Chapter 1 Part 1 Introduction to Health Promotion © John Hubley & June Copeman 2008 Refocusing upstream "I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. I jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out on the bank beside the man and work to revive her with artificial respiration. Just when she begins to breathe, I hear another cry for help. I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration. Just when he begins to breathe, I hear another cry for help. Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see who is upstream pushing them all in...." A story told by Irving Zola - but is used in an article by John B. McKinlay in "A Case for Refocusing Upstream: The Political Economy of Illness" McKinlay, J.B. (1981) healthy person Primary prevention onset of symptoms (reversible) Secondary prevention screening case finding early prevention advanced symptoms (not reversible ) disability death Tertiary prevention rehabilitation Death rates from lung cancer (per 1000) by number of cigarettes smoked, British doctors, 1951-61 Average number of cigarettes smoked per day Health Field Model Human Biology (Genetics) Lifestyle (Human behaviour) Health Services Environment Human behaviours important for health promotion • Community action - actions by communities to change their surroundings include community participation in health decision-making • Health behaviours – actions people undertake to be healthy • Utilization behaviours – utilization of health services • Illness behaviours - recognition of symptoms and prompt self-referral • Compliance (adherence) – following course of prescribed medicines • Rehabilitation behaviours – what people need to do after an illness/surgery to recover Saving Lives – Our Healthier Nation (1999) This White Paper from the Department of Health for England set the agenda for health policy for the next decade. Lifestyle and human behaviour was given a prominent role through its “Ten Tips for Better Health” 1. 2. 3. 4. Don't smoke. If you can, stop. If you can't, cut down. Follow a balanced diet with plenty of fruit and vegetables. Keep physically active. Manage stress by, for example, talking things through and making time to relax. 5. If you drink alcohol, do so in moderation. 6. Cover up in the sun, and protect children from sunburn. 7. Practise safer sex. 8. Take up cancer screening opportunities. 9. Be safe on the roads: follow the Highway Code. 10. Learn the First Aid ABC - airways, breathing, circulation Mortality from Coronary Heart Disease men aged 20-64 by social class, England and Wales, 1991-93 England and Wales = 100 Social Class 63 Professional 73 Managerial 107 Non-manual skilled 125 Manual skilled 121 Partly skilled 182 Unskilled 0 50 100 150 200 Standardized mortality ratios Source: Office for National Statistics (ONS), Health Inequalities charts.ppt Perinatal Mortality Rate By mother’s country of birth, England and Wales, 1997-99 combined Rate per 1,000 live & still births 20 15 14.3 13.5 10.2 10 9.6 8.8 7.9 5 0 Pakistan Caribbean Bangladesh India E Africa UK The Rainbow model - The main determinants of health Independent Inquiry into Inequalities in Health report Chairman: Sir Donald Acheson 1998 Jason’s story "Why is Jason in the hospital? Because he has a bad infection in his leg. But why does he have an infection? Because he has a cut on his leg and it got infected. But why does he have a cut on his leg? But why does he live in that neighbourhood? Because he was playing in the junk yard next to his apartment building and there was some sharp, jagged steel there that he fell on. Because his neighbourhood is kind of run down. A lot of kids play there and there is no one to supervise them. Because his parents can't afford a nicer place to live. But why can't his parents afford a nicer place to live? Because his Dad is unemployed and his Mom is sick. But why is his Dad unemployed? Because he doesn't have much education and he can't find a job. But why was he playing in a junk yard? But why ...?" Towards a Healthy future : second report on the health of the Canadians (1999) Causes of poor health Inequality Social Injustice Alienation Lack of empowerment Tobacco use Poor education Anxiety Low prestige Reckless riskPoverty taking Excess illness Low productivity Early death Proximal and distant causes of illness and premature mortality, JR Seffrin Journal of health education Sep – Oct 1997. Vol 28.No4. An effective response should • Provide the information and power for the community to make decisions • Make the healthy choice the easiest option • Remove barriers to action Health Promotion The process of enabling people to increase control over, and to improve, their health Ottawa Charter 1986 Ottawa Charter for Health Promotion Health Promotion - the process of enabling people to increase control over, and to improve, their health. Strengthen Community Action Enable Mediate Advocate Develop Personal Skills Reorient Health Services Create Supportive Environments Source: Canadian Public Health Association - An International Conference on Health Promotion - November 17-21 1986 Promoting health Health Education Communication directed at individuals, families and communities to influence: Behaviour change Determinants of behaviour change: awareness/knowledge decision-making beliefs/attitudes empowerment community participation Service improvement Advocacy Improvements in quality and quantity of services: Agenda setting and advocacy for healthy public policy: accessibility case management counselling patient education outreach social marketing policies for health income generation removal of obstacles discrimination inequalities gender barriers Health education. ‘A process with intellectual, psychological and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family and community well-being. This process, based on scientific principles, facilitates learning and behavioural change in both health personnel and consumers, including children and youth.’ (Ross and Mico, 1997) Service improvement. Promoting change in services to make them more effective, accessible or acceptable to the community. Advocacy. Activities directed at changing policy of organizations or governments. Advocacy • Influencing policy makers, leaders and media to raise profile of health programmes • Addressing legal, financial and service obstacles to health action • Tackling discrimination and inequalities Service Delivery • Improvement in capacity of staff – training and support • Development of new activities • Reorienting existing activities to make them more effective/acceptable • Strengthening communication/health education within services • Improved patient education • Outreach to schools, community, workplace • Involvement of personnel in supporting community health promotion Define health promotion strategy • Health promotion needs/situation analysis • • • • • • • • • Current situation? Health needs? Influences on health Influences on health actions? Target groups? • • Health Promotion Planning Cycle Evaluate, reflect, learn • • • Were our targets achieved? What lessons were learnt? How can we make our programmes better? Mix of health education, service improvement and advocacy? Health Education approach? Methods? Settings? Persons/groups involved in delivery? Timing? Targets? Implement • • • How to put it all together? How do we overcome barriers? How to monitor activities? The ten areas of competencies in public health identified by Faculty of Public Health 1. 2. 3. 4. 5. Surveillance and assessment of the population's health and wellbeing. Promoting and protecting its health and wellbeing. Developing quality and risk management within an evaluative culture. Collaborative working for health. Developing health programmes and services and reducing inequalities. 6. Policy and strategy development and implementation to improve health. 7. Working with – and for – communities to improve health and wellbeing. 8. Strategic leadership. 9. Research and development to improve health and wellbeing. 10. Ethically managing self, people and resources to improve health/wellbeing.