helped considerably by the past decade, notably the increase in research development of a recognized professional des- funding and infrastructure, renewed federal ignation in health promotion. Health Promotion 5/1/07 11:18 AM Page 381

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As a result of these two constituencies perhaps it will also continue to advance as a coming together, efforts are underway to rhizome. This may take the form that obtain government support to develop a O’Neill and Stirling have suggested calling College of Health Promotion in Canada. “the promotion of health” (see Chapter 3), in Whether this comes to fruition, and what its which the ideological dimensions of health implications would be in the various provinces promotion expand and extend throughout in the next decade remains to be seen, but it is the world. And it may be this second form clear that such discussions are now on the of development that has the greatest impact table. This is one challenge that the field in in this increasingly globalized world. Canada will have to address, particularly given According to Deleuze and Guattari the definition of health promotion as a pro- (1987), the rhizome is characterized by radi- fessional enterprise put forward in Chapter 3. cal heterogeneity, radical multiplicity, and radical rupture. Its productivity lies precisely in its slipperiness and its endless deferral of CONCLUSION: THE meaning, its unwillingness to be pinned RHIZOME OF THE down, its promiscuity, and even ability to PROMOTION OF HEALTH “betray” without regret. This sense of the pos- OR THE TREE OF sibility of betrayal is hinted strongly at by HEALTH PROMOTION? Kickbusch’s oblique reference, in her reflec- In her commentary, Ilona Kickbusch built on tions, to the Jakarta Conference’s acrimony the work of Deleuze and Guattari (1987) by over the involvement of the private sector, an employing the metaphor of the “rhizome”— acrimony that was even more obvious in the a typically post-modern image—to signify the recent debates over the Bangkok Charter way in which the ideology of the new public (RHPEO, 2006). There is a great unspoken health as disseminated by health promotion tension in health promotion surrounding the since the mid-1980s has helped to give health issue of the “private sector” and reference to a central place in our societies as a sort of het- “neo-liberalism” and other such global bogey- erogeneous network, which has an impact men. What is noticeably missing from the dis- through multiple and often unforeseen con- cussion of these issues is any sense of global nections. We would like to conclude this capitalism as a dynamic system; that is, one in chapter and this book by seeing how this rhi- which the “private sector” does not sit neatly zomatic way of seeing health promotion helps in its place, playing its appropriate role, as a us to reflect on the future of the field in kind of long-neglected dinner guest we sud- Canada and abroad. denly discover we can include in the conver- Perhaps the future of the field lies in the sation. “Neo-liberalism” was and is not just a interaction between the modern and post- collection of unfortunate ideas dreamt up by modern views of health promotion as a tree mistaken academics at the International and as a rhizome rather than in the displace- Monetary Fund and the World Bank; it is a ment of one by the other. We can envision hegemonic accumulation strategy that has health promotion evolving as a tree, to be a served an important purpose for global cap- professional enterprise conducted within the ital and will continue to do so. subsystem of public health services in the There is an interesting and continuing health systems of nation-states, with a rec- tension, albeit often not explicit, in the theo- ognizable and legitimate infrastructure. But retical trajectories that health promotion Health Promotion 5/1/07 11:18 AM Page 382

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finds itself following and in the hoped-for 2 on the concept of health, the material in solutions that are tied up with these differ- Chapter 3 pursuing a better and more precise ing trajectories. On the one hand, there is a definition of the concept of health promotion, sense of alliance with many of post-mod- or the effort in Chapter 4 to introduce the ernism’s preoccupations and critiques (e.g., thinking of Bourdieu and Giddens (the ulti- diversity, discourses, networks) and certainly mate “late modernist” sociologists) to help health promotion’s birth coincided with the theorize the notion of collective lifestyles. cultural ascendancy of post-modernism and Many of the real preoccupations of the book the alleged shift to post-modernity (Harvey, lament, not the over-rationalization and struc- 1989; Jameson, 1991; Lash & Urry, 1994). tural sluggishness of modern institutional- And, if we agree with Kickbusch’s argument, ization, but the lack of progress health the main success of health promotion to date promotion has made in developing, as a tree, in Canada and globally has been its post- a stronger ecological theoretical base with modern rhizomatic way of partaking in the clearer programmatic strategies to implement transformation of the place of health in con- and institutionalize its agenda for revolu- temporary societies. tionizing the societal approach to health, par- Yet, arguably, the flavour of most of the ticularly within the context of the modern thinking, as reflected in the contributions to state—still the primary funding body. Time this book, remains decidedly modern in the and again, we see the appeal to broaden the classic sense (Bauman, 1987; Habermas, 1987). use of available theoretical tools, whether they Take, for example, the early pieces of Chapter be social theory (Chapter 4), political analysis

BOX 22.3: POSTMODERNISM

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(Chapter 10), or political economy (chapters proof of its effectiveness, health promotion 7 and 12) to help explain, clarify, and guide increasingly finds itself having to decide on health promotion in the future. which side of the global political fence it sits So what to make of this tension between or, to put it in oversimplified terms, the a successful rhizomatic capacity to promote World Economic Forum at Davos or the the growing importance of health in societies, World Social Forum at Porto Allegre. It will generated, ironically, by health promotion’s have to make those choices, or the choice not inability to lodge itself institutionally to grow to choose—neutrality as Freire (1970) rightly as a tree or to build “palaces,” so to speak? points out, generally resulting in supporting In a sense, it is not as if there is a “choice” the powerful against the powerless. And to be made between what could be perceived these choices will have to be made in the con- as two very different trajectories. Rhizomatic text of how health promotion conceptualizes progress is certainly progress of a sort, and possible futures if the potential for collective may be a more “realistic” notion than the and counter-hegemonic struggles and the more ambitious one of fostering massive development of equitable societies in a mutu- institutional change. Yet, in the very strong ally supportive world really seems to be pos- appeals of Labonté for struggle on a global sible or if the hegemony of global capital has scale and Raphael’s uncompromising demand already taken us past a point of no return. that health promotion push for serious shifts We live in a diverse world of markets, in public policy to address health inequali- hierarchies, and networks, all organizational ties, there is a distinct tone of commitment forms that health promotion must confront to some very modernist principles of political in its day-to-day work. As much as one can action. Furthermore, on the level of knowl- be enamoured by rhizomatic networks and edge development, we detect an engagement appreciate their potential, markets and hier- in helping to advance a very young field and archies are still the dominant forms in which a willingness to explore many different our world is structured and are the primary approaches to build a cumulative and col- social processes through which health is lective knowledge base: another classically determined. What kind of politics, then, modern preoccupation. should health promoters practise? And what The reflection offered here is certainly kind of implications follow from an attach- not meant to discourage an engagement with ment to such notions as “equity,” “participa- some of the key currents in post-modern tion,” and “empowerment”? The latter are thought; many of these ideas are provocative all concepts derived from classically modern and stimulating, and bring important lessons premises concerning autonomy, authenticity, about modern approaches to theory and prac- and emancipation: whither do these concepts tice. It is more to ask that some of the issues go in a post-modern world? It is not clear generated by the more general debate sur- that health promotion has yet come to grips rounding the concepts of modernity and with these fundamental questions, but we post-modernity be considered as part of the definitely think they should be debated in the great health promotion dialogue. In partic- years to come. ular, in addition to establishing scientific Health Promotion 5/1/07 11:18 AM Page 384

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NOTE 1 Given our intent to give room to new and younger voices, the editorial team decided to engage in an intergenerational dialogue in preparing the conclusion by adding Valéry Ridde, from Quebec, and Simon Carroll, from British Columbia, to our group. This group made for an interesting mix in terms of age, gender, language, professional background, and geography. Our original idea was to engage in a sustained dialogue to reach if not consensual, at least well-debated conclusions. In the end, it was the younger generation that took up the challenge to draft the first set of conclusions, which we then debated as a group. This leadership is reflected in the order of authors of this chapter.

