Health promotion, health equity, and action on the determinants of health: an introduction
Previous attempts (Green and Raeburn 1988; Tones and Tilford 1994; Tones 2002) to situate health promotion within the broad field of public health have often used ‘health education’ as the starting point. This is an entirely sensible approach which we will discuss but it tends to underemphasize the radical departure health promotion aims to make from traditional public health approaches in general. Without claiming health promotion means everything all at once, thereby leaving its lofty rhetoric in the realm of the aspirational yet ineffectual, we aim to place health promotion more centrally in the ongoing saga of an increasingly globally aware public health. As one of the acknowledged founders and innovators of the modern health promotion movement has unceasingly argued, health promotion, at its most persistent and radical, heralds a ‘new public health’, not merely a more fine-tuned and effective tool-box for a less paternalistic health education (Kickbusch 1989, 2007).
We will begin with a clear definition of health promotion. Then, by unpacking the dense and sometimes opaque wording that define the elements of health promotion as a concept, we intend to open up some of its central, yet often hidden, connections to much broader themes in contemporary social and political movements and ideas.
Next, we situate health education and its internal critique as an important part of the history of health promotion, while providing more context concerning the specific historical/national trajectories that made the genesis of the modern health promotion movement a mixture of different influences, of which health education is only one.
We will consider how health promotion manages its ambiguous relationship with the history and ideological background of public health, and how it sees itself in relation to the past, present, and future of public health.
We suggest there is a new opportunity for health promotion to reconnect with the avant-garde in public health, which can be examined along two broad dimensions, namely how to achieve health equity, and the question of health in a global political-economic context. Particular attention will be paid to the recent work following up the World Health Organization (WHO) Commission on the Social Determinants of Health, led by Sir Michael Marmot, and the renewal of the Ottawa Charter action area of ‘healthy public policy’ in the Health in All Policies global movement, spearheaded by the WHO.
In a previous version of this chapter (Hills and Carroll 2009), we argued that there was an under-analysed political economy of health promotion; in this revision, we argue that this is partly to do with the relative lack of engagement with social theory within the health promotion field. We offer some suggestions and map out potential pathways towards more serious reflection on this missing social-theoretical base. Finally, we consider the emerging role of complexity theory and systems thinking in health promotion research.
In general, this chapter on health promotion is critical in the positive sense of the word. Previous surveys of the concept and practice of health promotion that provide excellent guidance to the field are referenced. However, we consider that practitioners and researchers in public health can benefit from a reflexive inquiry into the rich ambiguities and tensions that are embedded in the discourse and practice of health promotion. This is particularly the case if, as we argue, the development of health promotion is the development of a ‘new public health’.
‘Health promotion’: a definition and conceptual critique
In this chapter, we will follow the Ottawa Charter for Health Promotion (WHO 1986) definition of health promotion as ‘the process of enabling people to increase control over, and to improve their health’. However, we will also draw upon the expanded definition in the updated Health Promotion Glossary:
Health promotion represents a comprehensive social and political process, it not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health. Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. (WHO 1998, our emphasis)
Here, the ‘how’ and ‘why’ ideology is linked to the ‘what’ of the determinants of health (WHO 1998). This is crucial, because if health promotion is about anything, it is about action taken across the broad spectrum of health determinants, particularly directed towards the social, environmental, and economic conditions that support health (WHO 1984).
The Glossary also emphasizes that ‘participation is essential to sustain health promotion action’, and identifies the three Ottawa Charter strategies for health promotion: ‘Advocacy for health to create the essential conditions for health indicated above; enabling all people to achieve their full health potential; and mediating between the different interests in society in the pursuit of health.’
These strategies are supported by five priority action areas as outlined in the Ottawa Charter:
1. Build healthy public policy.
2. Create supportive environments for health.
3. Strengthen community action for health.
4. Develop personal skills, and
5. Re-orient health services. (WHO 1986)
As one can see from these definitions, we already have started the ‘unpacking’. A more nuanced analysis of some of the key elements in this definition is described in the following subsections: the ‘process’ of health promotion; ‘enabling’ and ‘empowering’; and for what, the outcome, ‘improved health’. This will be followed by an analysis of the Ottawa Charter strategies and its priority action areas (often called ‘action strategies’).
As soon as we begin, we find ourselves in murky waters, though not without some guidance. Ironically, although health promotion is, as Tones (2004) noted, an ‘essentially contested concept’, there has been a remarkable degree of effort, and consensus, concerning its ostensive definition. Few, if any, health promoters dispute the Ottawa Charter’s now canonical phrasing (WHO 2005).
The real ambiguity that surrounds the concept of health promotion is embedded in the elision of the concrete meaning of the elements that make up its agreed upon definition.
Health promotion as a process
The emphasis on process is important, if only because it warns against reducing health promotion to merely a technical function of public health. It connotes the wider meaning of the concept by signalling that the radical departure and critique of traditional public health lies in its advocacy for changing the way we do public health, just as much as what we change and why we change.
Health promotion, whether it be generated from an internal critique of health education or from other dissatisfactions with the way public health was being practised, is fundamentally concerned with change and, specifically, with the failure of traditional, paternalistic, and professionally dominated public health processes to bring about positive changes in health, particularly for those groups that suffer disproportionately negative health outcomes and the consequent disadvantages. What is substituted is a call for health promoters to create a dynamic, participatory engagement with individuals and communities, to help or ‘enable’ them to take control over the determinants of their own health.
The first ambiguity we meet when trying to analyse this ‘process’ turns on whether one interprets the health promotion process as, primarily: a revamped tool-box of health education techniques and social marketing devices, with a rhetorically efficient participatory gloss; or, as a values-based process of communicative interaction that has as its central premise the ethical foundation of respect for human dignity and autonomy. These are certainly polar extremes and there is no doubt that there is room for both aspects in a broad, ecumenical attitude to a diverse field of practical action. Yet, because health promotion is a process often dominated by professionals, in a context where its supposed beneficiaries are often those in a position of relative powerlessness, the tendency for professionals to retreat to an insulated cocoon of technical expertise is strong. The essence of the health promotion process is a focused shift of power from professionals to the community and to individuals within their communities who historically have had less power. To do this, it is crucial that the ‘process’ we focus on is the one that involves negotiating values, principles, ethics, and power, not the less complicated one of transferring a packet of new skills and technical tools to a community that is presumed to lack capacity. In order to achieve this shift in power, health promoters need to begin by examining their own values and assumptions that inform their actions.
Beliefs and assumptions underlying health promotion
Health promotion practice is influenced by the beliefs and assumptions we hold. While a detailed discussion of this topic is beyond the scope of this chapter, we outline how certain beliefs and assumptions influence how we act in health promoting ways in given situations.
Beliefs are learned through life experiences; they are what we hold as ‘true’. They are convictions that influence the way we think, feel, and act. Health promotion practice relies on a set of underlying assumptions that guide those who work in the field. Hartrick et al. (1994) contend health promotion is a ‘way of being’ that requires certain convictions in order to act in health promoting ways. These include:
1. All people have strengths and are capable of determining their own needs, finding their own answers, and solving their own problems.
2. Every person and family lives within a social-historical context that helps shape their identity and social relationships.
3. Diversity is positively valued.
4. People without power have as much capacity as the powerful to assess their own needs (people are their own experts).
5. Relationships between people and groups need to be organized to provide an equal balance of power (this includes professional/client relationships).
6. The power of defining health problems and needs belongs to those experiencing the problem.
7. The people disadvantaged by the way that society is currently structured must play the primary role in developing the strategies by which they gain increased control over valued resources.
8. Empowerment is not something that occurs purely from within (only I can empower myself), nor is it something that can be done to others (we need to empower the group). Rather, empowerment describes our intentional efforts to create more equitable relationships where there is greater equality in resources, status, and authority.
