Action statement for health promotion in Canada

Canadian Public Health Association
July 1996

Preamble

This Action Statement is the product of a two-year consultation process involving more than 1,000 people. Participants in the process were mainly health professionals and volunteers who work to promote health. Other participants came from areas such as social services, research, education, recreation, environment and law enforcement. These people share the values and ways of working that define health promotion, even though they may not call themselves health promoters. Together, we represent a community of shared purpose. The purpose of this document is to provide strategic direction to this community.

Canada has a rich legacy in health promotion. A New Perspective on the Health of Canadians (1974) demonstrated the wide array of influences on health. The Ottawa Charter for Health Promotion (1986) and Achieving Health for All: A Framework for Health Promotion (1986) articulated the principles of health promotion and proposed strategic frameworks for action. This document is not intended to replace or update the Ottawa Charter for Health Promotion. We believe the Ottawa Charter should continue to be used as the framework that defines health promotion as an approach and concept all of us can use. Rather, this statement is intended to focus our efforts in the current climate so different from the optimistic days when the Ottawa Charter was first written.

Today, poverty is increasing and the income gap between rich and poor is widening. Unemployment persists in spite of economic growth. Communities are under increasing pressure from global economic practices that imperil the environment and consolidate wealth and power in private corporations with few legal responsibilities to the common good. Cuts in government spending threaten the social safety net and health system that have served us well and have defined us as a caring people.

In light of these realities, promoting health requires that we focus our efforts and prioritize our actions by:

affirming and sharing the vision and values of health promotion;
emphasizing the creation of alliances across and between sectors;
honing our knowledge, skills and capacity to improve health;
emphasizing political commitment and the development of healthy public policies;
strengthening our communities; and
ensuring that health systems reform promotes health both inside and outside the health care system

Vision and Values

Health promotion's commitment is derived from a vision of how the world could be if it was based on an understanding of the determinants of health. The Ottawa Charter for Health Promotion identified the prerequisites for health as peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity. Today, with additional knowledge from population health research, we recognize that additional critical health determinants include healthy child development; adequate incomes; a small gap between rich and poor; the absence of discrimination based on gender, culture, race and sexual orientation; life-long learning opportunities; healthy life-styles; meaningful work opportunities with some control over decision-making; social relationships that respect diversity; freedom from violence or its threat; freedom from exposure to infectious disease; protection of humans from environmental hazards and protection of the environment from human hazards. In short, improving health is a vital component of human development.

Health promotion draws on an explicit values base.

Individuals are treated with dignity and their innate self-worth, intelligence and capacity of choice are respected.
Individual liberties are respected, but priority is given to the common good when conflict arises.
Participation is supported in policy decision-making to identify what constitutes the common good.
Priority is given to people whose living conditions, especially a lack of wealth and power, place them at greater risk.
Social justice is pursued to prevent systemic discrimination and to reduce health inequities.
Health of the present generation is not purchased at the expense of future generations.

Health promotion is guided by seven strategic principles.

Health promotion addresses health issues in context. It recognizes that many individual, social and environmental factors interact to influence health. It searches for ways to explain how these factors interact in order to plan and act for the greatest health gain.
Health promotion supports a holistic approach that recognizes and includes the physical, mental, social, ecological, cultural and spiritual aspects of health.
Health promotion requires a long-term perspective. It takes time to create awareness and build understanding of health determinants. This is true for organizations as well as for individuals.
Health promotion supports a balance between centralized and decentralized decision-making on policies that affect people where we live, work and play.
Health promotion is multisectoral. While program initiatives often originate in the health sector, little can be done to change unhealthy living conditions and improve life-styles without the support of other people, organizations and policy sectors.
Health promotion draws on knowledge from a variety of sources. It depends on formal knowledge from the social, economic, political, medical and environmental sciences. It also depends on the experiential knowledge of people.
Health promotion emphasizes public accountability. Those providing health promotion activities need to be accountable and to expect the same commitment from other individuals and organizations.