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RELEVANT WEB SITES

Global Forum for Health Research www.globalforumhealth.org The Global Forum for Health Research was established in 1998 to promote health research devoted to improving the health of people in developing counties.

Global Health Watch www.ghwatch.org The Global Health Watch is a broad collaboration of public health experts, non- governmental organizations, civil society activists, community groups, health workers, and academics. The Global Health Watch produces an alternative World Health Report.

People’s Health Movement (PHM) www.phmovement.org The People’s Health Movement has its roots in grassroots organizing. It is calling for a revitalization of the principles of the Alma-Ata Declaration of healthy for all by the year 2000.

World Health Organization Commission on Social Determinants of Health (CSDM) www.who.int/social_determinants/en/ The Commission on Social Determinants of Health supports countries and global partners to address the social factors leading to ill health and health inequities. Health Promotion 5/1/07 11:18 AM Page 389

Statistics Canada information is used with the permission of Statistics Canada. Users are forbidden to copy the data and redisseminate them, in an original or modified form, for commercial purposes, without permission from Statistics Canada. Information on the availability of the wide range of data from Statistics Canada can be obtained from Statistics Canada’s Regional Offices, its World Wide Web site at http://www.statcan.ca, and its toll- free access number 1-800-263-1136.

BOXES BOX 1.2: World Health Organization, “WHO Global Strategy for Health for All by the Year 2000,” from 64th Plenary Meeting, Resolution 36/43 (Geneva: WHO, 1981) http:// daccessdds.un.org/doc/RESOLUTION/GEN/NR0/406/69/IMG/NR040669.pdf?OpenElement

BOX 12.1: Ronald Labonte, Ted Schrecker, Amit Sen Gupta, “From Structural Adjustment to an HIV Pandemic,” from Health for Some: Death, Disease, and Disparity in a Globalizing Era (Toronto: Centre for Social Justice, 2005). Reprinted by permission of Centre for Social Justice.

FIGURES FIGURE 2.1: N. Joubert & J.M Raeburn, from Mental Health Promotion: People Power and Passion. International Journal of Mental Health Promotion, 1 (1998): 15-22.

FIGURE 2.2: “Centre for Health Promotion Quality of Life Model,” from Quality of Life Research Unit, http://www.utoronto.ca/qol/concepts.htm. Reprinted by permission of Quality of Life Research Unit.

FIGURE 4.1: G. A. Kaplan, S.A. Everson, & J.W. Lynch, “Multilevel Approach to Epidemiology.” In: B.D. Smedley & S.L. Syme, (Eds.), Promoting Health. Intervention Strategies from Social and Behavioural Research (Washington, D.C.: National Academy Press, 2000): 43.

FIGURE 4.2: A. Jetté, “Paradigmatic Obstacles in Improving the Health of Populations,” from Designing and Evaluating Psychosocial Interventions for Promoting Self-cure Behaviours Among Older Adults. National Invitational Conference on Research Issues Related to Self- Care Aging. Unpublished paper, 1994. 389 Health Promotion 5/1/07 11:18 AM Page 390

390 ■ Copyright Acknowledgements

FIGURE 8.2: Guoliang Xi, I. McDowell, R. Nair, R. Spasoff, “Report of Fair or Poor Self- Rated Health: Odds Ratios for Individual and Area Factors, Ontario, 1996,” from Canadian Journal of Public Health, 96 (3) (2005): 209.

FIGURE 8.3: Guoliang Xi, I. McDowell, R. Nair, R. Spasoff, “ Poor Scores (<50th percentile) on the Health Utilities Index: Odds Ratios for Individual and Area Factors, Ontario, 1996,” from Canadian Journal of Public Health, 96 (3) (2005): 210.

FIGURE 8.4: “Child Poverty in Wealthy Nations, Late 1990s,” from UNICEF, Child Poverty in Perspective: An Overview of Child Well-Being in Rich Countries Innocenti Report Card 7, 2007 (Florence, Italy: UNICEF Innocenti Research Centre, 2007): 6. Reprinted by permission of UNICEF Innocenti Research Centre.

FIGURE 11.1: Government of Manitoba, “A framework to promote, preserve, and protect the health of all Manitobans,” from Manitoba Health. www.gov.mb.ca/health/rha/planning.pdf.

FIGURE 12.2: Ronald Labonte, Ted Schrecker, Amit Sen Gupta, “How Debt Service Obligations Dwarf Development Assistance,” from Health for Some: Death, Disease, and Disparity in a Globalizing Era (Toronto: Centre for Social Justice, 2005). Reprinted by permission of Centre for Social Justice.

TABLES TABLE 8.1: “Age-Standardized Mortality Rates per 100,000 Population, for Both Sexes, or for Males and Females when Rates Differ by Gender, for Selected Causes of Death by Neighbourhood Income Quintile, Urban Canada, 1996,” adapted from Statistics Canada publication Health Reports Supplement, Catalogue 82-003-SIE, 13 (2002): 1-28. Reprinted by permission of Statistics Canada.

TABLE 10.3: “Gross Domestic Product Per Capita ($), by Province, Selected Years,” adapted from Statistics Canada CANSIM Database http://cansim2.statcan.ca, Series V691994, V691925 and V691902. Reprinted by permission of Statistics Canada.

TABLE 10.4: “Unemployment Rates (Percent), by Province, Selected Years,” adapted from Statistics Canada CANSIM Database http://cansim2.statcan.ca, Series V692006, V691937 and V691914. Reprinted by permission of Statistics Canada.

TABLE 10.5: “Seniors 65 Years and Over as a Proportion of Total in 2001,” adapted from Statistics Canada CANSIM Database http://cansim2.statcan.ca, Series V27572635, V27572974, V27572776 and V27572719. Reprinted by permission of Statistics Canada.

TABLE 16.1: Robert Roth, “Aids to Written Reflection,” from Preparing the Reflective Practitioner: Transforming the Apprentice Through the Dialectic Journal of Teacher Education, 40(2), March (1989): 31-35. Reprinted by Sage Publications Inc. Health Promotion 5/1/07 11:18 AM Page 391

PHOTOGRAPHS PART I OPENER: “Phrenology Head Stock x 249050,” by Mark Preston. From Stock.XCHNG.

PART II OPENER: “0008 (Friends Smiling for Camera).” From Health Canada Website and Media Photo Gallery, Health Canada, http://www.hc-sc.gc.ca. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006.

PART III OPENER: “Flags_Canada_Provincial 219117,” by Zennie. From www.istockphoto.com.

PART IV OPENER: By Valéry Ridde. Reprinted by permission of the photographer.

PART V OPENER: “0084 (First Nations, Nursing Infant).” From Health Canada Website and Media Photo Gallery, Health Canada, http://www.hc-sc.gc.ca Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006.