9. Shared power relations do not deny health professionals their specialized expertise and skills. Rather, professional expertise and skills are used in new ways that result in greater power equity in interpersonal and social relations. (Hartrick et al. 1994, p. 87)
So, for example, if we consider the first assumption in the list, believing that people are able to find their own answers and solve their own problems leads one to act in empowering ways because of the belief that people have this capacity to figure things out. On the other hand, if one believes that people need to be told what to do, or that they are not able to figure out issues on their own, it is more difficult to create conditions that are enabling. For some, it might even feel irresponsible to put people in these circumstances or to allow them to have control over these types of decisions.
Enabling and empowerment
At the time of the Ottawa Charter, the word ‘enabling’ was favoured, although later this tended to be replaced with the more direct and comprehensive concept of ‘empowerment’. Essentially, this meant that a prerequisite for the new approach was that individuals and communities were to directly participate in the planning and implementation of health promotion activities. The assumption was based on the notion that only by genuinely participating in the health promotion process would people be ‘enabled’ or ‘empowered’ to take control of what determined their health. However, the concept of ‘enabling’ also referred to the more general process of changing the social, economic, and environmental conditions that made it difficult for people to become empowered. There is a deep ambiguity here: it is not clear, for some commentators, whether more macro-scale action, at a policy level, also requires active participation of local communities. There is some room for an interpretation that tends to retain a traditional paternalism when it comes to healthy public policy, leaving the ‘participatory’ aspect of health promotion to the realm of ‘community action’. As will be argued throughout this chapter, health promotion is constantly at risk of sliding back into this paternalistic approach, leaving the more ‘complex’ and high-level ‘technical’ decisions to the experts. Yet, if there is a direct link between human dignity, autonomy, and equity, then all aspects of health promotion must integrate the fundamental perspective of participation. In fact, it is argued that the rhetoric of ‘empowerment’ often masks a continuing bureaucratic and professional dominance of the process of improving public health (Baum 2007).
A key aspect of this ambiguity can be seen when we consider the link to health inequity. Without a genuinely participatory, empowering process, it is those worst off who are left further behind as they suffer, not only a failure to affect those conditions most important to their health, but also a direct assault on their human dignity (Sennett 2003). Those who tend to manage any gains from processes that lack true participation are usually segments of the population that already have access to positions of status and the resources and capacities to take advantage of the interventions on offer. The distinction here is between a situation where already disadvantaged people are assumed to be too ignorant or incapable of participating and thus have solutions imposed on them, and a situation where people of a privileged status delegate, as equals, to professional experts. This is not to say that a participatory process is not better for everyone, regardless of class position or status; rather, it is to emphasize that non-participatory processes have a disproportionate adverse effect on disadvantaged groups.
On the positive side, an empowering health promotion process leaves the ownership and control of a health promotion activity or programme in the hands of the community itself. This is particularly important in communities that have suffered historical social injustices and have thus been actively ‘disempowered’ (an ugly but accurate term). Allowing people to participate in a genuine way in determining not only what they want but how they want to get it is demonstrably the most effective strategy for change. It is also the only strategy for sustaining progress in improving health and shifting control back to the community and away from a negative dependence on bureaucratic and professional power. In this model, professionals are not demons; they are just transformed from arrogant experts into supportive servants of the will of the community.
There is in these simple terms (‘enable’ or ‘empower’) the entire, complex, and ambiguous story of health promotion. All the themes that will be touched upon in this chapter can be traced back to just what is at stake in the ostensive goal of ‘empowering’ people to take control over what determines their health.
What is the ‘health’ in health promotion?
Understanding how we conceptualize health is a key reflective step in health promotion. How we think about health largely determines the types of action we take to promote health. We see below how different historical conceptions of health still shape the contemporary health landscape and continue to sustain ambiguities in how people approach health promotion itself. In the twentieth century, due to the relative success of the sanitation approach to public health and the emergent hegemony of the germ theory of disease, an implicit biomedical definition of health as the absence of disease dominated, and along with it, a narrow, individual treatment focus, centred on the healthcare system, was the preferred solution. The WHO had, in 1946, introduced the positive definition of health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (WHO 1946). Nevertheless, this definition had little concrete impact on actual health systems, leaving the absence of disease approach to health as the default option when governments turned their attention to the public’s health.
The Lalonde Report, an official document produced by the Canadian Department of Health and Welfare (Lalonde 1974), marked a significant change in thinking about health. Although the report is recognized internationally as the first government document to suggest that health promotion could be a key strategy for improving health, its other, more significant contribution, was to redefine how we view health. Lalonde’s report argued that the healthcare system plays only a small part in determining health, and suggested that health was determined by the interplay between human biology, healthcare organization, environment, and lifestyle. This view of health became known as the ‘lifestyle or behavioural approach to health’, partly because the ‘environmental’ dimension was either ignored or treated narrowly.
With the publication of the discussion paper on concepts and principles of health promotion (WHO 1984) and the endorsement of the Ottawa Charter for Health Promotion (1986), a third view of health arose: the socioecological approach. This approach defined health as ‘a resource for everyday life, not the objective of living’. ‘Health is a positive concept emphasizing social and personal resources as well as physical capacities’ (1986, p. 1). In order to reach this state of physical, mental, and social well-being, people must be able to identify and realize their aspirations, to satisfy their needs and to change, or cope, with their environment. This inextricable link between people and their environment provides the conceptual basis for this socioecological perspective on health and it forms the conceptual base for health promotion practice.
At first glance, these different views of health may appear to be developmental or historical. However, Labonté and others (Labonté 1993; Rootman and Raeburn 1994; Raeburn and Rootman 2007) argue that, in fact, all three views of health (along with many other definitions) continue to be endorsed by different people in the field of health promotion and, furthermore, that the view of health one holds influences one’s health promotion practice. Table 6.4.1 illustrates this connection between how we think about health, our view of health, and our actions (health promotion practice). For example, if we hold a view that health is the absence of disease, we are likely to talk about disease processes and risk factors and to manage the problem professionally by prescribing a treatment. If we hold a socioecological view of health, we are more likely to focus on the conditions in which the person is living, the factors that are influencing their ability to meet their needs, and to use enabling strategies to assist the person to have more control over their health.
Table 6.4.1 From concept to action: different approaches to health
Biomedical; absence of disease or disability
Individualized; physical-functional ability, physical well-being
Positive state connectedness; ability to do things that are important or have meaning; psychological well-being
Disease categories, physiological risk factors (e.g. hypertension)
Behavioural risk factors (e.g. unsafe sex)
Psychological risk factors (e.g. isolation) and socioenvironmental risk conditions (e.g. poverty)
Surgery, drugs, therapy, illness care, medically managed behavioural change
Advocacy for healthy lifestyle choices
Personal empowerment, small group development, community organization, coalition advocacy, political action
Negotiated with communities and professionals
Managed by community in critical dialogue with supporting professionals and agencies
The Ottawa Charter strategies
The three strategies mentioned in the Ottawa Charter are: to advocate, to enable, and to mediate. We have already reflected upon the second strategy, as it is part of the definition of health promotion. However, a few words need to be said about the other two strategies.
The concept of advocacy receives very little elaboration in the Ottawa Charter. In the Health Promotion Glossary, it is stated that advocacy ‘can take many forms including the use of the mass media and multi-media, direct political lobbying, and community mobilization through, for example, coalitions of interest around defined issues. Health professionals have a major responsibility to act as advocates for health at all levels in society’ (WHO 1998, p. 6). This raises one of the many thorny issues that come up when professionals are caught between highly mobilized and often highly critical communities and a state bureaucracy that is extremely reticent about providing funding that sanctions and supports the capacity for critical attention to its policies and programmes. Even at the level of independent professional organizations, the participation and funding provided by government bodies creates a tension around the organization taking strong critical perspectives. Another aspect of this strategy, as defined in the glossary and glossed over, is the potential contradiction between activities such as ‘political lobbying’ and ‘community mobilization’. Often, the same organization or individual will be less effective as a political lobbyist to the extent they are perceived to be directly associated with community mobilization efforts that the powerful are either indifferent to, or actively disfavour.
