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Delivering the Science
and the Art of Health Promotion |
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Robert F. Allen
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In This Issue
Editorial Team |
National Policy and Health Promotionby Bob Karch |
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Most governments throughout the world hold both statutory and regulatory authority over the health of the people they serve. As a result, governments often play a major role in providing and allocating varying degrees of financial resources with which to carry out public health initiatives deemed to be important. In some cases national governments allocate resources directly to the public, such as in national health insurance or financial assistance to retired or low-income individuals, while in others national governments provide resources directly to state and/or local governments.
However, community understanding of health needs often drives which objectives a government chooses to support and fund, and at what level. More specifically, by gathering extensive data through surveillance case studies, trend analysis, and forecasting, governments can consider all relevant information needed to make informed decisions.
Once decisions are made, the logical process that follows is the development of Health Policy, for it is through the Health Policy formation process that society determines what health problems and programs it wants to undertake, and what goals and outcomes it hopes to achieve. Thus, it is clear that if the health issues (smoking, lack of physical activity, stress, improper diet, etc.) central to the health promotion movement are to receive serious attention, then those issues must be brought forward in a way which has the power to stir public passion for change. Only then will societies call for transformations in strategy that may lead to the formulation and then implementation of policy. Indeed, it was public insistence that lead to policy and then regulation and legal strictures on the sale of tobacco, alcohol products, food labeling, and smoking in public areas. However, health promotion has not yet found its niche in the national policy making process in the United States. This may come as a surprise regarding the amount of research supporting the health and financial impact of health promotion. A major initiative has just been started to advocate for building health promotion into the national agenda. The goal is to bring the health promotion field together in a coordinated effort to make health promotion a priority in the national policy framework. This effort will culminate during next year's American Journal of Health Promotion conference, which takes place in Washington, DC, on February 12-17.
We all may learn a lot about future strategies by reviewing how health policy advocates have accomplished their objectives at the national level in the past, and we can also learn from some contemporary successes. Global Perspectives focuses on how several countries have approached the task of establishing and implementing progressive health-policy development processes. Peter Sainsbury, Marilyn Wise, and Don Nutbeam outline the history of national health and health promotion policy in Australia. Kerstin Baumgarten and Anke Schreiber of the University of Magdeburg report on Germany's efforts to implement a programmatic shift from an illness to a health orientation within their health care system.
This issue is also something of a landmark for Global Perspectives, since for the first time we are able to bring to our readers a report from Russia, a vast country with major health problems, and one of the few countries worldwide with decreasing life expectancy rates. Drs. Igor Glasunov and Andres Petrasovits consider the history and practices of health prevention and promotion policy in Russia.
Our country profile in this issue is a detailed overview by Jiri Rada of health and health promotion policy in New Zealand. In an increasingly multicultural world, there is much to learn from New Zealand's proactive approach to health promotion and disease prevention for a diverse population of Maori, European New Zealanders, and Pacific Islanders. Last but not least, I would like to direct your attention to the "Curitiba Declaration" of the International Institute for Health Promotion (IIHP), which evolved out of the 4th Annual IIHP Meeting last year in Curitiba, Brazil, and calls for the global advancement of health promotion in the 21st century. I would like to invite you to comment on the Declaration and provide feedback on how to further advocate for health promotion.
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and Science of Health Promotion Conference Omni-Shoreham Washington DC February 12-17, 2001 |
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Readers know the background well: the public health developments of the nineteenth century; the dominance of biomedicine and illness treatment for most of the twentieth century; the increasing awareness since the 1970s of the limits of those approaches; and in the last 25 years the "rediscovery" of the importance of public policy as a strategy to improve population health. The 1990s in particular saw a growing emphasis on changes in health policy, with a gradual but significant shift to linking health sector investment to improvements in population health. Australia has embraced the "new public health" with some enthusiasm; unfortunately the rhetoric has not always been reflected in policy development and implementation.
National Goals
In 1988, Health for All Australians set national goals and targets for the
major causes of premature death and morbidity, and behavioral risk factors.