Priority Areas for Action

The Ottawa Charter has set the strategic course for the past decade; its direction is as important today as it was ten years ago. A renewed health promotion thrust will focus on three of the Charter's strategies: advocating healthy public policy, strengthening communities and reforming health systems. To improve action in each area, the focus of practice needs to be sharpened and some infrastructures need to be strengthened or developed.

Governments at all levels, non-governmental and voluntary organizations, private sector organizations, community groups and individuals all have key roles in transforming this statement from words to action. But assuming that the Action Statement is everybody's business can lead to it becoming nobody's business.

We commit ourselves to ensuring that the public, private and not-for-profit sectors take action on the priority areas outlined in this statement. It is essential that each and all of the key players take a leadership or partnership role in the particular actions that best fit with their mandate, interest, ability, obligations and sphere of influence.

Advocate Healthy Public Policies

Policies shape how money, power and material resources flow through society and therefore affect the determinants of health. Advocating healthy public policies is the most important strategy we can use to act on the determinants of health. Current policies that emphasize deficit reduction and private sector economic growth can be unhealthy for people. These policies may increase economic inequalities, environmental degradation, social intolerance and violence.

Healthy public policies are required to:

reduce inequalities in income and wealth;
ensure that economic activity contributes to human development and is environmentally and socially sustainable;
protect people and the earth from toxic pollution, resource depletion and systemic global effects;
create safe, secure and meaningful work opportunities;
create opportunities for meaningful activities beyond the workplace (i.e., at home and in the community);
create safe, supportive environments in schools, workplaces and the community;
support the active participation of people significantly affected by a particular policy in discussing, choosing and implementing the best option;
ensure that individuals and families have access to the recreation opportunities and other programs we need to stay healthy; and ensure that individuals and families have access to the resources we need to choose and sustain healthy life-styles.

To date, most policies in the area of health promotion have supported healthy life-styles. Now we need to give more emphasis to policies that create healthy living conditions and work to ensure that the voices of society's least powerful express their concerns in these policy issues.

Advocating healthy public policy involves:

working with others to identify the most important areas where policy can make a difference;
finding partners with whom to develop policy options;
encouraging public dialogue on policy options;
persuading decision-makers to adopt the healthiest policy option; and
following up to make sure the policy is implemented.

Healthy Public Policies: Priorities for Action

Focus health promotion practice more on developing and implementing policies that create healthy living conditions and less on policies that influence personal life-style behaviors.
Participate in alliances to deal with critical issues such as growing income disparities, child and family poverty, environmental degradation, support for the caregiving role of family members, job security, unemployment and under-employment, independent living in old age and Aboriginal rights.
Provide training in healthy public policy "how-to's" including:
- analysis of health information;
- policy development;
- community participation;
- advocacy strategies; and
- evaluation of advocacy work in public policy.
Conduct research into healthy public policy options including:
- case studies of their implementation (process, infrastructure, effects); and
- evidence of their effectiveness
Undertake health impact assessments at all levels on public and private sector policies that are likely to have a significant effect on people's health.
Build the policy and resource capacity within local and regional health authorities to:
- act on the determinants of health;
- support health workers and community groups who advocate healthy public policies; and
- advocate healthy public policies with appropriate government levels and private sector organizations.
Issue periodic report cards on local, regional, provincial, territorial and national progress toward goals and objectives that address the determinants of health.
Create and maintain provincial and territorial health councils to advise on and monitor public policies that affect health. These multidisciplinary and multisectoral councils would be charged with generating action on health goals and objectives, and would be resourced sufficiently by government grants to perform their tasks, without interference in their day-to-day work.
Create intersectoral committees of provincial and territorial cabinets and within local governments to consider health impacts when approving policy and allocating resources.
Create an intersectoral committee of the federal cabinet to consider health impacts when approving policy and allocating resources.
Create a multidisciplinary focal point (organization or network) that has the capacity to undertake policy research and advocacy, support the development of alliances for health promotion and monitor key public and private sector policy initiatives.

Strengthen Communities

Communities are the dynamic groups that people form when they share common space, identities, interests and concerns. People experience community through close family and friendship ties and through relationships where they work, worship, study, volunteer, play and carry out their civic rights and responsibilities. Our health is created and sustained in these community relationships. Individuals belong to many different communities, not all of which embody the quality of sharing and caring which characterizes health promoting communities. There is abundant evidence that as sharing and caring disappear, health deteriorates.

