Today, health promotion is extremely important. Many outside factors influence health and social well-being, including socioeconomic conditions, patterns of consumption associated with food and communication, demographic patterns, learning environments, family patterns, the cultural and social fabric of societies, sociopolitical and economic changes, including commercialization and trade, and global environmental change. In such a situation, health issues can be effectively addressed by taking a holistic approach that includes empowering individuals and communities to take action for their health, fostering public health leadership, promoting intersectoral action to build healthy public policies across all sectors, and developing sustainable health systems. Although not a new concept, the Alma Ata Declaration provided the impetus for health promotion. It has recently evolved due to a series of international conferences, the first of which was held in Canada and resulted in the famous Ottawa charter. Efforts to promote health, including actions at the individual and community levels, strengthening health systems, and multisectoral collaboration, can be targeted at specific health conditions. It should also include a settings-based approach to health promotion in specific settings such as schools, hospitals, workplaces, residential areas, etc. Health promotion should be incorporated into all policies and, when implemented effectively, will result in positive health outcomes.
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Keywords: health promotion, health promotion mainstreaming, healthy public policy, issue-based approach, healthy settings
Health promotion is more important than ever in addressing public health issues. The global health scenario is at a crossroads, with the world facing a ‘triple burden of diseases’ comprised of an unfinished agenda of infectious diseases, newly emerging and re-emerging diseases, and an unprecedented rise in noncommunicable chronic diseases. Factors that aid progress and development in today’s world, such as globalization of trade, urbanization, ease of global travel, advanced technologies, and so on, act as a double-edged sword, leading to positive health outcomes on the one hand while increasing vulnerability to poor health on the other by contributing to sedentary lifestyles and unhealthy dietary patterns. There is a high prevalence of tobacco use, an increase in unhealthy dietary practices, and a decrease in physical activity, all of which contribute to an increase in biological risk factors, leading to an increase in noncommunicable diseases (NCDs). (1–3) Figure 1 depicts how lifestyle factors contribute to the rise in NCDs. (4) The negative effects of global climate change, sedentary lifestyle, increasing frequency of natural disasters, financial crisis, security threats, and other factors contribute to public health challenges today.
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IJCM-37-5-g001.jpg is the name of the object. Figure 1 depicts how lifestyle factors contribute to an increase in noncommunicable diseases (4)
According to the World Health Organization (WHO), health is the complete state of physical, social, and mental well-being, not just the absence of disease or infirmity. Enjoying the best possible health is regarded as one of every human being’s fundamental rights. (5) In recent decades, there has been a growing recognition that biomedical interventions alone cannot guarantee improved health. Outside of the health sector, factors such as social, economic, and political forces have a significant impact on health. These forces shape the conditions under which people grow, live, work, and age, as well as the systems put in place to address health needs, ultimately leading to health inequities between and within countries. (6) As a result, achieving the highest possible standard of health requires a comprehensive, holistic approach that extends beyond traditional curative care and involves communities, health providers, and other stakeholders. This comprehensive approach should empower individuals and communities to take charge of their health, foster public health leadership, encourage intersectoral action to build healthy public policies, and establish long-term health systems. These elements capture the essence of “health promotion,” which is about giving people control over their health and its determinants, allowing them to improve their health. It encompasses personal, organizational, social, and political interventions to facilitate adaptations (lifestyle, environmental, etc.) that benefit or protect health. (1,2)
Visit: Health Promotion: Historical Development
Health promotion is not a novel idea. Long ago, it was recognized that health is determined by factors other than those within the health sector. When the germ theory of disease was not yet established in the nineteenth century, the specific cause of most diseases was thought to be vapor.’ Still, there was an acceptance that poverty, deprivation, poor living conditions, lack of education, and other factors contributed to disease and death. William Alison’s reports (1827-28) on epidemic typhus and relapsing fever, Louis Rene Villerme’s report (1840) on Survey of the physical and moral conditions of the workers employed in the cotton, wool, and silk factories, John Snow’s classic studies of cholera (1854), and other documents bear witness to this growing understanding of disease causation.
