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Health promotion 

Health promotion
Health promotion

Evelyne de Leeuw

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date: 25 February 2021


The ‘Ottawa Charter for Health Promotion’ (1986) remains a benchmark for the global health promotion community, but the context for health promotion has changed with increasing recognition of the significance of inequities in health. Health promotion is a key strategy to deal with the social determinants of health that create these inequities. Attention has shifted from the mere recognition that all public policies may impact on health to active strategies and actions to move health concerns into all policies. Clinicians are key actors in shaping social and cultural priorities and beliefs: they should be committed to the reduction of health inequity, with health promotion as a core commitment and responsibility. ‘Why treat people, and then send them back to the conditions that made them sick?’ (Sir Michael Marmot).


Investing in better health and greater resilience of patients, families, and communities is a key responsibility of the health professional. This is a challenge that is quite different from providing services and interventions to return sick individuals to health, or engage in primary prevention efforts (see Chapter 2.11) for those at immediate risk of developing disease.

Building the health of individuals and populations has traditionally been the remit of public health services, the evolution of which has been described as having happened in waves, but rather than a new development superseding and replacing an earlier one, in public health the different ideas have built on, and complemented, each other. Fig. 2.13.1 shows the five public health developments since the early 1800s.

Fig. 2.13.1 Five stages of modern public health evolution since the 1800s.

Fig. 2.13.1 Five stages of modern public health evolution since the 1800s.

Through the structural stage (e.g. installation of sanitation hardware) and biomedical (e.g. surveillance and infection control) as well as clinical (e.g. vaccination, screening) stages, public health—by the end of the 20th century—embraced health as a social value and a social and economic resource, rather than just an individual attribute.

Some parts of the global community have not wholly advanced along all these five waves. In remote areas, even in wealthy countries, the full social and cultural dimensions of health often have not attained the same stature as they have in urban environments. Cities generally, even in middle- and low-income countries, offer opportunities for health that are better than elsewhere.

With the growth of the health industry (in many OECD countries the most important contributor to local economies) it seems we have moved even beyond this ‘social model of health’ and are embracing a ‘health society’. In this society the pursuit of health is a lofty goal and one that yields significant commercial and political interest. Health has become culture. Yet, at the same time not everyone benefits equitably from this health society. In fact, the health inequity gap is growing, and remains persistent even in the most egalitarian societies.

This chapter considers the components of modern health promotion that respond to and address the health society. Health promotion, as a concept, emerged from a more behaviourist approach to health development called health education. In many countries and cultures, the two concepts are still considered synonymous.

The Ottawa Charter for Health Promotion

The evolution of public health as described earlier, along with secular social change, created impetus for the World Health Organization, the Canadian Public Health Association, and Health Canada (the Canadian federal ministry of health) to convene an international conference in 1986. This conference on health promotion, with the subtitle ‘the move towards a new public health’ (Fig. 2.13.2) described priorities for health promotion in an ‘Ottawa Charter for Health Promotion’. This Charter has remained a benchmark for the global health promotion community. Follow-up global conferences ( fine-tuned the components of the Charter and updated them to new contexts.

Fig. 2.13.2 The cover of the Ottawa Charter for Health Promotion, including its logo describing action areas.

Fig. 2.13.2 The cover of the Ottawa Charter for Health Promotion, including its logo describing action areas.

Reprinted from The Ottawa Charter for Health Promotion, First International Conference on Health Promotion, Ottawa, 21 November 1986.

Historical developments

The development of the idea of health promotion was the result of changes in society, and our thinking about society, since the 1960s. Social movements emerged that claimed greater control over the plight and destinies of certain populations. The women’s health movement, for instance, put gender on social and clinical agendas and expected full involvement and control of women in their own health management. Since the early 1980s the scourge of HIV/AIDS created new forms of health activism. Greater attention was paid to critical analyses of the workings of society and its core institutions, including clinical medicine, for which terms like the ‘medical-industrial complex’ were coined. This was reflected in philosophy and social science, and applying such gazes to the world of health led, for instance, to the ‘discovery’ of iatrogenesis (challenges to health, or exacerbated disease conditions, created by the actions of the disease care system).

In medical sociology a breakthrough development was Aaron Antonovsky’s work on ‘salutogenesis’, the phenomenon in which health is built (rather than disease prevented) by shaping conditions for greater ‘sense of coherence’, which has three components. First, comprehensibility, the sense of understanding events in life and feeling able to predict what is likely to happen in the future. Secondly, manageability, a belief that you will be able to take care of things that might happen. Thirdly, meaningfulness, a belief that things are worthwhile and that there is good reason to care about what happens. Antonovsky found, in his research with Holocaust survivors, that individuals with a greater sense of coherence succumb less easily to disease and chronic health conditions. In the health promotion field, this is seen as ‘positive health’. It suggests that clinical intervention to ‘fix’ disease or infirmity and restore health is only the first stage on a continuum towards positive health. Investing in better social, economic, and natural capital would create individuals and communities with greater resilience.