Targets were proposed, however, only in areas where substantial national
statistics existed. Consequently possibilities for change in social, economic,
and environmental determinants of health were largely ignored. A review in 1993
added two new categories of goals and targets in the areas of personal health
literacy and healthy environments, and made a strong case for coordinated public
health action to tackle the determinants of health. The review served as a
catalyst for the inclusion in the health funding agreements between the Federal
government and the States of a commitment to develop national goals and targets
for improved population health. Previously these agreements had concerned only
the provision of publicly funded health care services. Unfortunately, in setting
priorities for national action to honor this commitment, the Australian Health
Ministers accepted that ‘the healthy environments concept, in its broadest
context, has not been addressed’ and acknowledged the need for a mechanism to
address this important area. This has not happened yet. Consequently, the
Australian health policy framework, within which health promotion operates,
remains dominated by health services provision, and risk factor identification
and reduction.
This national policy framework has been largely duplicated at local level. In the Australian States, area health services have been created to manage both the publicly funded health services, and the protection and promotion of the health of the area’s residents. Unfortunately, the area-based services have continued to place primary emphasis on the former, more traditional, responsibility. Again, the shift in health policy has not yet been matched by a shift in resources.
Implementations
These Australian experiences highlight the difficulty of moving from
well-intentioned policy statements to approved government policy and action.
They also demonstrate the continuing dominance, politically, financially and
operationally, of illness care rather than health promotion in health policy,
even in a country where the health system is primarily funded from taxation.
Additionally, they illustrate some of the frustrations in a Federated system of
government associated with developing national approaches to issues that are
primarily within the constitutional powers of the individual States.
Notwithstanding these difficulties in shifting health policy, Australia as a whole has had some notable successes in using public policy to reduce public health problems: for instance, declining road toll, decreasing tobacco use, improved occupational health and safety, greater gun control, safer sexual practices, and better child dental health. Policy changes have been driven by widely varying processes, including community outrage, consensus and action; persistent advocacy by interest groups; information and advice from experts; and the timely intervention of highly influential "champions".
Our experience indicates that effective public health policy development and implementation are never based simply on logical argument and scientific ‘evidence’ about the problem and its solution. On the contrary, as in nineteenth century Britain, health promoting advances in public policy are highly contested, overtly and covertly, and are frequently characterized by defeats and compromises before change is successfully introduced.
We believe that public policy is most effective as a strategy for promoting health when:
• There is evidence that the proposed solution will work;
• Advocates work with constituencies for change at grass-roots and political levels;
• Advocates are well organized, persistent and opportunistic, and prepared to compromise and accept incremental change;
• The policy supports, rather than leads, changing community attitudes, and is based on the voluntary adoption of solutions;
• All stakeholders, regarding the problem and the solution, are involved;
• Widely acceptable measures of reinforcement and enforcement are ongoing.
The challenge now is for Australian health promotion practitioners to build their own capacity to work with communities and government and non-government organizations to influence policy directions and develop alternative solutions to pressing public health problems.
Peter Sainsbury is Director of the Division of Population Health at the Central Sydney Area Health Service in Sydney, Australia. Marilyn Wise is Executive Director of Australian Centre for Health Promotion. Don Nutbeam is Professor of Public Health and Head of Department at the Australian Centre for Health Promotion at the University of Sydney, NSW 2006, Australia. Dr. Nutbeam’s email is donn@pub.health.usyd.edu.au
| Health Promotion: Global Perspectives Health Promotion: Global Perspectives, a
supplement to the American
Journal of Health Promotion, is published bimonthly by the American
Journal of Health Promotion, Inc., 1660 Cass Lake Road, Suite 104, Keego
Harbor, Michigan 48320. Annual subscriptions are FREE when you subscribe
to The Art of Health Promotion or American Journal of Health
Promotion. |
American Journal of Health Promotion American Journal of Health Promotion is the largest peer-reviewed journal devoted exclusively to health promotion. Published 6 times per year, The Journal publishes original research and reviews on the health and financial impact of health promotion programs, as well as editorials, abstracts from other journals, and critiques of other published studies. Michael P. O'Donnell, Ph.D., MBA, MPH, serves as editor-in-chief. Subscription price for individuals is $99.95 in the United States, $108.95 in Canada and Mexico, and $117.95 in all other countries. Institutional prices are $20 higher. To subscribe; Phone: 800-783-9913 or 760-738-4970. |
The Art of Health Promotion The Art of Health Promotion newsletter provides practical information to make programs more effective. Each issue is devoted to a specific topic, such as increasing program participation, increasing management support, cost benefit analysis, use of newer technologies, characteristics of industry experts. Larry S. Chapman, MPH, serves as newsletter editor. Published 6 times per year, the subscription price for individuals is $89.95 in the United States, $98.95 in Canada and Mexico, and $107.95 in all other countries. To subscribe; Phone: 800-783-9913 or 760-738-4970. |
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Background/History
Health policy is a multidimensional task, aimed at all determinants of
health, including medical care systems, lifestyles, social and physical
environments and hereditary factors. It creates an important frame for the work
of health professionals, especially by defining the rules for the distribution
of funding within the health care system.