Mediation is an even more delicate strategy for health professionals. Its original Glossary definition in relation to health promotion was: ‘A process through which the different interests (personal, social, economic) of individuals and communities and different sectors (public and private) are reconciled in ways that promote and protect health’ (WHO 1986). In the expanded definition of 1998, more explicit emphasis is given to the potential conflicts that often arise between the competing interests mentioned in the original definition. However, the goal of mediation as ‘reconciliation’ is left unchanged. While there is nothing inherently wrong with the idea of reconciliation, professionals should be extremely self-critical and reflexive when operating with this strategy. Two dangers are apparent with the strategy. First, in striving for ‘reconciliation’, one may simply paper over a conflict for the purposes of short-term peace, while leaving the principal reasons behind the conflict intact, thereby creating the potential for longer-term embitterment and strategic action by all parties, which ultimately undermines the appearance of agreement. Second, a very real threat to equity can arise when professionals reconcile a conflict between the powerful and the powerless and end up re-enforcing the powerful at the expense of the powerless. This tendency is very strong given the fact that professionals have little to gain personally from any radical re-structuring of power relations. Despite these important caveats, mediation has become even more critical for the success of health promotion in the future, especially in relation to the new global, multilayered context of health governance that the Bangkok Charter (WHO 2005) has set out to address and which will be discussed later.
The priority action areas of the Ottawa Charter were identified as those areas that were seen at the time of the charter (and still to this day) as critical arenas for health promotion’s strategic activities. We will not try and survey the myriad accomplishments of health promotion activity; rather, consistent with our general approach, we will offer a few critical comments on each action area:
Building healthy public policy
There are three elements of healthy public policy emphasized in the Ottawa Charter:
1. If, as the Lalonde Report (1974) argued, the determinants of health lay mainly outside healthcare itself, then policy action must come from policy sectors other than health. The health sector would still play an important, but not exclusive, role in public policy action to support health.
2. Healthy public policy requires the coordinated use of all policy levers available, including ‘legislation, fiscal measures, taxation, and organizational change’ (WHO 1986).
3. Healthy public policy requires the identification and removal of obstacles to the adoption of such policies in non-health sectors.
Without going into a long list of efforts and results in this area, the progress made can be summed up as substantial and encouraging in regard to changes in the rhetoric and discourse around health, in both developed nations and in many of the global institutions responsible for improving health and development worldwide. Conversely, one can equally characterize progress as ephemeral and demoralizing when it comes to the concrete goal of ‘coordinated action that leads to health, income and social policies that foster greater equity’ (WHO 1986). For a variety of reasons discussed in the later subsection on the political economy of health promotion, given the increasingly urgent crisis of widening inequities in health both between and within societies, the collective policy response of the most powerful countries on earth has been miserly and despicable. To call it ‘inadequate’ is a gross understatement and an unconscionable euphemism.
When action finally starts to catch up with some of the lofty rhetoric behind the calls for ‘health in all policies’ (Ståhl et al. 2006), health promotion can begin to find some satisfaction in the area of building healthy public policy. Since the last version of this chapter we have seen this contradiction intensify, as the global economic crisis brought on by the 2008 financial crash has led to some very regressive shifts in fiscal policy and thus social supports for a healthy public policy; meanwhile, at the level of rhetoric, global institutions, such as the WHO, have been increasingly supportive of the conceptual logic of healthy public policy. We will discuss some of the latter recent developments in relation to the Health in All Policies movement in a later section.
Creating supportive environments
This area forms the basis for what is called the socioecological approach to health. Here it is asserted that both the natural and built environments are inextricably linked with people’s health. It is crucial to understand that the conceptualization of supportive environments given here is consistent with the expanded, positive understanding of health as a ‘resource for everyday life’. It is not merely about threats to physical health, but involves creating conditions that allow people to have ‘living and working conditions that are safe, stimulating, satisfying, and enjoyable’. This entails the complex relationships between rapidly changing technologies, working conditions, resource use, climate change, urbanization, and health (amongst others).
In considering progress, past endeavours, and future prospects in this area, one must take into account the lofty ambition (and some would say naïvety) of this programme of action. As a project of knowledge development, its referral to the ‘complex interrelatedness’ of contemporary societies is but a cipher for the entire corpus of theoretical and empirical dispute and debate within the social sciences over how to characterize what are now acknowledged to be multiple, interrelated, global, national, regional, and local processes of socioeconomic and cultural change (Held et al. 1999). Later we consider some recent moves toward adopting complexity science and systems thinking to more adequately address this complex interrelatedness.
In the real world, we are not able to coordinate all the best knowledge sources available and neatly calculate what is best for health. Instead, we are left with tools like ‘health impact assessment’ (HIA) (Kemm 2006). The action area of creating supportive environments can be seen as a great boon to academic productivity, both theoretical and empirical; yet, before the final judgements of the academy can be handed down, actions must be taken and decisions must be made.
Communities and developers, politicians, and bureaucrats must decide whether to build this or that highway, license this or that mining operation, enact this or that employment regulation, and build this or that oil pipeline. We are thus forced, by the necessity to decide and act, into an inevitable reduction of complexity. The question is not whether this is a good or bad thing; it is how, by what process, is complexity reduced? Whither participation and empowerment in a field dominated by professional expertise and the cloistered secrecy of executive and administrative decision-making in both the public and private sectors?
We argue against the implication that instruments like HIA inevitably vitiate participatory processes (Kemm 2006). The natural tendency is always to define ahead of time, objectively, what elements of the built or natural environment are most important for enhancing people’s health. From a utilitarian perspective, locally defined needs and wishes may even legitimately be ignored in the name of some greater good for a larger population. However, health promotion should always err primarily on the side of the fundamental value of the autonomy and the dignity of people and their communities. In this mode, participation is foundational, even in what are prima facie obvious areas for the guidance of refined professional expertise. In enquiring into the best way to protect and enhance the built and natural environment for health, the first step is to find out what people actually identify as the things that would make life ‘safe, stimulating, satisfying, and enjoyable’. From the professional perspective this route has one incontestable drawback: people are inevitably confused, ignorant, inconsistent, contradictory, and even just ‘wrong’. ‘People’ will disagree with each other; will get annoyed or, even worse, angry; will disrespect experts, politicians, lawyers, and any number of people who ‘actually know’ about the issue. What is feared here is what is fondly called deliberative politics; in other words, the foundation of democratic civil society.
We are, as is universally acknowledged in the health promotion community, a long way from creating supportive environments for health, especially for those suffering gross inequities in social conditions and in consequent health outcomes. What is less often acknowledged is that part of the reason this is so difficult is that we consistently exclude the very people we are meant to be helping from determining the goals, and strategies necessary to move from here to there. Once again, we are led to believe that the ends can justify the means; we can have non-participatory processes as long as we intend to make changes to enhance the lives of the less fortunate. That we end up in a place we did not intend, is inextricably linked to the fact that, at crucial junctures, when inevitable changes of directions and compromises are made (local development processes are a prime example), the people who have an inherent interest in speaking up for the powerless (the powerless themselves) are nowhere to be seen, or are barely heard.
Strengthening community action
This action area is at the very heart of health promotion; in fact, it can be argued that this action area is the one where the basic principles of health promotion lie. You can imagine (wrongly) participation, equity, and empowerment to be contingent add-ons to the other action areas; with strengthening community action the essential unity of all the values of health promotion are embedded as necessary features of its realization. Indeed, what we see in this area is the place where the true spirit of health promotion is anchored in community development as a process. In fact, in the Ottawa Charter itself, there is a strange ellipsis where the term community development is introduced in the section on strengthening community action. It is as if one missed something: there is no linking phraseology relating community development to strengthening community action. This, we surmise, is no error: strengthening community action quite simply is community development.