In some realms of the prevention community, there was also dissatisfaction with the degree to which behavioural interventions yielded limited health gain. In fact, some saw that misguided behavioural interventions in fact amplified adverse health conditions through victim-blaming and social exclusion. It became increasingly recognized that different kinds of interventions (communicative, facilitative, and regulatory) should complement each other and in fact create synergy. For instance, mere knowledge provision on seatbelt use would only work to advance health if cars are equipped with such devices, and legislation mandates and sanctions their use. This logic applies throughout the health spectrum: the account of smallpox eradication shows that it was not just the clinical evidence that surveillance and control made eradication possible. This feat was only accomplished by a fortuitous alignment between clinical competence, technological advance (the bifurcated needle), strict rules, as well as social, political, and financial resourcing of the effort.

The authority and sovereignty of governments and professionals were also challenged. Globalization started to be seen as a threat to the livelihood of local communities. Views on the role of government changed to what some have called ‘laissez-faire’ governance (and others Thatcherism, Reaganomics, or New Public Management) since the late 1970s. Many scholars and activists felt that things like universal health coverage was eroded, sustainability and ecological balance suffered, and social justice was tested. It was time for a new vision on public health, and the Ottawa Charter provided it.

Ottawa Charter action areas

The Charter was developed over four days in the spirit that led to the need for the conference: ‘experts’ from all walks of life, including clinicians, scholars, and community representatives (albeit more dominantly male and from richer countries than female and from lower income states) worked to continually draft a simple, two-page message on priorities in action for the new public health.

Enable, mediate, advocate

The Charter recognizes that health is a resource for everyday life, and that its conditions are created in everyday life. ‘Settings’ such as school, work, sports clubs, the home, neighborhoods and cities, may all challenge and enhance health. There is a role for those who wish to promote health to enable individuals, groups, and communities to control the determinants of their health; to mediate between groups and organizations for health; and to advocate for health at all levels of policy and practice. This is a broader social objective, not just a role for one discipline.

Reorient health services

The conference considered that most health services are in fact disease services, and do very little to invest in positive health. Maybe worse, in the 1980s most health services were not too proficient at patient education and counselling and some had primitive ideas about how to secure best patient outcomes. The dominant model adopted the ‘Trust me, I’m a doctor’ position. The Ottawa Charter identified that health services, be they primary care posts, specialist hospitals, or tertiary care facilities, are pivotal social institutions in the communities they serve. Not just the health of their patients (or clients), but also of staff, visitors, and their ecological footprint could be considered important. Rather than disease cure institutions, they could become health-promoting health services including better, health enhancing architectural design, community hubs, and healthy workplaces.

Supportive environments

The emerging discipline of social epidemiology had provided evidence since the 1970s that the social, physical, natural, and economic environment impacts significantly on individual and community health. Like Sir Michael Marmot, many years later (2008) at the launch of the report of the WHO Commission on Social Determinants of Health said: ‘Why treat people, and then send them back to the conditions that made them sick?’, the Ottawa Charter urges individuals, groups, communities, practitioners, and politicians to see how these environments contribute to making healthier choices the easier choices. For instance, in most countries fat meat is cheaper than lean meat and changing the commercial environment to facilitate the healthier choices (e.g. through different slaughter procedures, subsidies, but also advocacy) would yield easier access to healthy food. The successful Heartbeat Wales programme inspired various aspects of the health promotion vision, including the effective partnerships between diverse partners in the food chain to accomplish exactly this. Heartbeat Wales significantly inspired the Charter from the early 1980s onward.

Personal skills and community action

There is no denying that health is mostly an individual attribute (although René Dubos already in 1959 explicitly included society in his definition: ‘Health is the expression of the extent to which the individual and the social body maintain in readiness the resources required to meet the exigencies of the future’—a view that aligns well with positive health). But health behaviour is not necessarily individual, it is shaped through social norms and community opportunity. The Charter identifies skills (such as a prescient view on health literacy) to deal with health challenges and opportunities, individually and collectively, as key to the success of health promotion.

Build healthy public policy

Many of the options and opportunities outlined here depend on collective choice, or (as Nancy Milio analysed) on public policy outside the health sector. This idea had started to take hold in Canada in the early 1970s with the Lalonde Report that advocated for action on elements of the ‘health field’ outside medicine. This idea was adopted by the Swedish government in the 1980s (Fig. 2.13.3) when they identified how action in one government sector could well have added effect across several health conditions: it has taken decades of deliberate health promotion action to allow the country to effectively implement its comprehensive health strategy. Milio systematically reviewed the policy literature and showed health impacts from all sectors under the influence of public policy (e.g. including agriculture, food, and nutrition; education and literacy; transportation and mobility; defence; economic development, and so on). The Ottawa Charter was straightforward in its call (Box 2.13.1) that making the healthier choice should also be the easier choice for all politicians.