PART VI OPENER: “0024 (Cyclists).” From Health Canada Website and Media Photo Gallery, Health Canada, http://www.hc-sc.gc.ca Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2006. Health Promotion 5/1/07 11:18 AM Page 392

INDEX

A “at-risk” populations Aboriginal peoples critique of approach, 51–52 approaches to health promotion, 173 as point of intervention, 48 “at-risk” population, 48 social context, 51–52 and victim blaming, 48 Atlantic Health Promotion Research Centre Aboriginal Planning Committee, 226 (AHPRC), 196, 198 academics, 373–374 Atlantic provinces Access to Essential Medicines Campaign, 215 Atlantic Health Promotion Research Centre Achieving Health for All. See Epp Report (AHPRC), 196 Afghanistan, 259–260 Atlantic-wide initiatives, 195 Afghanistan Centre at Kabul University, 261 coastal and workplace health, 194–195 Afghanistan Research and Evaluation Unit, 261 final thoughts, 196–198 agency, 54, 55 food security, 191–192 AIDS programs, 83 healthy children, 190 Alberta healthy schools, 193–194 capacity building for health promotion, 168–169 introduction, 187–189 gross domestic product per capita, 148 New Brunswick, 189–190 Health Sustainability Initiative (HSI), 146 Newfoundland and Labrador, 194 networks and coalitions, 169–170 Nova Scotia, 190–191 political traditions, 147 Prince Edward Island, 192–193 provincial health system reform, 167–168 Australia, 261–262 research to advance knowledge and practice, 168 Alberta Centre for Active Living, 170 B Alberta Coalition for Healthy School Banfield, Winnie, 199–201 Communities, 171 Bangkok Charter for Health Promotion, 26–27, 78, 238 Alberta Healthy Living Network, 171 Bangkok conference, 11 Alberta Heritage Foundation for Health Banque de Données en Santé Publique Research, 127 (BDSP), 268 Alberta Public Health Association, 171 Bartlett, Linda, 259–260 Alijasem, Layla, 273–274 BC Coalition for Health Promotion, 166, 328 Allain, Monique, 187–189, 189–190 behaviour modification techniques, 51–52 Alma-Ata conference, 1, 4, 5t behavioural change, 49 American Evaluation Association, 359 Bernier, Nicole F., 141–150 American Medical Association, 62 binding trade rules, 210 anglophones, 202–203 blame the victim, 48 Annapolis Valley Health Promoting Schools Bourdieu, Pierre, 54 Project (AVHPSP), 321 Boutilier, Marie, 301–311 Annis, Robert C., 176–181 Bradley, Deborah, 192–193 Arroyo, Hiram V., 284–285 brain drain, 223 Association for the Care of Children’s Health, 99 Brazil, 227–228, 263–264 Association pour la santé publique du Québec Brazilian Collective Health Graduate (ASPQ), 187 Association, 264

392 Health Promotion 5/1/07 11:18 AM Page 393

Index ■ 393

British Columbia Canada Health and Social Transfer, 142 capacity for health promotion, 164 Canadian academic publications, 293–294 health promotion in, 162–167 Canadian Coalition for Public Health in the 21st networks and coalitions for health Century, 99 promotion, 164–165 Canadian Coalition on Global Health Research, 220 political and policy processes, 165 Canadian Consortium for Health Promotion provincial health system reform, 162–163 Research, 101, 105, 124–125, 126t, 128–131, research to advance knowledge and practice, 132–133, 135, 137, 158, 223, 235, 245 163–164 Canadian Council on Learning (CCL), 127, 132 social assistance, reduction of, 143–144 Canadian Diabetes Strategy, 97 British Columbia Health Literacy Research Team, 69 Canadian-European connection, 5–8 British Medical Journal, 346 Canadian Evaluation Society, 359 broad health promotion approach, 39–40 Canadian Health Network (CHN), 45, 97, 128 Building on Values: The Future of Health Care in Canadian Health Network classification Canada, 99 scheme, 39–40 Bureau of Women’s Health and Gender Canadian Health Services Research Foundation, 346 Analysis, 88–89 Canadian Heart Health Initiative, 93, 354, 356 bureaucrats, 373–374 Canadian Index on Adult Literacy Research in French, 73 C Canadian Institute for Health Information, 98 Campbell, Nancy, 199–201 Canadian Institute of Advanced Research, 38, 94 Canada Canadian Institute of Children’s Health, 121 anglophones, 202–203 Canadian Institutes of Health Research (CIHR), 65, children in poverty, 113f 98, 111, 126, 131–132, 163 contributions to health literacy, 65–68 Canadian International Development Agency definition of health promotion in, 34 (CIDA), 235 discourse and practice, 250–251 Canadian Journal of Public Health, 65 federal/provincial/territorial landscape, 153–154 Canadian Medical Association Journal, 346 federal role in health promotion. Canadian Policy Research Institute (CPRI), 127 See federal government Canadian Policy Research Networks/Réseaux francophone minority communities, 202–204 canadiens de recherches sur les politiques global health promotion contributions, 217 publiques, 152 global infrastructure, impact on, 237–243 Canadian Population Health Initiative (CPHI), 105 health inequalities. See health inequalities Canadian Public Health Association (CPHA), 64, 96, health literacy concept, 63–65 99, 105, 227, 235 health promotion, lack of professional Canadian Social Research Links, 152 status, 32–33 Canadian Society for International Health, 221, health promotion practice in, 301 225, 235 health research infrastructure, 158 capacity, 23–25 influences on WHO, 237–239 capacity building international governmental infrastructure, Alberta, 168–169 influence on, 239 Brazil, 227–228 and international health promotion. British Columbia, 164 See international health promotion Canada’s contributions to international health (Canadian influence) promotion, 250 international leadership of, 375 Chile, 226–227, 227 international non-governmental infrastructure, China, 226 influence on, 239–240 for community leaders, administrators and international research collaboration, impact on, decision makers, 225 240–241 concepts of health, 23–25 medicare system, 144–145, 154 Croatia, 226 official languages, 154, 155 France, 225 public agenda, 145 for indigenous peoples, 226–227 women’s health, 76–77 integrated initiatives, 227–228 Canada Health Act, 145 international health promotion, 225–228 Health Promotion 5/1/07 11:18 AM Page 394

394 ■ Index

Mexico, 227 Click4HP, 31, 38–39, 45, 127, 137–138, 159 Nunavut, 201 climate change, 210 Ontario, 182–183 clinical epidemiology, 351–352 primary care workers and other health coastal health, 194–195 professionals, 226 collaboration, 251–252, 304–305 Ukraine, 225 collaborative reflection, 306 capacity development, 128–132 Collective Health Unit OPAS Brazil, 264 Cardaci, Dora, 276–277 collective lifestyles, 54–56 Caribbean Charter, 238 College of Education, University of North Texas, 315 Carroll, Simon, 330–341, 371–383 Commission on Social Determinants of Health case studies (CSDM), 388 Alberta, 167–171 communication difficulties, 305 Atlantic provinces, 187–198 communication of information, 228 British Columbia, 162–167 communities, 48 current actions and future directions, 157–160 community-based approach, 81–82 francophone minority communities, 202–204 community capacity building, 25 health sector reform, context of, 155–157 community development, 25 Manitoba, 176–181 Community Health Research Unit (CHRU), 226 New Brunswick, 189–190 concepts of health Newfoundland and Labrador, 194 Bangkok Charter for Health Promotion, 26–27 Nova Scotia, 190–191 capacity, 23–25 Nunavut, 199–201 capacity building, 23–25 Ontario, 181–183 community capacity building, 25 Prince Edward Island, 192–193 community development, 25 Quebec, 184–186 conclusions, 27–28 reflections on a practical situation, 309 equity, 25 Saskatchewan, 171–176 fundamental issue, 19 Case Study: Partners in Practice Port Colbourne, indigenous peoples, 25–26 Ontario, 315 influences since 1994, 21–27 Caughey, Amy, 199–201 introduction, 19–20 CDC Evaluation Working Group, 359–360 mental health promotion, 22 Centre de recherche Léa-Roback sure les inégalités migration, 25–26 sociales de santé de Montréal, 187 minorities, 25–26 Centre for Community Health Promotion multiculturalism, 25–26 Research, 166 multiplicity of, 20 Centre for Health Promotion, 101, 183–184, 225, in 1994, 20–21 226, 227, 360 population health, 22 Centre for Health Promotion Studies, 171 “positive” concept, 26–27 Centre for Social Justice (CSJ), 89, 122 poverty, 25 Centre for the Health Professions, 346 qualitative approaches, 26 Centre national d’études de la sécurité sociale, 225 quality of life, 23, 24f Centres of Excellence for Women’s Health, 77, 89 resilience, 22–23, 23f Cerqueira, Maria Teresa, 237–243 used by Canadian health promoters, 21 children Consortium for Health Promotion Research. See Annapolis Valley Health Promoting Schools Canadian Consortium for Health Promotion Project (AVHPSP), 321 Research healthy children, 190 Consortium national de formation en santé, 204 healthy schools, 193–194 constraints on individual capacity, 55 in poverty, 113f Corbin, J. Hope, 237–243 Chile, 226–227, 227, 265–266 Council of Chief State School Officers (CCSSO), 61 Chin-Yee, Fiona, 187–189, 195 CPHA Literacy and Health Program, 73 China, 226 Cric.ca, 152 CHN classification scheme, 39–40 Croatia, 226 choices, 54 Crowell, Sandra, 187–189 classification system, 34–35, 39–40 cultural/behavioural explanation, 107 Health Promotion 5/1/07 11:18 AM Page 395

