This article is the second of a 5-part series on health. The other articles in the series can be accessed here:
'Health promotion is the process of enabling people to increase control over, and to improve, their health.' That is the definition given by the World Health Organisation on their health promotion page. Let's unpack that definition and breakdown how it can be implemented effectively.
In the history of health promotion, the Ottawa Charter is described as a landmark document, laying a foundation for health promotion. Countries from around the world united in Ottawa Canada. The charter was signed in 1986, being the first of five international conferences on health promotion. The aim of the charter was to outline clear areas to achieve health for all.
The charter is divided into 3 sections:
Prerequisites for health
The 5 action areas
The 3 basic strategies for achieving health promotion
They include, enabling people to increase control over their health, mediating health factors and advocating for health.
This section focuses on the key requirements of human life before health can be promoted. A list of these requirements include:
Social justice and equity
The action areas are ordered steps on how to approach health promotion in an effective way. They target the issues of disease in a top down manner, first dealing with broad environmental issues then slowly narrowing down into the local.
Build healthy public policy.
The image above is a depiction of the 5 action areas. Within the image, effective health public policy contains all other areas. That is because it is the most key, the foundation off which every other areas are built upon. It should include polices across many branches of government and be a combination of legislative, regulatory and organisational measures.
Create supportive environments
This area aims to reduce the factors within an environment that encourages disease and increase the factors that promote health.
Strengthen community action
Encourage and promote community health initiatives.
Develop personal skills
This area focuses on increases the health literacy of individuals, so they can make their own best health decisions.
Reorient health services
This area is directly related to health promotion programs and will be discussed further later in the article.
Now that the basics and history of health promotion is known, we can now understand how to begin implementing health promotion programs.
Before health promotion can take place, a health needs assessment must be done. The needs assessment uncovers any unmet needs between the healthcare services that are needed, and the services received. Put simply, is the population's healthcare actually resulting in their health? In most cases, the answer to that question would be no. This would be first discussed in the research using standardised indicators (called the systematic approach). Then expressed in 4 seperate metrics.
Normative need - Is an expert opinion on the topic
Perceived need - Individual opinions on the the topic
Expressed need - The level of use for relevant services
Comparative need - Compares the previous three needs to other population levels
When looking at health promotion, it is beneficial to seperate each component into seperate areas (refer to the image above). Areas 1 and 2 have already been discussed. Area 3 refers to how easily and likely the proposed interventions will be utilised. For area 4, focuses on any challenges that may be experienced with the intervention (e.g skills shortage). The final area aims to understand if the proposed intervention is actually effective. This can be found by looking at research publications for the interventions. Hopefully by the end of this needs assessment process, a need for programs and strategies that promote health are evident. It is now time to understand the different forms of services and public policy strategies that can be used to satisfy these unmet needs.
The person is the subject of the WHO definition for health promotion. The person must improve their own health. Thus in the realm of health promotion, the population must be considered both as individuals and communities. Individuals for targeted promotion of health and communities for broad health promotion. The individual/person is a sum of many social, environmental and economical determinants. All of these determinants then directly impact an individuals health.
A person is often in a state of disease directly due to these determinants. Health behaviours (e.g nutrition, physical activity, health behaviours and smoking) are what often lead to disease. These health behaviours are patterned for the social and material inequalities present within communities. Thus, health promotion cannot be successful at reducing these health inequalities without addressing the social determinants of health.
As an example, dental caries is a disease with high population prevalence, high individual impact, socially patterned, known biological causes and are highly preventable. The two main causes of dental caries are increased free sugar exposure to the oral microbiome and poor oral hygiene. Both of these causes are more prevalent in people of lower socio-economic status (SES). Low SES peoples have lower levels of health literacy (thus less likely to have good oral hygiene). These people also have lower purchasing power for high quality food, thus will likely rely on unhealthy alternatives (foods with high free sugars). Therefore, you cannot promote oral health and reduce dental caries in a population without dealing with these inequalities.