Germany is a wealthy country with heavily structured social security. German health care is based on a federally mandated insurance system in which each employee contributes a certain percentage of his or her wages to a non-profit insurance company. Three critical time periods distinguish the history of this system: 1883 to 1989, and 1989 to 2000.
In 1883, Chancellor Bismark created the German health insurance law, which is still in place. Under the law, providing health insurance became obligatory for all employers. Employers and employees share health insurance fees, with each party paying 50 percent. However, the costs of health care and health insurance have grown steadily over the years. Reasons for this development are the increasing percentage of elderly people in the population, the growing number of chronic diseases, and medical and technical progress. Meanwhile, incomes have not grown as fast as costs, and a relatively high unemployment rate has also contributed to a financial crisis in the insurance system. Health policy in this period focussed on care of diseases and not on prevention and health promotion, and there was virtually no funding for health promotion activities by federal agencies or by non-profit insurance companies.
A first attempt to stop increasing costs was the health law reform in 1989. This legislation included health promotion in the catalogue of activity that could be financed by the health insurance companies. As a result, health insurance companies developed a preliminary infrastructure for health promotion, including measures in the field of occupational health promotion, individual health education courses and the support of self-help activities.
By and large, only patients or clients and the small group of health promotion professionals in Germany welcomed these reforms. In contrast, the interest groups belonging to the medical care system opposed these developments from the very beginning, claiming that health promotion would only increase costs and was not an appropriate strategy to balance out the insurance system. In 1997 the Federal Ministry of Health cancelled the health promotion activities financed by the insurance companies by law, using the following arguments:
- No evidence for a decrease of expenses in the health care system through
health promotion activities could be detected.
- There had been a lack of systematic evaluation of health promotion
interventions.
- Health promotion activities were being abused by being utilized as an element of marketing for health insurance companies.
With the election of a new federal government in 1998 health policy reached a another turning point, changing from a policy concentrated on the providing of medical care toward more strategic thinking in terms of health.
Health Reform Law 2000
A new health law reform has been in force since January 2000. The main aims
of this legislation are:
- Guarantee of the principle of solidarity in the health insurance system
(every insured person is entitled to the same level of health care).
- Preserve a certain level of health insurance fees.
- Empowerment of patients.
- Improvement of care.
The main points toward strategic thinking and health orientation are
the reestablishment of health promotion activities under the umbrella of health insurance companies and the improvement of patient rights and patient protection.
The health insurance companies are responsible for informing and educating their clients regarding prevention and health care, for establishing occupational health promotion programs and for supporting self-help groups again. The interventions are supposed to be based on quality criteria and are to be evaluated in order to avoid the abuse of moneymaking marketing actions by the insurance companies. The investment in health promotion by health insurance companies is financially limited and should not be higher than 5DM (USD $2.70) per client per year.
The expansion of patient rights and patient protection is focussed on the enabling and empowerment of individuals to increase control over the determinants of health, and thereby to improve their own health. The legislation requires and promotes the involvement of patients in the process of treatment.