Consider the definition of community development as agreed upon at the International Association for Community Development at a meeting in Budapest in 2004. Community development is a:
way of strengthening civil society by prioritising the actions of communities, and their perspectives in the development of social, economic and environmental policy. It seeks the empowerment of local communities, taken to mean both geographical communities, communities of interest or identity and communities organizing around specific themes or policy initiatives. (Craig 2005, p. 3)
For a more sustained treatment of the need to recognize the central place processes of community development and empowerment should play in health promotion, Raeburn and Rootman’s People-Centred Health Promotion is an essential reference (Raeburn and Rootman 1998). Raeburn and Rootman draw heavily, in their chapter on community development, on Meridith Minkler’s important piece, ‘Improving health through community organization’ (1990). In this seminal piece, Minkler outlines the five principles she sees as foundational to community organization or development:
◆ Community competence
◆ Issue selection
◆ Creating ‘critical consciousness’.
As is now obvious, we have run into some of these principles already, the key to which is that the community itself has collective control over the process of identifying issues and planning how to address them. In addition, the important notion of ‘critical consciousness’ is raised. This refers to the need for critical dialogue in the Freirian sense (Freire 1972); this is particularly important when working with historically oppressed or disadvantaged communities.
Developing personal skills
The new wave of health promotion has often downgraded attention to this critical aspect of its mandate. The Ottawa Charter tells us that health promotion ‘supports personal and social development through providing information, education for health, and enhancing life skills’. However, since the Ottawa Charter, health promoters, with some exceptions, have tended to either ignore or aim strong criticism at the developing personal skills area. This has come about for three reasons. First, as part of the critique of health education, it was argued that individually focused education approaches were generally ineffective in bringing about health promoting behavioural change; instead, a switch to an emphasis on the social factors that influence health was necessary to overcome the limitations of traditional counselling and other interventions circumscribed by the discipline of psychology. Second, the emphasis on developing personal skills was associated with the ‘victim-blaming’ element that many health promoters saw as the consequence of an interpretation of the Lalonde report and other government documents (particularly, the approach taken in the United Kingdom under the Thatcher governments) in the context of the neo-liberal rolling back of the state’s commitment to a strong social safety net. Finally, although developing personal skills is a central mechanism for empowering individuals to take control over their own health, many worried that, in this narrow approach, the collective strengthening of communities was adversely effected by too much emphasis on individual empowerment.
All of these concerns are legitimate, though in each of them there is a high risk that we will miss important opportunities by mistaking what are contingent tendencies for essential features.
As has recently been argued, the ignorance of, or even hostility to, work in this area may seriously damage health promotion’s potential impact (Godin 2007). First, while many health education and behaviour change approaches are limited in their effectiveness, there are some demonstrably effective interventions that should not be ignored (Kok et al. 1997). Furthermore, we can learn and are learning about why some approaches in this area have not been effective. Second, the fact that this area of health promotion can be enlisted as part of a more general ‘victim-blaming’ culture of health promotion, does not mean it must be enlisted; in fact, to the extent that genuinely empowering health education is taken seriously, the resulting improvements in self-esteem should work against victim blaming. Third, individual and community empowerment should not be a zero sum trade-off. It is only when an exclusive focus on individuals is emphasized that we will have the phenomenon of rescuing survivors from a sinking ship.
In summary, while we must be vigilant against the temptation and limitations of an individually focused, skills development approach, we must also re-engage with the most advanced and progressive elements in this area of work. If we fail to do this, we will jeopardize a key aspect of health promotion.
While we have made some important gains in the previous four areas, reorienting health services has proved more difficult. In general, throughout the world, health services remain medically dominated, cure and treatment focused, and individualistic. The Ottawa Charter states ‘the role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services’. However, ‘across the world, there appears to have been a stubborn resistance to systematic change in healthcare services and only limited examples of effective and sustainable health services reorientation’ (Wise and Nutbeam 2007). Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, and physical environmental components.
Health services are broad and far-reaching, with the most complex service for health promotion being the acute care hospital setting. There has been some advancement in this area with the creation of the healthy hospital settings movement, with some research evidence that it is possible to practice from a health promotion perspective even within this particularly medically dominated environment, for nurses at least (Hills 1998). However, we want to focus in this chapter on the area where health promotion should flourish but has not as yet—primary healthcare. Many who work in health promotion would argue that the Alma Ata Declaration (WHO 1978) was the precursor for the Ottawa Charter. These two documents share the same values, principles, and basic tenets; the Alma Ata Declaration addresses health systems more particularly while the Ottawa Charter has a broader mandate. But it is their relationship that provides the key to reorienting health services. That is, primary healthcare is a place for health promotion to focus its energy in terms of reorienting health services. In fact, the more that health promotion disassociates itself from primary healthcare, the more we give the impression that it is in the domain of medicine, not health. ‘The more health promotion becomes distinct from the world of curative care, the more the latter is allowed to continue to be seen as the real work of medicine’ (MacDonald 1992).
We want to be clear that when we are talking about primary healthcare, we are not talking about primary care. These terms are often confused or used interchangeably. Primary healthcare refers to the philosophy and principles articulated in the Alma Ata Declaration (WHO 1978). It calls for universal access to health services (universality) and the removal of geographic, social, economic, or cultural barriers to access (accessibility); it demands community participation in planning, operation, and evaluation of health services (participation); it requires integration across health and other sectors such as housing, education, and employment; it recognizes the power of multidisciplinary teams working as equal partners for the health of the community; it focuses on a range of services, determined by the community, that include health promotion, primary prevention, rehabilitative, and curative (essentiality); and, it demands a commitment to equity concerning issues of power and resources (equity and access). Therefore, primary healthcare resists the conceptual and operational separation of treatment and prevention which fits the engineering model of healthcare, with prestige and often scarce resources going to clinical medicine to the neglect of prevention, promotion, and rehabilitation (MacDonald 1992).
People who work in health promotion and understand its philosophy and principles must be involved in the development and implementation of primary healthcare. Many people working in health promotion are of the opinion that health promotion and healthcare are distinct and separate entities. They are critical of health promoters who talk about healthcare or health service delivery at the same time that they are talking about health promotion. We have a different opinion: it is necessary, not only to talk but to act as health promoters to facilitate primary healthcare reform.
Besides the Ottawa Charter outlining our responsibility to take up this challenge, there are two other reasons why it must be people who work in health promotion who participate in the reorientation of health systems to primary healthcare.
First, the health system is controlled by the powerful. There is a hegemony that supports a predominant treatment/cure paradigm. Power resides in these structures and with the health professionals who work in those systems. So, as advocates for equity and social justice, health promoters have a responsibility to take up this challenge. If we continue to work only in the community where we are comfortable, we will avoid confronting one of the greatest challenges of our times: creating a health system that is based on the principles of health promotion. We are not neutral in this process. As Paulo Freire (1972) said, ‘washing one’s hands of the conflict between the powerful and the powerless, means to side with the powerful, not to be neutral’. Kickbusch (1989) confirms this concern. She states, ‘herein lies the great historical opportunity and challenge. Maybe health promotion can break the deadlock of the health policy debate that is basically about medical care and provider dominance’ (p. 14). As she suggests, we are well beyond the burden of proof needed to claim that health promotion is successful—we have demonstrated this through our change in attitudes towards smoking, drinking, and nutrition—even if these are mainly concerns of the middle class and of high-income countries. ‘Accountability and the burden of proof should now lie with the medical system’ (Kickbusch 1989, p. 14).
The second reason that health promoters must take up this challenge can be summarized in one question: if health promoters do not advocate for primary healthcare based on the principles of the Alma Ata Declaration and the Ottawa Charter, what model of primary healthcare will dominate our countries?
Health promotion: history and influences
Health education plays a profound role in the history of health promotion. While it is true that health promotion is an ‘essentially contested concept’ claimed by a variety of different interests and actors (Green and Raeburn 1988), many of its most prolific commentators, particularly in the area of health promotion research and knowledge development, have been from the field of health education (Green and Kreuter 2005).