The term ‘Health Promotion’ was coined in 1945 by Henry E. Sigerist, a great medical historian, who defined the four major tasks of medicine as health promotion, illness prevention, sick restoration, and rehabilitation. His statement that health was promoted by providing a decent standard of living, good labor conditions, education, physical culture, and means of rest and recreation required the coordinated efforts of politicians, labor, industry, educators, and physicians were correct. It was reflected in the Ottawa Charter for Health Promotion 40 years later. Sigerist’s observation that “the promotion of health obviously tends to prevent illness, but effective prevention calls for special protective measures” emphasized the importance of considering both general and specific causes in disease causation and the role of health promotion in addressing these general causes. Around the same time, J.A.Ryle, the first Professor of Social Medicine in the United Kingdom, recognized the twin causality of diseases, drawing attention to its applicability to non-communicable diseases. (7)
The terms health education and health promotion are sometimes used interchangeably. Health education entails providing individuals and communities with health information, knowledge, and skills to enable individuals to adopt healthy behaviors voluntarily. It is a set of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or changing their attitudes. In contrast, health promotion takes a more comprehensive approach to promoting health by involving multiple players and focusing on multisectoral approaches. Health promotion has a much broader scope and is tuned to respond to developments that directly or indirectly impact health, such as inequities, changes in consumption patterns, environments, cultural beliefs, and so on. (3)
The Lalonde report, published by the Government of Canada in 1974, challenged the conventional ‘biomedical concept’ of health, paving the way for an international debate on the role of nonmedical determinants of health, including individual risk behavior. The report argued that cancers, cardiovascular diseases, respiratory illnesses, and traffic accidents were not preventable by the medical model and sought to replace the biomedical concept with the ‘Health Field concept,’ which included four “health fields”—lifestyle, environment, health care organization, and human biology—as determinants of health and disease. The Health Field concept outlined five health promotion strategies, regulatory mechanisms, research, efficient health care, goal setting, and 23 possible courses of action. Skeptics criticized the Lalonde report as a ploy to reduce the government’s rising healthcare costs by implementing health-promotion policies and shifting responsibility for health to local governments and individuals. However, the report was well received internationally, with countries such as the United States, the United Kingdom, Sweden, and others publishing similar reports. The seminal concept also sets the tone for future public health discourse and practice. (7–10) Health promotion received a major boost in 1978 when the Alma Ata Declaration recognized that promoting and protecting people’s health was critical to long-term economic and social development and contributing to a higher quality of life and world peace. (5)
Attend Health Promotion Conferences
Growing public health expectations worldwide prompted WHO to collaborate with Canada to host an international conference on health promotion in 1986. It was held in Ottawa and resulted in the “Ottawa Charter for Health Promotion” and served as a precursor to subsequent international health promotion conferences. According to the Ottawa Charter, health promotion empowers people to gain more control over and improve their health. An individual or group must be able to identify and realize aspirations, satisfy needs, and change or cope with the environment to achieve a state of complete physical, mental, and social well-being. As a result, health is viewed as a resource for daily life rather than the goal of living. Peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity are the fundamental conditions and resources for health. Thus, health promotion is the health sector’s responsibility and extends beyond healthy lifestyles to overall well-being. The Charter called for health advocacy to bring about favorable political, economic, social, cultural, environmental, behavioral, and biological factors for health, allowing people to take control of the factors influencing their health and facilitating multisectoral action. The Charter defined Health Promotion action as one that a) builds healthy public policy by combining diverse but complementary approaches such as legislation, fiscal measures, taxation, and organizational change to create policies that foster equity, b) creates supportive environments, c) supports community action by empowering communities – their ownership and control of their endeavors and destinies, d) develops personal skills by providing information, and (11)
This benchmark conference sparked a series of health promotion conferences in Adelaide (1988), Sundsvall (1991), Jakarta (1997), Mexico City (2000), Bangkok (2005), and Nairobi (2006). (2009). In Adelaide, member states agreed that when developing healthy public policy, government sectors such as agriculture, trade, education, industry, and communication must consider health. The Sundsvall statement emphasized the impact of poverty and deprivation on the health of millions of people living in severely degraded environments. Poverty, low women’s status, and civil and domestic violence were also identified as major threats to health in Jakarta. The Mexico statement urged the international community to address the social determinants of health to achieve millennium development goals related to health. The Bangkok charter identified four commitments to make health promotion (a) a core responsibility for all governments, (b) a key focus of communities and civil society, and (d) a requirement for good corporate practice. (12,13) The most recent conference, held in Nairobi in October 2009, emphasized the urgent need to strengthen leadership and workforce, mainstream health promotion, empower communities and individuals, improve participatory processes, and create and apply knowledge for health promotion.