Visions/Conclusions
The new health reform legislation delivers an important frame for health
promotion measures, and is definitely a programmatic shift from an illness to a
health orientation. Making the insurance companies responsible again for funding
health promotion activities creates a new opportunity for establishing
evidence-based health promotion actions in all relevant settings. While proving
the health effects of health promotion is very difficult, it is also essential,
and a monitoring and evaluation regimen has to be developed, otherwise new
health promotion activism may be easily attacked again by accusations of
ineffectiveness. In addition, patients and clients are now invited to be part of
the agenda setting process for health policy. How quickly and strongly patients
and clients can build up a powerful movement and create political advocates will
be crucial for any further development of health promotion in Germany.
Kerstin Baumgarten is Assistant Professor at the Department of Public Health and Social Work of the Fachhochschule Magdeburg (University of Applied Sciences) i Germany and can be reached at e-mail: Kerstin.Baumgarten@Sozialwesen.FH-Magdeburg.DE or fax: (49)-391-6716293.
Anke Schreiber is a research fellow at the University of Applied Sciences Magdeburg Germany, in the Department for Public Health and Social Work. Her areas of specialty are health communication, health promotion in the internet, and virtual self-help. She can be reached at e-mail:
anke.scheiber@sozialwesen.fh-magdeburg.de.
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Russia is in the process of developing policy and capacity for health promotion. Current activities focus on non-communicable disease (NCD) prevention. NCD accounts for over 75% of the total mortality and morbidity, and is a major cause of health care costs in Russia. Hallmarks of NCD, such as cardiovascular disease, common types of cancer related to major risk factors, such as smoking, high blood pressure, diabetes, high blood cholesterol, and excess alcohol consumption, are widespread. High prevalence of risk factors associated with lifestyles and environment support the need for population-based policies.
Major health gains can be made in Russia by health promotion strategies designed to create healthy living and working environments (e.g. tobacco free spaces) and bring about healthy lifestyles in nutrition, physical activity, and abstinence from smoking and substance abuse. The effective implementation of population health policies requires inter-sector collaboration with non-health sectors. This includes working with the private sector and government health departments in areas other than health to bring about healthy policies and required environmental change.
Models for Implementation
In 1992, the National Center for Preventive Medicine (NCPM) initiated a
systematic approach to implementation of a health promotion and population
health policy in Russia. The NCPM implemented an innovative model combining
health promotion and disease prevention strategies. The model has two main
characteristics: First it represents a systematic multi-phased approach to
developing a series of inter-linked strategies involving policy development,
building of epidemiological databases, carrying out demonstration programs at
the regional level, process evaluation and dissemination. The overall aim is to
enhance capacity for promotion and prevention (human resources, organizational,
technical, scientific) and use of partnership and coalitions as a management
model.
System Linkages
A second characteristic of the Russian health promotion and disease
prevention model is that it links systems, with the NCPM acting as "a
linkage agent" among various regional, national and international agencies,
and professional organizations concerned with NCD prevention. International
collaboration was especially important in positioning the NCPM as a linkage
agent, building the required capacity and providing leadership. Over the past
eight years, effective partnerships have been created with health agencies in
Canada (Health Canada), United States (CDC) and Sweden (Karolinska Hospital).
Collaboration with the European Office of the World Health Organization has been of special significance. Russia plays an important role in the WHO EURO Countrywide Integrated Non-communicable Disease Intervention Programme (CINDI), the roots of which go back to initiatives taken by the WHO in the mid-nineteen-eighties. The CINDI program pioneered an integrated approach to prevention and control of the risk factors common to major NCD. Russian contributions to CINDI are built on strong scientific and epidemiological capacity and on participation in international collaborative projects focusing on cardiovascular and NCD prevention.
Planning
The publication in 1994 of the "Towards a Healthy Russia: Policy for
Health Promotion and Disease Prevention: Focus on Major Non-communicable
Diseases" was a policy development milestone for health promotion and
disease prevention. This policy document was prepared in collaboration with
Health Canada. Follow-up development of the document led to a second, more
specific, policy blueprint with implementation steps taking into account the
rapidly evolving health care reform context in Russia. This second document,
"Towards a Healthy Russia: Policies and Strategies for the Prevention of
Cardiovascular and Other Non-communicable Diseases Within the Context of Public
Health Reforms in Russia," was published in 1997 in collaboration with the
CDC (US). These two policy documents were used by the Ministry of Health and the
multidisciplinary group to develop "a concept of the Russian population
health strengthening" which is currently under consideration by the
government. The Healthy Russia policy document served as a blueprint for similar
policy development initiatives in the Russian regions of Chelyabinsk and Tver.