These writers have often been concerned with the failure of traditional health education approaches to help motivate individuals to act on health information. Following Tones, we adopt his definition of health education as: ‘Any intentional activity which is designed to achieve health or illness-related learning, that is, some permanent change in an individual’s capability or disposition’ (Tones 2004, p. 7). This refers to what knowledge, attitudes, or skills can be acquired by individuals through a variety of health education processes. In relation to health promotion, key health educators have radically restructured the traditional approaches to influencing health behaviour. Most of this work has revolved around challenging what are now seen to be simplistic and mechanical models of health belief and health decision-making. At the centre of this change has been an adoption of the concept of empowerment and an advocacy for using participatory learning processes that break down the power imbalances between health professionals and lay members of society. Crucially, the relationship between devolving control, developing self-esteem, and bridging the gap between knowledge, attitude, and behaviour is highlighted.
In relation to the overall theme of health equity, the move away from traditional health education models has been critical. Without the concept of empowerment, and the development of capacities and self-esteem, the traditional ‘health action model’ of raising awareness and changing attitudes to health behaviours tended to exacerbate health inequalities, as the ‘prepared’ middle classes quickly adopted the new healthy practices of more exercise, less smoking, and a healthy diet. The efforts to help population groups that had both the worst health outcomes and the most intransigent health-related social conditions have not been nearly as successful.
A detailed account of these changes can be found in Tones (2004). One very important aspect of his account is how health promoters can learn, as professionals, to overcome the social gap in both power and understanding between them and the groups and individuals they aim to enable and empower. As Tones notes, the ‘holy trinity’ of counselling (respect, empathy and genuineness) is pertinent here. Often the more socioecological accounts of the health promotion process gloss over this crucial interactive aspect of health promotion. Whether it is with individuals or with groups, health promoters cannot act effectively without using highly developed skills of empathic understanding and facilitation. Particularly with group interactions, where often highly charged community issues are discussed, the professionals striving for neutrality and objectivity will find themselves unable to cope with the anger and resentment felt by people who perceive a history of grave social injustice behind their ‘health’ problems. It is important that these basic counselling skills are imparted to health promoters-in-training before they go out into communities and work with them on issues relevant to their health.
This shift in health education from an information-giving, pamphlet distribution approach to an empowerment liberatory approach has brought renewed interest in Freire’s emancipatory education paradigm (1972). Health promoters in several countries, most notably those in Brazil, have reclaimed and embraced his basic premises and have employed his dialogical problem-posing teaching strategies that help make health education more consistent with the principles and values of health promotion and the ‘new’ public health. Freire’s (1972) model of empowerment education describes a three-stage methodology consisting of listening, participatory dialogue, and action. Freire proposes that the main strategy of empowerment education, critical dialogue, requires us to engage in a process of problem-posing rather problem-solving. Problem-posing is different from problem-solving because it does not seek immediate solutions to problems. Rather, generative themes arising from the listening phase are ‘codified’ and posed as problematics to raise group consciousness about specific issues. Wallerstein and Hammes (1991) contend that this process recognizes the complexity and the time needed to create effective solutions to societal issues. ‘An effective code shows a problematic situation that is many sided, familiar to participants and open-ended without solutions’ (Wallerstein and Bernstein 1988, p. 383). Freire describes these as ‘generative’ themes because they generate energy and motivate people to act. Freire contends that, through a process of dialogue that reflects on the generative themes raised through listening, people become masters of their own thinking in interaction with others (1972, p. 95). As Wallerstein and Bernstein explain: ‘The goal of group dialogue is critical thinking by posing problems in such a way as to have participants uncover root causes of their place in society—the socioeconomic, political, cultural, and historical contexts of personal lives’ (1988, p. 382).
Freire cautions that ‘the liberating educator has to be very aware that transformation is not just a question of methods and techniques’ (1972, p. 35). If that were the case, we could simply substitute one set of methods for another. ‘The question is in a different relationship to knowledge and to society’ (1972, p. 35).
Many health promotion researchers preface their scholarly remarks on the birth and development of health promotion with a discussion of its relationship to its older, more developed discipline, public health (Kickbusch 1986; Terris 1992). How this history is understood is perhaps the most telling aspect of how health promotion and its progress are viewed as a contemporary phenomenon. The argument developed below is that there has been a tendency within health promotion to tell a story of public health as a ‘fall from grace’—a fall from its original reforming, perhaps even zealous, focus on the social and environmental causes of ill health, to a more restrictive, preventive biomedical era, and finally, to a broader scale but narrower scope in the ‘lifestyles’ approach focused on individual risk factors and behavioural change (Kickbusch 1986). Health promotion steps into the story to herald the era of a ‘new public health’, as a sort of re-emergence of the spirit of the nineteenth-century socioenvironmental model, with a modern gloss on the more subtle socioeconomic determinants of health. The purpose of this critical analysis is to challenge this tendency to nostalgia, and to explicate some of its continuing consequences for health promotion’s rather schizophrenic relationship to public health. The ‘golden age’ of public health was influenced by a particular philosophical and political outlook that still finds its expression today in its most modern and rigorous proponents.
The history of health promotion conventionally begins with the publication of the Lalonde Report, entitled A New Perspective on the Health of Canadians (Lalonde 1974). The report was the first high-level national government document in the world to advocate for health promotion as a basic strategy for improving population health. It was influential internationally and set the stage for future debate with its concept of the health field as the articulation of the argument that the medically dominated healthcare system was only one and perhaps the least significant determinant of health, alongside biology, the physical and social environment, and individual lifestyles. The Lalonde Report relied explicitly for its argumentation on such critiques of the healthcare system found in ‘social medicine’ as those comprehensively outlined by (McKeown 1976), but which had their roots in the classic public health tradition of William Petty, Johann Frank, Rudolf Virchow, and William Farr (White 1991). The report contains not only the notable tension between an emphasis on individual lifestyles and the subsequently neglected socioenvironmental factors, but also an equal tension, given its own chapter heading, of ‘Science versus Health Promotion’. Here it is made very clear that the ‘science base’ of the health field concept is epidemiology and, in this context, health promotion is seen as that type of action that must be taken even though the pertinent scientific questions have yet to be definitively answered. In some ways, this attitude allowed some initial breathing space for health promotion to prosper; however, by setting up this dichotomy, it ensured that, eventually, when ‘science’ made its accounting, health promotion would have its day of reckoning with epidemiology.
Meanwhile, many in the health promotion community, especially in Europe and Canada, were starting to develop an independent conceptual basis for their work, based on a rigorous reflection on the type of actions necessary to most effectively promote the health of individuals and communities. Much of this work evolved out of a complex internal critique of the failure of traditional health education approaches and a more sophisticated understanding of behavioural change (Kickbusch 1986; Tones 1993). Yet, in some countries, such as Canada, the absence of a strong health education tradition contributed strongly to a more socioecological approach to promoting health (with some of its most influential leaders being sociologists and nurses, rather than psychologists and health educators). Furthermore, for a variety of complex reasons (including, again, individual leadership), much of the discourse of contemporary social movements (new leftist, feminist, gay/lesbian, environmentalist) found its way onto the official agenda of major institutions such as the WHO and Health and Welfare Canada (Labonté 1994). As has been recognized by one of the leaders in health promotion internationally, Canada provided a hybrid and fertile mixture of traditional welfare state values and innovative community activism that seemed to provide the perfect ground for a push for the new socioenvironmental approach to health promotion (Kickbusch 1994). Out of this productive interaction between European ‘health promotion tourists’ (Kickbusch 1986, 1994) and many able Canadian activist/public health practitioners, grew the idea and finally the accomplishment of the Ottawa Charter for Health Promotion (1986).