The health promotion emblem [Figure 2], adopted at the first international conference on health promotion in Ottawa and evolved, represents the approach to health promotion. The logo consists of a circle with three wings. It includes five key areas of action in health promotion (creating supportive environments for health, strengthening community action for health, developing personal skills, and reorienting health services) as well as three basic HP strategies (to enable, mediate and advocate).
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IJCM-37-5-g002.jpg is the name of the object. Figure 2: Health Promotion Emblem
The outer circle represents the goal of “Building Healthy Public Policies” and the need for policies to “hold things together.” This circle contains three wings, which represent the need to address all five key health promotion action areas identified in the Ottawa Charter in an integrated and complementary manner.
The small circle stands for the three basic strategies for health promotion, “enabling, mediating, and advocacy.”
The three wings represent and contain the words from the five key action areas for health promotion: reorient health services, create a supportive environment, develop personal skills, and strengthen community action.
True to its recognition that factors outside the health sector have a greater influence on health, health promotion calls for coordinated action by multiple sectors in advocacy, financial investment, capacity building, legislation, research, and partnership building. The Ministry of Health oversees the multisectoral stakeholder approach, which includes participation from various ministries, public and private sector institutions, civil society, and communities. (3)
Visit: Health Promotion Approaches
Health promotion efforts can be directed toward high-priority health conditions involving a large population, and multiple interventions can be promoted. This issue-based approach will be most effective when combined with settings-based designs. Setting-based designs can be implemented in schools, workplaces, markets, and residential areas, among other places, to address priority health problems by taking into account the complex health determinants such as behaviors, cultural beliefs, practices, and so on that operate in the places where people live and work. The setting-based design also facilitates the incorporation of health promotion actions into social activities while taking into account existing local circumstances. (3)
Figure 3 depicts a conceptual framework that summarizes the approaches to health promotion. It considers the needs of the entire population. Any disease population can be divided into four groups: a) the healthy population, b) the population with risk factors, c) the population with symptoms, and d) the population with disease or disorder. To address the entire population’s needs, each of these four population groups must be targeted with specific interventions. In summary, it ranged from primary prevention for the healthy population to curative and rehabilitative care for the diseased population. Primary prevention aims to create and maintain conditions that reduce health risks. It comprises actions and measures that prevent the emergence and establishment of environmental, economic, social, and behavioral conditions, as well as cultural patterns of living that are known to increase the risk of disease. (15)
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Figure 3 Conceptual framework for health promotion (IJCM-37-5-g003.jpg)
Visit: Health Promotion Examples in Communicable and Noncommunicable Diseases
Measures to promote health are frequently aimed at several priority diseases, both infectious and non-communicable. The Millennium Development Goals (MDGs) identified several critical health issues, the resolution of which was deemed critical to development. These concerns include maternal and child health, malaria, tuberculosis, HIV, and other health determinants. Although not acknowledged at the Millennium Summit and not reflected in the MDGs, the last two decades have seen the emergence of NCD as the leading cause of disease burden and mortality worldwide. NCDs are largely preventable through effective and feasible public health interventions that address major modifiable risk factors such as tobacco use, poor diet, inactivity, and harmful alcohol use. Eliminating common risk factors, such as poor diet, physical inactivity, and smoking can prevent 80% of heart disease and stroke, 80% of diabetes, and 40% of cancers. (16) Against this backdrop, health promotion, defined as “the science and art of assisting people in changing their lifestyle to achieve a state of optimal health,” is a critical intervention in controlling NCDs. The following sections demonstrate an issue-based approach to health promotion, with infectious and non-communicable diseases as examples, capturing the components of individual and community empowerment, health system strengthening, and partnership development.
