health promotion i : turning the rhetoric into reality
TRANSCRIPT
Overview • Review of the development and evolution of the
Ottawa charter (the rhetoric)
• ‘Is the Ottawa charter for health promotion still useful
for today’s public health practice ?’ (Montreal Message
2006)
• IUHPE and CCHPR review of Global issues and
challenges facing health promotion- How has health
promotion permeated public health practice? (the
reality)
• What appears working well and why? What are the
remaining challenges? (the reality)
Context for Ottawa (Eriksson & Lindstrom 2007)
1940s-1960s WHO founded, health re-defined- biomedical model to prevention and protection
I970s Health promotion theme tackling preventable disease and risk behaviours
Lalonde report 1974 Alma-Ata 1978
1980s Concepts and principles of health promotion 1986b The Ottawa Charter 1986a
Health promotion theme continues stressing importance of complementary approaches
Ottawa Charter 1986
•Prioritise the social model
of health
•Target wider determinants
•Link achievements of
health to political,
economical and social
change
•Not just business of health
•Key role of health
promoters
•Healthy Public Policy
•Supportive environments
•Strengthen community
action
•Develop personal skills
• Reorientate health
services
Key principles Key actions
Scriven 2005, Scriven & Garman 2005
Subsequent iterations
WHO Conference
Adelaide, Australia 1988
Sundsvall, Sweden 1991
Jakarta, Indonesia 1997
Mexico, Mexico city 2000
Bangkok, Thailand 2005
Nairobi, Kenya 2009
Theme
Healthy public policy
Supportive environments for
health
Health promoting partnerships
‘settings’
Bridging the equity gap
The determinants of health
Bridging the implementation
gap
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The Settings approach
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‘the ethos of the setting
involves ensuring the
activities are mutually
supportive and combine
synergistically to
improve health and
wellbeing of those who
live, work or receive care
there’ Tones & Green
2004 p 271
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Behavioural
Social environmental
Salutogenesis
Evolution of approach over time
Medical model ignored the determinants of health?
•Environment
•Determinants of Health - Health Field Concept, Lalonde ‘74
•Lifestyle
•Healthcare System
•Biology
Lifestyle and personal behaviour
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•Plays a part •Assumes if acquire skills and knowledge then behaviour changes •Takes no account of social economic conditions ‘control’ • Blames the victims
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The Determinants of Heath (Dahlgren & Whitehead 1991)
More recently interest in ‘Salutogenesis’
• Antonovsky 1997
• What creates health?
• Sense of Coherence (SOC) and
Generalised Resistance Resources (GRR)
• SOC (comprehension, manageability and
meaningfulness)
Paradigm Wars
Implications for
prediction,
causation,
what to do /to prevent
and what to evaluate
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Explanations for social determinants of health inequality :
Biological
Psychosocial
Behavioural
Environmental
Political determinants
Traditional approach to researching social determinants and disease
Health Outcome
Social class
Environmental factor
Psychosocial Stress
Behaviour
Early Genes Culture
Life
SocialStructure
Materialfactors
Work
PsychologicalSocial
environment
Health
behaviours
Brain
Neuroendocrine
and immune
response
Pathophy siological
changes
Organ impairment
Well-being
MortalityMorbidity
A model of the social determinants of health showing biological pathways in a social context (Brunner & Marmot 1999).
Oral Health Promotion
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Oral health inequalities
Significant social class differences
• Caries
• Periodontal diseases
• Oral cancers
• Self reported oral health status
Individual, area and population level
Certain ethnic minority groups & socially
excluded groups
Close link with general health
(Watt and Sheiham, 1999; Locker 2001)
Common risk factor approach
School
Policy
Work place
Housing
Political environment Physical environment Social environment
Preventive Strategies: Risk and the Whole Population Approach’
Level Level
Frequency Frequency
Rose 1992
High risk
High risk
A B A
•Fiscal Measures
•National &/or local policy initiatives
•Legislation/Regulation
•Healthy Settings- HPS
•Community Development
•Training professional groups
•Media Campaigns
•School dental health education
•Chair side dental health education
•Clinical Prevention
‘Upstream’
Healthy Public Policy
‘Downstream’
Health Education & Clinical Prevention
Upstream - downstream interventions
Watt, CDOE (2007)
The Montreal Message (2006)
‘Is the Ottawa charter for health
promotion still useful for today’s
public health practice?
• Useable, useful and used?
• Up to date?
Global IUPHE & CCHR project
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•10 regional field reports to inform ‘Renewing our commitment to the Ottawa Charter: the way forward’ •Five key areas included: health promotion policy, health promoting services, funding and availability of resources, community participation in health research and information
‘Shaping the future of health promotion: Priorities for action’
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•Putting healthy public policy into practice •Strengthening structures and processes •Towards a knowledge based practice •Build a competent health promotion workforce •Empower communities
IUPHE/CCHR 2007
Putting healthy policy into practice
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Scriven & Speller 2007
•Field reports stressed need for multsectoral action to address social determinants •Link health promotion to social determinants •Adapt to local culture, politics, economy •State structures, processes funding etc for implementation •Late adopters moving faster
National oral health policies
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Oral health promotion integrated with general health promotion to act on determinants
•‘Healthy Japan 21’ 10 year national campaign
•Promotes healthy behaviours & build healthy
environments
•National objectives shared and discussed
•Oral health is one of nine areas
•Continuous sharing of experience of implement and
action plans important factor in success
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Miyasaki 2010,
Multisectoral action on inequalities
Brushing for life- (UK 2000) health
visitors distributing toothbrushes and
toothpastes to parents of young children
in most deprived areas of the country .