Index ■ 395

D Annapolis Valley Health Promoting Schools Dalil, Suraya, 259–260 Project (AVHPSP), 321 dangerous consumptions, 25 challenges, 323–324 debates about “real” health promotion, 38–39, 45 conclusions, 324–325 debt relief, 212 ecological approach, 317–318 debt service obligations, 212–213 example programs, 318–323 deconstruction of health multi-level “possibility framework” for promotion, 38 initiatives, 320t definitions of health, 19, 20 Promoting Action toward Health (PATH) definitions of health promotion Project, 318–319 approaches, 35–39 Quebec Ministry of Health and Social broad health promotion approach, 39–40 Services, 321–323 in Canada, 34 rise of the ecological perspective, 317–318 CHN classification scheme, 39–40 tobacco control initiative, 321–323 conceptual avenue to definitional dilemma, 40–41 ecological model, 49–50 disciplinary reasons for definition, 32–33 education, health promotion, 128–132 expert consensus, 38–39 effectiveness movement, 378 health promotion assessment checklist, 39–40, 45 emerging issues. See issues health promotion vs. other related concepts, 35–37 environmental factors importance of, 32–35 importance of, 7–8 Ottawa Charter definition, 40, epidemiology, 50, 50f, 53 242, 330 Epp Report, 2, 8, 93 political reasons, 33–34 equity, 25 practical reasons, 34–35 Eriksson, Monica, 280–282 professional reasons for definition, 32–33 Europe solving the definitional dilemma, 39–41 Canadian-European connection, 5–8 working definition, 39–40 EC funding, 242 demographics, 147–149, 177 health literacy concept, 63 Denmark, 280–282 European Union Master’s in Health Promotion determinants of health, 97–98, 157, 172–173 Consortium (EUMAHP), 242 determinants of health inequalities, 107–110, 112–113 evaluation developing countries. See globalization; international Canadian Heart Health Initiative, 354, 356 health promotion conclusions, 354–355 diagrams as reflection, 310 definitions of, 347–348 Dinca, Irina, 287–288 experimentalist tradition, 352–353 disadvantaged groups, 53 in health promotion, 348–350 disciplinary reasons for defining health health promotion interventions, 348 promotion, 32–33 health promotion programs, reasons for diversity in health promotion evaluation, 350–354 gender and health, 77–78 increasing effectiveness of interventions, 351–353 intersectional theory, 79–80, 81–82 program, as core type of intervention, 349–350 introduction, 75–76 quasi-experimental designs, 352 women’s health. See women’s health realistic evaluation, 378 Djakarta conference, 11 support of innovative practices, 353–354 Donchin, Milka, 270–271 tools, 229 donor country influence, 250, 283 two roles of, 347–355 double jeopardy, 80 Evaluation Center, Western Michigan University, 360 Dowbor, Tatiana Pluciennik, 263–264 evaluation theory, 228–230 downstream approach, 51 evidence base of health promotion, 377–379 Dupéré, Sophie, 1–12, 75–84, 247–257, 371–383 evolution of health promotion Canadian-European connection, 5–8 E decline, transformation or renewal, 10–12 e-mail bulletins, 128 general trends, 11 ecological, 27 golden era of health promotion, 8 ecological health promotion interventions health education era, 2–3 Health Promotion 5/1/07 11:18 AM Page 396

396 ■ Index

from health education to health promotion, 3–10 Frontier College, 64 international scene, 3–5 La Fundación Mexicana para la Salus landmark dates, 1–2 (FUNSALUD), 278 experimentalist tradition, 352–353 funding agencies, 126–127 expert consensus, 38–39 future of health promotion, 101

F G fair trade, 214 Gauvin, Lise, 317–325 Family Health Program, 264 gender federal government Bangkok Charter, 78 Business Line working groups, 96 concept of gender, 77 determinants of health, 97–98 empowerment, global, 211 federal-provincial relationships, 146–147 and health, 77–78 federal/provincial/territorial landscape, 153–154 in HIV/AIDS programs, 83 first two decades, 92–94 Ottawa Charter, 78 future of health promotion, 101 vs. sex, 79 health promotion, impact on, 96–97 gender inequality, 77–78 introduction, 92 Gerontology Research Centre, 166 laying the groundwork, 92–93 Gierman, Natalie, 222–231 moving on in the 1990s, 94–98 Global Forum for Health Research, 388 policy, impact on, 97–98 Global Fund to Fight AIDS, Tuberculosis, and population health approach, 95 Malaria, 213 Program Review, 95–96 global governance, 214–215 programs, impact on, 97 Global Health Watch, 221, 388 public health, 98–101 global infrastructure redirecting health promotion, 93–94 Canada’s contributions, 250 Strategies for Population Health: Investing in the conclusions, 242–243 Health of Canadians, 95 international governmental infrastructure, Federal Plan for Gender Equality, 77 237–239 federal/provincial/territorial landscape, 153–154 international non-governmental Federal Tobacco Control Strategy (FTCS), 97 infrastructure, 239–240 Fédération des communautés francophones et international research collaboration, 240–241 acadienne du Canada, 204 introduction, 237 Fiji School of Medicine (FSM), 284 global professional capacity, 250 financing, fair, 212–213 globalization Finland, 280–282 see also international health promotion First Canadian Conference on Literacy and binding trade rules, 210 Health, 63, 64 climate change, 210 First International Conference on Health conclusions, 215–218 Promotion, 7, 93 debt service obligations, 212–213 First Nations, 26 drivers of contemporary globalization, 209–210 see also Aboriginal peoples as emerging issue, 376–377 Fonds québécois de la recherche en santé du fair financing, 212–213 Québec, 127 fair governance, 214–215 food insecurity, 112 fair trade, 214 food security, 191–192 global recession, 208 Forum on Social Development, 225 and health, 210–211 Framework Convention on Tobacco Control, 215 healthy global public policy, 211–215 France, 225, 267 HIV pandemic, 209 francophone minority communities, 202–204 international private financial flows, 209–210 francophonie canadienne, 204 from international to global, 207–208 Frankish, Jim, 61–70, 162–167 reorganization of production across borders, 210 Frohlich, Katherine L., 46–56 Globalization and Health, 221 “From Research to ‘Best Practices’ in Other Settings Go Healthy Newfoundland Labrador, 198 and Populations” (Green), 298 Godin, Gaston, 367–369 Health Promotion 5/1/07 11:18 AM Page 397