To fully understand the impact that the Ottawa Charter had and continues to have, it is important to see that there was a crucial transformation from the epidemiological and bureaucratic dominance of the Lalonde Report to the emerging ‘more pluralistic (and messier) social-science paradigm of human and social relations’ embedded in the Ottawa Charter (Labonté 1994, p. 86). This shift is key to understanding the constant tension between a ‘scientific’ approach to health promotion and the ‘values’ underlying the Ottawa Charter that is renewed whenever health promoters are asked to more rigorously account for their activities. It raises the uncomfortable question for those who, correctly, see the importance of reconnecting health promotion to the new public health, of just how ‘new’ the new public health is willing to be, when it comes to its underlying philosophical commitments.
This same tension underlies some of the confusion within the health promotion research community about how to relate to the more recent (Evans and Stoddard 1990) emphasis on ‘population health’ (Labonté 1997; Poland et al. 1998; Raphael and Bryant 2002). On the one hand, there is a justified admiration for the advocates of population health for their influential arguments about socioeconomic determinants of health, even so far as to single out progressive population health researchers such as John Frank (Raphael and Bryant 2002). On the other hand, there is the well-articulated angst about the lack of health promotion principles within the population health perspective. The critiques of the population health perspective for its lack of emphasis on values, its weak or non-existent orientation to action, and its somewhat imperious attitude to what is to count as proper ‘knowledge’, are all cogent and well-aimed. The question is: why should this be a surprise? It is not enough to point out the baleful influence of a replacement ideology for health promotion. Where did it come from, and why is it so influential? Furthermore, is this newly emergent approach (Evans and Stoddard 1990) really so new? How far is it simply a modern, sophisticated renaissance of that very same ‘golden era’ of public health that health promoters so often return to as their intellectual and moral heritage?
Although health promoters themselves (especially Canadians, who were the ones facing this challenge directly) reacted strongly and were able to defend the rationale for keeping a health promotion focus, the more incisive critiques were often too ‘reactionary’ and came off rhetorically as overly defensive. A more accommodating response came from within Health Canada itself with Hamilton and Bhatti (1996) introducing the concept of population health promotion. This was clearly an attempt to marry these two potentially adversarial positions and to cement the term health promotion as an integral component of population health that could not be ignored.
Why is it that health promotion often seems ‘behind the game’ in the science debate? Partly, this is due to the fact that, as Labonté says and a Companion to Social Theory attests (Turner 2000), the social science world is ‘messy’. However, it may also be partially true that, for too long, health promotion has neglected its need to develop an independent ‘science base’ having unconsciously bought into that original Lalonde dichotomy. This is becoming increasingly clearer as many of the leading proponents in the field are pushing for more intensive theoretical development, a pressure that has become especially acute as the need for demonstrating effectiveness has increased (McQueen 2001; McQueen and Jones 2007; McQueen and Kickbusch 2007). To understand why health promotion has such a complex and ambiguous relationship to public health, it is necessary to dig more deeply into the foundations of modern public health and to unpack its driving philosophy and world view.
Politics and philosophy in public health and epidemiology
It is crucial to understand that the roots of the modern public health epidemiologists’ focus on individual risk factors and randomized controlled trials (RCTs) is not in contradiction with or a deviation from the Edwin Chadwicks, the John Simons, and the John Snows of the classical public health. Rather, the full flowering of a utilitarian calculus, an uncompromising economism, and an obdurate scepticism of anything but positivistic scientific knowledge, can be seen as the late fruit of more than three centuries of development in public health and epidemiology.
There is a dilemma and prima facie paradox that health promotion faces when confronting its genealogy in the history of public health. In terms of lives saved and healthy years lived, the early public health interventions to combat the spread of deadly and debilitating communicable diseases cannot be underestimated. However, it is no accident that once the environmental risk factors of the major communicable diseases were effectively neutralized, a shift in focus took place to providing preventive, immunization measures. As Kerr White (1991) so convincingly puts it, the history of public health and epidemiology can be read as successive and iterative ‘redefinings of the unacceptable’. Public health has always been concerned with an economistic and utilitarian approach to the health of the population; when things start to ‘cost too much’, the unacceptable becomes miraculously ‘visible’. To understand this history, one has to ignore the facile disciplinary chasm between public health and economics, which has only recently and tentatively been bridged (Evans et al. 1994). While economics became progressively theoretical and mathematical, public health continued the original classical liberal tradition of reformist, practical utilitarianism, most powerfully apparent in the Benthamite tradition’s attempt to rationalize government and public services. There is a great irony that the humanitarian idealism (an idealism at the core of health promotion’s values base) of the British ‘public health doctors’, such as Haygarth, Heysham, Thackrah, Baker, and Millar, was never the driving force behind concentrated public health action (Fraser 1973).
As we will discuss in the subsection on health promotion and social justice, public health shares with economics a default, often merely implicit, utilitarian ethics. This shared history is seldom acknowledged, but it is a history that health promotion must confront explicitly. Fortunately, and ironically, recent developments in public health have brought into question the utilitarian approach, finding it inadequate, particularly in relation to the question of health inequity (Anand et al. 2004). The argument fleshed out below is that health promotion must forcefully engage in helping public health move in the direction advocated for by Amartya Sen and others (Anand et al. 2004).
In this section, we briefly review one of the constitutive ambiguities at the heart of health promotion—many public health practitioners in the 1970s and early 1980s were increasingly cognizant of the lack of participatory involvement of the ‘public’ in public health programming.
A strong feature of the so-called ‘new social movements’ in the post-1968 period was a trenchant critique of bureaucratic structures and an increasingly administered society alongside the traditional leftist critique of capitalism. Some public health institutions, particularly urban public health units, decided to transform local public health practice by integrating a participatory model of programming that was heavily influenced by this anti-bureaucratic critique (Labonté 1994). However, as Dupéré et al. (2007) argue, despite its ambitions, health promotion is still not accurately described as a ‘social movement’, but rather a ‘professional movement that had successfully advanced a discourse about health and the production of health’. Yet, despite this acknowledged status, health promoters have recognized that much of their effectiveness depends on very high levels of social engagement. The more recent emphasis on health in the context of globalization (Labonté 2007) makes the necessity for health promotion to engage with larger social movements, particularly on the global development agenda, even more apparent.
Nevertheless, we find health promotion once again suspended between its constitutive desire to become one with the ‘community’ and its real position as a mediating professional fraction, often acting on behalf of formal public institutions. In the future, health promotion will have to sacrifice some of its cherished professional neutrality to choose sides, especially in its responsibility to advocate for health. While this new form of activist engagement must be balanced with the legitimacy attained from professional status, the balance must shift quite radically, given the growing threats to health represented by the inequity of contemporary societies in a globalized world.
Health promotion, health inequities, and social justice
We have, throughout this chapter, alluded to the commitment health promotion has to the principle of health equity. This is a fundamental and central value for health promoters and is often the touchstone for deciding why, where, and how to enact health promoting practice and policy. Yet, despite this nearly constant refrain, there is still confusion within health promotion about the theoretical and conceptual basis for its concern with health equity. While most, if not all health promoters, would see health equity as a basic goal of health promotion, seldom is the specific normative dimension that underlies this commitment fleshed out. The basic understanding is that health inequities are undesirable and should be eliminated because they are a set of systematic inequalities in health outcomes that are based on unjust inequalities of access to resources that provide for health. The Health Promotion Glossary describes what equity in health entails: ‘That all people have an equal opportunity to develop and maintain their health, through fair and just access to resources for health.’
However, this definition begs many key questions, such as: what is ‘fair’ and ‘just’ access? And, what are ‘resources for health’? While health promoters have often reflected deeply on health inequity, much of the appeal has been to an intuitive basis for supporting the elimination of inequity. We argue that this stance is no longer good enough. Health promotion must fully engage with recent work in political philosophy, particularly in the arguments surrounding the concept of social justice that have been developing since the publication of John Rawls’ A Theory of Justice (1971). Since Rawls’ groundbreaking work, an ongoing debate has taken place concerning what is the proper approach to justice for whole societies (Kymlicka 1990; Aveneri and de-Shalit 1992). More recently this debate has been expanded to consider how we are to think of justice in the global context (Nussbaum 2006). Health promoters should pay close attention to what is at stake in these debates for two reasons.
