Introduction to Health Studies Health Promotion II: Controversies and Issues Dennis Raphael School of Health Policy and Management York University, Toronto, Canada

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

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.

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.

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.

Social Health Promotion 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.

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.

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.

Community Quality of Life Study

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.

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.

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.

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.

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.

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.

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.

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.

Community (Healthy Communities in Ontario) Emphasizes participation, multi-sectoral involvement, local government commitment, and healthy public policy. Examples include: Food security in Peterborough. Advocacy: “The OHCC recognizes the important role that public policy plays in creating communities that support social, economic, and environmental health... Less action has been taken at the provincial and national levels because the OHCC is not an advocacy group.” See Inspiring change: Healthy cities and communities in Ontario. Toronto: Ontario Healthy Communities Coalition, 2000.

The OHCC works with the diverse communities of Ontario to strengthen their social, environmental, and economic well-being

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.

Structural (North York Heart Health Coalition) Recommended means to Reduce poverty Reduce social exclusion Restore social infrastructure to support health

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.

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.

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.

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.

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?

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?