The collaboration with CDC (US) continues with the aim of building educational
models for capacity development and a behavior risk surveillance scheme. The
work is supported by the Soros Foundation, with the assistance of CDC.
Developments
Three other projects relevant to health promotion and disease prevention are
currently underway. Initiated in 1997, "Prevention Health Care Systems in
Russia" is being undertaken under the auspices of European Union TACIS
program. The NCPM also participates in the G7-G8 Promoting Heart Health
Telematics Project, which forms part of the G7-G8 Health Care Applications
Program. This project is developing a case-study database to learn about best
practices, models for providing information to the public, and modules for long
distance learning and integration of cardiological patient databases. The World
Bank supports a third project on health care reform in Tver. This project has an
important health promotion component aimed at cardiovascular disease prevention.
A significant development was the establishment in 1997 of the journal "Disease Prevention and Health Promotion." This journal is published on a bimonthly basis. It has sections on: policy and strategy; structure and functions of preventive services; official communications; legislation; economic aspects; professional education; and clinical preventive guidelines. The journal contributes to capacity building for health promotion and disease prevention. Its abstracts in both English and Russian are accessible through the Internet address: http://www.mediasphera.aha.ru.
To strengthen health promotion and disease prevention in Russia, three strategies need to be pursued. First, build up infrastructure (resources, organization) with capacity to implement inter-sector health promotion and disease prevention initiatives. Second, enhance the practice of prevention in both public health services and primary health care, in other words, reorient the health system towards prevention. And third, strengthen civil society, and in particular the voluntary health sector, by supporting new NGOs in some areas and strengthening existing ones. The Russian Public Health Association, Organization of Strengthening Public Health are cases in point. Promoting partnerships within and without the health system, and stimulating international collaboration and links at all levels are key factors to make health promotion and disease prevention accessible to all citizens and communities in the Russian Federation.
Dr. Igor Glasunov is Head of the Department of Policy Development at the National Centre for Preventive Medicine in Moscow, Russia.
Dr. Andres Petrasovits is the Head of the Heart Health Unit and WHO Collaborating Centre at Health Canada in Ottawa, Canada, and can be reached at andy121@attglobal.net
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"Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change." (American Journal of Health Promotion, 1989, 3, 3, 5.) |
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Global Initiatives
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The Fifth Global Conference on Health Promotion will take place June 5-9, 2000 in Mexico City, Mexico. This ground-breaking Conference will bring together Ministers of Health and Ministers responsible for other sectors whose decisions have an impact on health; representatives from communications, academia and the private sector; and many others from around the world.
IIHP will be one of those participating at Mexico City with a presentation on workplace health promotion.
The Ministers of Health will show their commitment to health promotion in practical terms by signing the Mexico Ministerial Statement on Health Promotion.
Participate
Even if you are unable to attend the Fifth Global Conference on Health
Promotion, you can participate. WHO has set up an interactive Health Promotion
Discussion web-site facilitating an on-line discussion on prominent health
promotion issues. Questions are posted on the site by administrators so that
visitors to the site may post responses which are then reviewed and selected for
upload to the site. WHO’s Health Promotion Department hope to compile many of
your contributions into a panel to be displayed at the Conference in Mexico City
this June. In this way, Ministers of Health from around the world, as well as
discussion and conference participants, will have the chance to benefit from the
visions of those who can not be in Mexico. The URL is http://www.who.int/hpr/conference/participate/discuss.html
Healthy People 2010 Sets Goals
Healthy People 2010 builds on initiatives pursued over the past two
decades. In 1979, Healthy People: The Surgeon General’s Report on Health
Promotion and Disease Prevention provided national goals for reducing premature
deaths and preserving independence for older adults. In 1980, another report,
Promoting Health/Preventing Disease: Objectives for the Nation, outlined 226
targeted health objectives for the Nation to achieve over the next 10 years.