Health promotion strengthens communities by supporting community groups that strive to create healthy living conditions and healthy life-styles. Initiatives such as the healthy communities' movement have been particularly helpful in this work. Some communities do not have all of the resources necessary to ensure their own health. This may be particularly true for some poor families with young children, people with disabilities, Aboriginal communities, new immigrants and refugees, and older people. Efforts to promote health need to give priority to these communities.

Strengthen Communities: Priorities for Action

Participate in local alliances working to change unhealthy living conditions and support environments that promote healthy life-styles.
Support a settings approach to practice (e.g., healthy communities, schools, workplaces and health care facilities).
Make community development a priority with people whose living and working conditions (especially the lack of wealth and power) place them at greatest risk for poor health.
Help strengthen the capacity of community members to identify issues and persuade politicians to implement change.
Share power more widely within health organizations. Many health care and community workers feel powerless in their own organizations. Before we can share power, we first must have power to share.
Provide multidisciplinary training opportunities in how to undertake community development, work with vulnerable groups and multicultural diversity, analyze and synthesize knowledge-based practice, and develop and use appropriate evaluation methods.
Provide funding that supports:
- mutual aid and self-help networks;
- community groups acting to nurture citizenship, maintain a sense of community, sustain the environment and foster healthy living conditions; and
- national, provincial, territorial and local efforts to use health information technology to strengthen communities, foster self-help and break down inequities.
Support networks for healthy communities. Secure sufficient funding to allow networks to share experiences, translate local lessons and concerns into provincial, territorial, national and international policies, and, advocate these policies to appropriate provincial, territorial, national and international governments and non-governmental organizations.
Develop appropriate evaluation methods for community-based health promotion work, community development and healthy communities projects.

Reform Health Systems

Health systems reform has two objectives: to shift the emphasis from treating disease to improving health, and to increase the effectiveness and efficiency of the health care system. These objectives are expressed in most provincial and territorial policy documents concerning health services restructuring and goals for population health.

The reality of the reform process, however, is quite different from its rhetoric. The broad determinants of health have not been addressed and political and public debate continues to focus on insured medical treatments and reducing the number of hospital beds. Provincial health councils, which brought a determinants of health perspective to health reform, have largely been disbanded. In some cases, devolution of power to local and regional health authorities has become a downloading of responsibility without sufficient money, staff, authority and training to do the job.

Health promotion infrastructures have been weakened and in some areas they have been dismantled. Power imbalances within the system and between health professionals and their clients have been slow to change. In many areas, supports for client-centered primary health care, community-based services, family care-givers and community action have been cut, rather than increased. Mass layoffs in the health care sector (which employs a significant percentage of the working population) will only worsen the health consequences associated with forced retirement and unemployment. There are now fewer professionals to work with vulnerable Canadians at the very time they are most needed. Families, especially women, are expected to pick up the slack.

Shifting the emphasis from treating disease to improving health requires:

improved access to client-centered primary health care services;
increased support for community development work;
improved community-based care services;
increased support for family-based care;
stronger health protection programs;
increased support for informed community participation; and
increased priority given to the promotion of health in the public, not-for-profit and private sectors.

The actions that follow are designed to ensure that the reality of reform is true to the stated values and strategic principles of health promotion.