As discussed above, health promotion effort directed at the dental caries using just dental awareness campaigns will likely be unsuccessful. Why? Although the campaign may be good, they do nothing to address the second determinant of dental caries (Low SES leading to poor diet). What is being achieved is just health education not health promotion. It is not a targeted approach and actually does more to increase health inequalities as opposed to achieving health equity.
How so? Higher SES groups will also have access to the intervention allowing them to benefit (due to them having a higher health literacy). Members of the targeted group with access to the education will benefit partially, while those who do not have access will not benefit at all (refer to the next image for a visualisation). Thus any information based health promotion effort should be combined with other social uplifting actions in order to reduce health inequalities.
Going back to the given definition, successful health promotion must enable the person to increase control and improve their health. Thus the types of interventions, to do achieve this definition are better methods of promotion.
The image above is a pyramid outlining the types of health promotion programs and their corresponding population impact and individual effort. At the tip of the pyramid is counselling and education, which requires health professionals to actively inform the patient with knowledge. This is requires a high level of individual effort and there isn't any population impact because patients can only be addressed one at a time (very similar to clinical/medical treatments in that regard).
The last 3 levels of the pyramid are key health promoting systems. Long-lasting protection programs (e.g vaccination and tobacco cessation campaigns), require some level of individual effort but have a significant level of population impact. An even better program would be something like water fluoridation, which would come under the 4th level. Making the default options in public environments to be the healthy option drastically reduces diseases. However, the base of the pyramid is the most important of systems to promote health. As you might have already guessed this level is directly linked to the social determinants of health. Therefore, the base is mostly influenced by public policies actioned by political parties.
As you have likely come to understand, health promotion is a giant balancing act. How are you going to use the limited available resources to help high risk groups while also having high population impact, while also promoting health equity? Although the topic of health promotion is comprehensive, there are no definitive answers to the questions above. As it stands, professionals in public health argue for health services that create more community and national impact over targeting high risk.
The high risk approach aims to promote health by targeting health services and programs at high risk groups within communities. The resources used will create a high level of individual and personal impact. In turn this also greatly improves health equity. However, it is unlikely that this approach will result in any change in the population levels of disease. It may be difficult identify related high risk groups. Finally, this approach does not change the drivers within the environment that cause disease.
This is the predominant public health approach. It aims to shift the entire population distribution of the disease. This is achieved by removing the factors for disease. In turn the approach benefits everyone and has a large population impact. On the other hand, it does nothing to address health inequalities and presents minimal personal benefit. As The father of health promotion Geoffrey Rose puts it, the idea is that "a large group of people at low risk, can often give rise to more disease that a small group of people at low risk."
The two approaches to health promotion do not need to be separated. In contrary, when many different and targeted health promotion services (with different approaches) are utilised together, they can create comprehensive systems of disease prevention. These levels of disease prevention act as barriers for disease progression at every stage. These stages include:
This system sections the entire population into disease categories. The first level of prevention (primary prevention) focuses on the population who are without the disease. This stage then aims to prevent that section of the population from encountering that disease. This is usually in the form of population approach health promotion programs (e.g water fluoridation for caries prevention).
The secondary level of prevention is more involved and requires more individual effort. It focuses on the section of the population who show early signs of the disease and prevent the disease from getting worse (e.g small fillings preventing decay from getting worse). The final stage of tertiary prevention focuses on the population with established disease and seeks to control the disease, actively treat it and prevent it from worsening or reoccurring (e.g root canal treatment for heavily decayed teeth).
It is clear how both high-risk and population approaches of health promotion can be combined together to provide quality comprehensive health services. These services would then effectively support individuals at every disease stage within a population.
This article briefly discussed the elements of health promotion and public health. Both topics are vast and this article may serve as an entry into them. With all that you have learned, what should you do now? Well, to end off, the great scholar Al Gazali once said "action without knowledge is foolishness, knowledge without action is wastefulness." So, go and promote some health.