Healthy People 2000: National Health Promotion and Disease Prevention
Objectives, released in 1990, identified health improvement goals and objectives
to be reached by the year 2000. The Healthy People 2010 initiative continues in
this tradition as an instrument to improve health for the first decade of the
21st century.
The Goals
1: Increase Quality and Years of Healthy Life
The first goal of Healthy People 2010 is to help individuals of all ages increase life expectancy and improve their quality of life. Healthy People 2010 seeks to increase life expectancy and quality of life over the next 10 years by helping individuals gain the knowledge, motivation, and opportunities they need to make informed decisions about their health. At the same time, Healthy People 2010 encourages local and State leaders to develop community wide and statewide efforts that promote healthy behaviors, create healthy environments, and increase access to high-quality health care. Given the fact that individual and community health are virtually inseparable, it is critical that both the individual and the community do their parts to increase life expectancy and improve quality of life.
2: Eliminate Health Disparities
The second goal of Healthy People 2010 is to eliminate health disparities among different segments of the population. These include differences that occur by gender, race or ethnicity, education or income, disability, living in rural localities, or sexual orientation. Healthy People 2010 recognizes that communities, States, and national organizations will need to take a multidisciplinary approach to achieving health equity that involves improving health, education, housing, labor, justice, transportation, agriculture, and the environment. However, our greatest opportunities for reducing health disparities are in empowering individuals to make informed health care decisions and in promoting community wide safety, education, and access to health care. Healthy People 2010 is firmly dedicated to the principle that—regardless of age, gender, race, ethnicity, income, education, geographic location, disability, and sexual orientation—every person in every community across the Nation deserves equal access to comprehensive, culturally competent, community-based health care systems that are committed to serving the needs of the individual and promoting community health.
The Objectives
The Nation’s progress in achieving the two goals of Healthy People 2010
will be monitored through 467 objectives in 28 focus areas. Many objectives
focus on interventions designed to reduce or eliminate illness, disability, and
premature death among individuals and communities. Others focus on broader
issues, such as improving access to quality health care, strengthening public
health services, and improving the availability and dissemination of
health-related information. Each objective has a target for specific
improvements to be achieved by the year 2010.
Country Profile
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New Zealand is a South Pacific state with a population of almost 3.5 million people. The indigenous Maori make up approximately 10% of the population, and Polynesian people approximately 4% of New Zealand's multi-cultural society. Highly urbanized, yet economically dependent on agriculture, New Zealand enjoys a high standard of living. It is a member of the British Commonwealth. New Zealand has similar public health priorities to most developed countries. These priorities are being addressed within an increasingly multi-cultural society that is experiencing growing inequalities in income and resources for health. Health promotion is continually trying to address both individual health behaviors and the multiple determinants of health.
Health Promotion New Zealand Style
In New Zealand, the practice of health promotion is based on the 1840 te
Tiriti o Waitangi (the Treaty of Waitangi, the country's founding agreement
between Mäori and the Crown) and the 1986 Ottawa Charter for Health Promotion.
The key principles of the Treaty are tino rangatiratanga (absolute sovereignty)
and mana motuhake (the right to control one's own destiny). This approach
requires that health be understood in the context of the social, economic and
cultural position of Mäori (indigenous people). This includes mental and
emotional wellbeing (te taha hinengaro); physical wellbeing (te taha tinana);
spiritual well-being (te taha wairua); and the importance of family support (te
taha whanau). In addition, emphasis is also placed on the physical and social
environment (te ao turoa) and the importance of language (te reo rangatira).
Brief History
In 1984, the Department of Health appointed a training officer who
established a national training program (a Certificate) in health promotion and
trained several dozen health promotion workers, public health nurses and health
protection officers. In 1990, the Certificate was offered jointly by the
Department of Health and the Wellington School of Medicine. For the past six
years, those interested in health promotion can take both undergraduate and
graduate studies at the University of Otago. In 1998, the Certificate in Health
Promotion was listed in the "Top 10" distance learning programs in the
world by the World Health Organization.