Navigate to: Communicable Diseases
These diseases can be effectively addressed through a health promotion strategy. Here’s an illustration:
Improving ITN use to prevent malaria: In malaria-endemic areas, insecticide-treated bed nets (ITNs) are recommended as a key individual intervention in malaria prevention by preventing mosquito-human contact. (a) At the individual level, health promotion would entail making ITNs available and encouraging their regular and proper use every night from dusk to dawn. The evidence suggests that social marketing campaigns to promote ITN demand are the most effective way to accomplish this. Messages should be tailored to cultural beliefs, such as the belief in some communities that mosquitoes play no role in malaria etiology. ITN distribution should ideally be followed by ‘hang up’ campaigns by trained healthcare workers educating the community on how to use the nets and assisting them in hanging the nets, particularly for the most vulnerable groups. (b) Community empowerment efforts would yield positive results, such as collaborating with the community to understand cultural beliefs and behaviors and educating them about the disease. There are documented examples of how women in a community empowerment program in Thailand developed family malaria protection plans, provided malaria education to community members, implemented mosquito-control measures in a campaign, increased the use of insecticide-impregnated bed nets, instituted malaria control among migrant laborers, and participated in income-generating activities. Another program in Papua New Guinea empowered village residents to take responsibility for the procurement, distribution, and effective use of bed nets, significantly reducing malaria-related mortality and morbidity. (c) Strengthen health systems; integrating malaria vector control and personal protection into the health system via innovative linkages to ongoing health programs and campaigns is likely to result in strong synergies, economies, and faster health system strengthening than new vertical programs. Successful examples include piggybacking ITN distribution through antenatal care or measles and polio immunization campaigns. (d) Because multiple sectors are involved in malaria control, partnerships are essential. Outside the health sector, efforts to remove barriers to malaria prevention strategies have included lobbying for lower or waived taxes and tariffs on mosquito nets, netting materials, and insecticides, as well as stimulating local ITN industries. Intersectoral collaboration has been critical in vector control measures for malaria prevention, such as environmental modification and larval control. (17)
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Two groundbreaking studies in NCDs deserve special mention. The Framingham Heart Study (which began in 1951) and the study on smoking among British doctors (which began in 1948) have contributed to our understanding of how lifestyle influences various NCDs. A study of British doctors found that smoking cigarettes from early adulthood tripled age-specific mortality. The excess mortality associated with smoking was primarily due to vascular, neoplastic, and respiratory diseases. The Framingham Heart Study identified major CVD risk factors such as blood pressure, triglycerides, and cholesterol levels, as well as age, gender, and psychosocial issues (Framingham Heart Study). (18)
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Men in Finland had the world’s highest mortality rate from coronary heart disease in the early 1970s. The Finnish population’s diet was centered on dairy products, and their food was high in saturated fats and salt and low in unsaturated fats, fruits, and vegetables. North Karelia, a relatively rural and economically poor province, saw the launch of the North Karelia project, a major community-based intervention. This project developed comprehensive community-based strategies to change the population’s dietary habits, with the main goal of lowering the population’s high cholesterol levels. The strategy centered on lowering saturated fat and salt consumption while increasing fruit and vegetable consumption. Individual and community health information and nutritional counseling were made available, skills were developed, social and environmental support was provided, and community participation was ensured. The healthcare system was heavily involved in the project. Strong partnerships were also formed with schools, health-related and other nongovernmental organizations, supermarkets and the food industry, community-based organizations, and the media. Collaborations with the food industry were formed to reduce the fat and salt content of common foods such as dairy products, processed meat, and bakery items. A Berry project was launched to encourage dairy farmers to switch to berry farming. The North Karelia project was expanded to include the entire country, with health care services, schools, and nongovernmental organizations all responsible for implementing nutrition and health education. National nutrition education and collaboration with the food industry were supported by legislative actions and yielded remarkable results. From 1971 to 1995, surveys revealed a shift in dietary habits, with a significant reduction in saturated fat and salt consumption, and declared ischemic heart disease mortality decreasing by 73% in North Karelia and 65% in Finland. (19)
Visit Diabetes Mellitus.