Index ■ 397

Goldberg, Carmelle, 347–355 in Canada, 107–110 golden era of health promotion, 8 conclusions, 115–116 Govereau, Wayne, 199–201 cultural/behavioural explanation, 107 governance, fair, 214–215 determinants of, 107–110, 112–113 government. See federal government; provincial identification of source of, 112–113 governments income, as determinant, 107–110 Government of Commonwealth of Puerto Rico, 286 international perspective, 107, 114–115, 255 Green, J., 36 introduction, 106–107 Green, Lawrence W., 296–297 materialist/structuralist explanation, 107 Gregson, Carol, 199–201 social determinants, 112–113 growth-health-growth virtuous circle, 211 health literacy Guillaumie, Laurence, 267 in Canada, 63–65 Canadian contribution, 65–68 H conceptual contributions, 65–66 habitus, 54 criticism of, 62 Harvard School of Public Health, Health Literacy definitions of, 67, 69 Studies, 73 described, 61 Haut Comité de la Santé Publique (HCSP), 268 and health promotion, 68–70 health history of, 61–65 see also concepts of health Institute of Medicine health literacy definitions of health, 20 framework, 63, 63f determinants of health, 97–98, 157, 172–173 international perspective, 61–63 and gender, 77–78 introduction, 61 and globalization, 210–211 introduction of, 64 positive conceptualization of health, 76 issues, 68–70 right to health, 216 literacy and health research conceptual social model of health, 76 framework, 66f WHO definition, 19 moving beyond the conceptual, 69–70 women’s health. See women’s health plain language materials, 64 Health Action International, 215 practice and policy contributions, 67–68 Health and Social Services Department of Nunavut, proponents of, 62–63 202 research contributions, 65–67 Health Canada, 96, 97, 98, 125, 133, 135, 159 study of, in Nova Scotia, 65, 68 Health Canada Population Health Approach, 122 Health Literacy in Rural Nova Scotia Project, 74 health care resilience, 144–145 The Health of Canadians — The Federal Role, 99 Health Communication Unit, University of Toronto, health professions 360 in Canadian health promotion health education movement, 373–374 era of, 2–3 capacity building, 226 evolution to health promotion, 3–10, 35 conclusions, 340–341 in France, 35 and definitions of health promotion, 32–33 vs. health promotion, 35 global professional capacity, 250 resurrection and reinvention, 36 health professional practice, health “revitalized” definition, 36 promotion in, 334–338 in US, 35 introduction, 330–331 Health Education Assessment Project (HEAP), 61 lack of professional status, 32–33 health field concept medical education, health promotion in, 332–333 elements of, 4 nursing clinical practice, health promotion influence of, 20 within, 336–338 “Health for All by the Year 2000” (HFA) resolution, nursing curriculum, health promotion within, 4–5, 5t, 6 333–334 Health in Action, 328 nursing education, 338 health inequalities physician clinical practice, health promotion addressing, 379–380 within, 335–336, 337–338 agenda for addressing, 111–115 physician education, 337–338 Health Promotion 5/1/07 11:18 AM Page 398

398 ■ Index

primary care workers, 226 vs. population health, 36 primary health care as key strategy, 338–340 postmodernism, 382 primary health care/health promotion and primary health care, 338–340 alliance, 338–339 professional status, lack of, 32–33 reflexive practice, 302 professionals in Canadian health promotion trends in health promotion engagement, 331–338 movement, 373–374 health promotion vs. promotion of health, 40–41, 42f Aboriginal approaches, 173 in the provinces and territories. See provincial academics, 373–374 governments alignment with settings, 49 vs. public health, 36–37 broad health promotion approach, 39–40 realistic evaluation, 378 broad policy focus, 237 redirection of, 93–94 bureaucrats, 373–374 reflexivity as to social location of, 56 Canada’s international leadership, 375 resilience of, 371–373 CHN classification scheme, 39–40 rhizome analogy, 363–366, 381–383 competencies, 40 scientific nature, 33 concepts of health. See concepts of health social views, 21 continuing development of, worldwide, 363–366 structural vs. individual change, 373 debates about “real” health promotion, 38–39, 45 summer schools, 129t deconstruction of, 38 as “third public health revolution,” 37 definitions of. See definitions of health promotion training programs, 129t education and training, 128–132 tree analogy, 363–366, 380–383 effectiveness movement, 378 trends in engagement, by physicians and electronic resources, 159 nurses, 331–338 evaluation in, 348–350 voluntary sector, 374 evidence base, 377–379 and women’s health, 78–80, 81–82 evolution of. See evolution of health promotion worldwide presence, lack of, 375–376 expert consensus, 38–39 “yellow document,” 7, 93 federal role. See federal government Health Promotion: A Discussion Document on the future of, 101 Concept and Principles (WHO), 93 globalization, 376–377 Health Promotion and Education Online, 59–60 golden era of health promotion, 8 health promotion assessment checklist, 39–40, 45 vs. health education, 35 Health Promotion Center, 264 health inequalities, addressing, 379–380 Health Promotion Clearinghouse (Nova Scotia), 328 and health literacy, 68–70 Health Promotion Directorate (HPD), 92–93, 126 in health professional practice, 334–338 Health Promotion Forum of Aotearoa-New Zealand individual approach, status of, 367–369 (HPF), 279 individualistic behavioural views, 21 health promotion intervention influence of new or borrowed concepts, 61 “at-risk” populations, 48 and intersectional theory, 81–82 collective lifestyles, as heuristic device, 54–56 lack of agreement about, 34 ecological health promotion interventions. as leading public health strategy, 237 See ecological health promotion interventions main emerging issues, 376–381 evaluation, 348, 351–353 marginal nature of, 371–373 increasing effectiveness of, 351–353 within medical curriculum, 332–333 individual-level theories, 47 mental health promotion, 22 introduction, 46 modernism, 382 issues, 46–48 need for theory, 378–379 physical inactivity, points of intervention for, 52f within nursing clinical practice, 336–338 program, as core type of intervention, 349–350 within nursing curriculum, 333–334 risk factors, focus on, 47 and organization and classification of settings, 48–50 information, 34–35 social context, 47–48, 50–53 points of intervention. See health promotion structure-agency debate, 54 intervention target of individuals vs. collectivities, 348 policy views, 21 what can be done differently, 54–56 Health Promotion 5/1/07 11:18 AM Page 399