There have been many successful programs. The Help Prevent Cot Death program is an example of a highly effective intervention based on a well designed and well-conducted epidemiological study that specifically identified the health promotion measures necessary. This plan was shared by all child health agencies that were mutually concerned about the problem of New Zealand's very high SIDS rate. Since the program was launched, the SIDS rate fell from 4.2/1000 to 2.5/1000. Other outstanding programs include melanoma awareness, smoking cessation, asthma prevention, injury reduction, and Mäori health initiatives.
While applied as well as academic training went on, the Health Promotion Forum was being established. The Forum’s aim was to coordinate regional and voluntary opinion and to liaise with government organizations in the establishment of national goals. Its first task was to establish a national database of health promotion research and programs; later on strong social advocacy, policy emphasis, as well as education resource production skills were added. Today, the organization’s focus is more on the concept of health promotion than on the specific health issues of much of the workforce.
Evidence-Based Health Promotion (EBHP)
New Zealand has developed a framework to prioritize interventions in 22
health promotion areas identified by the Minister of Health. It uses a broad
range of different kinds of evidence, including scientific research,
organizational capacity, socio-cultural factors, and local community-based
knowledge related to the determinants of health. Additionally, it is based on
the premise that like evidence-based medicine, evidence-based health promotion
must employ both quantitative and qualitative evidence and that the final
judgement about purchasing of health promotion initiatives is essentially
subjective and political.
The framework is based on the methodology developed by the Canadian Task Force on the Periodic Health Examination, adopted by the U.S. Preventive Services Task Force. However, it also accommodates the philosophy and practice of health promotion and takes account of the government’s obligations to Mäori under the Treaty of Waitangi. The economic evaluation was based on the work of Drummond which has already been incorporated into the evidence-based work of the Canadians and the Americans. The assessment of validity of research has been modified from Schechter’s 1994 work on critical appraisal of published research.
Specified health promotion measures are those that health purchasers can influence. Changes in national laws or taxation are outside of the scope of this framework. It also acknowledges that any effective and efficient preventive health care has to consider (and combine) the best health promotion interventions and the best clinical preventive strategies.
The framework is based upon the core purchasing principles of effectiveness. Any health promotion program that is effective within the New Zealand context must meet the effectiveness criteria in four inter-related dimensions. Specifically, it must:
- Provide scientific evidence of need and effectiveness (scientific dimension).
- Fit policy framework and fulfill Treaty-based obligations (organizational dimension).
- 3. Be sensitive to social and cultural needs (socio-cultural dimension).
- 4. Adopt recognized health promotion principles (health promotion dimension).
The framework acknowledges the importance of evidence outside the narrow scientific paradigm, and that successful health promotion programs require an integrated approach. That is, consideration must be given to a number of dimensions, and one cannot be viewed in isolation from the others.
At the core of the framework are four dimensions of effectiveness: rules of evidence; adherence to government objectives, including the Treaty of Waitangi; sensitivity to socio-cultural context and equity of opportunity; and an emphasis on the Ottawa Charter approach. At the second level, these dimensions of effectiveness are expanded to identify five relevant key themes. Each key theme in turn gives rise to a number of measurable indicators to provide guidance as to the types of evidence that will be required in assessing program effectiveness. While the framework offers examples of measurable indicators, the list is not exhaustive as the most appropriate indicators are best negotiated between the purchasers and the providers and may vary according to the target population and the local situation. Further, in some cases a suggested indicator may relate to more than one key theme, and therefore indicators are not specifically linked to a particular key theme.
Importantly, the framework maintains the flexibility to allow for purchasing of innovative programs by incorporating a developmental approach. The developmental approach recognizes that in some areas, such as indigenous health, there is limited scientific evidence available to inform purchasing decisions and in these situations greater weight should be accorded to the strength of evidence in the remaining three dimensions. Many of the issues raised in this framework apply not only to New Zealand and in this respect the framework may have wider application and be useful in evidence-based health promotion purchasing internationally.
