Introduction to Health Studies Health Promotion II: Controversies and Issues

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Introduction to Health Studies Health
Promotion IIControversies and Issues

• Dennis Raphael
• School of Health Policy and Management
• York University, Toronto, Canada

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Current Controversies

• Health Promotion and Values
• Values and Health Promotion The Medical and
  Social Cases
• Individual, Community or Societal Focus
• Top-Down (Expert) or Bottom-Up (Community)
  Direction
• Evidence (Scientific, Lay, Critical)
• Current Practice Some Examples
• A Final Word Health Promotion Principles from
  the WHO
• Exercise Putting Health Promotion Principles
  into Action

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Medical Approach (Traditional, Biomedical)

• Health Concept is biomedical, absence of disease
  and/or disability
• Leading Health Problems defined in terms of
  disease categories and physiological risk factors
  such as physiological deviation from the norm
  CVD, AIDS, diabetes, obesity, arthritis, mental
  disease, hypertension, etc.

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Values and Health Promotion The Medical
(Traditional) and Social (Structural) Cases

• Medical Health Promotion
• Scientific Objectivity, Evidence Based, Expert
  Driven
• Prudence, Utilitarianism
• Preserve the Status Quo, Conservatism
• Values identified by David Seedhouse in Health
  Promotion Philosophy, Principles, and Practice,
  New York John Wiley Sons, 1997.

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Socio-Environmental Approach (Structural)

• Health Concept is a positive state defined in
  connectedness to one's family/friends/community,
  being in control, ability to do things that
  are important or have meaning,
  community and societal structures supporting
  human development
• Leading Health Problems defined in terms of
  psychosocial risk factors and socio-environmental
  risk conditions poverty, income gap, isolation,
  powerlessness, pollution, stressful environments,
  hazardous living and working conditions, etc.

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Values and Health Promotion The Medical
(Traditional) and Social (Structural) Cases

• Social Health Promotion
• Fairness, Empowerment, Solidarity
• Egalitarianism, Social Democracy, Socialism,
  Marxism
• Values identified by David Seedhouse in Health
  Promotion Philosophy, Principles, and Practice,
  New York John Wiley Sons, 1997.

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Health Promotion Focus Individual, Community or
Societal

• Individual focus sees the target of intervention
  as the individual. Can be applied within the
  medical, lifestyle, or structural models.
• Screening, lifestyle change, emancipatory
  education.

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Health Promotion Focus Individual, Community or
Societal

• Community focus sees the target of intervention
  as the community.
• Can emphasize community organizing in the service
  of medical screening, behaviour change, or
  effecting structural change.

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Community Quality of Life Study
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Health Promotion Focus Individual, Community or
Societal

• Structural focus sees societal institutions as
  influencing health.
• Usually recognizes the presence of resource and
  power inequalities and the need to address these
  inequalities in society. May involve a class,
  gender, or ethnicity approach.
  

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Top-Down (Expert) or Bottom-Up (Community)
Decision-Making

• Who decides what the health issues are?
• Who decides how to address these issues?
• Who benefits from these actions?
• Much of public health and health policy decisions
  are made by "experts" whose life experience may
  share little with those of the clients whose
  interests they are serving.
• Public health and health policy decisions may be
  based traditional models of health that may be
  too narrow in their outlook and not what citizens
  want.

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Evidence in Health Promotion I

• Decision-making in health promotion should be
  influenced by at least three kinds of knowledge.
• Instrumental knowledge is also known as
  traditional, scientific, positivist,
  quantitative, or experimental and is the dominant
  paradigm in health research.

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Evidence in Health Promotion II

• Lay or Interactive knowledge is derived from
  lived experience. Also known as constructivist,
  naturalistic, or ethnographic, knowledge, its
  focus is on meanings and interpretations
  individuals provide to events.

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Evidence in Health Promotion III

• Critical knowledge is reflective knowledge and is
  concerned with the role that societal structures
  and power relations play in promoting
  inequalities and disenabling people.

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Current Practice in Ontario Some Examples

• Individual/Lifestyle (Heart Health in Ontario)
• The Ontario Ministry of Health has allocated
  17,000,000 over five years to programs that
  address the cardiovascular health risk factors of
  tobacco use, poor diet, and physical inactivity.
• Examples include smoke-cessation workshops
  contests, heart-health recipe contests, nutrition
  workshops, direct mail print materials, walking
  trails, screening for CVD risk factors, mailed
  material about healthy weight, videotapes about
  lifestyle issues, food label information, etc.

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Individual/Lifestyle (Heart Health in Ontario)

• The program is based on medically oriented models
  that view the cause of disease as traditional
  biomedical risk factors of high cholesterol,
  tobacco use and physical inactivity. It is
  believed that through community-based activities,
  these risk factors can be modified.

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Community (Healthy Communities in Ontario)

• Healthy Communities Ontario evolved from the
  Healthy Cities approach of the City of Toronto.
  Emphasizes local social, economic, and
  environmental issues.
• Community animators work with community members
  to promote discussion and action on the linkages
  between problems and their root causes.
  

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Community (Healthy Communities in Ontario)

• Emphasizes participation, multi-sectoral
  involvement, local government commitment, and
  healthy public policy.
• Examples include Food security in Peterborough.

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The OHCC works with the diverse communities of
Ontario to strengthen their social,
environmental, and economic well-being
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Structural (North York Heart Health Coalition)

• Produced a report questions the value of reliance
  on medical and lifestyle approaches to CVD
  prevention.
• Stresses differences among Canadians in CVD
  status.
• Identified income and social exclusion as causes
  of CVD.

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Structural (North York Heart Health Coalition)

• Recommended means to
• Reduce poverty
• Reduce social exclusion
• Restore social infrastructure to support health

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Health Promotion Principles from the WHO

• Health promotion initiatives should be planned
  and implemented in accordance with the following
  principles
• Empowering Health promotion initiatives should
  enable individuals and communities to assume more
  power over the personal,
  socioeconomic and environmental factors that
  affect their health.

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Health Promotion Principles from the WHO

• Participatory Health promotion initiatives
  should involve those concerned in all stages of
  planning, implementation and evaluation.
• Holistic Health promotion initiatives should
  foster physical, mental, social and spiritual
  health.
• Intersectoral Health promotion initiatives
  should involve the collaboration of agencies from
  relevant sectors.
  

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Health Promotion Principles from the WHO

• Equitable Health promotion initiatives should be
  guided by a concern for equity and social
  justice.
• Sustainable Health promotion initiatives should
  bring about changes that individuals and
  communities can maintain once initial funding has
  ended.

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Health Promotion Principles from the WHO

• Multi-strategy Health promotion initiatives
  should use a variety of approaches, including
  policy development, organizational change,
  community development, legislation,
  advocacy, education and communication, in
  combination with one another.

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A Final Exercise

• Imagine that you were charged with reducing the
  use of tobacco among teenagers within a
  community.
• What might be some activities be that you would
  carry out?
• How would you decide which activities to carry
  out?

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A Final Exercise

• What might be some barriers to carrying out your
  program to promote tobacco use reduction?
• What principles and values are influencing your
  program's approach?