Index ■ 399

health promotion practice Institut National de Prévention et d’Education pour evaluation, two roles of, 347–355 la Santé (INPES), 268 program, as core type of intervention, 349–350 Institute for Gender and Health, 127, 134 reflexive practice. See reflexive practice Institute for Population and Public Health, 127 health promotion programs. See public health and Institute for Social Research and Evaluation, 167 health promotion programs Institute of Aboriginal People’s Health, 127, 134 Health Promotion WHO Afro, 289 Institute of Health Promotion Research, 134, 166 health-related choices, 54 Institute of Medicine health literacy framework, 63, health research 63f, 66 health literacy, 65–67 Institute of Nutrition and Food Technology (INTA), health research infrastructure, 158 University of Chile, 266 international health promotion, 228–230 Institute of Population and Public Health, 99 international research collaboration, 240–241 Instituto Nacional de Salud literacy and health research conceptual Pública, 278 framework, 66f Inter-American Consortium of Universities and health research infrastructure, 158 Training Centres, 286 health sector reform, 155–157 Inter-American Network of Training, 225 Health Sponsorship Council, 280 interactions, 251–252 healthiness, 19, 26 International Conference on Health Promotion and healthy cities concept, 21 Health Education, 101 Healthy Communities initiative, 8 International Covenant on Economic, Social and healthy living, 157 Cultural Rights (ICESCR), 216 Healthy Municipalities Study, Research, and international governmental infrastructure, 237–239 Documentation Center, 264 international health promotion healthy schools, 193–194 see also globalization Hiatt, Robert A., 296–297 Afghanistan, 259–260 high-risk populations. See “at-risk” populations Australia, 261–262 Hills, Marcia, 123–135, 162–167, 330–341 Brazil, 263–264 HIV pandemic, 209 children in poverty, 113f HIV programs, 83 Chile, 265–266 holistic, 27 continuing development of, 363–366 holistic approach, 82 Denmark, 280–282 Hyndman, Brian, 181–183 discrepancies in conception, value and approaches, 255 I evolution of health promotion, 3–5 Iceland, 280–282 Finland, 280–282 inclusive, 27 France, 267 income general observations, 254–255 as determinant of health inequalities, health inequalities, 107, 114–115, 255 107–110 health literacy concept, 61–63 and ill health, 108–110 Iceland, 280–282 increasing income inequality, 112–113 improvement of health of population, 255–256 predictor of health indicators, 108 international health promotion. See international indigenous peoples, 25–26, 226–227 health promotion (Canadian influence) see also Aboriginal peoples Iran, 269 individual approach, 367–369 Israel, 270–271 individual change, 373 Japan, 272 individual-level theories, 47 Kuwait, 273–274 individualistic behavioural views of health Latin America, 275–276 promotion, 21 Mexico, 276–277 Infant Feeding Action Coalition, 215 New Zealand, 278–279 infrastructure. See knowledge development Nordic Union, 280–282 innovative practices, 353–354 Norway, 280–282 Institut national de la santé publique du Québec, Pacific Island Nations, 283 187, 225, 329 Puerto-Rico, 284–285 Health Promotion 5/1/07 11:18 AM Page 400

400 ■ Index

Romania, 287–288 partnerships, types of, 251–253 Senegal, 288–289 policy recommendations, 229–230 strengths and weaknesses of analysis, 256–257 practical experience, contribution of, 250 Sweden, 280–282 Puerto-Rico, 284–285 Switzerland, 290–291 Romania, 287–288 Tunisia, 292 Senegal, 288–289 Ukraine, 292–293 strengths and weaknesses of analysis, 256–257 United Kingdom. See United Kingdom Switzerland, 290–291 United States, 296–297 theoretical and conceptual knowledge, WHO global strategy, 6 contribution of, 248–250 international health promotion (Canadian influence) training contributions, 250 academic contributions, 250 training for educators, 224–225 access to exchanges, 251 Tunisia, 292 Afghanistan, 259–260 Ukraine, 292–293 Australia, 261–262 United Kingdom, 293–294 Brazil, 263–264 United States, 296–297 Canada’s international leadership, 375 WHO Collaborating Centres, 231 Canada’s leadership role, 224 International Journal of Education & the Arts, 316 Canadian discourse and practice, 250–251 International Monetary Fund, 11, 208, 212, 214 Canadian websites, 252t international non-governmental infrastructure, capacity building, 225–228 239–240 capacity building international private financial flows, 209–210 contributions, 250 international research collaboration, 240–241 Chile, 265–266 International Union for Health Promotion and collaborations, types of, 251–253 Health Education (IUHPE), 2, 15, 59–60, 125, 131, communication of information, 228 239–240, 246, 286, 290 conclusions, 230–231, 257 International Union of Health Education (IUHE), 1 country commentaries by region, 249t intersectional theory, 79–80, 81–82 described, 248–254 intersectoral strategies, 98 diverse types of influences, 248–251 intervention. See health promotion intervention donor country, influence as, 250 Iran, 269 evaluation theory, research and practice, 228–230 Israel, 270–271 evaluation tools, 229 issues France, 267 effectiveness movement, 378 global infrastructure, 250 evidence base of health promotion, 377–379 global professional capacity, 250 globalization, 376–377 impact, diversity of, 253–254 need for theory, 378–379 integrated capacity-building initiatives, 227–228 as point of health promotion intervention, 46–48 intensity levels, diversity of, 253–254 realistic evaluation, 378 interactions, types of, 251–253 and social context, 51 international projects in training and capacity social health inequalities, addressing, 379–380 building, 223–228 ItsLife, 316 introduction, 222–223 Iran, 269 J Israel, 270–271 Jackson, Suzanne, 123–135, 222–231 Japan, 272 Japan, 272 Kuwait, 273–274 Jassem, Amal Hussain, 273–274 Latin America, 275–276 Jimba, Masamine, 272 leadership role in guiding health public policy, 250 Johns Hopkins University Press: Journals, 298 major Canadian players, 223t journal reflections, 307–310 Mexico, 276–277 Journal Writing, 316 mutual influences, 251–252 New Zealand, 278–279 K Nordic Union, 280–282 Kanawakhe School Diabetes Prevention Project, 354 Pacific Island Nations, 283 Kaszap, Margot, 61–70 Health Promotion 5/1/07 11:18 AM Page 401

Index ■ 401

Kickbusch, Illona, 5, 8, 11, 62–63, 363–366 M Kirby Report, 99 Macdonald, Gordon, 293–294 knowledge development MacKay, Marlien, 187–189, 189–190 Canadian Consortium for Health Promotion mad cow disease (BSE), 98 Research, 124–125, 126t Manchester Metropolitan University, 316 Canadian Consortium for Health Promotion Mandala of Health, 21 Research contributions, 128–131, 132–133 Manitoba capacity development, 128–132 changes, challenges and future directions, 179 conclusions, 135 demographics, 177 critical analysis, 133–135 health promotion beyond the health system, 178 funding agencies, 126–127 health system reform, 177 health promotion education and Manuel, Rick, 187–189, 190–191 training, 128–132 Marzouki, Moncef, 292 infrastructure since 1994, 124–128 Mason, Robin, 301–311 introduction, 123–124 materialist/structuralist new knowledge development, 132–133 explanation, 107 sharing knowledge, 127–128 medical curriculum, 332 Komarova, Nadiya, 292–293 Medical Research Council of Canada, 126 Korgak, Ainiak, 199–201 medicare system, 144–145, 154 Kuwait, 273–274 Melville, Lilach, 270–271 mental health promotion L Bangkok Charter, 27 Labonté, Ronald, 207–218 emergence of, 22 Lalonde Report Mexico, 227, 276–277 action following release of report, 92 Mexico conference, 11 cluster of concepts, influence of, 61 Michael Smith Foundation for Health Research, concept of health, 21 127, 163 described, 21 midstream approach, 51 health field concept, 20 migration, 25–26 HFA resolution and, 3–4 Millennium Development Goals (MDGs), impact on international health promotion. 212, 236 See international health promotion Ministère de la santé et des services sociaux du (Canadian influence) Québec, 187 implementation, 6 Ministry of Health, Vida Sana Section, 266 release of, 1 Ministry of Health (New Zealand), 280 Lamarre, Marie-Claude, 237–243 Ministry of Health Promotion, 184 Latin America, 224–225, 275–276 minorities, 25–26 Latin American Regional Office (ORLA) of the minority language legislation, 154 IUHPE, 286 Mittelmark, Maurice B., 237–243 Learning from SARS: Renewal of Public Health in modernism, 382 Canada, 99 Montreal Region Public Health Unit, 122 left-wing party, 147 Mozambique, 224 Levin-Zamir, Diane, 270–271 multi-level approach to epidemiology, 50, 50f lgreen.net, 298 multiculturalism, 25–26 life chances, 54 multinational enterprises (MNEs), 210 life choices, 54 Multiple Risk Factor Intervention Trial (MRFIT), 51 lifestyle, 54 Murashova, Maryna, 292–293 lifestyles counselling, 330 Murnaghan, Donna, 187–189, 193–194 Lindstrom, Bengt, 280–282 mutual influences, 251–252 linguistically marginalized groups, 160 literacy and health research conceptual N framework, 66f National Aboriginal Health Institute, 98 Livne, Irit, 270–271 National Adult Literacy Database, 74 Loubert, Kelly, 199–201 National Child Benefit, 98 Lyons, Renee, 187–189 National Children’s Agenda, 98 Health Promotion 5/1/07 11:18 AM Page 402

402 ■ Index

National Collaborating Centres for Determinants O of Health, 127 official development assistance, 212 National Collaborating Centres for Public Health, 100 official languages, 154, 155 National Federation of Family Benefit Insurance O’Neill, Michel, 1–12, 32–42, 371–383 Boards, 225 Ontario National Forum on Health, 98 capacity building, 182–183 National Health Promotion Plan (MINSAL), 227 gross domestic product per capita, 148 National Health Research Development Fund, 94 networking, 182–183 National Health Research Development Program political traditions, 147 (NHRDP), 123, 125, 126, 127 politics and policy, 182 National Institute for Clinical Excellence (UK), 296 public health crises, 183 National Institute for Research and Development, 288 public health expenditures cuts, 145 National Literacy and Health Program (NLHP), 64, 65 social assistance, reduction of, 143–144 National Literacy and Health Research Program, 74 Ontario Health Promotion e-mail bulletin, 128, National Literacy Secretariat, 64 138, 184 National School of Public Health (ENSP), 227 Ontario Health Promotion Resource System, 328 National Summer Institute on Literacy and Health Ontario Health Promotion Summer School, 226, 227 Research, 132 Ontario Prevention Clearinghouse, 184, 329 Naylor Report, 99 Ontario Public Health Association, 64 need for theory, 378–379 Ottawa Charter for Health Promotion Neighbourhoods Alive!, 181 broad goals, 46 neo-liberalism, 145–146 Canada’s influence on, 248–250 New Brunswick, 189–190 concept of health, 21 new health technologies and innovation, 210–211 gender, 78 new knowledge development, 132–133 health promotion definition, 40, 242, 330 A New Perspective on the Health of Canadians. health promotion following release of, 1 See Lalonde Report and health promotion practice in Canada, 301 New Zealand, 278–279 implementation of strategic areas of, 237 Newfoundland and Labrador, 194 international consensus, 8 NHS Centre for Reviews and Dissemination, 295 international health promotion, influences on. Nisga’a Health Authority, 157 See international health promotion Nomura, Yuka, 272 (Canadian influence) Nordic Medico-Statistical Committee, 282 international Health Promotion Conferences, Nordic Union, 280–282 goal of, 8 Norway, 280–282 nature of programs implied by, 350 Nova Scotia opportunity to revisit, 240 case study, 190–191 personal skills development, 46–47 study of health literacy, 65, 68 release of, 2 Nova Scotia Health Promotion, 199 rhizome analogy, 363–366 Nunavut values-based orientation, 330 background, 199–200 vision outlined in, 340 capacity building, 201 and working definition of health Government of Nunavut website, 202 promotion, 39–40 health promotion infrastructure, 200 health protection and primary care, 201 P program and activities examples, 200–201 Pacific Island Nations, 283 nursing Pan-American Health Organization, 37, 99, 229 education, 338 Pan-Canadian Healthy Living Strategy, 97 health promotion within nursing curriculum, participatory approach, 81–82 333–334 Partners in Public Health, 100 nursing clinical practice, health promotion partnerships, 251–252 within, 336–338 PATH Project, 318–319 practice, 338 Pederson, Ann, 1–12, 75–84, 153–160, 371–383 regulation, as profession, 32 People’s Health Movement (PHM), 215, 221, 388 scientific discipline vs. practice, 33 personal skills development, 46–47, 330 Health Promotion 5/1/07 11:18 AM Page 403

Index ■ 403

Perspectives on Health Promotion (CPHA), 96 practical reasons for defining health physicians promotion, 34–35 education, 337–338 Prairie Region Health Promotion Research health promotion within medical curriculum, Centre, 175–176 332–333 primary health care, 288–289, 338–340 health promotion within physician clinical Primary Health Care, 346 practice, 335–336 Prince Edward Island, 192–193 practice, 338 Prince Edward Island Healthy Living Strategy, 199 Pinder, Lavader, 92–102, 239 professional reasons for defining health plain language materials, 64 promotion, 32–33 planned change of lifestyles, 41 professions. See health professions points of intervention. See health promotion programs. See public health and health intervention promotion programs Poland, Blake, 46–56 Promosanté, 128, 138 policy Promoting Action toward Health (PATH) Canada’s leadership role, international, 250 Project, 318–319 demographics, wealth and prosperity, 147–149 promotion of health, vs. health promotion, 40–41, 42f divergence, understanding, 146–149 Promotion Santé Suisse, 291 federal government impact, 97–98 prosperity, 147–149 federal-provincial relationships, 146–147 provincial governments healthy global public policy, 211–215 see also case studies; specific governments left-wing party, 147 differential behaviour, 149 recommendations, 229–230 federal-provincial relationships, 146–147 social investment paradigm, 145 federal/provincial/territorial landscape, 153–154 views of health promotion, 21 health promotion in the provinces and Policy.ca, 152 territories, 153–160 political reasons for defining health promotion, 33–34 health promotion program experiences, 141–150 PolitiquesSociales.net, 152 orientation of provincial public health, 142t Pontifical Catholic University of Chile, Initiative Provincial Health Services Authority (PHSA), 157 Healthy University, 266 provincial health system reform Poole, Laraine, 187–189, 192–193 Alberta, 167–168 population health British Columbia, 162–163 federal government approach, 95 Manitoba, 177 framework, 38 public health vs. health promotion, 36 funding, 19 influence on health promotion, 22 vs. health promotion, 36–37 vision of, 36 respect for, 98–99 Population Health Initiative, 98 sedimentation approach, 37, 37f Population Health Promotion: An Integrated social capital, 78 Model of Population Health and Health Public Health Agency of Canada (PHAC), 99–101, Promotion, 96 125, 127, 128, 133, 134, 135, 157, 159, 245, 329 positive-negative distinction, 26–27 Public Health Agency of Canada (PHAC), Atlantic postmodernism, 382 Regional Office, 199 Potvin, Louise, 347–355 public health and health promotion programs Poureslami, Iraj M., 269 conclusions, 149–150 poverty as core type of intervention, 349–350 see also income demographics, wealth and prosperity, 147–149 children in poverty, 113f differential behaviour of provinces, 149 determinant of health inequalities, 112 evaluation, reasons for, 350–354 and health promotion, 25 federal-provincial relationships, 146–147 power fiscal austerity and program vulnerability, 141–143 and collaborations, 305 health care resilience, 144–145 focus on, in health promotion, 304–305 left-wing party, 147 relations, 55–56 nature of programs implied by Ottawa in sexual decision making, 83 Charter, 350 Health Promotion 5/1/07 11:18 AM Page 404