Diabetes mellitus is one of the NCDs that has resulted in high rates of morbidity and mortality worldwide. Health promotion is increasingly recognized as a viable, cost-effective diabetes prevention strategy. Individual and community interventions include lifestyle modification programs for weight control and increased physical activity with community participation through culturally appropriate strategies. The Diabetes Prevention Project (KSDPP) at the Kahnawake School in Canada is an example of a project involving the local Mohawk community, researchers, and health service providers in response to community requests to develop a diabetes prevention program for young children. KSDPP’s long-term goal was to reduce the incidence of type 2 diabetes through short-term goals of increasing physical activity and healthy eating. Such preventive interventions must be accompanied by health system strengthening, which includes the identification of high-risk groups, risk factor surveillance, and the availability of trained primary health care providers for risk assessment and diabetes management. Online training courses provide an innovative approach to improving health system capacity for diabetes prevention, such as a course aimed at workers in remote indigenous communities in the Arctic to foster learning about the Nunavut Food Guide, traditional food and nutrition, and diabetes prevention. Partnership and network development are critical to achieving these goals. In South Auckland, New Zealand, as part of the city-wide ‘Let’s Beat Diabetes initiative,’ the district health board, with support from the local government, upgraded parks to provide safe environments for physical activity and collaborated with the food industry to provide healthier food options at retail outlets to reduce consumption of sweetened soft drinks and energy-dense foods. Customers were given sugar-free soft drinks as default options unless they specifically requested otherwise. Intersectoral action on diabetes risk factors also affects the determinants of other major risk factors for the NCD burden, such as heart disease, cancer, and respiratory disease, so health promotion activities to reduce diabetes risk have additional benefits. (17)
Go to: An Environment-Based Approach to Health Promotion
The concept of “healthy settings,” which maximize disease prevention through a whole-system approach, arose from the WHO’s Health for All strategy and the Ottawa Charter. The Sundial declaration of 1992 and the Jakarta declaration of 1997 followed the call for supportive environments. The setting’s approach is based on community participation, partnership, empowerment, and equity principles. It replaces reliance on individualistic methods with a more holistic and multidisciplinary approach to integrating action across risk factors. WHO’s ‘Healthy Cities’ program, launched in 1986, was quickly followed by similar initiatives in smaller settings such as schools, villages, hospitals, etc. (20)
Visit: Health Promotion Schools
Health-promoting schools incorporate health into all aspects of school and community life because health is essential for learning and development. To advance this concept, WHO and other UN agencies launched the ‘Focusing Resources on Effective School Health (FRESH) initiative, emphasizing the benefits to both health and education if all schools implemented school health policies, a healthy school environment with safe water and sanitation as an essential first step, skills-based health education, and school-based health and nutrition services. (21)
Visit: Healthy Workplaces
Currently, an estimated two million people die each year from occupational accidents, illnesses, or injuries at work, and 268 million nonfatal workplace accidents result in an average of three lost workdays per casualty and 160 million new cases of work-related illness each year.
(22) Healthy workplaces aim to create a healthy workforce while providing healthy working conditions. Healthy workplaces result in better health outcomes for employees and better business outcomes for organizations. (23)
Visit Health Promotion in India.
Health promotion is deeply embedded in all national health programs, with implementation envisioned through the primary healthcare system based on equitable distribution, community participation, intersectoral coordination, and appropriate technology. Nonetheless, it has received less attention than clinical care. The government has always worked to address the lack of information, which is a major barrier to increasing access to health care services through the component of IEC. (24) The National Rural Health Mission (NRHM) advocated for a synergistic approach to health care by linking health to determinants of good health, such as nutrition, sanitation, hygiene, and safe drinking water, as well as revitalizing local traditions and mainstreaming the Ayurvedic, Unani, Siddha, and Homeopathic systems of medicine. (25) The National Rural Health Mission (NRHM) provides an excellent opportunity to target and reach every beneficiary with appropriate interventions by incorporating microplanning into the district planning process. (26)
The health promotion component must be strengthened by using simple, cost-effective, innovative, culturally and geographically appropriate models that combine issue-based and settings-based designs while ensuring community participation. It is necessary to assess the replicability of successful health promotion initiatives and best practices from around the world and within the country. Efforts have already been made to create healthy environments such as schools, hospitals, and workplaces. (20,22,27) To effectively implement health promotion, we must engage sectors other than health and take a health-first approach to all policies rather than just health policy.
Proceed to: Conclusions
Today, there is a global acceptance that health and social well-being are determined by a variety of factors outside the health system, such as inequities caused by socioeconomic and political factors, new patterns of consumption associated with food and communication, demographic changes affecting working conditions, learning environments, family patterns, the culture and social fabric of societies; sociopolitical and economic changes, including commercialization. To address the challenges posed by changing scenarios such as demographic and epidemiological transitions, urbanization, climate change, food insecurity, financial crisis, and so on, health promotion has emerged as an important tool; however, the need for newer, more innovative approaches cannot be overstated. To positively modify the complex socioeconomic determinants of health, a multisectoral, adequately funded, evidence-based health promotion program with community participation that targets complex socioeconomic and cultural changes at the family and community levels are urgently needed.
: Health Promotion
Using one of the health issues identified for your community, discuss health promotion areas at two of the three levels primary, secondary, or tertiary promotion.