First, without an awareness of these important arguments, health promotion is liable to accept a default utilitarianism that it inherits from public health, which in turn the latter shares with orthodox economics. It is argued here that this unacknowledged utilitarianism is in direct contradiction to two profound moral intuitions that form the core of health promotion values: that it is wrong to increase overall health at the expense of the least well off; and, that human dignity and personal autonomy are overriding values.
Second, important developments in these debates are directly relevant to concerns with acting on the social determinants of health. Recent arguments have been refined concerning why and how we should address the issue of health inequity, both within and between societies (Anand et al. 2004; Nussbaum 2000). As health promoters, charged with the responsibility to advocate, enable, and mediate for equity in health, we should be armed with the very best arguments supporting our position.
We argue here that the one of the most promising theoretical developments in political philosophy that have implications for health promotion are in the evolving ‘capabilities’ approach to social justice and equity (Nussbaum and Sen 1993; Nussbaum 2000, 2006). This approach most nearly matches the health promotion approach to health as a ‘resource for everyday living’; according to this doctrine, the ‘social bases for health’ would count as a primary good, or capability that should, by right, be provided to all citizens (and by extension, all human beings) at a minimum standard (Nussbaum 2006). It cannot be assumed that arguments for equity in health are unassailable and intuitively obvious for two reasons. First, without some substance behind what is meant by equity and what kinds of resources are to be distributed equitably, the demand for equity in health can be dismissed as either empty or naïvely utopian. Second, differing conceptions of what is just will lead to different outcomes in terms of actions to promote health. For example, unless we are very clear, ‘equal opportunity’ can be understood in an absolute minimalist sense and can allow powerful institutions to continue to support vast inequities in resources for everyday living. As we will see below, how we conceive of social justice has a profound impact on the types of actions we can imagine as solutions to the gross inequities in health we find across the world. Specifically, it has become apparent that the goals of health promotion are intimately related to the goals of a socially just global development agenda. Next we focus on an important element that tends to be lost in much of the discourse on health equity: what are the political, economic and social mechanisms by which the social determinants of health are reproduced as unequal resources for health? This is followed by considering one emerging global initiative aimed at policy solutions in this area: the Health in All Policies agenda.
The political economy of health promotion
Much good work has been done on the ‘political economy of health’ (the analysis of how different politico-economic social structures affect health outcomes), yet an enormous amount is still required (Navarro and Shi 2001; Navarro 2002; Langille 2003; Raphael 2003). Furthermore, there have been some excellent analyses of the ‘political economy of healthcare’ (the analysis of the effect of different political and economic arrangements on the quality and differential access to health services). In this subsection, we outline a different question: what is it about our contemporary political and economic structures that vitiates against the implementation of health promotion strategies and actions as they are conceived in the Ottawa Charter?
To begin to answer this question, we need to consider the three fundamental dimensions to health promotion: empowering communities and individuals, building health public policy, and creating supportive environments.
As has already been argued, empowerment is a key dimension of health promotion. By its very nature, empowerment aims to rebalance existing power arrangements by enabling those currently without power to gain access to the resources necessary to live fulfilled and happy lives. In order to do this with any success, health promoters must do two things: they must have a clear-headed view of existing power structures and relations; and, they must recognize, as professionals, how they themselves fit into those power relations and how they help, often unconsciously, to reproduce them. One way of seriously addressing this issue is to pay more attention to the concepts of class and status mentioned on the section on social justice and health promotion.
Health promotion, to be successful, must rely on concerted action by governments around the world, both within their own territories and in cooperation to address needs that require global action, such as on climate change. However, while these wishes are often articulated (WHO 2005), seldom are we offered an analysis of the structure and dynamics of the contemporary state system in a global context. A more reflective perspective is important here, as theorists of the state argue that certain issues and certain groups, using specific strategies, are more or less likely to be successful changing the nature of hegemonic projects and reversing the direction of state policies (Jessop 2002). Health promotion must become more strategic in how it operates vis-à-vis the state; it must recognize in an explicit way the limitations and opportunities available and integrate theoretical perspectives and practical actions in regard to one of its key areas: building health public policy.
Finally, creating a supportive environment is even more wrapped up in the dynamics of global capitalism than all the other areas combined. The fundamental prerequisites for health as outlined in the Ottawa Charter are: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. These are the elements that, when in adequate supply, make up many of the properties of a supportive environment for health. Yet, each of these elements is in large part determined by the particular structure and dynamics of our global socioeconomic system.
It is necessary to develop an awareness of the fundamental political and economic drivers behind the dynamics of contemporary societies in both the developed and developing worlds. If equity in health relies on the fundamental fairness of social, political, and economic institutions, then ignoring these basic realities is no longer an option for a serious approach to health promotion. These important insights should no longer be gained in an ad hoc way but should be seen as part of what should constitute core knowledge for competent health promoters.
Social theory and health promotion
Recently, particularly following the report of the WHO Commission on Social Determinants of Health (2008), there has been a raft of activity by both academia and governments aimed at developing knowledge about the social determinants of health. There has also been a marked (and needed) shift of emphasis to what types of action societies need to take to address the consequences of the iniquitous distribution of resources that support health. Less prominent are attempts to confront theoretically the main causal mechanisms that produce and reproduce the social inequalities that lead to health inequities. While there have been recent attempts by some health promotion researchers to re-engage with fundamental debates in social theory (McQueen et al. 2007), for the most part the public health community as a whole, and health promotion by proxy, is still dominated by the narrowly focused methodological lens of epidemiological science. This failure to confront the ghost of social theory’s past is most apparent in the way that the categories of class and status are dealt with in health promotion and public health discourse. Where they are mentioned at all, they tend to be conceptualized as epidemiological variables that measure an individual or group’s socioeconomic attributes or properties (e.g. income, education level, wealth, job status), not as social processes that reproduce structural disadvantages for most and accumulate power and privilege for a few (see Scambler (2012) for an excellent review of this problem). The key elements of social theory that should be at the forefront of debate in health promotion circles are considered more extensively in two recent sources (McQueen et al. 2007; Carroll 2012).
The Health in All Policies Movement
Launched as Finland’s main theme of its 2006 European Presidency, Health in All Policies (HiAP) is a strategy to help link health and other policy sectors in an over-arching intersectoral approach to improving health and well-being and reducing health inequity (Ståhl et al. 2006). It is an attempt to reinvigorate the original emphasis in the Ottawa Charter on healthy public policy, and to follow up on the work done at the WHO conference in Adelaide, Australia in 1988 (WHO, 1988). Since that meeting, there has been much reflection on both the details of how to implement healthy public policy and the particular challenges posed by integrated, coherent, intersectoral action for health. More recently, the WHO reconvened in Adelaide to produce an international statement on HiAP called the ‘Adelaide statement on health in all policies: moving toward a shared governance for health and well-being’ (WHO, 2010). It is no coincidence that it lays heavy emphasis on ‘governance’. This was followed by two important publications in 2012, also focusing on governance (Kickbusch and Gleicher 2012; McQueen et al. 2012). The central challenge of implementing HiAP has been the difficulty of managing the governance and accountability structures necessary to sustain both vertical (levels of government, non-governmental and private sector) and horizontal (cross-ministry, inter-departmental) intersectoral collaboration. We are only now beginning in public health and health promotion circles to appreciate the different type of knowledge base required to assess the effectiveness of policy implementation. We are still largely stuck in an outmoded attempt to squeeze what are really matters for political science, economic sociology and the sociology of the state into the narrow methodological confines of standard epidemiological research designs. Some emerging work (Lawless et al. 2012; Carroll et al. 2013) examines case studies of HiAP in order to better understand the key mechanisms underlying success and failure, but this is in its infancy. Clearly, HiAP is required to move forward on the intersectoral action agenda outlined in the Ottawa Charter; however, there is a large knowledge gap concerning implementation and sustainability that needs to be addressed in the future.