404 ■ Index

neo-liberalism and social investment, 145–146 reflexivity, 56, 303–304 policy divergence, understanding, 146–149 reform, 155–157 program, described, 349–350 Regina Qu’Appelle Health Region, 176 program resilience, understanding, 143–146 Regional Resources Centre in Health Promotion provincial experiences, 141–150 “Promesa,” University of Concepción, 266 social assistance programs, similarity to, 143 Reid, Colleen, 75–84 state legitimacy, 143–144 research. See health research Public Health Association of British Columbia, 167 research infrastructure, 158 Public Health Network, 100 Réseau Francophone des Villes-Santé de l’O.M.S., 291 public health nurse, 272 Réseau Francophone International Pour la Public Health Training in the Context of an Promotion de la Santé, 290 Enlarging Europe Project (PHETICE), 242 Réseau francophone international pour la promotion public policy. See policy de la santé (REFIPS), 187 Puerto-Rico, 284–285 resilience concept of health, 22–23, 23f Q health care resilience, 144–145 qualitative approaches, 26 health promotion programs, 143–146 quality of life, 23, 24f, 27 neo-liberalism and social investment, 145–146 Quality of Life Research Unit, 31 state legitimacy, 143–144 quasi-experimental designs, 352 Restrepo, Helena E., 275–276 Quebec Reviews of Health Promotion and Education federal-provincial relationship, 146–147 Online, 15 gross domestic product per capita, 148 rhizome analogy, 363–366, 381–383 public health institute, 159 Richard, Lucie, 184–186, 317–325 public health subsystem, changes in, 184–185 Ridde, Valéry, 222–231, 259–260, 371–383 social policy innovations, 159 right to health, 216 status of health promotion, 185 risk factors, 47 Quebec Ministry of Health and Social Services, 321–323 Ritchie, Jan, 283–284 Romania, 287–288 R Romanian Ministry of Health, 288 Racher, Fran, 176–181 Romanow Report, 99 Raeburn, John, 19–28 Rootman, Irving, 1–12, 19–28, 61–70, 123–135, Raphael, Dennis, 106–116 371–383 rational choice theory, 142 Royal Society of Canada, 134 RE-AIM, 329 Rural Development Institute, Brandon realistic evaluation, 378 University, 181 reflection, 303 Rural Nova Scotia Project, 74 reflective health promotion practitioner, 306–310 reflexive practice S becoming a reflective health promotion Salinas, Judith, 265–266 practitioner, 306–310 SARS epidemic, 98, 159, 183 conclusion, 310–311 Saskatchewan contextual elements, 301–302 Aboriginal approaches to health promotion, 173 diagrams as reflection, 310 change of focus to determinants of health, 172–173 encouragement of, 82 northern communities, 174 health promotion practice, 301 Saskatchewan Health journal reflections, 307–310 Publications, 176 origins of, 303 Saskatchewan Population Health and Evaluation power and collaboration, focus on, 304–305 Research Unit, 176 and professionals, 302 schools, 193–194 “reflection,” origins of, 303 Seaton Commission, 162 “reflexive,” origins of, 303–304 Seck, Awa, 288–289 reflexivity, 303–304 Second Canadian Conference on Literacy and “what if?” questions in collaborative reflection, 306 Health, 68 written reflection, 306–308 Secretan a de Salud, 278 Health Promotion 5/1/07 11:18 AM Page 405

Index ■ 405

Secretariat of the Pacific Community (SPC), 284 T sedimentation approach to public health, 37, 37f The 10-Year Plan to Strengthen Health Care, 100 Senegal, 288–289 territorial governments. See provincial governments settings tobacco control, 321–323 alignment of health promotion work, 48–49 Tones, K., 36 critique of approach, 59 training, 128–132, 224–225, 250 as point of intervention, 48–50 Training for Health Renewal Program, 224 and social context, 52–53 tree analogy, 363–366, 380–383 social environment approach, 49–50 Tunisia, 292 support for behavioural change, 49 WHO Settings for Health approach, 60 U sex, vs. gender, 79 UK Department of Health, 122 sharing knowledge, 127–128 Ukraine, 225, 292–293 Signal, Louise, 278–279 UN Millennium Development Goals (MDGs), Simos, Jean, 290–291 212, 236 smoking, 53 unemployment rate, 148, 148t social capital, 78 United Kingdom social context commentary on Canadian academic acknowledgment of, 47–48 publications, 293–294 collective lifestyles, 54–56 Department of Health (website), 296 high-risk populations, 51–52 health inequalities, 114–115 issues and, 51 National Institute for Clinical Excellence, 296 and settings, 52–53 population health approach, 149 social environment approach to, 49–50 United Nations Development Programme: structure-agency debate, 54 Romania, 288 social determinants of health, 97–98 United Nations Economic and Social Commission social determinants of health inequalities, 112–113 for Asia and the Pacific (UNESCAP), 284 Social Determinants of Health listserv, 138 United Nations Population Fund: Romania, 288 Social Determinants of Health Task Force, 101 United States social environment approach, 49–50, 52–53 Canada’s influence on health promotion, 296–297 social health inequalities. See health inequalities health literacy concept, 61–62 social investment, 145–146 University of New South Wales School of Public social model of health, 76 Health, 59 social norms, 48 upstream approach, 51 social practices, 55 US Centers for Disease Control, 134 social science quasi-experimental designs, 352 Social Sciences and Humanities Research Council (SSHRC), 64–65, 94, 123, 125 V social structure, 55 Valentini, Helene, 222–231 social views of health promotion, 21 victim blaming, 48 Société Santé en Francais, 203–204, 204 Vollman, Ardene, 330–341 Société Santé Mieux-être en français du Nouveau- voluntary sector, 374 Brunswick, 204 Solberg, Shirley, 187–189, 194–195 W state legitimacy, 143–144 Wahidi, Shukrrullah, 259–260 Stirling, Alison, 32–42 Walkerton, Ontario, 183 Strategies for Population Health: Investing in the Health wealth, 147–149 of Canadians, 95 wealth inequality, 112–113 Strengthening Community Health project, 8 Weber, Max, 54 structural change, 373 welfare state functions, 143 structure-agency debate, 54 West Nile Virus, 98 suboptimal health outcomes, 48 Western Michigan University Evaluation Center, 360 summer schools, 129t Westphal, Márcia Faria, 263–264 Swanson, Eleanor, 187–189, 194 “what if” questions, 306 Sweden, 280–282 Williams, Lewis, 171–176 Switzerland, 290–291 Williams, Patricia L., 187–189, 191–192 Health Promotion 5/1/07 11:18 AM Page 406

406 ■ Index

Willms, Doug, 187–189, 190 Wilson, Doug, 167–171 Wilson-Forsberg, Stacey, 187–189, 190 Wise, Marilyn, 261–262 women’s health in Canada, 76–77 gender inequality, and morbidity, 78 and health promotion, 78–80 implications for health promotion practice, 81–82 intersectional theory, 79–80, 81–82 workplace health, 194–195 World Bank, 11, 208, 212, 214 World Economic Forum, 215 World Health Assembly, 1, 4, 215 World Health Organization (WHO) Canadian influences, 237–238 Collaborating Centres, 231 Commission on Social Determinants of Health (CSDM), 388 Commission on the Social Determinants of Health, 101 European Regional Office, 318 European Working Group on Health Promotion and Evaluation, 240–241 global network, 237 global strategy for health for all, 6 health, definition of, 19 health promotion (website), 245 International conferences, 2, 11 main contributions at global level, 237–238 settings approach, 60 website, 15 “yellow document,” 7, 93 World Social Forum, 215 World Trade Organization, 11, 210, 214 written reflection, 306–308

Y “yellow document,” 7, 93 Yunan Mother and Child Project, 226

Z Zero Hunger Program, 264