Reform Health Systems: Priorities for Action

Provide local and regional health authorities with the mandate and resources they need to support families, strengthen primary health care, improve community-based services and work in multidisciplinary teams.
Provide mechanisms for increasing representative community participation in decision-making in local and regional health authorities. Ensure that board membership includes people with knowledge of health promotion and the broad determinants of health. (Consider becoming a member of local or regional health boards yourself.)
Develop and maintain appropriate infrastructure support for health promotion within the health system and assign dedicated resources to the promotion of health.
Collect consistent baseline data on the determinants of health and develop regional health profiles that measure health status. The information must be accessible, comprehensive and free.
Ensure that evidence on the effectiveness of curative and preventive interventions is considered when resources and priorities are allocated within the health system.
Present health promotion research results in a manner that is readily understood and usable by health professionals, the public and the media. State-of-the-art technology, such as the Internet, should be used to further disseminate this information.
Capitalize on life-style programs and issues as entry points for actions on the broader determinants of health and provide resources for this work.
Advocate the preservation of universal health care as set out in the Canada Health Act. Vigorously oppose user fees, since they discriminate against people with low income and protest federal decreases in transfer payments.
Empower health professionals to support the self-care efforts of their clients.
Address the power imbalances between health professionals within the health system.
Improve multidisciplinary practice for health promotion by:
- increasing understanding of the strategic relationship between primary health care, disease and injury prevention, health protection and health promotion;
- documenting case studies of multidisciplinary health programs that integrate efforts in primary health care, disease and injury prevention, health protection and health promotion; and
- strengthening training in health promotion theory and strategies in post-secondary curricula for various health disciplines.
Build stronger alliances among those who are working in health promotion, population health, community social services and primary health care in order to:
- share different perspectives on how to promote health;
- strengthen disease and injury prevention efforts;
- encourage multidisciplinary action on the determinants of health; and
- strengthen the collective voice for advocating healthy public policies.

Supporting Effective Action

While there are many factors that contribute to effective action, at this time the two most urgent factors are enhancing our knowledge base and building stronger alliances.

Enhance Knowledge and Skills

Considerable knowledge of effective health promotion action exists. Some of this knowledge has been generated through formal research and some through the experiences of community-based initiatives. Indeed, this accumulated wisdom is the basis of this Action Statement. However, certain skills need to be enhanced to shift the focus of practice. These skills include utilizing community development, working with vulnerable groups, developing healthy public policies, working in multidisciplinary settings, doing social marketing and using health impact assessment tools and appropriate evaluation methods.

A better understanding of the interaction of the determinants of health is needed in order to focus priorities for healthy public policies and health promotion actions, and to determine the best methods to evaluate their impacts. Several university-based Centres for Health Promotion Research now exist and are contributing to this understanding. But, health promotion research and training remains underfunded, especially when contrasted to funding for medical research. More support is needed for participatory research.

Contemporary research agendas need to focus on:

demonstrating the effectiveness of health promotion;
increasing the role of community in research;
translating lessons from research into practice and practice into research; and
investigating conceptual and methodological issues (e.g., qualitative, quantitative and participatory research).

Build Alliances

Alliances are coalitions or partnerships among different organizations that share a common goal. Through joint planning, resource sharing and increased political strength, alliances can accomplish more than groups acting alone. Health promotion has a long history of coalition and partnership work. Most of this work, however, has tended to involve only those concerned about specific disease or life-style issues. A concerted effort is required to form alliances across sectors that can advocate and affect change on the broad determinants of health. These alliances need to be formed at local, regional, provincial, territorial, national and international levels.

Building alliances for action on health determinants necessarily involves people and organizations with different goals and priorities. Developing a common strategic goal around which all member groups can mobilize requires patience, persistence and flexibility. Within the framework of our visions and values, we need to negotiate a common agenda with our partners, rather than imposing our agenda on them.

Alliances for action on health determinants need to give more attention to working with the private sector, non-governmental organizations, and with members of vulnerable groups who often require resources and support in order to participate.

Conclusion

This Action Statement for Health Promotion in Canada is directed toward all who share the values of health promotion. But, Canada exists within a global community. Political, economic and environmental conditions around the world determine the health of Canadians, just as conditions in Canada determine the health of many people beyond our borders. Health promotion works within political boundaries but is not confined by them. We believe this Action Statement is important for health promoters around the world and hope that it will inspire action elsewhere. We commit ourselves individually and collectively, locally and globally, to demonstrate these actions in our lives, our families, our work, our communities, our organizations and our public policies.

Follow-up

The Canadian Public Health Association is committed to working with a variety of organizational and community partners to:

facilitate action on the ideas presented in this statement; and
monitor and report on our progress.

The financial support provided to the Perspectives on Health Promotion project by the Health Promotion and Programs Branch, Population Health Directorate, Health Canada is greatly appreciated.