Since the last version of this chapter, little has changed in the field that might signify a shift in this direction. Training in health promotion still lacks any real engagement with scholarly debates in the social science disciplines that have insight into these key problems.
Complexity, context, and causality in health promotion research
Over the past 15 years, a series of publications have charted the specific methodological challenges for evaluating the effectiveness of health promotion interventions (IUHPE 1999; Rootman et al. 2001; Zaza et al. 2005; McQueen and Jones 2007). There has been some scepticism about applying the methodological protocols of evidence-based medicine (EBM) and RCTs as the gold standard because of the problems of complexity and context (McQueen 2007). One emerging alternative has been to use different methods for synthesizing evidence, such as the realist (Pawson et al. 2005) or meta-narrative (Greenhalgh et al. 2005) review approaches. A more detailed treatment of these latter approaches is beyond the scope of this chapter; however, one further potential for advancing beyond traditional EBM-type methods, is in the use of so-called ‘systems thinking’ or ‘complexity science’ to understand the rich complexity and contextual subtlety of the settings within which health promotion interventions take place, and of the interventions themselves.
Key to understanding the critique of EBM and some of the proposed alternative strategies is the different nature of how causality is conceptualized. The realist alternative has a direct, philosophical critique of the underlying empiricist-positivism of EBM’s approach to causality (Bhaskar 2008). Conversely, systems thinking and complexity science approaches are more concerned with EBM’s inability to take account of the interactive, emergent, and non-linear dynamics of causation that are crucial to understanding health promotion interventions as complex adaptive systems that intervene in the context of settings that are themselves complex adaptive systems.
Some health promotion researchers have started to take seriously the potential for a complexity or systems approach to health promotion interventions (Rickles et al. 2007; Shiell et al. 2008; Hawe et al. 2009; Trickett et al. 2011). These emergent attempts to apply complexity science have yet to show fruit (though systems thinking in public health has a longer pedigree), yet they hold much potential to transcend the current impasses in health promotion effectiveness research.
The role of social media
Finally, an important emerging issue, and one that has attracted much attention, is the potential role of social media in public health. The pervasive use and influence of the Internet and social media in nearly all parts of the world, presents new opportunities and challenges for health promotion and health education (see Chapter 4.3). A key feature that differentiates social media from more traditional communication processes is its interactive nature, where communications are not a one-way process, and where users also play an active role. This allows the formation of new online communities, which can enable virtual participation and collaboration among its members.
In this way, social media can provide resources as well as social support for patients with specific diseases or individuals with specific needs. In view of this, social media is emerging as a key platform for the dissemination of preventive health information. This can provide additional scientific information for individuals and communities, which can facilitate and enable greater public participation in the discussion about how the evidence base could be best used for the community. However, there are risks too that social media platforms could be used as avenues of persuasion by industry and other players who have vested interests in promulgating specific points of view.
Nevertheless, social media can also be used as a tool to listen to a much wider range of individuals and groups within the community and internationally. This can provide very useful inputs that could balance the traditional, more top-down, nature of public health programming. As a corollary, social media provides a major platform for health advocacy and activism that could lead to the strengthening of community action, the transformation of personal skills, and draw attention to health issues arising from social inequalities.
We have chosen not to give a technical survey of the health promotion field for which there are many excellent sources available (Tones and Green 2004; Green and Kreuter 2005). Two global perspectives on health promotion have been published, covering substantive areas and technical research problems concerning health promotion effectiveness (McQueen and Jones 2007).
Instead, we have attempted to offer the reader a chance to reflect on a set of core conceptual issues that underlie the health promotion problematic. The five key messages we want to impart about health promotion are listed here:
◆ Health promotion is a complex, often ambiguous concept and set of practices. Health promotion finds its core values and principles in the Ottawa Charter which bears careful examination to comprehend the essence of health promotion.
◆ Health promotion has an intimate connection to health education, with many of its most important and prolific thinkers having a health education background. The revolution in health education practice is directly connected to the birth of health promotion but beyond this, health promotion has its roots in the deep history of public health and has been invigorated by contemporary social movements.
◆ Health promotion is fundamentally about ethics, values, and social justice. Only secondarily is it about technical strategies for behaviour change. The foundational principles of health promotion are equity, participation, and empowerment.
◆ Health promotion is a professionally dominated movement. This requires health promotion professionals to be critical and reflexive in their practice; they must acknowledge power imbalances that favour professional dominance and work to restore power to individuals and communities.
◆ Health promotion must take its duty to enable people to control the determinants of their health seriously. To do this it must engage more directly with contemporary arguments in political philosophy and it must be aware of the dynamics of the global political economy and its effect on the potential for health promotion.
Some of these issues are well known, such as the problem of professional dominance; while others, such as the political economy of health promotion, or the engagement with political philosophy, are not addressed or require much deeper reflection.
We have argued that, at its heart, health promotion is about a radical shift in values for public health. It is not that public health was never concerned with equality or alleviating the misery of the poor; arguably, the so-called ‘golden age’ was driven by exactly these moral questions. However, these intuitive commitments were not sufficiently followed through when it came to not just what outcomes to change but how to change them. Too much of public health, for too long, was driven by a benevolent paternalism that, particularly when it came to dealing with chronic diseases and with vulnerable populations, ended up being counterproductive. Indeed, not only was this paternalism ineffective in many areas, it was unethical. It assumed the authority of experts and professionals, not only to determine technical solutions, but to determine needs. If we are to take the concepts of equity and empowerment seriously, they have profound implications for how we do public health interventions. We have learned that by addressing needs without first establishing a participatory framework that enables individuals and communities to determine those needs for themselves, we fatally undermine one of the most crucial capacities for health: human dignity and self-respect. This is particularly so in communities that have suffered historical social injustices. As Richard Sennett says, people subjected to this disempowering process, experience ‘that peculiar lack of respect which consists of not being seen, not being accounted as full human beings’ (Sennett 2003, pp. 12–13).
We hope to have demonstrated that there are many barriers to realizing this change in power relations; yet, there are also very important opportunities, such as with the Millennium Development Goals and the Commission on the Social Determinants of Health, where there is an increasing clamour for action to redress health inequities through empowering processes. It is notable that even the World Bank, often the subject of brutal criticism for exacerbating inequalities (Stiglitz 2003), has made significant moves toward recognizing the importance of reducing inequity in human development and has integrated an empowerment approach (World Bank 2006). It remains to be seen whether these gains can be translated into major policy changes and effective implementation; nevertheless, it is at this level where health promoters and all public health practitioners and researchers must have a strong advocacy position.
We hope that it is apparent that, in our interpretation, health promotion is much more than a set of technical public health interventions aimed at revamping traditional health education for the twenty-first century. We cannot let go of the core competencies built up by health education and other contributing fields, but we cannot be limited in our vision either. Health promotion has to face up to the fact that, while it may only be a junior partner in the global struggle to develop a more just and equitable world, when it comes to a key human capability and resource, health, it must take a lead role in making the argument for equity, develop and present the evidence for what action is necessary to achieve equity in health, and finally, to hold the powerful accountable where they fail to live up to the demands of justice for health. Embedded in health promotion is an imperative to act ethically and justly. In this case, unlike most, there is no choice.
Text extracts from Hartrick, G. et al. Family nursing assessment: meeting the challenge of health promotion, Journal of Advanced Nursing, Volume 20, Issue 1, pp. 85–91, Copyright © 1994, reproduced with permission from John Wiley & Sons, Inc.
Text extracts from World Health Organization, Health Promotion Glossary (WHO/HPR/HEP/98.1), WHO, Geneva, Switzerland, Copyright © 1998, reproduced with permission from the World Health Organization, http://www.who.int/healthpromotion/about/HPR%20Glossary%201998.pdf?ua=1.
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