Dr. Jiri Rada is a health consultant and is interested in health promotion, injury prevention, fitness and risk management. He has developed undergraduate and graduate training in health promotion in the country and for ten years was teaching public health at the Wellington School of Medicine. He can be reached at jiri@paradise.net.nz
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International Institute for Health Promotion News Flashes |
Curitiba Declaration of the International Institute for Health Promotion (IIHP)
The IIHP held its 4th Annual Meeting in Curitiba, Brazil from October 10-13,
1999. One of the outcomes of the discussions in Curitiba is the following
declaration which calls for an increased focus on health promotion in the 21st
century.
The Declaration
The Curitiba Declaration calls for the global advancement of health promotion in the new millennium through sound policies supporting health promotion and enhanced resource allocation for the promotion of healthy lifestyles.
New Challenges in Global Health
The majority of chronic diseases, the number one killer in the world now, are related to unhealthy lifestyles and behaviors which are preventable. In line with economic growth, people in developing countries are acquiring the unhealthy behaviors of the industrialized countries (e.g., smoking, inactivity), resulting in a changing disease pattern. Most countries will face a tremendous economic burden in the next century as health care costs are on the rise. Improved medical technologies and more efficient care will not solve this global dilemma.
Health Promotion is the Answer
Academic institutions, government authorities, international organizations, private corporations, insurance companies, schools, hospitals, medical groups, community groups as well as individuals in health promotion have joined the universal effort to improve the quality of life. As a result, many multinational corporations are now taking a close look at the health status of their global workforce and are designing and implementing health promotion programs to respond to their needs. Numerous well-designed programs have shown an increase in productivity, reduction in health care costs, and improved morale among employees.
The IIHP believes that governments and decision-makers around the world must make health promotion a high priority at the dawn of the new millennium. If they fail to do so, they will be regarded by future generations as having been grossly negligent because they had the knowledge and means to improve global health.
Call for Action
The IIHP calls on all government agencies (not just health ministries) to make health promotion a high priority on their agenda by developing and endorsing progressive health promotion policies, by allocating and providing more resources, and by creating supportive environments. The IIHP also calls on all health-related international organizations to advocate health promotion more aggressively in all available forums.
IIHP Hires New Managing Editor for Global Perspectives
This number of Global Perspectives is the first to be edited by Vivian
Blaxell, the newsletter’s new managing editor.Vivian hails from Australia via
Japan, Hawaii, and Vermont. She was a practicing RN for ten years, and holds a
Ph.D. in political science from the University of Hawaii. She has been recipient
of numerous academic awards, grants, and fellowships for research on Japanese
and Southeast Asian topics ranging from colonialism, through capital punishment,
to AIDS education. Prior to moving to Washington, DC to study for the MFA in
Creative Writing at American University, Vivian was Professor of History and
Politics at Marlboro College in southern Vermont, USA. She speaks reads and
writes both Japanese and Spanish, and is fluent in Australian slang.Vivian’s
e-mail address is vblaxell@earthlink.net, and she may always be contacted by
telephone at +1-202-352-1045.
3rd International Workshop on the Assessment of Health-Related Fitness hosted by the UKK Institute for Health Promotion Research, Tampere, Finland, May 21-24, 2000.
2nd Conference on "Health Status of Central and Eastern European Populations After Transition", Warsaw, Poland, June 5-7, 2000.
5th Global Conference on Health Promotion: "Health Promotion - Bridging the Equity Gap" hosted by WHO, PAHO, and the Ministry of Health of Mexico. Mexico City, June 5-9, 2000.
The First International Conference on "Exercise & Nutrition for Better Health and Chronic Diseases" hosted by the Chinese Sports Science Society (CSSS) and organized by the Chinese Sports Medicine Society (CSMS) and Institute of Sports Medicine of Beijing Medical University. Beijing, China, June 11-16 , 2000.
Health Promotion/Quality of Life Seminar for Human Resource Managers hosted by CPH Tecnologia em Saude and American University, São Paulo, Brazil, July 10-14, 2000.
The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe. It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations. More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation. Email the IIHP at iihpaa@american.edu. The IIHP website is http://www.healthy.american.edu/iihp.html.
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