Set up in order to tackle inequalities
Dinky project (UK 2009) Training staff
in nurseries to use ‘play’ to promote
speech language and oral health in
deprived wards
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Strengthening structures and processes
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Scriven & Speller 2007
•Strategy has given direction •Evidence of multi sectoral action and a ‘settings’ approach •Health care takes on responsibility for health promotion •National centres of excellence •Lack of funding •Lack of boundaries
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Smiling for life- (UK 2001) targeting preschool children attending day care facilities and the staff of facilities. Detailed planning with parents and children and staff before implementation, to create a preschool ‘setting’
Multi sectoral action and oral health
British Columbia Oral Cancer Prevention Program links community dental practices, referral centres and created partnerships with scientists and clinicans
National policies
•Sugars in medicine
•National Fruit Schemes
•Water in schools scheme (ban fizzy
drinks)
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Strengthening structures & Processes
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Scriven & Speller 2007
•Evidence of multisectoral approaches and the settings approach •Reach of settings approach could be expanded •Health care take on responsibility for health promotion and community development, but some paradox •Need for centres of excellence
Settings approach- Schools and oral health promotion
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•School children often primary but not all •Level out gradient in morbidity, risk factors, knowledge attitudes and behaviours •Often small, started by visionaries or external funders
Settings approach- Schools and oral health promotion
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•Integrate health promotion into structure of the education system, mirrored in teacher training and educational materials and syllabus •Personnel at all levels should be involved and skill set developed to support implementation •Involve parents and schools, creation of school as a supportive setting- ownership and sustainability •Involve health sector to ensure accurate advice and technical assistance
Jurgensen 2010
Possilpark (Blair 2004)
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Towards knowledge based practice
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•Field reports stressed need for multsectoral action to address social determinants •Link health promotion to social determinants •Adapt to local culture, politics, economy •State structures, processes funding etc for implementation •Late adopters moving faster
Scriven & Speller 2007
•Funding key to develop knowledge based practice •Little evidence of impact and outcome • Need to increase research and reporting of evaluations •Dissemination of information •Policy makers and health promoters need to access information
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Lack of funding for building capacity and competency
Health promotion structures, processes weakened
Insufficient resources for systematic evaluation
Lack of evidence of effectiveness
Inadequate funding Health promotion omitted from policy
Relationship between funding opportunities and priorities
Dissemination example: Public Health Agency of Canada! www.publichealth.gc.ca
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Best practice in relation to oral health promotion interventions •Strategic Planning for Oral Health •Dental Surveillance, Monitoring and Screening •Oral Health Promotion and Integration of Services •Oral Health Promotion for Vulnerable Populations •Oral Health Promotion for Infants & Preschool Children •Oral Health Promotion for Children and Youth
Building a competent workforce
•Lack of capacity linked to inadequate funding
•Infrastructure preferred to health promoters
•Lack of skill set and training compromising knowledge
based practice
•Lack of centres for training
•Balance between creating a specialist team and
widening ownership and contribution to health
promotion
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Scriven & Speller 2007
SCHOLARSHIP OF COMMUNTIY ENGAGEMENT Triad Partnership Model: The CHESP Model
Community Higher
Education
Service
Provider
• PARTNERSHIP
•(HEI staff and
students)
Source: Lazarus, 2001
Empowering communities
•Essential- and grass roots civil society have sustained
programmes when govt funding withdrawn
•What works best appears to be working with and
participation from local communities, using local culture
to shape and promote health
•Community participation standard practice
everywhere
•What about does who exist outside ‘communities’
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Scriven & Speller 2007
Oral health as part of community development and empowerment •Possilpark , food co-operative started as
breakfasts in schools
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Oral health as part of supportive environments and empowerment • Regeneration Schemes
• Sure starts/Head starts
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‘to deliver the best start in life for every child by
bringing together early education, childcare,
health and family support’
•participation of local parents and carers, joined
up working, cultural sensitivity and avoidance of
stigma
•National objectives
•geographically defined areas, high levels of
deprivation, under 4 population 600-800
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Surestart programmes
Oral health needs assessment in local Surestart in Southeast London
•SSLP was identified as an important source of information,
support and social interaction for participants
•Informal networks in SSLP authoritive as formal networks
• Concerns related to introducing healthy eating, tooth
brushing, teething and access to dental care
•Parenting skills and the social support provided by the
SSLP
•Oral programme tap into wider interventions supporting
support needs of parents
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The implementation gap
•Putting Policy into practice: is moving forward with
some notable examples of good practice on policy and
inequalities
•Strengthening structures & processes: good practice
around settings and multi sectoral action. Need greater
links with academic, specialists societies to support
quality of implementation, need centres of excellence
and dissemination.
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The implementation gap’ continued
•Building capacity: a huge challenge, chronic underfunding, lack
of training opportunities , but increased skills and
professionalization in developed countries. More Multi sectoral
working to build capacity and reach required
•Knowledge based practice: much more work needed,
hampered by funding, lack of expertise and dissemination
•Community empowerment: some good examples and works
because underlying intervention tackling wider determinants
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Returning to the Montreal Questions (2006)
‘Is the Ottawa charter for health promotion still useful for today’s
public health practice?
• Useable (need more structure and process, intervention )
• Useful ( need to be more radical)
• And used? ( (curate’s egg), but could be spread wider)
• Up to date ? (yes moving towards contemporary
understandings)
A lot achieved, a lot more to do……….. • Being clear about how radical Ottawa is, insist
on policy and clear structures/processes
• Advocacy for and implementation in its wider
sense
• Enhancing and developing the workforce
• Increasing focus on knowledge based practice
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