Fig. 2.13.3 The Swedish government’s map of public sector impacts on health and disease (HS90—the Swedish Health Services for the 1990s, 1984).

Fig. 2.13.3 The Swedish government’s map of public sector impacts on health and disease (HS90—the Swedish Health Services for the 1990s, 1984).

Reprinted from The Ottawa Charter for Health Promotion, First International Conference on Health Promotion, Ottawa, 21 November 1986.

A health promotion for the 21st century

The Ottawa Charter remains an important benchmark for global health promotion. It has influenced policies and practices around the world. On its 25th and 30th anniversaries the legacy of the statement was reviewed. Progress has been made in virtually all action areas, either in practice or in scholarship. There is, however, also evidence that health services are still facing problems to redefine themselves as ‘health-promoting environments’.

The context for health promotion also has changed. The debate around health equity has intensified, with many countries around the world (led by WHO) having inequalities in health on national and local agendas. Health promotion is still seen as a key strategy to deal with the social determinants of health that create these inequities. Attention has shifted from the mere recognition that all public policies may impact on health to active strategies and actions to move health concerns into all policies. This is called ‘Health in All Policies’ and cunning leadership of the health sector and its professionals is identified as critical to the future success of health promotion and global health.

A clinical commitment and challenge

For public health doctors it will be clear what their roles and commitments in health promotion are. They mediate, advocate, and enable diverse groups of stakeholders that shape environments for health to be explicit about the health impacts and choices available to the individuals, groups, and communities they serve. In this way they will contribute to the development of Health in All Policies, and support people in individual and community action for health.

For the clinician dealing with individual patients, the responsibility may be less clear. The concepts discussed in this chapter may be considered abstract and divorced from the individual complaint voiced in the surgery, clinic, or ward. However, clinicians are key actors in shaping social and cultural priorities and beliefs, and their commitment to the reduction of health inequity should be in no way less than those of public health specialists.

The British Medical Association responded to this challenge and presented its members, and the rest of the world, with a grid that sees levels of clinical action, both geographically (local and international) and in terms of performance (treating patients—community leadership—advocacy—research)—see Table 2.13.1.

Table 2.13.1 What doctors can do in health promotion to address social determinants of health and health equity (BMA, 2011)

Treating patients

Community leadership























To contribute to better health of individuals and communities, and to reduce inequities in health between groups, there are important roles for doctors:

  • Practice holistic medicine from a patient-centred perspective

  • Embrace and exploit the social and community stature of the medical profession in the community to bring together partners for health

  • Advocate for, do not just treat, marginalized and socially excluded individuals and their communities

Health promotion is a core commitment and responsibility of the clinician. As the Declaration of Geneva states: I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient.

Further reading

Baum F, Lawless A, Williams C (2013). Health in All Policies from international ideas to local implementation: policies, systems and organizations. Health promotion and the policy process: practical and critical theories, 188–217.Find this resource:

British Medical Association (2011). Social determinants of health—what doctors can do. British Medical Association, London.Find this resource:

de Leeuw E (2011). The boulder in the stream. Editorial, ii157–ii160. In: de Leeuw E (ed) The Ottawa Charter 25 Years On. Health Promotion International, 26(suppl 2), ii157–ii272.Find this resource:

de Leeuw, E (2017). Engagement of sectors other than health in integrated health governance, policy, and action. Annual Review of Public Health, 38, 329–49.Find this resource:

de Leeuw E, Ståhl T, Tang KC (eds) (2014). The eighth global conference on health promotion. Helsinki, June 2013. Health Promotion International, 29(suppl 1), i1–i151.Find this resource:

Dubos R (1959). Mirage of health: utopia, progress, and biological change. Doubleday, Garden City, NY.Find this resource:

Eriksson M, Lindström B (2006). Antonovsky’s sense of coherence scale and the relation with health: a systematic review. J Epidemiol Community Health, 60(5), 376–81.Find this resource:

Huber M, et al. (2011). How should we define health? BMJ, 343, d4163.Find this resource:

Milio N (1981). Promoting health through public policy. FA Davis Co, Philadelphia, PA.Find this resource:

Newby L, Denison N (2014). ‘If you could do one thing.’ Nine local actions to reduce health inequalities. The British Academy, London.Find this resource:

Pelikan JM, et al. (2005). 18 core strategies for health promoting hospitals (HPH). In: Groene O, Garcia-Barbero M (eds) Health promotion in hospitals: evidence and quality management. World Health Organization, Copenhagen.Find this resource:

Ståhl T, et al. (2006). Health in all policies. Prospects and potentials. Finnish Ministry of Social Affairs and Health, Helsinki.Find this resource:

Ziglio E, Simpson S, Tsouros A (2011). Health promotion and health systems: some unfinished business. Health Promot Int, 26(suppl 2), ii216–ii25.Find this resource: