Health Promotion in Canada: Critical Perspectives

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HEALTH PROMOTION IN CANADA

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HEALTH PROMOTION IN CANADA CRITICAL PERSPECTIVES

SECOND EDITION

EDITED BY

MICHEL O’NEILL ANN PEDERSON SOPHIE DUPÉRÉ IRVING ROOTMAN

Canadian Scholars’ Press Inc. Toronto

Some images and text in the printed version of this book are not available for inclusion in the eBook.

Health Promotion in Canada: Critical Perspectives Second Edition edited by Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman First published in 2007 by Canadian Scholars’ Press Inc. 180 Bloor Street West, Suite 801 Toronto, Ontario M5S 2V6 www.cspi.org Copyright © 2007 Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman, the contributing authors, and Canadian Scholars’ Press Inc. All rights reserved. No part of this publication may be photocopied, reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, or otherwise, without the written permission of Canadian Scholars’ Press Inc., except for brief passages quoted for review purposes. In the case of photocopying, a licence may be obtained from Access Copyright: One Yonge Street, Suite 1900, Toronto, Ontario, M5E 1E5, (416) 868-1620, fax (416) 868-1621, toll-free 1-800-893-5777, www.accesscopyright.ca. Every reasonable effort has been made to identify copyright holders. CSPI would be pleased to have any errors or omissions brought to its attention.

Canadian Scholars’ Press Inc. gratefully acknowledges financial support for our publishing activities from the Government of Canada through the Book Publishing Industry Development Program (BPIDP).

Library and Archives Canada Cataloguing in Publication Health promotion in Canada : critical perspectives / edited by Michel O’Neill ... [et al.]. — 2nd ed. Includes bibliographical references and index. isbn 978-1-55130-325-3 1. Health promotion—Canada—Textbooks. I. O’Neill, Michel, 1951– ra427.8.h45 2007

613'.0971

07 08 09 10 11

c2007-901472-0 5 4 3 2 1

Cover art: “Happy Friends (children)” © Daniela Andreea Spyropoulos. From www.istockphoto.com. Cover design, interior design and layout: Susan MacGregor/Digital Zone Printed and bound in Canada by Marquis Book Printing Inc.

During the course of the year that we spent working together on this book, the circle of life continued to touch our lives. Each of us would like to honour the past and celebrate the future by dedicating this book to the memory or new life of people near and dear to us. Michel would like to honour Laurent Pauzé-Dupuis, who passed away in Beijing on April 3, 2006, and was the best friend of Sébastien Couchesne-O’Neill, his son, to whom he wishes a great journey in his future life as a scholar and sociologist. Ann would like to celebrate the birth of Nicholas Good, her grandson, on October 31, 2005, and to remember the passing of her mother-in-law, Marion Spruston, on February 18, 2006. Irv would like to express joy for the birth of his first grandson, Tobyn Rootman, on September 23, 2005, and to acknowledge the passing of his uncle, Sam Rootman, on February 10, 2006, and his son David’s fiancé, Zoey Quarter, on December 6, 2006. Sophie would like to dedicate this book to the memory of her grandfather, Jacques Champagne, who died on March 22, 2006, and whose passion and dedication to his family and work has always been a great source of inspiration for her.


TA B L E O F C O N T E N T S

Acknowledgements ...........................................................................................x Foreword: Health Promotion in Canada and the 19th World Conference of the International Union of Health Promotion and Health Education ................xiii Marcia Hills and David McQueen Chapter 1: Introduction: An Evolution in Perspectives ..........................................1 Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman

PART I: CONCEPTUAL PERSPECTIVES ...................................17 Chapter 2: A New Appraisal of the Concept of Health ........................................19 John Raeburn and Irving Rootman Chapter 3: The Promotion of Health or Health Promotion? ................................32 Michel O’Neill and Alison Stirling Chapter 4: Points of Intervention in Health Promotion Practice ...........................46 Katherine L. Frohlich and Blake Poland Chapter 5: Health Literacy: A New Frontier.......................................................61 Irving Rootman, Jim Frankish, and Margot Kaszap Chapter 6: Addressing Diversity in Health Promotion: Implications of Women’s Health and Intersectional Theory .......................................................................75 Colleen Reid, Ann Pederson, and Sophie Dupéré

PART II: NATIONAL PERSPECTIVES .........................................91 Chapter 7: The Federal Role in Health Promotion: Under the Radar....................92 Lavada Pinder Chapter 8: Addressing Health Inequalities in Canada: Little Attention, Inadequate Action, Limited Success....................................................................................106 Dennis Raphael Chapter 9: Developing Knowledge for Health Promotion ..................................123 Irving Rootman, Suzanne Jackson, and Marcia Hills vii

PART III: PROVINCIAL PERSPECTIVES ..................................139 Chapter 10: Health Promotion Program Resilience and Policy Trajectories: A Comparison of Three Provinces ....................................................................141 Nicole F. Bernier Chapter 11: 12 Canadian Portraits: Health Promotion in the Provinces and Territories, 1994–2006 ......................................................................................153 Ann Pederson

PART IV: INTERNATIONAL PERSPECTIVES ........................205 Chapter 12: Promoting Health in a Globalizing World: The Biggest Challenge of All? ..........................................................................207 Ronald Labonté Chapter 13: Canada’s Role in International Health Promotion............................222 Suzanne F. Jackson, Valéry Ridde, Helene Valentini, and Natalie Gierman Chapter 14: The Impact of Canada on the Global Infrastructure for Health Promotion.......................................................................................237 Maurice B. Mittelmark, Maria Teresa Cerqueira, J. Hope Corbin, and Marie-Claude Lamarre Chapter 15: Views on the International Influence of Canadian Health Promotion............................................................................................247 Sophie Dupéré

PART V: PRACTICAL PERSPECTIVES ......................................299 Chapter 16: The Reflexive Practitioner in Health Promotion: From Reflection to Reflexivity ..........................................................................301 Marie Boutilier and Robin Mason Chapter 17: Building and Implementing Ecological Health Promotion Interventions ...................................................................................................317 Lucie Richard and Lise Gauvin Chapter 18: Health Promotion and Health Professions in Canada: Toward a Shared Vision ...................................................................................330 Marcia Hills, Simon Carroll, and Ardene Vollman Chapter 19: Two Roles of Evaluation in Transforming Health Promotion Practice ..........................................................................................347 Louise Potvin and Carmelle Goldberg

PART VI: CONCLUDING THOUGHTS ......................................361 Chapter 20: Health Promotion: Not a Tree But a Rhizome.................................363 Ilona Kickbusch Chapter 21: Has the Individual Vanished from Canadian Health Promotion? ..........................................................................................367 Gaston Godin Chapter 22: Conclusion: The Rhizome and the Tree ..........................................371 Sophie Dupéré, Valéry Ridde, Simon Carroll, Michel O’Neill, Irving Rootman, and Ann Pederson Copyright Acknowledgements .......................................................................389 Index ..............................................................................................................392

AC K N OW L E D G E M E N T S

s was our experience in preparing the first edition, the enthusiasm of the contributors— who numbered over 60 people this time as compared to 25 in 1994—has supported and inspired us throughout the process of putting the book together. We think this support for our project reflects the co-operative culture of health promotion as well as individual contributors’ personal commitment to the field of health promotion. Key ideas for our own analyses emerged through our interactions with all the contributors; however, we are especially grateful to the country and the provincial contributors whom we forced to work within tight space constraints so we could maximize the number of perspectives provided. Everybody worked graciously within tight deadlines and we are also very grateful about that, knowing how everybody is overextended these days. We have released a version of this book in French and would like to release versions in other languages as another way of nurturing the exchanges and alliances we think are so important for the evolution of the field beyond our traditional boundaries within Canada and abroad. We therefore thank CSPI whose enthusiasm and professionalism was as great as if they had been one of our authors, particularly publisher Jack Wayne, who facilitated publication in other languages, and managing editor Megan Mueller with whom we have had an extremely rewarding partnership. We also extend our thanks to the Faculté des sciences infirmières de l’Université Laval, and especially to Carole Laverdière, for providing much appreciated support for many of the operational aspects of the book; to the Réseau de recherché en santé des populations du Québec, which helped the publication through a grant in its scholarly publications program; to the British Columbia Centre of Excellence for Women’s Health for providing support to Ann Pederson’s involvement with this project; and to the Michael Smith Foundation for Health Research for its financial support of Irv Rootman based at the Centre for Community Health Promotion Research at the University of Victoria through a Distinguished Scholar Award. We would also like to thank the two external reviewers who provided us with feedback on the draft manuscript and the large group of reviewers who commented on the first edition; all the feedback has helped us to reflect more critically upon our work and we trust it has improved the quality of the final product. Thanks also to Karine Aubin, Aïssata Moussa-Abba, and Samira Dahi, all doctoral students in the community health program at Laval University, who played a variety of crucial roles in finalizing the manuscript. Finally, we would like to thank our families and friends from whom we borrowed time to complete this book, particularly Francine Courchesne, Barry Spruston, and Barb Rootman.

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A NOTE ABOUT THE FRENCH VERSION Une version française de cet ouvrage est disponsible aux Presses de l’Université Laval, à Québec, intitulée «La promotion de la santé au Canada et au Québec, perspectives critiques» sous la direction de Michel O’Neill, Sophie Dupéré, Ann Pederson, et Irving Rootman. On peut la commander au [http://www.pulaval.com/index.html].

A NOTE FROM THE PUBLISHER Thank you for selecting the second edition of Health Promotion in Canada: Critical Perspectives. The publisher has devoted considerable time and careful development (including meticulous peer reviews at proposal phase and first draft) to this book. We appreciate your recognition of this effort and accomplishment.

TEACHING FEATURES This volume distinguishes itself in several ways. One key feature is the book’s well-written and comprehensive part openers, which add cohesion to the section and to the whole book. The contributors have added pedagogy, including questions for critical thought, annotated further readings, and annotated related Web sites. There are also figures, tables, and boxed inserts throughout the book.


F O R E WO R D

H E A LT H P RO M OT I O N I N C A N A DA A N D T H E 1 9 T H WO R L D C O N F E R E N C E O F T H E I N T E R N AT I O N A L U N I O N O F H E A LT H P RO M OT I O N A N D H E A LT H E D U C AT I O N Marcia Hills and David McQueen he editors of this book are to be congratulated on revisiting the theme of health promotion in the Canadian context, following up on the successful first edition of the book. This new edition promises to have an even greater impact on the field than the first, given that this is no mere update, but an entirely original set of chapters that push the boundaries of thinking and reflection on health promotion’s place in Canada and Canada’s influence internationally on health promotion. It also arrives on the international health promotion scene at a critical juncture when a resurgence of interest in the social determinants of health presents a great opportunity, but also a great challenge for the future of the field. It will enter the public sphere just at the time that Canada hosts in Vancouver, in June 2007, the 19th World Conference of the International Union of Health Promotion and Education (IUHPE). As co-chairs of the scientific program of the 19th World Conference, we recognize that the questions raised by this book have helped to shape this event, will guide future directions in the field, and are likely to contribute greatly to the crucial discussions raised in Vancouver. The book offers a superb retrospective survey of where health promotion in Canada has travelled in the last decade or so, both at the federal level and in each of the provinces. Readers will learn much about the wax and wane of health promotion’s prospects in the Canadian context and international readers will find these important reflections informative for their own struggles to advocate for policy change and to improve practice in their respective countries. While the latter excellent set of reflections is what a reader might expect of a new edition of a book that did such a good job the first time around, a pleasant surprise awaits in the very substantial new contributions the book makes to strengthening and informing health promotion practice with fresh theoretical perspectives. It is particularly impressive that many of the chapter authors have managed to take up this emerging concern with theory’s role in health promotion and what particular theoretical perspectives might offer for the future of health promotion research, policy, and practice. An innovative addition has been made to one of the original book’s strengths in including international perspectives on Canada’s role in health promotion globally. In the first edition, one of the authors of this foreword (McQueen) was an international contributor, along with two other authors (Larry Green and John Raeburn). The editors have obviously felt that this international perspective needed to be broadened, particularly in expanding beyond the narrow confines of the Anglo-Saxon world (the US and New

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Zealand) and have managed to fashion a much larger section that includes a true diversity of global perspectives on Canada’s role in health promotion. This is a welcome addition that reflects health promotion’s important recent efforts to move beyond a Eurocentric and Western bias in its priorities and concerns as, for instance, in IUHPE’s global program on the effectiveness of health promotion in which both of us are deeply involved. Another innovation that deserves praise and credit is the decision by the original editors to bring in Sophie Dupéré as a fourth editor, signalling an effort to include the emerging leadership in the field and to reflect this inclusion with several substantive contributions from younger authors. This explicit strategy is very important as it addresses a reflection by many senior people in the field that health promotion needs to do a better job in allowing the next generation of health promoters to develop and flourish as the originators of the field pass on the torch in the long-distance struggle to impact systemic change. In conclusion, if the contents of this substantial and insightful book are any indication of where health promotion is moving, then we can be reassured that the field will meet many challenging obstacles, yet has an equally great potential to progress and to further the promotion of health. Once again, this edition shows why Canada has had such an important role to play in the development of health promotion globally and we are convinced that IUHPE’s world conference in Vancouver will be another very significant opportunity to actualize this interface.

CHAPTER 1

I N T RO D U C T I O N : A N E VO L U T I O N I N P E R S P E C T I V E S Michel O’Neill, Ann Pederson, Sophie Dupéré, and Irving Rootman

he first edition of this book was released in 1994, 20 years after the Lalonde Report, under the title, Health Promotion in Canada: Provincial, National, and International Perspectives. In that book we looked with a critical eye at health promotion in Canada over those 20 years, particularly the period following the release of the Ottawa Charter for Health Promotion in 1986. Today, more than a decade later, we are aware that Canada continues to be regarded as a powerhouse of health promotion around the world. As researchers, students, and practitioners, we want to understand and document what has happened over the last 10–12 years with respect to the evolution of health promotion in Canada, as well as to understand Canada’s role within the field internationally. Accordingly, in contrast to many other books in this field, this book is not a “how-to” book in health promotion, explaining how to develop and/or evaluate effective interventions (e.g., programs, policies, and so on), but rather a book on health promotion as it is practised in Canada and how what happens in Canada links to what is happening throughout the rest of the world. In this introductory chapter, we therefore want to accomplish three things. First, we want to remind the reader of the general evolution of health promotion as a field, internationally and in Canada, using elements from several chapters that appeared in the first edition of the book but do not appear in the second. As we will see—though it may sur-

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prise people who are unaccustomed to thinking of Canada as playing important roles on the global scene—international and Canadian developments in health promotion are closely intertwined. Canada has been—and still is— perceived as an important, if not the leading, country for the development of the field worldwide (though we will argue that this is sometimes for the right and sometimes for the wrong reasons). Second, we want to explain the aim of the first edition of the book and what we achieved. Together, these two elements will frame our third goal, the explanation of the aims of this second edition. Some dates and events will be constantly referred to in the rest of the book; these are the often-recited litany of the main milestones of the field here in Canada and abroad. We want to enunciate these landmarks at this point so the reader has the entire context and story correct at the beginning: 1951, the year of the foundation and the first global conference of the International Union of Health Education (IUHE), sending the signal that health education, as both a professional and scientific endeavour, was sufficiently mature to create its own international organization; 1974, when A New Perspective on the Health of Canadians (the famous Lalonde Report) was released; 1979, the year the World Health Assembly adopted its “Health for All by the Year 2000” resolution as a follow-up to the Alma-Ata conference on Primary Health Care, which had been held the year before; 1986, the year of the 1

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first World Health Organization (WHO) International conference on health promotion, held in Ottawa, at which two major documents were released: an international one (the Ottawa Charter for Health Promotion) and a Canadian one (Achieving Health for All, also known as the Epp Report); 1994, which turned out to be the watershed year between health promotion and population health in Canada when two influential books were published: the first edition of this book (Pederson, O’Neill, & Rootman, 1994) and Why Are Some People Healthy and Others Not? (Evans, Barer, & Marmor, 1996); and, finally, 2007, the year in which the health promotion world will come back to Canada, this time in Vancouver, for the 19th global conference of the International Union for Health Promotion and Health Education (IUHPE) and which we think is the year in which the timid renewal of commitment to health promotion that we observed in Canada over the last two or three years will either flourish or vanish. We will return to these dates and events in the discussion that follows, positioning them within three broad time periods: the years prior to the Lalonde Report of 1974; 1974–1994, which was the period covered by the first edition of our book; and 1994–2007, the period covered by this second edition.

BEFORE 1974: THE HEALTH EDUC ATION ERA In the first edition of the book, Robin Badgley (1994) traced the various types of activities and programs undertaken by the public authorities of Canada (be they local, provincial, or federal), from the early 1600s through to the middle of the 19th century, to promote the health of the “colony’s” population. He argued that, “for a period of some 250 years, a regulatory philosophy was the main means by which government sought to protect and

modify the health of Canadians” (Badgley, 1994, p. 21). According to him, the “dissemination of sanitary information” became an important concern in the 1880s for the provincial, and newly established federal government (following the British North America Act of 1867), but this was in a context in which the need for this information was “[…] so apparent to everybody as not to need proof” (Badgley, 1994, p. 22). This missionary zeal among sanitary reformers dominated the field for several decades, up to the end of World War II. The production of pamphlets and posters, the writing of books and newspaper columns, as well as, later, the production of film strips and the broadcast of radio messages, occupied most of the time, energy, and resources at the central levels, with scarce public health personnel relaying this information in one-to-one or small group situations at the local level. According to Badgley, very little interest was devoted to scientifically grounding or evaluating these activities. Similar developments were underway in most industrialized countries (e.g., see Green and Kreuter [1999] for a discussion of developments in the United States), and it was only in the late 1940s and early 1950s that a more systematic and scientific approach to educating the public on health matters began to emerge. In 1951, in response to the need to link together those working on health education and to promote the exchange of experience and information on these new ways of working, a group of European and North American public health people, under the leadership of two Frenchmen, Léo Parisot and Lucien Viborel, created in Paris what was to become the most important international non-governmental organization in the field: the International Union for Health Education (Modolo & Mamon, 2001). From then until the mid-1970s, in the industrialized world the dissemination of

INTRODUCTION: An Evolution in Perspectives ■ 3

health education information was increasingly targeted toward the professional–patient encounter (primarily the doctor–patient relationship) to make sure that the patient understood and used the information provided. The general public also became the target of the campaigns of health education specialists, initially in order to encourage the proper use of the health services (especially preventive ones) governments were establishing in the post-World War II welfare state era. Over time, it became clear that an epidemiological pattern of so-called “diseases of civilization” was rapidly displacing the earlier pattern of infectious disease in industrialized countries. When it was observed that the risk factors for these new sources of mortality (e.g., cardiovascular diseases, cancers, accidents) were largely behavioural, these “at-risk” behaviours themselves (e.g., smoking, sedentary lifestyles, eating habits, etc.) became the prime targets of health education. What also distinguished this era from the pre-1950s period was a conscious and sustained effort to ground health education interventions scientifically and to recruit other kinds of scholars and practitioners besides health personnel in this task. The 1950s and 1960s thus witnessed the increasing involvement of social scientists (mostly social psychologists and sociologists) and communication specialists in the development of models to try to understand and predict health-related behaviour and/or in the design of health education campaigns. These scientific developments largely occurred in the United States, which did not undergo the post-war reconstruction of the European nations and thus had greater resources available for such purposes. It was during this period, for instance, that the famous Health Belief Model (Becker, 1974), the first of a long series of theoretical models of individual health behaviour, was conceived at the Johns

Hopkins School of Hygiene and Public Health in Baltimore. These developments gradually seeped into the day-to-day practice of health educators in Canada, as elsewhere (Badgley, 1994), and were reflected in programs, manuals (e.g., Gilbert, 1963), and the training of personnel. These practices were built upon a deeply rooted, virtually unquestioned belief that educating the public was intrinsically good; the hope was therefore that health would improve with the help of science and a more systematic way of conducting health education. All this occurred, however, in a context in which public health and health education services, which were almost the only type of health-related governmental intervention up to the 1950s, were quickly dwarfed and eventually marginalized as the governments of Western industrialized societies became heavily involved in establishing public acute medical care systems (Gilbert, 1967).

1974–1994: FROM HEALTH EDUC ATION TO HEALTH PROMOTION It became increasingly obvious during the 1970s that health education was not having the desired effects, and that individuals, though better informed, did not necessarily adopt the healthful behaviours expected of them. A series of events resulted in significant revision to the way health education had been conceived up to that point and led to its transformation into health promotion.

The International Scene Internationally, the mid-1970s marked the end of 30 years—often called the “glorious thirties”—of sustained growth within the Western post-war economies. This economic situation allowed the “welfare state” to flourish in the


1950s and 1960s. In Canada, as in most Western countries (with the notable exception of the US, which never established the same level of welfare state infrastructure), governments were sufficiently wealthy to become involved in insuring the welfare of their populations through the direct or indirect provision of services to fulfill basic needs, notably in the sectors of health and education. However, a major reorganization of the world economy, triggered by the so-called “oil shocks” of 1973 and 1976, completely changed this picture. The “glorious thirties” were followed by 20 gloomy years of economic stagnation or minimal growth within the Western economies, which deprived governments of taxation revenues and forced them to borrow heavily to maintain the level of public services they had committed to provide to their populations.

It was in this context that the Lalonde Report, released in 1974, received immediate worldwide attention because it was the first document by the central government of a major developed country advocating for the importance of investing resources beyond health services for the health of populations (Lalonde, 1974). As seen in Box 1.1, the “health field concept,” introduced in A New Perspective on the Health of Canadians, identified four sets of factors—later to be called “determinants of health”—that contributed to the health of populations. In contrast to all or so, the report made the novel suggestion that governments stop investing solely in providing more acute care services and instead seriously consider addressing the three other sets of factors through a “health promotion” approach.

BOX 1.1: ELEMENTS OF THE HEALTH FIELD CONCEPT

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In the following months and years, given the macro-economic context alluded to above but seldom made explicit, almost every Western industrialized country produced its own version of the Lalonde Report, encouraging investment in areas other than health systems, which were increasingly difficult to finance through public monies. This context also produced a major international expert conference in 1978, co-sponsored by two UN agencies (WHO and UNICEF), at which delegates proposed that the world stop investing in costly acute care systems, recognizing that after more than 30 years, such systems had not yielded the expected results

in the developed world and had been almost irrelevant for the developing world. The Alma-Ata conference thus suggested a return to the basics—to “Primary Heath Care” (PHC) and to address the set of issues described in Table 1.1. In response to these recommendations, and mindful of the economic context, the ministers of health of most countries of the world gathered in what is called the World Health Assembly (the supreme decision-making body of the World Health Organization), and voted in 1979 for the famous “Health for All by the Year 2000” (HFA) resolution, which proposed a set of measures in keeping with the

INTRODUCTION: An Evolution in Perspectives ■ 5 TABLE 1.1: PRIMARY HEALTH CARE AS DEFINED IN THE ALMA-ATA DECLARATION

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spirit of the Lalonde Report and the Alma-Ata declaration. These measures were further operationalized in a global strategy in 1981 (see Box 1.2).

The Canadian–European Connection The events that took place in Canada from the release of the Lalonde Report to the proclamation of the Ottawa Charter are very well described and analyzed by Lavada Pinder in Chapter 7 in this book, so we will not reproduce them here. What we will highlight, however, is the central role Canada

played in the international developments that followed the HFA resolution of WHO. Ilona Kickbusch, then chief officer of Health Education at the European division of the World Health Organization (WHOEuro) based in Copenhagen, has described a chain of events that began with the implementation of HFA in Europe in the early 1980s and ultimately led to the transformation of Health Education into Health Promotion (Kickbusch, 1986, 1994). Aware that many of the concerns articulated by PHC and HFA (access to clean water, basic immunization of populations, etc.) were

6 ■ HEALTH PROMOTION IN CANADA BOX 1.2: W H O G L O B A L S T R AT E G Y F O R H E A LT H F O R A L L BY THE YEAR 2000

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largely irrelevant in Europe and that health education was the key strategy to address, Kickbusch and her European colleagues toured the world and came to North America. In the US, they looked at the developments

in health education and self-help whereas in Canada they examined the implementation of the Lalonde Report. It was quickly apparent that Canada’s social-democratic political climate was more compatible with Europe


than the neo-conservative one that had already begun to take hold in the US (Kickbusch, 1994). A very close collaboration with a few Canadian individuals and institutions was then established, which led to the production by the European Office of WHO of the “Yellow document” on health promotion (WHO-Euro, 1984) and ultimately to

the First International Conference on Health Promotion held in Ottawa in 1986. A key outcome of this collaboration was to demonstrate the importance of environmental factors in health, which—although identified by the Lalonde Report—had received only limited attention in Canada (Labonté & Penfold, 1981) and elsewhere.

F I G U R E 1 . 1 : N E W P U B L I C H E A LT H F O R C E F I E L D

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The health education community had already begun to articulate its own internal critique during the second half of the 1970s (Brown & Margo, 1978; Freudenberg, 1978), conscious that providing health information alone and focusing on individual behaviour could lead to “blaming the victim” for its health problems (Ryan, 1976). Critics charged that changing the environment should become as much a concern for health education as changing individual behaviour if it was to ensure, as Nancy Milio (1986) famously said it, that the “healthiest choice became the easiest choice.” Environments had to become supportive of, rather than barriers to, individual changes. To signal this evolution from a traditional, individually focused health education, the words “health promotion” were key in the ecological, multi-level models that emerged in 1986 following the years of collaboration between Canada and WHOEuro. These models paid particular attention to environmental factors without dismissing the others. This is clear in Kickbusch’s own work (1986) (see Figure 1.1), in the Ottawa Charter (WHO, 1986) (see Figure 1.2), which was the international consensus emerging out of the first international conference, as well as in the Canadian document Achieving Health for All (Epp, 1986) that was launched then (and which is discussed in greater detail in Pinder’s chapter).

1986–1994: The Golden Era of Health Promotion After 1986, health promotion received significant international attention. Following the development of the European program, its main international champion, Ilona Kickbusch, was moved to WHO headquarters in Geneva to develop a global health promotion strategy. The second and the third

international Health Promotion Conferences, aimed at better understanding two of the strategies proposed in the Ottawa Charter— healthy public policy and creating supportive environments—were held in Adelaide, Australia, in 1988 and in Sundsvall, Sweden, in 1991 respectively. It is well documented that the years immediately following the release of the Ottawa Charter and the Epp Report were very important ones for health promotion within Canada (see Pinder’s chapter). Some additional resources were given to the Health Promotion Directorate of Health and Welfare Canada, programs and initiatives to follow up on the Epp Report were started, and a knowledge development strategy was established. Many of these developments were described in detail in the first edition of the book, as well as two important federal initiatives, the Strengthening Community Health project (Hoffman, 1994) and the Healthy Communities initiative (Manson-Singer, 1994), both of which reflect the flurry of activity of the period.

The First Edition of the Book The original intuition that led us to the preparation of the first edition, which analyzed the 1974–1994 period, was a strong sense of cognitive dissonance between what we heard in our travels about the role of Canada in health promotion and what we observed at home. More specifically, while Canada may have been regarded as the world leader in health promotion, we observed a large gap between the international reputation of the federal government and the actual practice of health promotion provincially (the provinces and territories having the constitutional responsibility for health services). We wanted to explore this intuition from a historical and critical perspective using a sociology of knowledge approach. Our view was that

INTRODUCTION: An Evolution in Perspectives ■ 9 F I G U R E 1 . 2 : T H E OT TAWA C H A RT E R

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what happens in a field can be better understood if we observe the various actors who are promoting it or blocking it at one moment in time, and what discourses and instruments of power they use to do so in the general societal context in which they operate. Our intent was to help the field reflect on itself and even-

tually become more aware of these issues and better equipped to deal with them. What we concluded at the end of the first book (O’Neill, Rootman, & Pederson, 1994) was related to both Canada’s position in the global health promotion scene and to the evolution of health promotion within Canada.


Immediately prior to our conclusion, though, in a provocative paper, one of the key pioneers of the health promotion movement both in Canada and internationally argued that in 1994 the movement had “won a battle,” but was far from having “won the war” (Hancock, 1994). Hancock argued vociferously that to really make a difference, health promoters should become more political and enrol in party politics, especially in the Green Party as its value base was closest to the one promoted by health promotion. However, as editors, we did not go in the same direction as Hancock. With respect to international developments, we were able to document the impact of the WHOEuro/Canada alliance in the evolution of the field from health education to health promotion, as noted above, and to identify key individuals and institutions. We also noted the beginnings of the mainstreaming of health promotion, as was evident, for instance, in its use in the reconstruction of the health systems of Central and Eastern European countries. We recognized the potential tensions of this transition when, in the words of sociologist Max Weber, the “charisma” of the early pioneers is “routinized” and loses some of its original purity and vision, but is embraced and serves a much larger group of people. Finally, we were convinced that the future of health promotion would be directly influenced by the future direction of the general political economy of the world. With respect to Canada, we were already observing the stagnation, if not the beginning of the decline, of the federal leadership in the field, and we wondered who would champion health promotion in Canada in the future if this decline actually occurred. In comparing and contrasting provincial and territorial developments, we realized how the ambiguity of the health promotion discourse had been used both by

social democratic and conservative political parties to justify their reorganization of the health care system of their respective jurisdiction. Moreover, we saw a persistent, entrenched approach to health promotion as individual lifestyle change rather than the more structural ones espoused in official discourse. Finally, despite the fact that some people may have hoped otherwise, we concluded that health promotion was clearly not a widespread social movement in Canada, despite the growing importance in the general population of lifestyle and quality of life issues. Rather, it appeared to us to be more of a “professional movement” promoted by small groups of public health professionals, academics, and community leaders. Later, and probably supported by other movements with related discourses and ideologies like the feminist or the environmentalist ones, health promotion had proposed (with a certain degree of success) a new discourse on health, which had been adopted by various political constituencies but, as mentioned above, was used in a variety of ways (if at all). We were thus interested in what would happen in the next decade and offered a few predictions for what we thought might happen both in Canada and internationally. We will return to those at the end of this second edition, but let us now consider the time period covered by this book.

1994–2007: HEALTH PROMOTION: DECLINE, TRANSFORMATION, OR RENEWAL? The title of this subsection plays with the titles of some of the papers we have published since the release of the first edition of the book as we continued to track the evolution of the field (O’Neill, Pederson, & Rootman, 2000; Pederson, Rootman, & O’Neill, 2005).


It is clear to us that 1994 marked the beginning of an era of weakened support for health promotion both in Canada and abroad. Since then, has it declined or simply been transformed by becoming more mainstream? Is health promotion experiencing a revival at the moment or is it actually fading from the radar screen? Let us examine a few major trends and then address the main intent of this second edition of the book.

Some General Trends Internationally, it is important to note that from the mid-1990s on, the shift away from the welfare state that began in the late 1980s, due to the macro-economic evolution of the world since the mid-1970s, was clearer. The litany of the rhetoric of balanced government budgets, of deficit reduction, of a diminished role for the state and an increased one for the market, of the necessity of global economic competition in a neo-liberal era: all this has been more present and operative. The dominance of this economic view of the world over the more social one that the welfare states had promoted for several decades has had consequences; for example, it has led to a decrease in the importance and influence of most organizations of the United Nations system (such as WHO) and to an increase in the power of transnational corporations and economic global institutions such as the World Bank, the International Monetary Fund, and the World Trade Organization. As described by Ron Labonte in Chapter 12 of this book, these global tendencies, in conjunction with the collapse of the former communist world in the early 1990s, which left the US virtually alone to define the “new world order,” have had important consequences for the evolution of health promotion. In the concluding section of this book, Ilona Kickbusch updates an earlier story she

wrote to describe the evolution of the field and reminds us that in this context, several of the key institutions that had been instrumental in the birth of health promotion almost abandoned it after 1994. For example, after the Sundsvall conference of 1991, instead of continuing its pattern of hosting international conferences almost every other year (as it did initially) to address the three remaining strategies of the Ottawa Charter, WHO was forced to hold them at irregular intervals and on topics that addressed the interest of the host countries rather than its overall strategy. The Djakarta (1997), Mexico (2000), and Bangkok (2005) conferences each reflected this new order of things. Consequently, the global health promotion community publicly voiced its concern about the WHO’s lack of commitment at the Mexico conference (Mittlemark et al., 2001) and about the inclusion of the private sector as a key partner in the Bangkok Charter (see the debate in the series From Ottawa to Vancouver on the electronic journal RHPEO, details of its Web site at the end of the chapter). Moreover after 1994, as fully described in this edition’s Chapter 7 by Lavada Pinder, the federal government abandoned its international and Canadian leadership as the population health approach gained greater currency.

Main Intentions of the Second Edition The general orientation of this second edition remains the same: this is not a book in but a book on health promotion, which looks critically at the evolution of the field since 1994 and at Canada’s engagement with health promotion relative to the rest of the world. Three sets of modifications were made, however, in compiling this new edition. First, following discussion with our new publisher, we agreed that the audience of the book needed to be re-examined. For the first


version, we envisioned several audiences: graduate students; scholars; and practitioners, professional or lay, interested in health promotion from a variety of health, social science, and other backgrounds in Canada and abroad. However, over the years, a variety of sources have revealed that the largest group of readers of the first edition has been undergraduate students in health sciences within Canada, with the other groups forming an important, but smaller, audience. We have assumed that this will continue to be the case for this second edition and have therefore addressed this understanding explicitly in the design and content of the book. Without altering the general intent or the rigour of the analysis, we have used a style and format that we hope makes this edition more usable in undergraduate courses, while maintaining an orientation that is also useful for other readers here and abroad. Second, we also realized from feedback on the first edition that we should more explicitly address how and why reflecting on a field is crucial for the practice of this field. We have thus introduced a new section in this edition on “Practical Perspectives.” In this new section, contributors address a series of issues that aim to demonstrate how being or becoming a more reflexive practitioner increases a person’s capacity to be relevant and effective in practice. Hence, in this second edition, we encourage the reader to not only think about but also to apply this thinking to his or her actual practice, whatever and wherever it is. Third, given that health promotion is still a very young field, its original pioneers in many places are still active. For the field to survive and evolve, however, we need to ensure the place of the younger generations as we move from the activism of the pioneers to a more mainstream (although always fragile)

state of affairs. Consequently, to enrich the perspectives proposed in the book, we have made a deliberate effort to introduce a mix of younger and more experienced contributors. To foster diversity, we have also approached a variety of academics, practitioners, students, and policy makers as well as people from various parts of Canada and from a wide sample of countries to contribute to this book. The book is therefore organized into six sections dealing successively with Conceptual, National, Provincial, International, and Practical perspectives followed by some Conclusions, each of which we have tried to infuse with a spirit of critical reflection. As the book’s new subtitle is intended to suggest, these perspectives are “critical” in various ways. First, they introduce what we think are “important or crucial” elements of reflection and analysis. Moreover, they do so with the rigour and the “inclination to criticize,” which are used in “critical social science” not to lay blame but rather to assess without complacency the status of a phenomenon. Two other meanings of “critical” are also relevant here. On the one hand, we use the term “critical” in the sense of its meaning in nuclear reactions; that is, has health promotion reached sufficient “critical mass” to trigger a chain reaction that will make it explode and mushroom both in Canada and internationally? On the other hand, we will also try to determine whether 2007 will be— for both Canadian and global health promotion—a “critical turning point” or juncture as were 1951, 1974, 1986, or 1994. We hope that this book will successfully engage in critical appraisal of the health promotion field, and, in the conclusion, we will synthesize, through an intergenerational dialogue, what the various chapters have told us about the past and the present, and our current vision of the future of health promotion in Canada.


REFERENCES Badgley, R. (1994). Health promotion and social change in the health of Canadians. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 20–39). Toronto: W.B. Saunders. Becker, M.H. (1974). The health belief model and personal health behavior. Thorofare: Charles B. Slack. Brown, R.E., & Margo, G.E. (1978). Health education: Can the reformers be reformed? International Journal of Health Services, 8(1), 3–26. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Santé et Bien-être social Canada/Health and Welfare Canada. Evans, R.G., Barer, M.L., & Marmor, T.R. (1996). Être ou ne pas être en bonne santé. In Biologie et déterminants sociaux de la maladie. Paris/Montréal: Les Presses de l’Université de Montréal/John Libbey Eurotext. Freudenberg, N. (1978). Shaping the future of health education: From behavior change to social change. Health Education Monographs, 6(4), 372–377. Gilbert, J. (1963). L’éducation sanitaire. Montréal: Presses de l’Université de Montréal. Gilbert, J. (1967). The grandeur and decadence of health education. Canadian Journal of Public Health, 58, 355–358. Green, L.W., & Kreuter, M. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View: Mayfield. Hancock, T. (1994). Health promotion in Canada: Did we win the battle but lose the war? In A. Pederson, et al. (Ed.), Health promotion in Canada (pp. 350–373). Toronto: W.B. Saunders. Hoffman, K. (1994). The strengthening community health program: Lessons for community development. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 123–139). Toronto: W.B. Saunders. Kickbusch, I. (1986). Health promotion: A global perspective. Canadian Journal of Public Health, 77, 321–326. Kickbusch, I. (1994). Tell me a story. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 8–18). Toronto: Saunders. Labonté, R., & Penfold, S. (1981). A critical analysis of Canadian perspective in health promotion. Health Education, 19(3–4), 4–10. Lalonde, M. (1974). Nouvelle perspective de la santé des canadiens/A new perspective on the health of Canadians. Ottawa: Gouvernement du Canada/Government of Canada. Manson-Singer, S. (1994). The Canadian healthy communities project: Creating a social movement. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 107–122). Toronto: W.B. Saunders. Milio, N. (1986). Promoting health through public policy (2nd ed.). Ottawa: Canadian Public Health Association. Mittelmark, M.B., Akerman, M., Gillis, D., Kosa, K., O’Neill, M., Piette, D., et al. (2001). Mexico conference on health promotion: Open letter to WHO director general, Dr. Gro Harlem Brundtland. Health Promotion International, 16(1), 3–4. Modolo, M.A., & Mamon, J. (2001). A long way to health promotion through IUHPE conferences (1951–2001). Perugia: University of Perugia, Inter university Experimental Center for Health Education. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141.

14 ■ HEALTH PROMOTION IN CANADA O’Neill, M., Rootman, I., & Pederson, A. (1994). Beyond Lalonde: Two decades of Canadian health promotion. In A. Pederson et al. (Eds.), Health promotion in Canada (pp. 374–387). Toronto: W.B. Saunders. Pederson, A., O’Neill, M., & Rootman, I. (Eds.). (1994). Health promotion in Canada: Provincial, national, and international perspectives. Toronto: W.B. Saunders. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future? In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). London: Palgrave Macmillan. Ryan, W. (1976). Blaming the victim (rev. ed.). New York: Vintage Books Edition. UNICEF. (1978). The declaration of Alma-Ata. International Conference on Primary Health Care. AlmaAta: United Nations Children’s Fund and World Health Organization.WHO. (1981). 64th plenary meeting, Resolution 36/43. WHO. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. WHO-Euro. (1984). Health promotion: A discussion document on the concept and principles. ICP/HSR 602 (m01). Unpublished manuscript, Copenhagen.

CRITIC AL THINKING QUESTIONS 1. What have been the four main periods in the evolution of health promotion in Canada? 2. What has been the role of Canada on the international health promotion scene before 1986? 3. Can we consider that the Ottawa Charter for Health Promotion is a Canadian document? Why? 4. Why has the Lalonde Report received so much international attention? 5. Given what you know now, do you think 2007 will be the beginning of a new era in Canadian health promotion?

FURTHER READINGS Modolo, M.A., & Mamon, J. (2001). A long way to health promotion through IUHPE conferences (1951–2001). Perugia: University of Perugia, Inter university Experimental Center for Health Education. A most interesting history of the main international organization in Health Promotion, published on the 50th anniversary of its foundation. Pederson, A., O’Neill, M., & Rootman, I. (Eds.). (1994). Health promotion in Canada: Provincial, national, and international perspectives. Toronto: W.B. Saunders. The first edition of the book, which analyzes the 1974–1994 period of Canadian Health Promotion. The various charters and declarations of the six WHO international conferences on health promotion, including the most famous of all, the Ottawa Charter. Can be found on the WHO Web site indicated in the Web sites section below.


RELEVANT WEB SITES International Union of Health Promotion and Education (IUHPE) www.iuhpe.org/

The International Union for Health Promotion and Education (IUHPE) is the only global organization entirely devoted to advancing public health through health promotion and health education. This site is an important source for news and events in health promotion in three languages (English, Spanish, French). Reviews of Health Promotion and Education Online www.rhpeo.org/

The Web site of IUHPE’S electronic journal, the Reviews of Health Promotion and Education Online (RHPEO); see especially the series Ottawa 1986–Vancouver 2007: Should we revisit the Ottawa Charter? World Health Organization www.who.int/healthpromotion/conferences/en

WHO Web site on global Health Promotion conferences, including charters, declarations, etc., as well as the complete text of the Alma-Ata Declaration on Primary Health Care.


PA RT I

CONCEPTUAL PERSPECTIVES

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C

e qui se conçoit clairement s’énonce facilement et les mots pour le dire arrivent aisément” (What is clearly conceived is easily said and words to say it come easily), said French preacher Bossuet a few centuries ago. And, “There is nothing more practical than a good theory,” said American social psychologist Kurt Lewin a few decades ago. In a nutshell, these two sentences capture why we open this book with a section on conceptual perspectives. While many people, particularly those with practical demands on them, resist conceptual discussions or perceive them as irrelevant intellectual or academic debates of little use in their day-to-day work, we think that addressing conceptual perspectives up front is central to improving our practice. Indeed, it is a consistent observation by health promotion scholars that despite the availability of much solid conceptual and theoretical work, most programs are not developed with a theoretical base, resulting in both less effective and fewer interventions. Hence in this first part we try to address some of the major conceptual issues of the field and how they are relevant to Canada and to reveal some of 17


their practical consequences. If we are promoting health, what exactly are we promoting? Is health promotion distinct from health education, or public health, or population health? If not, then there is no reason to have a distinct scientific and practical field by this name, or jobs in health promotion. If so, then we need to clarify and agree on what it is so we can practise it, teach it, and build the scientific base required to understand and improve it. This part deals with these basic and several other related issues. In Chapter 2, Raeburn and Rootman review the dilemmas generated by the enlargement of the concept of health over recent decades, how developments since the first edition of this book in 1994 have had an impact on the concept, and, using the definition of health proposed in 2005 in the Bangkok Charter for Health Promotion, suggest their own way for Canadian health promoters to address these dilemmas. In Chapter 3, O’Neill and Stirling argue that there has been and continues to be a conceptual confusion about what constitutes “health promotion.” After showing some of the very practical consequences of such confusion using work done for the Internet-based Canadian Health Network, they propose a way to clarify the confusion, at the same time showing that there is indeed a specific field of health promotion for which specific skills are needed. In Chapter 4, Poland and Frolich show that health promotion interventions have been traditionally approached either from the perspective of health issues, population groups, or the settings in which people live, work, or play as entry points. They discuss the conceptual and practical consequences of using one or the other or a combination of these entry points and show how the notions of social context and collective lifestyles help clarify how we might enhance our approach to thinking about health promotion interventions. In Chapter 5, Rootman, Frankish, and Kaszap, using the current international developments in health literacy—to which Canadian scholars and practitioners have made significant contributions—illustrate how a new concept moves from theory into research and practice. In Chapter 6, Reid, Pederson, and Dupéré write about the lessons those working in the health promotion field can draw from theoretical and practical developments in the field of women’s health. They specifically point to the value of intersectional theory for addressing issues of diversity, a question that feminists, women’s health researchers, and theorists have been considering for some time. At the end of this section, the reader should thus have a clear idea of the major current conceptual debates in the field of health promotion, should be able to state his or her own positions on these debates, and should be able to see the practical consequences of these positions for her or his work.

CHAPTER 2

A NEW APPRAISAL OF THE CONCEPT O F H E A LT H John Raeburn and Irving Rootman

INTRODUCTION he concept of health we implicitly or explicitly use in our health promotion work provides the whole framework and context for how we think about the health promotion enterprise. In this chapter, we present a point of view about the kind of concept we feel is needed to advance health promotion in Canada and elsewhere in the light of the challenges and new health promotion environment of the 21st century. Considerations of concepts of health in a health promotion context immediately raise a fundamental issue—that of a broad, positive, and predominantly social concept of health versus the more disease-oriented, biomedical concept of health favoured by most of the health sector. We strongly believe in the former. Indeed, we feel that what ultimately distinguishes health promotion from the rest of the health endeavour is its positive nature—its building of healthiness rather than just the prevention or treatment of illness and other negative conditions. What we write here is from this healthiness perspective (the term “healthiness” is the noun derived from “healthy,” defined as “having or showing good health,” where “health,” in turn, is defined as “soundness of body or mind” (Concise Oxford Dictionary, 1982). In a health promotion context, the term “health” can largely be seen as relating to two broad areas. One defines a sector of societal activity, different from other public sectors

T

like education or justice—as in the name “Health Canada.” The other defines an aspect of the human condition, having to do with the status of body and/or mind, as exemplified by the 1947 World Health Organization’s definition of health (see below). It is the body–mind condition version we are mainly concerned with here. Each of these two broad usages of “health” can be construed in positive or negative ways to do with healthiness or illness respectively (we are using the term “illness” loosely here to cover negative conditions of the organism). We would argue that health promotion’s concerns are ultimately to do with promoting healthy states of the human condition, especially the body and mind dimensions. Viewing health this way is, however, a minority position. For example, in 2005, only 5.5 percent of Canadian publicly funded health services were in the category of “public health” (which would presumably include much of health promotion) (CIHI, 2005), so it is reasonable to assume that almost always when one hears the term “health” in the health sector, it actually means “illness,” conceived in a medical/clinical frame. And this is also the case even of public health or heath promotion work, which is generally done within an illness rather than in a healthiness orientation (see Chapter 4, for instance). In this chapter, we thus look briefly at how we considered the concept of health in the first edition of this book, then suggest how influences since that time should be fac19

20 ■ PART I: Conceptual Perspectives

tored into current concepts of health for health promotion. Our sense is that health promotion has languished to some extent in Canada and internationally in the past few years, and that we now need new concepts to reinvigorate it. We believe a meaningful, new, positive, and inclusive concept of health for health promotion in the 21st century is essential to set both the conceptual frame and the goals of our undertakings for the future.

WHAT WE FOUND IN 1994 The 1994 version of this chapter emphasized the multiplicity of concepts of health, describing the territory as a “minefield.” These concepts came from medicine, nursing, the World Health Organization, the Ottawa Charter for Health Promotion, academics, American

holism, and lay people (see Box 2.1). The concept deemed most influential internationally from a health promotion perspective was the 1946 World Health Organization constitution’s definition of health as “a state of complete physical, mental, and social wellbeing, and not merely the absence of disease and infirmity” (World Health Organization, 1946). Probably the other most influential concept of health for health promotion internationally was “the health field concept” from the 1974 Canadian federal government document A New Perspective on the Health of Canadians, dubbed the Lalonde Report (see below) (Lalonde, 1974), discussed next. We concluded that concepts of health were largely determined by their context and who was expressing them. We thus looked at the Canadian health promotion context. The landmark Lalonde

BOX 2.1: S O M E D E F I N I T I O N S O F H E A LT H

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CHAPTER 2: A New Appraisal of the Concept of Health ■ 21

Report, named after the then federal minister of Health (Lalonde, 1974), said that health was determined by more than just health services, and listed four broad contributory factors or “elements” making up the “health field”: human biology, environment, lifestyle, and health care organization. For health promoters, it was especially the Lalonde Report’s introduction of lifestyle and environment into the health determinants discourse that came to be remembered, especially lifestyle, a concept that dominated Canadian and international health promotion thinking and action for a decade, and still lingers on. During the 1980s, there was a move away from individualistic behavioural views of health promotion to more social and policy views. In Canada, 1984–1985 were important for Hancock’s influential concepts of “healthy cities” and the “Mandala of Health” (Hancock & Perkins, 1985), although these tended to focus on disease reduction as an output rather than health. Then, in 1986, came the revolution of the Ottawa Charter, with its concept of health as a resource for living, and its cementing in of a broad social determinants model of health (World Health Organization, 1986). This social model of health was echoed in the 1986 Canadian government document Achieving Health for All: A Framework for Health Promotion (Epp, 1986), albeit with a more personal and friendly tone (using concepts like “self-help” and “mutual aid”), and a strong emphasis on equity, as befits Canadian culture. In 1989, the authors of this chapter tried to combine the health concepts of the Lalonde Health Field Concept and the Ottawa Charter (Raeburn & Rootman, 1989), and in 1993, Labonté (1993) took up the issue of subjective and objective views of health, a precursor of the qualitative revolution to come. The 1994 chapter went on to say that, while the term “health” covered many different concepts, its

common conceptual feature was that it related to a broad domain of life that could be differentiated from other broad domains, such as those of economics, politics, justice, and education. The distinctive feature of this domain was that it related to the human organism’s condition, well-being, and functioning. We concluded by asking whether a concept of health as used by Canadian health promoters could be discerned (“CHP Health” for short), and came up with the following somewhat awkward statement: Health as perceived in a Canadian health promotion context has to do with the bodily, mental and social quality of life of people as determined in particular by psychological, societal, cultural and policy dimensions. Health is seen by Canadian health promoters as being enhanced by a sensible lifestyle and the equitable use of public and private resources to permit people to use their initiative individually and collectively to maintain and improve their own well-being, however they may define it. (Rootman & Raeburn, 1994, p. 69)

INFLUENCES SINCE 1994 Much has happened in Canada and the world since 1994, and much has happened in health and health promotion. These changes make what we were talking about in 1994 seem somewhat dated, and we feel it is time to explore new concepts more relevant to the 21st century. We wish to tackle this here by considering some of the changes and developments in the past few years as pointers to how we might reconceptualize health for health promotion in the 21st century. Our choice of influences and how we interpret these are based on our own experience and values as health promoters, and we present what follows as a trigger for discussion rather than as the last word on the topic.


Population Health As outlined in Chapter 7 by Pinder, perhaps the greatest single new influence on Canadian health promotion at the national level has been the population health paradigm. It is hard to say what this means in terms of an underlying concept of health. However, Canadian health promotion traditionally embraced core values like empowerment, mutual aid, participation, and “enabling,” and gave primacy to community action. In contrast, the medical-epidemiology ethos of the population health movement seemed to represent a more top-down, depersonalized, and less community perspective (e.g., Poland et al., 1998). According to Poland and several other critics, the centre of gravity has, in spite of population health’s social determinants rhetoric, subtly moved back to a more “old-fashioned” public health and medicalized viewpoint (versus a more socially oriented “new public health”). Our view is that health promotion now needs to reassert its own identity outside the population health paradigm, and return to a more positive, empowering, and community concept of health as its basic frame of reference.

Mental Health Promotion Although the concept of mental health promotion has been around notionally since the 1980s, in the mid-1990s it emerged as a significant new area, spearheaded in Canada and the world by the work of the Mental Health Promotion Unit in Health Canada, Ottawa (Joubert, 1995). In 1996, a trail-blazing international workshop at the University of Toronto on the concept of mental health promotion came up with the following concept of mental health: Mental health is the capacity of each and all of us to feel, think and act in ways that enhance our

ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of equity, social justice, interconnections and personal dignity. (Joubert & Raeburn, 1998; p. 16)

This concept is quite different from the disease-oriented concepts that have tended to dominate the professional and academic mental health field. Certainly, it seems that the time has come for mental health to get more attention in health promotion, even if it seems ironic that we need to use disease statistics to justify this. For example, mental health issues currently comprise five of the top six burden of disease categories in industrialized countries (World Health Organization, 2001). In addition, depression is becoming increasingly evident in developing countries, especially among women, to the extent that depression is predicted to be the second largest global disease burden category by 2020 (Murray & Lopez, 1996). Canada was one of the first countries to put the area of mental health promotion on the agenda; however, it now appears to have fallen behind what is happening in the rest of the world (c.f. Saxena & Garrison, 2004). Although mental health promotion is a distinctive field, it has much in common with conventional health promotion, and the two fields need to look at how each can integrate with the other. An inclusive concept of health could help us do that, as we will illustrate below.

Resilience A particular contribution of mental health promotion to the field of health promotion worthy of mention in its own right is the concept of resilience. Resilience refers to people’s capacity to draw on their own resourcefulness to deal effectively with the demands of life, to return to full functioning after setbacks, and


to learn from such experiences to function better in the future (Mangham, Reid, & Stewart, 1996). This is illustrated in Figure 2.1, a Canadian conceptualization (Joubert & Raeburn, 1998). The concept is also applicable to communities, as discussed some years

ago in a notable Alberta think tank on the topic (Kulig & Hanson, 1996). We feel that such a concept of resilience could be extended to the whole of health promotion as a key marker of healthiness, independent of pathology measures.

F I G U R E 2 . 1 : A schematic representation of resilience as it relates to individuals in a mental health promotion context, where the arrow represents the lifespan from birth to death, and the wavy line the ups and downs of life. Good mental health is seen as flourishing where there are resilient people in supportive environments.

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Quality of Life Related to the above types of concepts are several years of studies in Ontario on subjectively experienced quality of life (QOL) (Renwick, 2004). Although it originated in the developmental disability sector, we think the Ontario concept of QOL is universally applicable, can be applied to whole communities as well as individuals, and can be quantitatively measured. QOL is defined as “The degree to which a person enjoys the important possibilities of his or her life” (Quality of Life Research Unit, 2006), and is represented in nine life sectors grouped as Being, Belonging, and Becoming, as shown in Figure 2.2. What we have here is

a powerful concept to drive health promotion considerations, and the present authors have suggested a concept of “health-related QOL” to do this (Raeburn & Rootman, 1995, 1998).

Capacity and Capacity Building Two of the strongest health promotion concepts to emerge since the mid-1990s regarding a positive rather than a deficit or disease concept of health have been those of “capacity” and “capacity building.” “Capacity” is closely allied to other positive concepts, such as “strengths” (Rapp, 1998) and “assets” (Kretzmann & McKnight, 1993). Of particular interest is the concept of “community

24 ■ PART I: Conceptual Perspectives F I G U R E 2 . 2 : C E N T R E F O R H E A LT H P RO M OT I O N Q UA L I T Y O F LIFE MODEL

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capacity,” and Canada has led the way with studies of community capacity building (e.g., Jackson et al., 2003). Capacity is both quantitatively and qualitatively measurable, with a notable review of measures for community capacity being that of Smith and colleagues in Alberta (Smith, Littlejohns, & Thompson, 2001). “Capacity building” is a term used to describe the development of both personal and social abilities, and there is strong evidence that interventions based on the concept of capacity may be more effective than conventional prevention approaches (Pransky, 1991; Raeburn et al., 2005). It could be argued that capacity building, which is close to the concept of empowerment (Laverack, 2005), is the way of the future for health promotion practice.

Community Development and Community Capacity Building Our sense is that community development (and its more recent manifestation as community capacity building) has been perhaps the most salient characteristic of Canadian health promotion at provincial and local levels for many years. However, the population health approach seems to have weakened the status of this area in that population health tends be primarily concerned with populations larger than communities, and its approach is philosophically different. Yet other than policy development and advocacy, community development/capacity building is arguably the most important single approach available to health promotion practitioners, one that fully embodies the central health promotion principles of empowerment, participation, and a sense of control by ordinary people. We argue that the community development dimension needs to be strongly re-endorsed in current and future concepts of health for health promotion.

Poverty and Equity Of particular importance to health promoters in the new globalized world are the very large numbers of people who are impoverished. It is well known that health declines with poverty, and we believe that issues of poverty should be a primary concern for health promoters. Equity (the gap between rich and poor) seems to have suffered under the New Right regimes seen in Canada and around the world. In Canada, the gap between rich and poor is increasing, and it is known that this is a major predictor of ill health and other negative indicators (Wilkinson, 1996), as well as being a social justice issue. This is part of a larger picture of the consumer and globalized world of the past 15 years, and here, poorer people are especially vulnerable to what in some countries are called “dangerous consumptions” (Adams, 2006), i.e., commercially driven lifestyle forces such as electronic gambling and fast foods, which typically take their greatest toll on the poor and minority groups. Social justice and equity have always been a part of public health and health promotion thinking, and it is imperative that we retain and strengthen this dimension in our future concepts of health.

Multiculturalism, Minorities, Migration, and Indigenous Peoples Perhaps one benefit of a population health approach is that it alerts us to the various “populations” of which our society consists. Although Canadian health promotion has traditionally given attention to the rights of women, gays, children, and the disabled, the globalization perspective brings to our attention the plight of many ethnic minorities both in Canada and around the world, including those in multicultural settings, indigenous peoples, internally displaced people because


of commercial or war pressures, those affected by environmental catastrophes, and the stresses generally of being a migrant or refugee. Canada has generally been very open with regard to immigration and accepting refugees, with the result that multiculturalism is a major Canadian reality. What this signifies, among other things, is that our concepts of health probably have to be pluralistic, since different cultures have distinctive views of health, which are often holistic in nature, and which are tied into the deepest parts of their identity, well-being, and spirituality. Similarly, the concepts and rights of First Nations as indigenous peoples are extremely important to know about and respect, since the power of the mainstream is a constant threat to them. Therefore our concept of health has to be able to accommodate and honour the diversity seen in different cultures and groups, with primacy given by right to First Nations perspectives.

Qualitative Approaches If one thing were to characterize today’s Canadian health promotion to the outsider, it would be a significant investment in university-based research (see Chapter 8). With at least 16 university-based centres of health promotion research, Canada is strong in this area. Increasingly, the realization is that health promotion research is probably best served by a predominantly qualitative research methodology, a trend started in Canada in the early 1990s. Most medical and health science, including most public and population health science outside health promotion as such, is still driven by a positivist paradigm, whereas the more subjective, life experiential, and naturalistic ethos of health promotion is probably better suited to qualitative methods or, at least, to a mix of qualitative and quantitative methods. From a

health concept point of view, a qualitative perspective has a more experiential and personal aspect compared with concepts of health based primarily on disease statistics. If health promotion is to be true to its peoplecentred origins, and since health is largely about how people feel, a qualitative concept of health is probably one that should increasingly dominate health promotion considerations.

The Bangkok Charter At the time of writing, we are still in the early stages of digesting the import of the Bangkok Charter for Health Promotion. While most people will probably focus on the globalization, action, and commitments aspects of the Charter, one of its resounding contributions is its new concept of health. After affirming “the values, principles and action strategies” of the Ottawa Charter, the Bangkok Charter (World Health Organization, 2005) says: “[Health promotion] offers a positive and inclusive concept of health as a determinant of the quality of life and encompassing mental and spiritual well-being.” Although this seems slightly garbled, it does contain some important components that could lead us toward a new overall concept of health for health promotion. First, the concept is “positive.” As stated earlier, although health promotion is ostensibly a positive enterprise, the pressures from the dominant system often lead instead to a focus on disease and deficit rather than “healthiness.” The positive–negative distinction has profound repercussions for how we health promoters conceptualize what we are doing. A positive approach is about capacity building, empowerment, resilience, and QOL, whereas a disease/deficit approach is about dealing with risks and negative states of the organism. Hopefully, the Bangkok


Charter’s clear statement about positivity will put this clearly back on the health promotion agenda. Second, the Bangkok Charter concept is “inclusive,” for which read “ecological” or “holistic.” This is helpful for the same reason as above—that is, it takes our concept of health beyond disease and narrowly conceived risks and determinants. It will hopefully also encourage thinking beyond the current social determinants model of both public and population health in that there are more types and levels of health determinants than are generally represented in this model. These include culture, psychological factors, interpersonal dealings, stress, spirituality, and social behaviour. Hopefully, the use of the term “inclusive” in the Bangkok Charter will open up the rather limited conceptual base for health and its determinants we have lived with in health promotion for many years. Third, the concept of “quality of life” is included. This is, of course, both positive and inclusive. As we saw before, QOL could be a very useful way of conceptualizing what we are dealing with in health promotion, especially when thinking of health as a goal or an output, and its inclusion in the Bangkok Charter should open up this discussion. Fourth, the Bangkok Charter’s concept of health encompasses “mental well-being.” At last, the mental health area gets a mention in a mainstream World Health Organization health promotion document! Moreover, its representation as “mental well-being” encourages us to think beyond “mental illness” when we talk about mental health in a health promotion context. We argued above that mental health is a major issue facing modern health promotion and the allusion to it here puts it squarely on the health promotion agenda. Fifth, and most surprisingly, the Bangkok Charter mentions “spiritual well-

being.” This indeed brings us into the 21st century, where it is clear that spiritual (a term going well beyond “religious”) issues are at the core of health and well-being for a majority of the world’s people (Raeburn & Rootman, 1998), yet spirituality has not been recognized as such in most official health promotion thinking. Indeed, given their fundamental importance to so many, one wonders why there is so much resistance to both mental health and spiritual concepts in conventional health promotion. What does this say about us? In spite of the resistance to acknowledging the role of spirituality among many health promoters, there is a growing research literature that supports the positive role of spirituality in health (e.g., Miller & Thoreson, 2003). Indeed—but this will be going too far for many—one could argue that spiritual health (that is, health at the deepest level of our being, and which is to do with our relationship to the whole scheme of things) is what health promotion is ultimately about. But we may need to wait until the 22nd century before this is accepted! Overall, then, the Bangkok Charter appears to lead us toward a new concept of health, one to which it is likely that Canadian health promotion can relate easily given its established history of interest and leadership in much of what is discussed here.

CONCLUSIONS As stated, we believe a new concept of health for health promotion is necessary for the 21st century to help in a much needed reinvigoration of health promotion, and to make it more relevant to the present and the future. This concept not only needs to incorporate the valued efforts and principles of the past, but needs also to take into account directions that have appeared in recent times, some of which we have covered in this chapter.


An overview of what has been said in this chapter suggests that such a concept would need to be: • positive—not based on pathology or deficit • inclusive—with a broader set of determinants and attributes than are customarily used • particularly attentive to the mental health dimension, and inclusive of quality of life and spirituality • able to be used both as a framework and as an overall goal • able to accommodate scientific measurement, while fully capturing the qualitative dimension • able to represent the current realities of what affects health and mental health in Canada and the world of the 21st century • able to inspire and give clear guidance as to where future health promotion should go Taking these points into account, a possible concept of health for health promotion in the 21st century is now given. We have aimed to make this as concise as possible,

while summarizing much of what we have covered here. It is as follows: In the health promotion domain, health is equivalent to healthiness and is related to concepts of resilience and capacity. It refers primarily to mental and physical dimensions of healthiness, has strong experiential and social aspects, and is determined by many internal and external factors, including those of a personal, collective, environmental, political, and global nature.

We realize that the risk of offering a concept like this is that if it is rejected out of hand, it may therefore seem to invalidate the rest of the chapter. However, we hope that if such rejection occurs, consideration will still be given to our contention that a new concept of health is needed for health promotion, and that the other points made in this chapter still warrant consideration. We close in the hope that what we have offered here will help to stimulate a robust discussion on how we can have a strong, positive, exciting, and relevant concept of health for health promotion, one that will take us forward in the 21st century.

REFERENCES Adams, P. (2006) Identity talk on dangerous consumptions down-under. Addiction Research and Theory, 13(6), 515–521. Alster, K.B. (1989). The holistic health movement. Tuscaloosa: University of Alabama Press. CIHI. (2005). National health expenditure trends 1975–2005. Ottawa: Canadian Institute for Health Information. Concise Oxford Dictionary. (1982). Oxford: Clarenden Press. Contandriopoulos, A.P. (2005). A “topography” of the concept of health. In R. Lyons (Ed.), The social sciences and humanities in health research (pp. 13–15). Ottawa: Canadian Institute of Health Research. Critchley, M. (Ed.). (1978). Butterworth’s medical dictionary. London: Butterworths. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: Health and Welfare Canada. Hancock, T., & Perkins, F. (1985). The mandala of health: A conceptual model and teaching tool. Health Education, 24(1), 8–10. Jackson, S., Cleverly, S., Poland, B., Burman, D., Edwards, R., & Robertson, A. (2003). Working with

CHAPTER 2: A New Appraisal of the Concept of Health ■ 29 Toronto neighbourhoods toward developing indicators of community capacity. Health Promotion International, 18(4), 339–350. Joubert, N. (1995) Mental health promotion: The time is now. Ottawa: Mental Health Promotion Unit, Health Canada. Joubert, N., & Raeburn, J. (1998). Mental health promotion: People power and passion. International Journal of Mental Health Promotion (Inaugural Issue), 1(1), 15–22. Kretzman, J.P., & McKnight, J.L. (1993) Building communities from the inside out: A path toward finding and mobilizing a community’s assets. Chicago: ACTA Publications. Kulig, J., & Hanson, L. (1996). Discussion and expansion of the concept of resiliency: Summary of a think tank. Lethbridge: University of Lethbridge. Labonté, R. (1993). Community health and empowerment. Toronto: Centre for Health Promotion. Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Health and Welfare Canada. Laverack, G. (2005). Public health: Power, empowerment, and professional practice. Hampshire: Palgrave Macmillan. Mangham, C., Reid, G., & Stewart, M. (1996). Resilience in families: Challenges for health promotion. Canadian Journal of Public Health, 87(6), 373–374. Miller, W.R., & Thoreson, C.E. (2003). Spirituality, religion, and health: An emerging research field. American Psychologist, 58(1), 24–35. Murray, C.J., & Lopez, A.D. (Eds.). (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Global burden of disease and injury, vol. 1. Cambridge: Harvard School of Public Health. Poland, B., Coburn, D., Robertson, A., & Eakin, J. (1998). Wealth, equity, and health care: A critique of a “population health” perspective on the determinants of health. Social Sciences and Medicine, 46(7), 785–798. Pransky, J. (1991). Prevention: The critical need. Springfield: Burrell Foundation & Paradigm Press. Quality of Life Research Unit, University of Toronto. Retrieved July 14, 2006, from www.utoronto.ca/ qol/concepts.htm. Raeburn, J., Akerman, M., Chuengsatiansup, K., Mejia, F., & Oladepo, O. (2005). Building community capacity to promote health. Technical paper for 6th Global Conference on Health Promotion, Bangkok, August 7–11, 2005. Geneva: World Health Organization. Raeburn, J., & Rootman, I. (1989). Towards an expanded health field concept: Conceptual and research issues in a new era of health promotion. Health Promotion International, 3(4), 383–392. Raeburn, J., & Rootman, I. (1995). Quality of life and health promotion. In R. Renwick, I. Brown, & M. Nagler (Eds.), Quality of life in health promotion and rehabilitation: Conceptual approaches, issues, and applications (pp. 14-25). Newbury Park: Sage. Raeburn, J., & Rootman, I. (1998). People-centred health promotion. Chichester: John Wiley & Sons. Rapp, C. (1998) Strengths model: Case management with people suffering from severe and persistent mental illness. New York: Oxford University Press. Renwick, R. (2004). Quality of life: A guiding framework for practice with adult with developmental disabilities. In M. Ross & S. Bachner (Eds.), Adults with developmental disabilities: Current approaches in occupational therapy (pp. 20–38). Bethesda: AOTA Press. Rootman, I., & Raeburn, J. (1994). The concept of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada: Provincial, national, and international perspectives (pp. 139–152). Toronto: W.B. Saunders Canada.

30 ■ PART I: Conceptual Perspectives Rootman, I., & Raeburn, J. (1998). Quality of life, well-being, health, and health promotion: Toward a conceptual integration. In W. Thurston et al. (Eds.), Doing health promotion research: The science of action (pp. 119–134). Calgary: University of Calgary. Sarafino, E.P. (1990). Health psychology: Biopsychosocial interactions. New York: John Wiley & Sons. Saxena, S., & Garrison, P. (Eds.). (2004). Mental health promotion: Case studies from countries. Geneva: WHO/WFMH. Smith, N., Littlejohns, L., & Thompson, D. (2001). Shaking out the cobwebs: Insights into community capacity and its relation to health outcomes. Community Development Journal, 36(1), 30–41. Spector, R.E. (1985). Cultural diversity in health and illness. Norwalk: Appleton-Century-Crofts. Wilkinson, R. (1996). Unhealthy societies: The afflictions of inequality. New York: Routledge. World Health Organization. (1946). Constitution. Geneva: Author. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. World Health Organization. (2001). The world health report 2001—Mental health: New understanding, new hope. Geneva: Author. World Health Organization. (2005). Bangkok Charter for Health Promotion. Geneva: Author. www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html

CRITIC AL THINKING QUESTIONS 1. What concept or concepts of health do you prefer? Why? 2. Do you agree that the concept of health for health promotion needs to be positive and inclusive? Why or why not? 3. Does everyone who is interested in health promotion need to agree broadly on what we mean by “health” in a health promotion context? Why or why not? 4. Do you think we need a new concept of health for health promotion for the 21st century? Why might a new concept of health for health promotion rejuvenate the field? Or should we just leave things as they are? 5. What do you think of the concept of health suggested at the end of this chapter? If you do not like it, can you think of another that would suit you? If there could be only one commonly accepted concept of health for health promotion, what might it be? Why?

FURTHER READINGS Antonovsky, A. (1979). Health stress and coping. San Francisco: Jossey Bass; and Antonovsky, A. (1987). Unravelling the concept of health. San Francisco: Jossey Bass. These two books raise the question of what creates “health” rather than “disease.” Antonovsky suggests and discusses the term “salutogenesis” to encourage more thinking and research about the determinants of health rather than of disease. A recent commentary on the concept has been published by Lindstrom and Erickson (Lindstrom, B., & Erickson, M. (2005). Salutogenesis. Journal of Epidemiology and Community Health, 59, 440–442). Lindstrom has recently established a research centre in Finland built around salutogenic research (see Chapter 16).

CHAPTER 2: A New Appraisal of the Concept of Health ■ 31 Contandriopoulos, A.P. (2005). A “topography” of the concept of health. In R. Lyons (Ed.), Social sciences and humanities health research (pp. 13–15). Ottawa: Canadian Institute of Health Research. This is an interesting article about the concept of health that considers contributions from the social sciences and humanities to thinking about the concept. Also in the same volume is a one-page article (p. 120) by Contandriopoulos and other Canadian colleagues on a proposed project to integrate approaches and perspectives about the concept of health from the social and life sciences. Rootman, I., & Raeburn, J. (1994). The concept of health. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada (pp. 139–152). Toronto: W.B. Saunders. This chapter, which appeared in the first edition of Health Promotion in Canada, presents an overview of the development of the concept of health in Canada up to 1994, along with some useful diagrams. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. This Charter is important for all students of health promotion to read and understand. It can be obtained at www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf World Health Organization. (2005). Bangkok Charter for Health Promotion. Geneva: Author. The Bangkok Charter is the most recent international agreement regarding future directions for health promotion. It can be obtained at www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html

RELEVANT WEB SITES Click4HP www.lsoft.com/scripts/wl.exe?SL1=CLICK4HP&H=YORKU.CA

Click4HP is a listserv that was established by the Ontario Health Promotion Clearinghouse in 1996 and is operated by York University. It has an archive of discussions that have taken place since it was established on a wide range of health promotion topics, including the concept of health. Quality of Life Research Unit www.utoronto.ca/qol/unit.htm

This site provides information about the Centre for Health Promotion Model of Quality of Life, including a description of the conceptual framework developed over the last decade by researchers associated with the Centre as well as the tools that have been developed to measure quality of life and how to order them.

CHAPTER 3

T H E P RO M OT I O N O F H E A LT H O R H E A LT H P RO M OT I O N ? Michel O’Neill and Alison Stirling

INTRODUCTION here are several important reasons for having a clear definition of health promotion. In this chapter, we will first explain why we think defining health promotion is so crucial. Second, we will look at two ways in which defining the field has been undertaken. Finally, we will make suggestions about two possible avenues to solve the dilemmas raised by this definitional issue: a more operational one, showing how the health promotion affiliate of the Canadian Health Network (CHN) decided to address and try to solve it, and a more conceptual one by suggesting differentiating “health promoting” from “health promotion” activities. We think the latter has a significant potential to clarify the definitional confusion that has plagued the field for a long time.

T

WHY DEFINING HEALTH PROMOTION IS IMPORTANT Disciplinary and Professional Reasons There is much debate about whether or not health promotion is or should be considered a discipline like medicine, nursing, sociology, or biology (Bunton & MacDonald, 2004). The notion of a discipline is itself a complex one, with scientific and practical dimensions. These concerns, which exist for any domain, are more evident when a professional category of practitioners, which is recognized 32

in a society at one point in time, needs to be considered and legitimized. All health-related professions are caught up in these debates. Let us take nursing as an example to identify the terms of the issue, and then apply them to look at health promotion. In Canada, in all provinces, nursing is currently a profession regulated by specific laws. How a specific group achieves the status of a recognized, and even more, a legally regulated profession in modern societies has been studied by sociologists for decades, with special attention devoted to the health professions, given their diversity and the “dominant” power of medicine in relation to the others (Coburn, 1988; Freidson, 1977). These authors usually agree that a profession is defined by a certain number of features: a specific body of knowledge, a code of ethics, and a self-regulated practice to insure quality control and protect the public from dangerous practitioners (see Chapter 17 for additional elements on professions). In contrast to other countries such as Australia, in Canada, health promotion has not gained the status of a profession. Is this a problem? In the international literature, there is no unanimity (Ottoson et al., 2000). In this debate, we believe both positions have pros and cons. Some people argue that, in order to make sure that the public gets the best possible services, health promoters should be trained properly according to the latest scientific or practice developments, that

CHAPTER 3: The Promotion of Health or Health Promotion? ■ 33

there should be quality-control mechanisms, that it is very important to professionalize health promotion, that specifically identified health promotion jobs exist, etc. On the other hand others believe that health promotion skills should be part of the training of all health professionals and even of some other types of professionals working on the nonmedical determinants of health; for them, there is no need for a specific profession, notably because the current health promotion body of knowledge (at the scientific or the practice levels) does not justify the existence of a distinct profession. When we speak about a distinct body of knowledge, we open up another avenue of reflection on the field of health promotion, notably around the notion of its scientific nature as required to define a discipline, which in our societies is a very important element. Going back to nursing as an example, as for many other health-related professions, its definitions often allude to “the art and the science of,” as is also the case in Winslow’s (1920) famous old definition of public health still echoed in a recent glossary of health promotion: “Public Health is the science and art of promoting health, preventing disease and prolonging life through the organized efforts of society” (Nutbeam, 1998, p. 3). A lot of words have been used in nursing to discuss if, beyond the art of practising it, it is a scientific discipline of its own or if it is a practical field drawing the knowledge it needs to intervene properly from a variety of scientific disciplines and from other sources (e.g., Donaldson, 2000; Thorne, 2005). In an era where science is believed to be a major, if not the major, basis to organize human life in modern societies as reflected in the current and lively debates around “evidencebased” professional practices, the same question can be asked of medicine, public health, and now health promotion (O’Neill,

2003; Raphael, 2000): Are they scientific disciplines of their own or fields of practice drawing on a variety of other sources to do their job properly? We will not enter into these debates here, which have been thoroughly conducted elsewhere (Bunton & MacDonald, 2004; McQueen & Anderson, 2000), but state our own position. Specifically, we think that because they do not have a specific substantive area of study of their own (the main criterion used by epistemologists, sociologists, and philosophers who study what is required to constitute a science), none of the health disciplines mentioned above are sciences; they are rather fields of practice, drawing on a variety of sources, including scientific knowledge from other disciplines, to construct the body of knowledge required to intervene optimally.

Political Reasons If health promotion in Canada is not a profession or a scientific discipline, but a field of practice, does it have a specificity that differentiates it from the other health-related fields of practice? The answer to this question has a lot of consequences that we will qualify here as political and which are a second set of reasons for paying attention to the definition of health promotion. If health promotion has no identity of its own, it becomes very difficult to decide what to include in the training of people who are supposed to practise it and then to justify having programs devoted to it in universities, colleges, or elsewhere. It also becomes very difficult to establish what kind of knowledge needs to be scientifically (through academic research notably) or otherwise developed to properly ground its practice. And this, in turn, will have consequences for whether or not specific skills in health promotion will be required from certain sets of


people in certain types of jobs, be they actually labelled health promotion jobs or not. Overall, then, it will have a lot of impact on the amount and the nature of scarce resources that a specific society will be willing to allocate for this purpose. If we look at Canada on that count, since the Lalonde Report of 1974, can we say that health promotion is clearly enough defined as to have found its niche? As is made obvious in the rest of this book, the answer is not really, and not enduringly. Even if there has been a health promotion discourse, health promotion training programs, research endeavours, and even health promotion governmental programs and eventually a few policies, it has never known as much substantial development as other sectors of society or of the health system have; using the image of Pinder in Chapter 6, it has even been just below the radar screen for almost a decade. We think that one of the main reasons for this has been health promotion’s incapacity as a field to properly differentiate itself from neighbouring fields because of its inability to define itself clearly, internally, and for others; it has thus been very vulnerable when others became politically attractive as was the case when population health became trendy around 1994. It is thus obvious that health promotion, if it wants to exist and survive, must go beyond the self-promoting interest of its academic and practitioner community and clearly articulate what it is and what it has to offer the world, otherwise the world might have no use for it.

Practical Reasons The lack of agreement on what health promotion is about and what it does also has practical consequences. Take the example of a health promotion clearinghouse, a type of facility one of us (AS) has been working in

for over 15 years, whose mandate is to support the capacity of people involved in health promotion practice to do their work effectively. Simply trying to organize resources on different definitions of health promotion highlights conceptual confusion on the nature, values, and purpose of the field (Seedhouse, 1997). Should the “practice” of health promotion be organized according to risk conditions, diseases, or issues (e.g., lifestyles and/or living conditions), or by functions and strategies (e.g., education, policy, communication), or by settings (e.g., schools, workplaces, communities)? Of course, the scope of health promotion practice encompasses all of these aspects and much more: principles, processes, causes, cross-discipline approaches (Duncan, 2004; Nyamwaya, 1997; Raphael, 2000). The practitioner needs all of these resources, but may consider health promotion to be limited to one focus, such as “workplace health.” A clearinghouse has thus a double duty: to anticipate the breadth of possible needs for information and resources on what might fall under the rubric of “health promotion” and to assist its users in considering and applying interrelated elements of the field instead of just a single strategy, issue, or setting. In order to be retrieved and made available to practitioners, information has thus to be organized or classified in a way that reflects the core categories and boundaries of a field and still remain understandable. For example, a classification system for health promotion indicators that uses the Ottawa Charter for Health Promotion has been proposed by a European group; it includes systems, structures, and processes in action areas, health capacities, and health practices (Bauer et al., 2003). It is an elegant model in structure and concept, but it would be difficult for users to browse through the terms and know that they are looking at health promotion practice.


Without the guide of a common definition, how can we expect anyone to search for “health promotion” and get usable results?

APPROACHES TO DEFINING HEALTH PROMOTION If we agree then that, even if difficult, it is crucial to define health promotion, there are many ways to do it. Information science, for instance, would sort out a set of concepts that provide overall structure, pointers, and access for a body of works, which would guide the information searcher into the ideas and knowledge encompassed by a field (Albrechtsen & Jacob, 1997; Kwasnik & Rubin, 2003). We will explore two of these ways here. On the one hand, we will look at what is meant by health promotion in contrast with other closely related concepts or areas, i.e., health education, population health, and public health. On the other hand, we will look at two attempts, mostly undertaken by Canadian experts, to reach a consensus on what health promotion is all about.

Health Promotion versus Other Related Concepts Health Promotion versus Health Education

As seen in Chapter 1, for most people, health promotion as a field emerged as an evolution of the field of health education, which had formalized itself at the beginning of the 1950s and worked from then on to influence individual health-related behaviours. However, at the end of the 1970s, many health educators realized that trying to influence individual behaviours without altering the environments in which they occurred produced very limited results. In the mid-1980s, the field as a whole relabelled itself “health promotion” to signify notably that from then on, just working to change individual lifestyles was no longer a viable option. A

much broader way to see things, soon to be called ecological (see Chapter 18), was seen as required to understand and influence health-related behaviours. For many, the transition from traditional individualistic health education toward a more ecologically oriented health promotion requesting to intervene at a variety of levels was difficult (Green & Raeburn, 1988). For instance, it is only at the very end of 1993 that the main professional and scientific global organization in the field, the International Union for Health Education (IUHE), decided to follow the trend and rename itself the International Union for Health Promotion and Education (IUHPE), keeping the two expressions within its new title. Even today, in several countries like the US or France, the words “health education” have more currency than “health promotion” in many quarters, sometimes to designate the old version of individualistic health education, sometimes using these words to designate the new, enlarged field called “health promotion” elsewhere. Chapter 16 in this book shows several of these variations worldwide. We can thus say: “Health education comprises consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health” (Nutbeam, 1998, p. 4). Box 3.1, written especially for this book by the former editor of one of the most important journals in the field, Health Education Research, shows that the debate is far from over. No wonder people are still confused today when asked how to differentiate the two! Let us conclude this section then by agreeing with most people today that health education is one strategy within the larger field of health promotion.

36 ■ PART I: Conceptual Perspectives BOX 3.1: H E A LT H E D U C AT I O N : Resurrection and Reinvention

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Health Promotion versus Population Health

The way in which, in Canada, a “population health” vision replaced the health promotion discourse from 1994 on and for about 10 years has been thoroughly addressed elsewhere in this book, especially in Chapter 6. We share Pinder’s conclusion that both have now found their respective niches in the recent structural and conceptual developments that have taken place since 2002. What is worth mentioning, though, is that from its Canadian origins in the early 1990s, the population health vision has globalized to the point that in 2003, the famous American Journal of Public Health devoted a special issue to the topic. So, what differentiates health promotion from population health? Not much, as some of us have argued elsewhere (Pederson, Rootman, & O’Neill, 2005) because, as we will see below, they are slight variations on the theme of the “new public health,” itself the current reincarnation of a public health vision as old as the human species itself. But different enough to have crystallized the belief that population health is theoretical and polit-

ically conservative as well as epidemiologically, economically, and individually driven; in contrast, for many, health promotion is practical, politically progressive, sociologically and policy-oriented, as well as collectively driven (Labonté, 1995; Robertson, 1995). We think, however, that it is caricaturing both orientations and “in general, the proponents of population health can be seen as allies [of health promotion] in the move towards the new public health, particularly since overall, neither framework has significantly challenged the dominance of biomedicine in the health field” (O’Neill, Pederson, & Rootman, 2000, p. 141). Health Promotion versus Public Health

Finally, we will argue here that for most people involved in the field, health promotion is seen as one of the essential functions of public health, as defined above by Nutbeam. Public health functions are usually identified as protection, surveillance, prevention, and promotion as indicated in several recent documents, but especially the ones derived from a large consensus-building process organized


by the Pan-American Health Organization. In that document, health promotion is defined primarily as: “The promotion of changes in lifestyle and environmental conditions to facilitate the development of a culture of health” (Pan-American Health Organization, 2002, p. 67). It is also interesting to note that health promotion (as symbolized by the Ottawa Charter) has been identified as the “third public health revolution” of humankind (Breslow, 1999); after the first, which had tackled infectious diseases, and the second chronic illnesses, the health promotion era,

according toBreslow, embarks on the journey toward health and not against diverse types of diseases. This is illustrated in Figure3.1, where we can see that with the evolution of humankind, of the epidemiological patterns of disease and of the technological means available, the various functions of public health have successively developed in a series of layers like sediments, the latter not displacing but building on top of the former, which needs the previous ones to continue to function properly.

F I G U R E 3 . 1 : SEDIMENTATION APPROACH TO PUBLIC HEALTH THROUGHOUT HUMAN HISTORY

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Defining Health Promotion through Expert Consensus In addition to definition by differentiation from close concepts, expert consensus is another way that has been frequently chosen. A good example of that approach is the socalled “yellow document.” As WHO regularly does, a group of international experts was convened to address a specific topic—the concept and principles of health promotion— and came up with what is the forerunner of the Ottawa Charter (WHO-Euro, 1984). It is also through such a process that a group of the Canadian Institute of Advanced Research, an institution funded mostly through private monies that convenes task forces on topics that are of major importance for the future of Canada, came up with the famous “population health” framework after a couple of years of intensive work (Frank, 1995). We will explore here two of these efforts of experts to define heath promotion, led largely by Canadians: a more systematic one, done in the context of a major reflection on the evaluation of health promotion (Rootman et al., 2001), and a collection of spontaneous ones that emerged over the last 10 years on Click4HP, an electronic international discussion list monitored out of Toronto. Deconstructing Health Promotion

In an exemplary effort to define what health promotion is all about, in order to discuss how to evaluate it, Rootman and his colleagues

identified 13 of the “most important” definitions of the concept and thoroughly analyzed them according to goals, objectives, processes, and activities. At the end of their content analysis, they conclude endorsing the “preeminence” of the definition proposed by the Ottawa Charter (see below) and by the fact that “[…] the primary criterion for determining if an initiative should be considered health promoting, ought to be the extent to which it involves the process of enabling or empowering communities” (Rootman et al., 2001, p. 14). The “What Is ‘Real’ Health Promotion” Debates on Click4HP

The Click4HP (Click for health promotion) listserv started in April 1996 as a short-term pre-conference public discussion on the uses of the Internet for health promotion, but rapidly grew into a long-lasting, vibrant international online forum on the nature of health promotion and its applications. Click4HP has grown from 350 to a constant 1,200 subscribers since 2000, engaging in exchanging information, seeking solutions, and building connections in more than 10,500 postings in 10 years, at an average of 85 postings a month. On top of being used as a platform to exchange information of all kinds to facilitate the day-to-day work of practitioners, more general debates and exchanges have occurred regarding empowerment, advocacy, healthy lifestyles, wellness, illness prevention, and rehabilitation, foundations and values,

BOX 3.2: C L I C K 4 H P : A N E L E C T RO N I C V E N U E F O R D E B AT I N G H E A LT H P RO M OT I O N I S S U E S

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settings and strategies, and the myriad determinants of health. Regularly, there are vigorous debates on the list on the definitions and the breadth of health promotion. The longest of these was in September 1996 with more than 30 postings on “What is ‘real’ health promotion” (see annotated Web sites below), followed by a 1998 learned discussion among HP scholars on foundations and limits of the field (18 long postings), a lively exchange in 1999, and again in the fall of 2000 on what is HP (contrasting definitions of population health, HP, and prevention), and, finally, a vigorous exchange in 2004, rekindled in 2005, following a question of whether health promotion was dead or heading there. Each time, these debates show that HP is alive and kicking, but at the same time that “health promotion continues to be constrained by the lack of a consistent, clear and usable definition” (Click4HP, 2004), which explains why such debates erupt over and over again on Click4HP and in many other venues.

TRYING TO SOLVE THE DEFINITIONAL DILEMMA The CHN Classification Scheme of Health Promotion In 1998 the Canadian Health Network (CHN) was launched as a federally funded health promotion initiative to provide, through a national bilingual Web site, highquality, credible, and relevant health information for the general public and health professionals. It has been seen as a public sector response to consumers’ increasing use of the Internet to search for health information among a morass of very uneven sources (Cline & Haynes, 2001; Fox & Rainie, 2000; Health Canada, 2000; Korp, 2006). CHN operates through a unique collaboration involving affiliates who are key partner organizations in 22

topic areas and link to hundreds of organizations that contribute electronic resources to the CHN Web site; affiliates select resources, produce feature articles, and respond to health information requests. Why a Definition of Health Promotion Was Needed across CHN

Although CHN was labelled from the outset a “health promotion network,” there had been little consistent vision of what that meant in practice. With the proliferation of health information Web sites by governments and health agencies, CHN needed to make clear what it did differently. In 2003, CHN’s Advisory Board set new strategic directions for 2004–2007, the first of which was to strengthen its focus on health promotion, including all of the determinants of health, across the entire network (CHN, 2003). However, a commitment to health promotion is not enough to ensure consistency in application across so broad an organization. In the 2004 round of affiliate renewals, a new health promotion affiliate was thus established with a dual goal of building the online resources as well as health promotion capacity of CHN as a whole. CHN’s Working Definition of Health Promotion and a Tool to Assess It

A working definition of health promotion was agreed upon through a series of workshops held in 2005. It integrated the Ottawa Charter’s definition with a recognition of levels of intervention and attention to determinants that encompassed the breadth of perspectives given the many affiliates. A simple one-page tool was then developed to assess how this definition could be reflected in all the work of CHN. The health promotion assessment checklist (see annotated Web sites below) uses a matrix-like frame addressing who, where, why, how, and what is considered in an initiative. Each term


on the bilingual HP checklist is hyperlinked to a Web-based definition or explanation of what it means in context. The checklist is designed to be concise, comprehensive, and yet simple, customizable by affiliates, and compatible with other forms, tools, and qualitytesting mechanisms required for CHN collection of resources. Testing took place in spring 2006, with a subsequent evaluation and modifications. Is CHN’s Problem Solved?

Integrating a broad health promotion approach that requires considering multiple strategies, determinants, and levels into what used to be a rather individualistic health information service is difficult. It comes at a time when there are pressures for quality assurance of all content on CHN through peer review, evidence-based resource selection, and establishment of standards of practice (Balka, 2005). Demonstration of health promotion “competencies” for all CHN affiliates in staffing and organizational practice is expected for the next round (Fall 2006) of affiliate application process for three-year contracts. As we have been able to observe thus far, for many of the diverse health and social organizations forming the CHN collaboration, there seems to be little difference between their usual work through individual lifestyle behaviour-change messages and the health promotion approach and definition that they now are expected to apply. Consequently, concerns from government and health agencies in CHN that health promotion is not a clearly defined area are likely to continue, at least for a while.

The Promotion of Health versus Health Promotion: A Conceptual Avenue to Solve the Definitional Dilemma? So, is there such a thing as health promotion? Are there ways to solve the confusion that is

pointed out by so many people, even among the most knowledgeable? Our answer is yes, and for this it is helpful, as one of us proposed in the first edition of this book (O’Neill & Cardinal, 1994), as well as in several other venues since then (O’Neill, 1997, 1998, 2003), to distinguish between two things. On the one hand, there is the discourse on the place of health in societies, often called the “new public health” discourse, which we will label here the promotion of health. On the other hand, there is the specialized field of intervention within the broader field of public health, aimed at the planned change of behaviour and environments related to health, which we will call health promotion. This distinction is well illustrated if we contrast two of the best-known definitions of the field, the one from the Ottawa Charter (WHO, 1986, p. 1): “The process of enabling people to increase control over, and improve, their health” with the one (Green & Kreuter, 2005, p. 462): “[…] any planned combination of educational, political, regulatory and organizational supports for actions and conditions of living conducive to the health of individuals, groups or communities.” The Ottawa Charter’s definition, as well as the preface to this book by Kickbusch and most governmental health policy documents in Canada or around the world since the mid1970s, are typical of the reflections on what health is or should be; on the place health should have in societies; and on who should undertake health promoting, health restoring, or health-maintaining endeavours (individuals, governments, civil society, corporations, the health sector—including public health professionals—other sectors, etc.), hence the idea of naming this a discourse on the promotion of health. Basically, it is nothing but the old public health discourse, which has been around for centuries (Fassin, 2000) and which tries to reflect upon what health is in societies


or populations; what produces or hinders it; and what can be done to improve it, reduce the risk of losing it, or restore it when compromised. The discourse on the promotion of health in modern societies, which has been rekindled by the efforts of the European Office of WHO and is so strongly symbolized by the Ottawa Charter since the mid-1980s, is usually referred to as the “new” (Ashton & Seymour, 1988; Martin & McQueen, 1989) or the “ecological” public health (Chu & Simpson, 1994; Kickbusch, 1989) in order to differentiate it from the more classical discourse of “hygiene” or “old” public health, which is better adapted to traditional societies with an epidemiological pattern of infectious disease. Consequently, it is why we argue here that population health, as it emerged in Canada in 1994, is but a variation of this new public health discourse on the promotion of health. Conversely, if we look at Green and Kreuter’s definition, it is more in line with the idea that health promotion is a specialized subarea, or essential function, of the public health sector of health systems whose specificity is the planned change of lifestyles and life conditions having an impact on health, using a variety of specific strategies, including health education, social marketing, and mass communication on the individual side, as well as political action, community organization, and organizational development on the collective side. If we agree with this, then the planned change skills of properly trained health promoters can be used at whatever stage in the natural history of any illness or health problem (thus in primary or secondary prevention, in acute care, in rehabilitation, or in tertiary prevention) and at any level, from the individual to the societal, including the family and the community. Moreover, a variety of value bases can be used to work with these health promotion skills and, conversely, the value base promoted by

the Ottawa Charter (social justice, participation, empowerment, etc.) is in no way restricted to specialized health promotion interventions, but belongs to anybody working in the new public health era, be they public health, health or other professionals, or even lay people. Finally, if they want to be as effective as they can be, planned change health promotion interventions need to be knowledge-based or even evidence-based when that type of information is available. The relationship between the promotion of health and health promotion is illustrated in Figure 3.2.

CONCLUSION As discussed in this chapter, it is obvious that the two elements are often present together when people use the words “health promotion,” which maintains the confusion and the impression for many that health promotion as a specialized subfield of public health does not exist. This is due notably to the fact that the Ottawa Charter’s definition, and the value base it carries, are by far dominant on the planet when one hears “health promotion.” As seen throughout this book, it gives a very clear and distinct orientation to how people perceive Canadian health promotion, despite the fact that different value bases and different ways of approaching health promotion do exist here as well. Hence, in conclusion, we suggest using the words “new public health” or “ecological public health” when we talk in general about the discourse on the promotion of health, and reserve the expression “health promotion” to designate the specific planned change skills needed to complement the types of skills developed in other subareas of public health practice in order to achieve the results desired by the “new public health” discourse.

42 ■ PART I: Conceptual Perspectives F I G U R E 3 . 2 : T H E P RO M OT I O N O F H E A LT H V E R S U S H E A LT H P RO M OT I O N

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REFERENCES Albrechtsen, H., & Jacob, E.K. (1997). Classification systems as boundary objects in diverse information ecologies. In E. Efthimiades (Ed.), Advances in classification research: Proceedings of the 7th ASIS SIG/CR Classification Research Workshop (pp. 1–13). Medford: Information Today. Ashton, J., & Seymour, H. (1988). The new public health. Philadelphia: Open University Press. Balka, E. (2005). Redefining P3: Political economy, policy, and privacy issues on the Canadian health information highway. In L. Shade & M. Moll (Eds.), Communications in the public interest, vol. 2: Seeking convergence in policy and practice (pp. 512–547). Ottawa: Canadian Centre for Policy Alternatives. Bauer, G., Davies, J.K., Pelikan, J., Noack, H., Broesskamp, U., & Hill, C. (2003). Advancing a theoretical model for public health and health promotion indicator development. European Journal of Public Health, 13(3 Suppl.), 107–113. Breslow, L. (1999). From disease prevention to health promotion. JAMA, 281(11), 1030–1033. Bunton, R., & MacDonald, G. (Eds.). (2004). Health promotion: Disciplines and diversity (2nd ed.). London and New York: Routledge.

CHAPTER 3: The Promotion of Health or Health Promotion? ■ 43 CHN. (2003). Canadian Health Network Advisory Board proceedings. Retrieved November 2003 from www.canadian-health-network.ca/servlet/ContentServer?cid=1086089762068&pagename=CHNRCS/Page/ShellCHNResourcePageTemplate&c=Page&lang=En Chu, C., & Simpson, R. (1994). Ecological public health: From vision to practice. Toronto: Centre for Health Promotion; University of Toronto; Participaction. Click4HP. (2004). Posting made September 27, 2004. Cline, R.J.W., & Haynes, K.M. (2001). Consumer health information seeking on the Internet: The state of the art. Health Education Research, 16(6), 671–692. Coburn, D. (1988). The development of Canadian nursing: Professionalization and proletarianization. International Journal of Health Services, 18(3), 437–456. Donaldson, S.K. (2000). Breakthroughs in scientific research. The discipline of nursing: 1960–1999. Annual Review of Nursing Research, 18, 247–311. Duncan, P. (2004). Dispute, dissent, and the place of health promotion in a “disrupted tradition” of health improvement. Public Understanding of Science, 13, 177–190. Fassin, D. (2000). Comment faire de la santé publique avec des mots. Une rhétorique à l’œuvre. Ruptures, revue transdisciplinaire en santé, 7(1), 58–78. Fox, S., & Rainie, L. (2000). The online health care revolution: How the web helps Americans take better care of themselves. Washington: Pew Internet & American Life Project. Frank, J. (1995). Why population health? Canadian Journal of Public Health, 86(3), 162–164. Freidson, E. (1977). Professional dominance: The social structure of medical care. Chicago: Aldine Publishing Company. Green, L.W., & Kreuter, M.W. (2005). Health program planning: An educational and ecological approach (4th ed.). Boston, Toronto: McGraw-Hill Higher Education. Green, L.W., & Raeburn, J.M. (1988). Health promotion: What is it? What will it become? Health Promotion, 3(2), 151–159. Health Canada. (2000). Blueprint and tactical plan for a pan-Canadian health infostructure. FederalTerritorial Advisory Committee on Health Infostructure. Ottawa: Health Canada, Office of Health and the Information Highway. Kickbusch, I. (1989). Good planets are hard to find. Copenhagen: FADL Publishers. Korp, P. (2006). Health on the Internet: Implications for health promotion. Health Education Research, 21(1), 78–86. Kwasnik, B.H., & Rubin, V.L. (2003). Stretching conceptual structures in classifications across languages and cultures. Cataloging & Classification Quarterly, 37(1/2), 33–47. Labonté, R. (1995). Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health, 86(3), 165–168. Martin, C.J., & McQueen, D.V. (Eds.). (1989). Readings for a new public health. Edinburgh: Edinburgh University Press. McQueen, D.V., & Anderson, L.M. (2000). Données probantes et évaluation des programmes en promotion de la santé. Ruptures, revue transdisciplinaire en santé, 7(1), 79–98. Nutbeam, D. (1998). Health promotion glossary. Geneva: World Health Organization, WHO/HPR/HEP/98.1. Nyamwaya, D. (1997). Health promotion practice: The need for an integrated and processual approach. Health Promotion International, 12, 179–180. O’Neill, M. (1997). Health promotion: Issues for the year 2000. Canadian Journal of Nursing Research, 29(1), 71–77.

44 ■ PART I: Conceptual Perspectives O’Neill, M. (1998). Defining health promotion clearly for teaching it precisely: A proposal. Promotion & Education, 5(2), 14–16. O’Neill, M. (2003). Pourquoi se préoccupe-t-on tant des données probantes en promotion de la santé? SPM International Journal of Public Health, 48(5), 317–326. O’Neill, M., & Cardinal, L. (1994). Health promotion in Québec: Did it ever catch on? In A. Pederson et al. (Eds.), Health promotion in Canada (pp. 262–283). Toronto: W.B. Saunders. O’Neill, M., Pederson, A., & Rootman, I. (2000). Health promotion in Canada: Declining or transforming? Health Promotion International, 15(2), 135–141. Ottoson, J.M., Pommier, J., Macdonald, G., Frankish, J., & Dorion, L. (2000). The landscape in health education and health promotion training. Promotion & Education, 7(1), 27–32. PAHO. (2002). Public health in the Americas (Technical publication #589). Washington: Pan-American Health Organisation. Pederson, A., Rootman, I., & O’Neill, M. (2005). Health promotion in Canada: Back to the past or towards a promising future. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 255–265). London: Palgrave. Potvin, L. (2005). Présentation dans le séminaire doctoral SAC-66008, Université Laval, octobre 17, 2005. Raphael, D. (2000). The question of evidence in health promotion. Health Promotion International, 15(4), 355–367. Robertson, A. (1995). Theory divides, data unite: Health promotion meets population health. Unpublished manuscript, Toronto. Rootman, I., Goodstadt, M., Potvin, L., & Springett, J. (2001). A framework for health promotion evaluation. In I. Rootman, M. Goodstadt, B. Hyndman, D. McQueen, L. Potvin, J. Springett, & E. Ziglio (Eds.), Evaluation in health promotion: Principles and perspectives (pp. 7–38). Copenhagen: WHO-Euro. Seedhouse, D. (1997). Health promotion philosophy, prejudice, and practice. Auckland: Wiley. Thorne, S. (2005). Conceptualizing in nursing: What’s the point? Journal of Advanced Nursing, 51(2), 107–107. Tones, K., & Green, J. (2004). Health promotion: Planning and strategies. London: Sage. WHO. (1986). Ottawa Charter for Health Promotion. Ottawa: World Health Organization, Health and Welfare Canada, Canadian Public Health Association. WHO-Euro. (1984). Health promotion: A discussion document on the concept and principles. ICP/HSR 602 (m01). Unpublished manuscript, Copenhagen. Winslow, C.E.A. (1920). The untilled fields of public health. Science, 51, 23.

CRITIC AL THINKING QUESTIONS 1. If you had to define health promotion to the following people, what would you say? • Your uncle Jack in a family gathering • A graduate student in physics • Ms. Jones at the neighbourhood centre community group 2. Do you now personally think that defining health promotion is important? Why? 3. Following the instructions in Box 3.2, browse the archives of Click4HP for at least an hour; after that, do you think you should subscribe to keep current about Canadian developments in health promotion? Why?


4. Explain the difference between the promotion of health and health promotion. Do you believe it is a useful distinction or not? Why? 5. After browsing the CHN Web site at www.canadian-health-network.ca for at least an hour, do you think it is a health promotion site? Why?

FURTHER READINGS Bunton, R., & MacDonald, G. (Eds.). (2004). Health promotion: Disciplines and diversity (2nd ed.). London and New York: Routledge. One of the key books to reflect on whether or not health promotion can be considered a discipline. Green, L.W., & Kreuter, M.W. (2005). Health program planning: An educational and ecological approach (4th ed.). Boston, Toronto: McGraw-Hill Higher Education. If you had to buy just one book in health promotion in your life, it should be this one for its positioning of the field as well as for its famous PRECEDE-PROCEED planning framework.

RELEVANT WEB SITES Canadian Health Network www.canadian-health-network.ca

A key Canadian Internet resource on health-related issues. Health Promotion Assessment Tool www.opc.on.ca/draft/HPChecklist.htm

Provides the current version of CHN’s checklist to assess if a resource or initiative can be considered a health promotion one. What Is “Real” Health Promotion? www.web.ca/~stirling/c4hpreal.htm

An edited compilation of more than 30 postings made during September 1996 on Click4HP about “What is real health promotion?”

CHAPTER 4

P O I N T S O F I N T E RV E N T I O N I N H E A LT H P RO M OT I O N P R AC T I C E Katherine L. Frohlich and Blake Poland

INTRODUCTION istorically there have been three major points of intervention in health promotion practice: (1) issues; (2) “at-risk” populations; and (3) settings. Each of these approaches to intervention embodies different assumptions about what shapes health outcomes; that is, what is most important and what can most feasibly be changed. As a result, each of these approaches has singled out different aspects of analysis and intervention. In all three approaches there is a more or less explicit acknowledgement that individuals are not completely autonomous decision makers and that the social context has both relevance and importance to what they do. Nevertheless, the ways in which each of these approaches has dealt with the social context differs in important ways. Followup from acknowledgement of the importance of social context to action has not, for the most part, been as systematic or comprehensive as we believe is necessary for an effective and enlightened health promotion. We detail the reasons for believing so in this chapter. We begin by giving a brief description of each of the three traditional approaches to intervention. We then briefly outline how each of these approaches has grappled with the notion of the social context, discussing their strengths and weaknesses. We conclude with some suggestions as to the role that social context could play as a point of intervention in health promotion practice by

H

46

examining some potential avenues for both research and practice.

ISSUES, POPULATIONS, AND SETTINGS AS POINTS OF HEALTH PROMOTION INTERVENTION Issues The Ottawa Charter for Health Promotion (World Health Organization, 1986) set the stage for health promotion practice as we understand it today. While the goal of the Ottawa Charter was extremely broad, covering five large areas of action and multiple conditions and resources for health, one of the areas of action taken up most enthusiastically by the health promotion community, in line with health education interventions (which had been in place since the 1950s), has been that of developing personal skills. Within the Charter, developing personal skills was described as being possible through “providing information, education for health, and enhancing life skills. By so doing, it increases the options available to people to exercise more control over their own health and their environments, and to make choices conducive to health” (World Health Organization, 1986, p. 3). Before the Ottawa Charter, and definitively since then, health promotion practice has shown enormous dedication to developing these personal skills in three major ways:

CHAPTER 4: Points of Inter vention in Health Promotion Practice ■ 47

(1) by focusing on a reduction in the prevalence and incidence of those diseases most burdening the population (cardiovascular disease, diabetes, and HIV/AIDS); (2) by focusing on the reduction of health behaviours linked to the most egregious health problems facing the population (such as smoking, poor eating habits, lack of exercise, lack of condom use), as well as (3) by reducing risk conditions such as homelessness, which is neither a disease nor a health behaviour. While the goals described as the development of personal skills were laudable at the time, these goals have largely been translated into interventions and policies that have ended up focusing on the reduction of the nefarious health lifestyle habits such as smoking, poor diet, lack of exercise, and risky sexual behaviour through information and education programs. A larger focus on increasing the options available to people to exercise more control over their own health and their environments in order to reduce disease prevalence, incidence, and risk conditions has been, for the most part, more evident in rhetoric than in practice. The focus on risk factors in health promotion interventions has a protracted history stemming from health promotion’s historical roots in both epidemiology and health education. Tannahill (1992) explored this relationship between epidemiology and health promotion. He describes the fundamental role that epidemiology plays for health promotion in identifying and prioritizing prevalent health problems and their causes. First, in response to epidemiologic studies and their results, health promotion researchers largely focus their programs and interventions on preventing the problems highlighted by these studies. So, for instance, the focus on cardiovascular disease, diabetes, or HIV/AIDS, driven by epidemiologic studies, has created great impetus for health promotion programs

to address these issues. Second, epidemiologists derive categories of risk factors associated with these health problems, which, if prevented, are presumed to reduce illness and death (Frohlich & Potvin, 1999). These risk factors are then often directly translated into health promotion programs. Because many of these risk factors (high blood pressure, overweight, and risky sexual behaviour) are modifiable through behaviours (exercise, fat content reduction in one’s diet, condom use), the focus of health promotion has often been more on the proximal, supposedly modifiable, individual-level risk factors. Because of its focus on individual-level risk factor reduction, health promotion needed individual-level theories to guide the creation of its intervention programs. These theories, the basis of health education, come largely from models of social psychology, such as the health belief model (Becker, 1974), Bandura’s social cognitive theory (Bandura, 1986), and Ajzen and Fishbein’s theory of reasoned action (1980). These models and theories all focused attention on the major biomedical and behavioural risk factors for developing the major health problems of concern at the time. Underlying these models, population prevalence of adverse risk conditions are thought to be modifiable by providing education and behaviour-change tools to individuals to help them achieve lifestyle changes (Barnett et al., 2005). Where these interventions and theories have acknowledged the social context has thus largely been through the individual and her or his decision making. So, for instance, social context within some individual-level risk factor models tends to focus on the more proximal interpersonal or physical environment (Poland et al., 2006), examining influences such as peers, co-workers, family members, and other role models. Social context is thus understood as being the immedi-


ate individual-level influences that come about due to individual social interactions. Interventions addressing these issues have also considered the social context in terms of the influence of social norms on individual behaviour. Huge efforts have been undertaken in many areas of health promotion, most strikingly in the area of tobacco consumption, to de-normalize the practice of smoking. In the context of social behaviours (such as cigarette smoking), de-normalization seeks to change attitudes regarding what is considered normal or acceptable behaviour in order to shape individuals’ views regarding the unacceptability of smoking.

Specific “At-Risk” Populations A second important point of intervention in health promotion, focusing on “at-risk” populations, has largely sought to target particular groups or populations thought to share certain key characteristics. These characteristics are frequently thought to predispose these groups to be at risk for “suboptimal” health outcomes, for instance, disease, compromised resilience/coping, etc. It is sometimes assumed with varying accuracy that populations function as “communities” with shared interests and values, for example, the homeless, the elderly, Aboriginal peoples, or new immigrants. The main advantage of this approach over the former, which focused more specifically on diseases or risk factors, is that this approach provides an opportunity to see how behaviours cluster within populations, and links these behaviours to some of the life circumstances and conditions that they share in common. This approach also fits structurally with how many organizations (governmental and non-governmental) and funding bodies are organized with separate structures for Aboriginal health, organizations working with the homeless, the elderly, etc.

To elaborate on the importance of understanding “at-risk” populations, we draw on the example of Aboriginal peoples in Canada (Adelson, 2005; Frohlich, Ross, & Richmond, in press). Aboriginal peoples are a diverse group of many tribes, languages, and cultures, but they all share a common experience of colonization and all that this has entailed (forced resettlement, residential schools, removal of ancestral lands, rights to minimum services defined according to governmental arbitration of who qualifies as status or non-status Indians, and so forth). The resultant cultural upheaval, family and community breakdown, sedentarization, disrupted connection to the land, etc., has had severe consequences in terms of community and individual mental, social, spiritual, and physical health (examples of the outcomes include issues of addiction, diabetes, suicide, etc.). Aboriginal leaders have long fought, among other things, against the dominant Western cultural paradigm’s tendency to blame the victim (labelling Aboriginal peoples as lazy, stupid, backwards, or uneducated) and to advocate instead for an understanding that places current community health problems in their proper historical context (as impacts of colonization, institutional racism, etc.). In so doing, health promotion practice focuses more on the structural constraints component of the social context for this population.

Settings The final point of intervention to be addressed in this chapter involves the emergence of settings as a key focus and approach in health promotion practice (Poland, Green, & Rootman, 2000). This issue has been driven by both pragmatic and conceptual issues. On the pragmatic side, and under the leadership of the World Health Organization, there has been an alignment of health promotion work with the places in which popu-


lations of interest are to be found (World Health Organization, 1998). Efforts have been made to access relatively captive audiences for health education programming (for example, children are accessed through schools, adults through the workplace, the homeless through shelters, etc.). Note that there are some perverse consequences of this. For example, negotiations may be difficult with the gatekeepers with whom access to “their” populations must be negotiated and may be at odds with those of the health promoter. For instance, the former may want public health to teach their workforce stress-management skills, and the latter may be more drawn to mobilizing workers to demand better working conditions and a living wage. A second thrust behind the recent interest in the settings approach for health promotion practice is a more substantial one from our point of view: It has to do with the realization that behaviour change needs to be supported with environmental conditions that are most favourable to its emergence and maintenance (that is, making healthy choices easier choices). Thus, physical activity requires access to playgrounds for children as well as parks/green spaces and public paths for the entire population; smoking cessation requires access to smoke-free spaces in the workplace and in the community; weight control and healthy eating requires changes to school cafeteria menus, availability of healthy foods in communities, etc. It has further been acknowledged that by altering the social conditions that shape health behaviours, health promotion assists not only in reducing the risk of poor behaviours for those currently at risk, but simultaneously reduces the risk of future generations (Smedley & Syme, 2000). So, for instance, by increasing the number of bicycle paths within a city, one increases the likelihood that people who suffer from obesity might be better able

to exercise in order to reduce their problem of being overweight. At the same time, and by virtue of the bicycle paths existing, children and adults who might later be at risk of obesity are provided with an opportunity (granted they own a bike and know how to ride one!) to exercise daily, thus potentially protecting them from future problems with being overweight. This point addresses the necessary focus on increasing the options available to people in order to exercise more control over their health. A third thrust is through what has been called the social environment approach to social context (Barnett et al., 2005; Emmons, 2000; Marmot, 2003; Smedley & Syme, 2000). Barnett et al. (2005) offer a definition of the social environment: Social environments encompass the immediate physical surroundings, social relationships, and cultural milieus within which defined groups of people function and interact. Components of the social environment include built infrastructure; industrial and occupational structure; labour markets; social and economic processes; wealth; social, human and health services; power relations; government; race/ethnic relations; social inequality; cultural practices; the arts; religious institutions and practices; and beliefs about place and community. (p. 107)

The advantages of this approach, the authors claim, are that programs and interventions focus “upstream” and thus the onus is not as much on the individual to control or change his or her behaviour, but rather on policies and programs to provide the opportunities for populations to change their practices. As described by Smedley and Syme, the social environmental approach is based on an ecological model (McLeroy et al., 1988; Stokols, 1996; see also Chapter 18). This model assumes that differences in levels of health are


affected by an interaction between biology, behaviour, and the environment, an interaction that unfolds over the life course of individuals, families, and communities. This model also assumes that age, gender, race, ethnicity, and socio-economic differences shape the context in which individuals function and therefore directly and indirectly influence health risks and resources. This ecological

model is best operationalized, according to these authors, by a social environmental approach to health interventions. As illustrated in Figure 4.1, this approach emphasizes how individuals’ health is influenced not only by biological, genetic functioning, and predisposition, but also by social and familial relationships, environmental contingencies, and broader social and economic trends.

F I G U R E 4 . 1 : MULTI-LEVEL APPROACH TO EPIDEMIOLOGY

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One of the most cited and successful examples of the social environmental approach has been in tobacco control over the last two decades. An important shift has taken place away from a strict focus on educating individuals about the dangers of smoking and toward changing the social environment. More specifically, and in many provinces, excise taxes on cigarettes have been introduced, changes have been made to laws with regard to smoking in public places, and there has been an attempt to reduce and further regulate the marketing of tobacco. Such social environmental changes have been found to

reduce heart disease mortality (Fichtenberg & Glantz, 2000) and the incidence of lung cancer in California since the state-wide tobacco control program was implemented in 1988 (Barnoya & Glantz, 2004).

WHY FOCUSING ON ISSUES, BEHAVIOURS, POPULATIONS, AND SETTINGS CAN COME UP SHORT WHEN ADDRESSING THE SOCIAL CONTEXT Thus far we have documented three of the most important points of intervention in


health promotion practice. We have addressed some of their successes and described some of the ways in which each of these addresses the social context. We now turn to some of the problems that have been noted with regard to each of these approaches in order to highlight the ways in which an alternative approach to addressing the social context could better enable us to intervene in the future of health promotion.

Issues and Social Context: Some Limitations With regard to the approach by issues, one of the most substantiated critiques of the “developing personal skills” approach to health promotion practice has been that most individually based models of behaviour change have actually proven to be ineffective in helping people change their high-risk behaviour. One of the most infamous of these examples is illustrated by the Multiple Risk Factor Intervention Trial (MRFIT). In this study 6,000 men, all of whom were in the top 10–15 percent risk group in the United States due to their high rates of cigarette smoking, hypertension, and hyper-cholesterol levels, were enrolled in a six-year intervention program. The intervention was state-of-the-art: well funded, well staffed, and used the best behaviour-change techniques available. Even so, the results were enormously disappointing: 62 percent of the men were still smoking after the six-year period, 50 percent still had hypertension, and few men had changed their dietary patterns (Multiple Risk Factor Intervention Trial Research Group, 1981, 1982). Among the many reflections that have taken place since the MRFIT experience, one of the most important has been that even if the MRFIT had been a success, it would have affected only 6,000 men and there would always be 6,000+ more men to replace them

as high-risk candidates for cardiovascular disease since the social contextual conditions creating the problem in the first place remain unchanged. The underlying problem with the high-risk behaviour modification approach, if one is truly interested in sustained population change, is that it does not address what has been termed the “fundamental causes” (Link & Phelan, 1995). The fundamental cause posits that one has to understand the factors, as well as the mechanisms, that put people at risk (that is, the social context), and not just focus on risk factors alone.

High-Risk Populations and Social Context: Further Limitations The problem with the high-risk approach has also been articulated in terms of levels of intervention. In order to deal with health promotion concerns, one can address “downstream” individual-level phenomena (such as individual, behavioural factors, or physiologic pathways to disease), “midstream” factors (such as population-based interventions that aim to change either behaviours or some influence that is affecting entire populations), as well as “upstream” phenomena (such as public policies) as illustrated in Figure 4.2, which is derived from Jetté’s (1994) work. The midstream and upstream approaches have received less attention, but are critical for several reasons. First, many of the risks for disease are shared by large groups of people. If we think of the major health problems facing Canada today, we can figure here obesity, cardiovascular disease, and diabetes. Some of the behaviours associated with these health problems, such as poor diet, lack of proper exercise, and smoking, can be addressed using individual behaviour-modification techniques, but these techniques do little to address the reasons why individuals may be eating poorly, exercising less than they should, and smoking.

52 ■ PART I: Conceptual Perspectives F I G U R E 4 . 2 : POINTS OF INTERVENTION FOR PHYSICAL INACTIVITY

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Furthermore, the one-to-one interventions do little to change the population distribution of diabetes, obesity, or cardiovascular disease as new people continue to enter the high-risk category since the causes of these risks have not been addressed. Another critique in relation to interventions focusing on “at-risk” population approaches is that even if one solves the health problems for some individuals within the “at-risk” populations, such as the homeless, Aboriginal peoples, or the elderly, there are population patterns that persist within these groups. This patterned consistency of disease rates among these groups emphasizes the importance of social and other environmental factors in creating disease rates. Again, the question to be asked is: Why are these groups more at risk than others? A final critique of the “at-risk” population approach is that it falls short in terms of its potential to understand what it is that marginalized groups share in common and how social relations are structured in ways that generate non-random distributions of material, social, and health consequences. In other words, the danger of focusing on at-risk populations is that one overemphasizes difference while failing to account for the ways in which

processes of marginalization look remarkably similar across marginalized groups. These similarities have their roots in power relations that are structured in society to create cleavages along race, class, and gendered lines (Grabb, 1997). This is the structured relationships between what Saul Alinsky (1969) would call the have and the have-nots. These are the ways in which power operates through control over material resources, ideological resources, and human resources. So, there is a need to link up across marginalized groups, for example, to understand the larger forces at play as well as the meso- and micro-level forces that cause them to play out as they do for particular subgroups and individuals in particular places and points in history.

Settings and Social Context: Final Limitations In relation to approaches focused on settings, while some of the social environmental approaches have been shown to have positive population-level effects on health outcomes, there is growing evidence, despite these efforts, that health problems, such as tobacco use, are increasingly concentred among the most underprivileged subpopulations in soci-


ety such as people of lower income and education levels (Health Canada, 2001; US Centres of Disease Control and Prevention, 2001), as well as people experiencing serious mental illness and homelessness (Conner, Cook, & Herbert, 2002; Lawn, Pols, & Barber, 2002). So, while the overall population rates of smoking are going down, the rates are decreasing much less quickly, if not increasing, for the most disadvantaged groups in society. This concentration of smoking among particular subgroups of the population is not a naturally occurring or “random” event, but is tied to how our society is organized. Underlying these inequities are complex social processes fundamental to understanding the continued prevalence and unique social distribution of smoking. This problem raises two important issues. First, it is a well-known fact that the people who benefit the most from health promotion interventions of all types are those who are best off socially and economically. So, while socio-environmental approaches may attempt to reach the population as a whole, in reality many of the interventions tend to reach only those in socio-economically advantaged situations. As mentioned above, this has been evidenced by the efforts and effects of the tobacco-control community. Second, socio-environmental approaches do not really leave room for asking why a health behaviour, such as smoking, is socially distributed in the way that it is, and thus does not ask why the behaviour is more acceptable in some milieus than in others. What this entails is that our interventions may be inappropriate for those who most need them, and indeed may be aggravating the situation of those who are most disadvantaged. Overall then, we propose that among the shortcomings associated with models akin to the social environmental approach is that they are extensions of a classic epidemiological

model to understanding disease and healthrelated behaviour. Indeed, while attempts to define social environment, such as that of Barnett et al. (2005), are laudable, they do not help us explain how the numerous factors listed in their definition—such as wealth, cultural practices, or race/ethnic relations— influence health outcomes. Shim (2002, p. 129) has argued similarly, stating that, “multi-factorial models and accompanying representations of race, class and gender amount to a black box in which ‘individualised’ inputs to epidemiological sociology are routinised, while the interior workings of the black box—how inequality, poverty and powerlessness affect health—remain unexamined.” Shim then further suggests that the epidemiological method distills the effects of social and relational ideologies, structures, and practices thereby rendering invisible the very social relations supposedly responsible for the disease outcomes of interest. We will come back to this point more specifically when discussing issues of power relations.

Shortcomings: A Summary What seems clear is that there are some lacunas with the current points of intervention in health promotion practice. We need to know, more specifically, how social inequities in health are produced, and thus, what exactly it is about the various factors comprising the social environmental model that contribute to ill health; not only what factors are important, but how and why they are important. What is needed is an understanding of how individuals, their behaviours, and their social circumstances interact to bring about the health problems faced by health promotion today. Only by knowing this can we intervene more appropriately.


WHAT C AN BE DONE DIFFERENTLY? The Structure/Agency Debate Studies of the social context of health behaviours and outcomes bring us inevitably to a critical discussion as old as Western philosophy—that of individual free will versus structural determinism, or what is today referred to as the structure–agency debate. Proponents of structural explanations emphasize the power of structural conditions in shaping individual behaviour (Cockerham, 2005). So, for instance, if one were to take a structural position to understanding tobacco consumption, one might be particularly concerned with the role of social class (one instantiation of the social structure) in shaping smoking. Advocates of agency, on the other hand, accentuate the capacity of individual actors to choose and influence their behaviour regardless of structural influences. This structure–agency dichotomy was also defined in terms of chances and choices by Max Weber (1922), who was, coincidentally, the first theorist to discuss the term “lifestyle.” Weber viewed life chances as the opportunities that people encounter due to their social situation (their position within the social structure). Choices, on the other hand, are the decisions people make. So, whereas health-related choices are voluntary, life chances either enable or constrain choices, as choices and chances interact to shape behavioural outcomes. What Weber highlighted, then, is that both chances and choices are socially determined, and thus choices cannot simply be individually controlled. In so doing, Weber also underscored the collective nature of behaviours by associating lifestyles with status groups, and not solely with individuals; that is, choices are shaped by one’s position within the social hierarchy. What Weber witnessed was that people from different

social classes tended to share certain behaviours and practices, a position also shared by French sociologist Pierre Bourdieu, who describes a similar phenomenon through his notion of habitus (Bourdieu, 1980, 1992).

Collective Lifestyles as a Useful Heuristic Device to Address Social Context Issues in Health Promotion A theory-based sociological approach to what we call collective lifestyles (Frohlich et al., 2002), building on the ideas of Weber and Bourdieu, has the potential to offer more to health promotion practice than serving as a synonym for patterns of individual risk behaviours and packages of variables. Bear in mind, however, that considerations of the role of lifestyle are far from new in health promotion practice. Green and Kreuter (1999), for instance, pay particular attention to the important role that lifestyle has played in permitting health promotion to move away from its earlier emphasis on health behaviour alone. While these authors were mindful of the collective aspect to lifestyles, they tend to consider them more in terms of practice and behavioural patterns, rather than situating these practices within the social structure as Weber and Bourdieu do. Using a collective lifestyles approach, therefore, can help not only to prevent a reductionist and individual-centred perspective, but with this approach we can also take into account both behaviours and social circumstances (Abel, Cockerham, & Niemann, 2000). Collective lifestyles comprise interacting patterns of health-related behaviours, orientations, and resources adopted by groups of individuals in response to their social, cultural, and economic environment (Abel, Cockerham, & Niemann, 2000, p. 63). Viewed in this way, collective lifestyles are akin to the social environmental approach in that they


take into consideration the social, cultural, and economic environments in which people live, get sick, and die. There are a number of important differences, however, between these two approaches that make the collective lifestyle option increasingly palatable to a health promotion hungry for change. First, the collective lifestyles framework develops further the issue of choices and chances by adopting current sociological language. Within this framework, therefore, we speak of social practices (Bourdieu, 1980, 1992; Giddens, 1984) (or behaviours) and social structure (or social conditions). Social practices are routinized and socialized behaviours common to groups. Social structure is defined as the way in which society is organized, involving norms, resources, policy, and institutional practices. Similarly to choices, social practices are understood as emerging from the structure, and thus the relationship between structure and practices is always explicit. In this way, an individual behaviour, or social practice, is never divorced from its position within the social structure. Further, this relationship is not unidirectional; the structure is seen to shape people’s social practices, but in turn, people’s social practices are understood to influence the structure by both reproducing and transforming it. So, social practices are embedded within the social structure, but have a critical role in transforming it. Second, social practices are not considered purely in terms of health behaviours. If taking a collective lifestyles approach to obesity prevention, for instance, one would examine not only what people eat and whether they exercise or not, but also people’s other activities that might have a bearing on obesity. Examples might be examinations of the constraints on physical activity such as lack of time, poor neighbourhood infrastructure for practising physical activity, or the replacement of physical activity by video games. One

would seek to further understand the reasons behind the uneven social distribution of these activities such as the roles of race, gender, and class in structuring health experiences, life opportunities, etc. A third component to the collective lifestyle framework, in contrast to past perspectives, is a focus on the constraints on individual capacity (agency) and what the implications of the constraints are for true empowerment to take place. People’s position within the social structure clearly shapes their agency. Approaches that focus on changing health behaviours give attention to agency, but what is often missing is a well-developed analysis of the structural constraints to individual agency; that is, a direct link established between structure and agency. While the Ottawa Charter initially suggested focusing on increasing the options available to people to exercise more control over their health, in practice this has been addressed mostly through environmental change; that is, changing the conditions rather than focusing on how these changes might increase individual control. The collective lifestyle framework suggests that one has to understand people’s agency in relation to the social context of the health problem of concern. Using again the example of obesity, certain groups of people may not have the ability to exercise given lack of money and familial constraints. While they may have the knowledge and desire to exercise, their agency is reduced due to economic and other constraints. Knowledge of this barrier to agency would enable health promotion interventions to address some of these barriers in order to more successfully reach some of these hard-to-reach populations. Fourth, an implicit but underdeveloped aspect to the collective lifestyle framework is the issue of power. Power relations are central to shaping the uneven social distribution of health behaviours and disease outcomes


among groups and ultimately in creating and sustaining the social structure. A focus on power relations draws attention to the ways in which the social patterning of health behaviours and disease outcomes mirrors the patterning of other processes of marginalization and disadvantage through both the social structure and social practices. A focus on power further invites us to consider our role, within health promotion practice, as active actors within systems of power. We are, of course, active participants in the social context of health promotion as we influence through our research and interventions the way disease, health, and behaviours are understood. We are also capable of shifting power in society by creating the conditions for some segments of the population to be healthy participants and others not. Reflections and action on such issues are vital for a true focus on social context to be realized. Lastly, the final important aspect of a collective lifestyle framework for understanding the social context is reflexivity with respect to the social location of health promotion as a field (see also Chapter 17 on the importance of reflexivity for health promotion practice). By reflexivity we mean the maintenance of a self-critical attitude and a questioning of the taken-for-granted assumptions regarding the political nature of our work and its intended and unintended effects, as well as the social distribution of these effects (Caplan, 1993; Poland et al., 2006). More concretely this could include: (1) attention to the tacit knowledge and perspectives that practitioners bring to their work; (2) an openness to being transformed by the experience of engaging with individuals who may question the practice of health promotion; (3) a questioning of “received knowledge” (what we hold to be self-evident and true); (4) a curiosity about and openness toward other perspectives and ways of seeing; and (5) an awareness of power

relations and one’s own social location and positionality (how we fit into class and gender relations and how this affects the work we do individually and as a group performing health promotion).

CONCLUSIONS Health promotion has come a long way since the Ottawa Charter in its position on where the points of intervention in health promotion practice could and should be. We have learned much in health promotion practice and research by focusing on issues, “at-risk” populations, and settings. As we have seen, however, there are significant critiques of these approaches that require reviewing. We offer an alternative approach to addressing social context as a point of intervention using some aspects of the collective lifestyles framework as well as issues relating to power and reflexivity. In so doing, we address a number of the critiques discussed throughout this chapter. First, by focusing on social practices and their relationship to the social structure one would no longer focus only on high-risk behaviours, but rather the conditions that structure, and are structured, by behaviours. Second, because the focus of collective lifestyles is on conditions and behaviours, one would address the issue of high-risk individuals replacing those who are no longer at risk, as the conditions are addressed, not just the behaviour alone. Third, the collective lifestyles approach focuses on group influences and thus potentially addresses how to change population patterns of disease and behaviours. And lastly, the collective lifestyles approach focuses specifically on why groups of people partake in the practices they do, and thus a purposive focus is given to ensuring that issues of inequalities are addressed.


REFERENCES Abel, T., Cockerham, W.C., & Niemann, S. (2000). A critical approach to lifestyle and health. In J. Watson & S. Platt (Eds.), Researching health promotion (pp. 54–77). London: Routledge. Adelson, N. (2005). The embodiment of inequity: Health disparities in Aboriginal Canada. Canadian Journal of Public Health, 96, S45–S61. Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behaviour. Englewood Cliffs: Prentice-Hall. Alinsky, S.D. (1969). Reveille for radicals. New York: Vintage Books. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs: Prentice-Hall. Barnett, E., Anderson, T., Blosnich, J., Halverson, J., & Novak, J. (2005). Promoting cardiovascular health: From environmental goals to social environmental change. American Journal of Preventive Medicine, 29, 107–112. Barnoya, J., & Glantz, S. A. (2004). Association of the California Tobacco Control Program with declines in lung cancer incidence. Cancer Causes Control, 15, 689–695. Becker, M.H. (1974). The health belief model and personal health behaviour. Health Education Monographs, 2, 324–508. Bourdieu, P. (1980). Le sens pratique. Paris: Les Éditions de Minuit. Bourdieu, P. (1992). Réponses: Pour une anthropologie réflexive. Paris: Éditions du Seuil. Caplan, R. (1993). The importance of social theory for health promotion: From description to reflexivity. Health Promotion International, 8, 147–157. Cockerham, W. (2005). Health lifestyle theory and the convergence of agency and structure. Journal of Health and Social Behavior, 46, 51–67. Conner, S.E., Cook, R.L., Herbert, M.I., et al. (2002). Smoking cessation in a homeless population—there is a will, but is there a way? Journal of General Internal Medicine, 17, 369–372. Emmons, K.M. (2000). Health behaviors in a social context. In L.F. Berkman & I. Kawachi (Eds.), Social epidemiology (pp. 242–266). New York: Oxford University Press. Fichtenberg, C.M., & Glantz, S.A. (2000). Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. New England Journal of Medicine, 343, 1772–1777. Frohlich, K.L., Corin, E., & Potvin, L. (2002). A theoretical proposal for the relationship between context and disease. Sociology of Health and Illness, 23, 776–797. Frohlich, K.L., & Potvin, L. (1999). Health promotion through the lens of population health: Toward a salutogenic setting. Critical Public Health, 9, 211–222. Frohlich, K.L., Ross, N., & Richmond, C. (in press). Health disparities in Canada today: Evidence and pathways. Health Policy. Giddens, A. (1984). The constitution of society. Cambridge: Polity Press. Grabb, E.G. (1997). Theories of social inequality: Classical and contemporary perspectives (3rd ed). Toronto, Ontario: Harcourt Brace. Green, L.W., & Kreuter, M.W. (1999). Health promotion planning: An educational and ecological approach (3rd ed.). Mountain View: Mayfield Publishing Company. Health Canada. (2001). Smoking in Canada: An overview: CTUMS (Canadian Tobacco Use Monitoring Survey). Annual, February–December.

58 ■ PART I: Conceptual Perspectives Jetté, A. (1994). Designing and evaluating psychosocial interventions for promoting self-cure behaviours among older adults. Paper presented at the National Invitation Conference on Research Issues Related to Self-Care Aging. NIA. Lawn, S.L., Pols, R.G., & Barber, J.G. (2002). Smoking and quitting: A qualitative study with community-living psychiatric clients. Social Science and Medicine, 54, 93–104. Link, B.G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, Extra Issue, 80–94. Marmot, M.G. (2003). Understanding social inequalities in health. Perspectives in Biology and Medicine, 46, S9–S23. McLeroy, K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15, 351–377. Multiple Risk Factor Intervention Trial Research Group. (1981). Multiple Risk Factor Intervention Trial. Preventive Medicine, 10, 387–553. Multiple Risk Factor Intervention Trial Research Group. (1982). Multiple Risk Factor Intervention Trial: Risk factor changes and mortality results. Journal of the American Medical Association, 24, 1465–1476. Poland, B., Frohlich, K.L., Haines, R.J., Mykhalovskiy, E., Rock, M., & Sparks, R. (2006). The social context of smoking: The next frontier in tobacco control? Tobacco Control, 15, 59–63. Poland, B.D., Green, L.W., & Rootman, I. (2000). Settings for health promotion: Linking theory and practice. Thousand Oaks: Sage Publications. Shim, J.K. (2002). Understanding the routinised inclusion of race, socioeconomic status, and sex in epidemiology: The utility of concepts from technoscience studies. Sociology of Health and Illness, 24, 129–150. Smedley, B.D., & Syme, S.L. (Eds.) (2000). Promoting health: Intervention strategies from social and behavioral research. Washington: National Academy Press. Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10, 282–298. Tannahill, A. (1992). Epidemiology and health promotion: A common understanding. In R. Bunton & G. Macdonald (Eds.), Health promotion: Disciplines and diversity (pp. 42–65). London: Routledge. US Centers for Disease Control and Prevention. (2001). Cigarette smoking among adults—United States, 1999. Morbidity and Mortality Weekly Report, 50, 869–873. Weber, M. (1922). Wirschaft und Gesellschaft (Economy and society). Tübingen, Germany: Mohr Siebeck. World Health Organization. (1986). Ottawa Charter for Health Promotion. Ottawa: Canadian Public Health Association. World Health Organization. (1998). Health promotion: Milestones on the road to a global alliance. Retrieved April 1, 2006, from www.who.int/mediacentre/factsheets/fs171/en/

CRITIC AL THINKING QUESTIONS 1. What are the advantages and disadvantages to the three points of intervention discussed in this chapter? 2. Are there other ways in which we could be intervening in health promotion that would better take into account the social context? 3. Do current interventions in health promotion stand to be improved and, if yes, why? 4. Is there a danger of increasing inequalities in health by intervening in health promotion?


FURTHER READINGS Emmons, K.M. (2000). Health behaviors in a social context. In L.F. Berkman & I. Kawachi (Eds.), Social epidemiology (pp. 242–266). New York: Oxford University Press. This chapter reviews data on risk factor change and examines some of the factors that help to explain the relatively low rate of long-term change produced by most health promotion interventions. Frohlich, K.L., Corin, E., & Potvin, L. (2002). A theoretical proposal for the relationship between context and disease. Sociology of Health and Illness, 23, 776–797. This article develops the notion of collective lifestyles drawing on the work of Pierre Bourdieu, Anthony Giddens, and Amartya Sen. Poland, B., Frohlich, K.L., Haines, R.J., Mykhalovskiy, E., Rock, M., & Sparks, R. (2006). The social context of smoking: The next frontier in tobacco control? Tobacco Control, 15, 59–63. This article moves beyond the discussion developed in this chapter to include the exploration of social context through the sociology of the body as it relates to smoking, collective patterns of consumption, the construction and maintenance of social identity, the ways in which desire and pleasure are implicated in these latter two dimensions in particular, and smoking as a social activity rooted in place. Poland, B.D., Green, L.W., & Rootman, I. (2000). Settings for health promotion: Linking theory and practice. Thousand Oaks: Sage Publications. This book outlines the history, content, and utility of the settings approach in health promotion interventions. Williams, G. (2003). The determinants of health: Structure, context, and agency. Sociology of Health and Illness, 25, 131–154. Williams reviews the ways in which the concept of social structure has been deployed within medical sociology, paying particular attention to its role in the debate over health inequalities and the role of the social context in shaping these inequalities.

RELEVANT WEB SITES A critique of the settings approach, hosted by University of New South Wales School of Public Health www.ldb.org/setting.htm

Health promotion recognizes the idea that people live in social, cultural, political, economic, and environmental contexts. This acknowledgement may have been new for public health; however, sociologists and social psychologists have been aware of the embeddedness of behaviour into larger contexts for a longer period of time. However, the acknowledgement by public health practitioners that health is developed in the context of everyday life, which itself is structured by its related social system, has not led to a fundamental reconsideration of the social science basis of public health concepts and its incorporation into planning and activity. Health Promotion and Education Online www.rhpeo.org/

RHP&EO is the electronic journal of the International Union for Health Promotion and Education (IUHPE). The journal published an editorial response to the previous


article, arguing about the conceptualization of “settings” employed in the earlier piece. See Mittelmark, M.B. (1997). Health promotion settings. Internet Journal of Health Promotion, 1997. From www.rhpeo.org/ijhp-articles/1997/2/index.htm.s World Health Organization—Settings Approach www.who.int/mediacentre/factsheets/fs171/en/

This multilingual site describes the history of the WHO Settings for Health approach. Specifically, Settings for Health emphasizes practical networks and projects to create healthy environments such as healthy schools, health-promoting hospitals, healthy workplaces, and healthy cities. Settings for Health builds on the premise that there is a health development potential in practically every organization and/or community.

CHAPTER 5

H E A LT H L I T E R AC Y: A N E W F RO N T I E R Irving Rootman, Jim Frankish, and Margot Kaszap

INTRODUCTION “

ealth literacy is the ability to access, understand, assess and communicate information to engage with the demands of different health contexts to promote good health across the life-span” (Kwan et al., 2006). Fields of study and practice constantly change or evolve. One of the reasons why this happens is the introduction or development of concepts that significantly affect the way in which the field is viewed or the way in which people organize their work within the field. In other words, concepts can help to revitalize or reshape a field. An excellent example of this is how the cluster of concepts introduced by the Lalonde Report into the field of health in 1974, including the concept of health promotion, significantly changed the way in which policy makers, practitioners, researchers, and the public looked at health and led to changes in policies and practices related to health. It also contributed significantly to the development of the field of health promotion itself, as discussed in Chapter 1. Within the field of health promotion, there are also many examples of the substantial influence of new or borrowed concepts on how we view and carry out our work. These include concepts such as “healthy cities,” “healthy public policy,” and “quality of life,” all of which were introduced or developed by Canadians in the context of health promotion. A recently introduced concept to which Canadians have made or are

H

making a contribution is the concept of “health literacy,” which is the subject of this chapter. Specifically, in this chapter we will discuss the history of the development of the concept of health literacy in health promotion, the Canadian contribution to its development, definitions of health literacy, as well as debates over the concept in health promotion and where it is going.

HISTORY OF HEALTH LITERACY CONCEPT International The concept of health literacy first appeared in the literature in 1974 in an article by Simonds (1974), who used the term in relation to health education, particularly in schools. Specifically, he suggested: “Minimum standards for ‘health literacy’ should be established for all grade levels K through 12” (Simonds, 1974, p. 9). For some reason, however, the concept was not embraced with enthusiasm in health education or other fields until about two decades later when, among other things, in 1993, the Council of Chief State School Officers (CCSSO) in the United States established the Health Education Assessment Project (HEAP), which has developed tools to assess health literacy as an outcome of health education efforts in schools (Council of Chief State School Officers, 1998). In the same period, an ad hoc Committee of the 61


American Medical Association published a report on health literacy in the context of medicine in the United States (American Medical Association, 1999). This was stimulated by a series of research projects in the US on the impact of health literacy on health outcomes (e.g., Baker et al., 1997; Williams et al., 1995). Following these developments, the US Department of Health and Human Services specified improved health literacy as a health objective for the United States (United States Department of Health and Human Services, 2000). At about this time, the concept made its appearance in print in the field of health promotion in a paper by Ilona Kickbusch (1997) in Health Promotion International. This was followed by its inclusion in a glossary on health promotion (Nutbeam, 1998) and a paper by Don Nutbeam (2000) in Health Promotion International in which he argued that health literacy is a key outcome of health education activity, which should be situated in the broader context of health promotion and which people working in health promotion should be held accountable for. Another article by Kickbusch (2001) in the same journal suggested that health literacy was one way in which we could address the divide between health and education. Several other papers on health literacy have been published in Health Promotion International (e.g., Levin-Zamir & Peterburg, 2001; Ratzan, 2001; Renkert & Nutbeam, 2001; St. Leger, 2001; Zarcadoolas, Pleasant, & Greer; 2005) and various international meetings and workshops on health literacy and health promotion took place, several of which were organized by Ilona Kickbusch. This growing enthusiasm for the concept of health literacy within health promotion has by no means been endorsed by everyone in the field. One vocal critic of its use has been Keith Tones, the former editor of Health Education Research. In an editorial

entitled “Health Literacy: New Wine in Old Bottles,” he argued strenuously against adopting this concept in health promotion. According to him, “the kind of territorial expansion involved in translating limited, but clearly defined concepts into much broader, semantically unrelated constructs is both unnecessary and counter productive” (Tones, 2002, p. 288). After critiquing the expanded definition of health literacy suggested by Nutbeam (1998, 2000), Tones concluded that “there seems little if any justification for extending the original formulation of health literacy and incorporating it in re-packaged versions of existing theoretical formulations” (Tones, 2002, p. 289). On the other hand, the proponents of the concept of health literacy have suggested a number of reasons why it should be pursued in the context of health promotion. For example, in addition to suggesting that health literacy is a key outcome of health education and one that health promotion could legitimately be held accountable for, Nutbeam (2000) also noted that: expansion of the concept is consistent with current thinking in the field of literacy studies; it broadens the scope and content of health education and communication, both of which are critical operational strategies in health promotion; the expanded definition implies that “health literacy” not only leads to personal benefits, but to social ones as well, such as the development of social capital; and it helps us to focus on overcoming structural barriers to health. Similarly, in addition to noting that the concept of health literacy helps strengthen the links between the fields of health and education, Kickbusch (2002) suggested that: health literacy is important for social and economic development; that measuring it could be a major first step in developing a new type of health index for societies; that the expanded view emphasizes the need for public participation in policy development;

CHAPTER 5: Health Literacy ■ 63

and it allows us to consider the ambiguities of the fit between health promotion strategies and wider social trends. In any case, it has become clear that in spite of Tones’s admonition, interest in the concept has continued to grow within health promotion. Internationally, Kickbusch and colleagues have continued to argue for the recognition of health literacy as “a key competence in the health society” (Kickbusch, Maag, & Sann, 2005, p. 7). They further suggest that it is “critical both in developed and developing societies” (Kickbusch, Maag, & Sann, 2005, p. 10) and that it is a “critical strategy for the empowerment of citizens, communities, consumers and patients” (Kickbusch, Maag, & Sann, 2005, p. 2). Furthermore, according to them, “enhancing Health Literacy will strengthen the direction towards active citizenship for health by bringing together a commitment to citizenship with health promotion and prevention efforts” (Kickbusch, Maag, & Sann, 2005, p. 2). Moreover, their arguments appear to be gaining favour at least in Europe, with one of the European Commission’s policy areas pointing out that “Health Literacy will need to become a key literacy in European societies” (Kickbusch, Maag, & Saan, 2005, p. 2).

Similarly, in North America, interest in health literacy has continued to grow, partly as a result of a report of the Institute of Medicine Committee on Health Literacy (2004), which was established in response to the findings about the impact of health literacy on health outcomes noted above. Although the report was framed within a medical or health context, the influence of several members of the committee, with a health promotion background or interest (including two from Canada), made the report relevant to health promotion. In particular, as illustrated in Figure 5.1, the committee noted that health literacy is not just an individual phenomenon, but is the result of an interaction between the individual and different health contexts, including health promotion contexts.

Healthy Literacy in Canada The concept of health literacy did not make its appearance in Canada until 2000 when it was introduced into a workshop on research at the First Canadian Conference on Literacy and Health. However, during the 1990s there was a growing interest in Canada in the concept of literacy and health, stimulated by a

FIGURE 5.1: INSTITUTE OF MEDICINE HEALTH LITERACY FRAMEWORK

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project with this title carried out from 1989–1993 by the Ontario Public Health Association in partnership with Frontier College, the country’s oldest literacy network. Their first report made the case that literacy and health was an important issue that needed to be addressed by public health and health promotion in Canada (OPHA & Frontier College, 1989). Their second report (Breen, 1993) documented the increasing collaboration between literacy workers, health service providers, and learners on issues related to literacy and health, some of which had been stimulated by the first report. Partly as a result of this project, in 1994 the Canadian Public Health Association (CPHA) established the National Literacy and Health Program (NLHP) with funding from the federal government’s National Literacy Secretariat. Through the NLHP, CPHA has collaborated with 27 national partners to improve health services for less literate consumers. They have carried out several projects, organized conferences, and generated the publication and dissemination of countless “plain language” materials. The NLHP is considered to be a model for raising awareness, exploring issues, developing resource materials, and building partnerships in this field. Its work helped Canada to become recognized as an international leader in literacy and health practice. However, very little research on literacy and health was conducted in Canada in the 1990s. One exception was a study carried out by Bert Perrin for the OPHA/Frontier College project noted above (Perrin et al., 1989). Another was an analysis of data on the relationship between literacy and health among Canadian seniors, which made the case for more attention to these matters (Roberts & Fawcett, 1998). However, none of the research that was done used the concept of health literacy. In Canada, our francophone colleagues

were talking of alpha-santé and alphabétisation à la santé since 1999, and mainly were doing research in health education for lowliterate elderly, as reported in the Quebec journal of nursing L’Appui (Viens et al., 1999) and in a research report (Ajar et al., 1999) for the National Literacy Secretariat. They focused on topics such as: the educational needs of the elderly; the healthy grocery as a new place for health “alphabetization”; a pedagogical kit for heart disease patients; and new technology and health education for people with low literacy (Dubois et al., 2001; Fortin et al., 2002; Kaszap et al., 2000; Viens et al., 2000; see RECRAF Web site below). At the First Canadian Conference on Literacy and Health, the concept of health literacy was introduced by Rima Rudd from Harvard University and Irving Rootman from the University of Toronto. Rudd (2000) presented work being done using this concept in the United States and Rootman (2000) presented a framework for research on health literacy that he had developed based on the research that had been carried out by Perrin et al. (1989) as well as his own reading and participation in international meetings on the topic. Both Rudd and Rootman, however, made the point that health literacy needed to be seen in relation to the broader concept of literacy and health that was dominant in Canada. Following the conference, Rootman embarked on the development of a national program of research on literacy and health for Canada in collaboration with others, including the co-authors of this chapter. Among other things, they were successful in obtaining funding from the Social Sciences and Humanities Research Council (SSHRC) in 2001 and 2002 to develop such a program of research. Doing so has involved conducting a national environmental scan and needs assessment; organizing a national workshop


to define a research agenda for Canada on literacy and health; organizing a summer school and summer institute on literacy and health research; conducting several workshops on literacy and health at national conferences; making numerous presentations; submitting proposals for funding; conducting several studies, including an evaluation of the National Literacy and Health Program; and publishing papers, including a comprehensive review of the literature on literacy and health research in Canada (Rootman & Ronson, 2005). Detailed reports on most of these activities can be obtained through the Web site established as part of the project (see list of relevant Web sites below). In addition, Rootman and his colleagues have obtained funding for several research projects on health literacy, including two funded by the Canadian Institutes of Health Research (CIHR) to develop new measures of health literacy for different population groups (including students), and one funded by SSHRC to evaluate the impact of a new British Columbia health education curriculum on health literacy. Others in Canada have also undertaken research projects on health literacy, including Doris Gillis and Alan Quigley, who were funded by SSHRC to conduct a study of health literacy in Nova Scotia (see Web site below). Other proposals are currently being evaluated by funding agencies, including a proposal to develop measures of health literacy for the Latin American community in Canada. Thus, since the conference in 2000, there has been a significant growth in research on health literacy in Canada, most of it related to health promotion and in the context of literacy and health. It is likely that these trends will continue for the foreseeable future. Thus, it is useful to explore what the Canadian contribution to work on health literacy has been and is likely to be in the future.

THE C ANADIAN CONTRIBUTION TO HEALTH LITERACY Although it is still early days, Canada has made some contributions to research, practice, and policy in health literacy within the context of health promotion. Some of the key accomplishments are described in this section.

Contributions to Research The Canadian contributions to research on health literacy have so far been mostly at the conceptual level, although we may be able to shortly make a contribution to the development of methodology. With regard to conceptualization, as mentioned, we have done some work to develop a conceptual framework that locates health literacy within the context of literacy and health. Specifically, the preliminary framework that was presented at the First Canadian Conference on Literacy and Health was revised as a result of extensive consultations with researchers, practitioners, and policy makers across Canada and has been published in a special supplement of the Canadian Journal of Public Health (Rootman & Ronson, 2005). As can been seen in Figure 5.2, this framework locates health literacy in relation to general literacy and other kinds of literacies; indicates both possible direct and indirect impacts of literacy on health; suggests that general literacy, health literacy, and other literacies are affected by the broader determinants of health; and that the types of interventions that are used in health promotion also can be used to affect general literacy, health literacy, and other literacies. Although this is by no means a “causal” model, it does place health literacy in a conceptual space that recognizes its perhaps limited contribution in relation to the overall contribution of literacy to health. It also implies that the impact

66 ■ PART I: Conceptual Perspectives FIGURE 5.2: L I T E R AC Y A N D H E A LT H R E S E A R C H C O N C E P T UA L F R A M E WO R K

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of health literacy on health may be more direct than indirect. Thus, the framework that seems to have the broad acceptance of researchers, practitioners, and policy makers in Canada does make some contribution to thinking about the role of health literacy in health and health promotion, which may be of interest beyond Canada. Another conceptual contribution that Canadians are in the process of making is in relation to the definition of health literacy. For example, we have developed an operational definition of health literacy, mentioned at the outset of this chapter, for our work on measurement; it builds on previous definitions and may be of interest beyond the project that we are doing (see Box 5.1). The definition comes from several sources. Firstly, it builds on the

definition of health literacy endorsed by the Institute of Medicine Committee (see Box 5.1) and the idea expressed in the committee’s conceptual framework (see Figure 5.1) that health literacy has to do with the interaction between individuals and different health contexts. It also adopts the goals of promoting health from the Nutbeam glossary definition (see Box 5.1) as well as the idea of “interactive” and “critical” health literacy by using the words “communicate” and “assess.” Finally, it adopts the idea of the importance of “lifelong learning” from the national workshop mentioned above. With regard to our potential contribution to measurement, we are currently testing some new measures of health literacy with seniors. These measures are intended to measure health literacy in a health promotion

CHAPTER 5: Health Literacy ■ 67 BOX 5.1: D E F I N I T I O N S O F H E A LT H L I T E R AC Y

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context. To that end, 229 communitydwelling older adults were interviewed about their experiences in finding, understanding, and communicating information in relation to “healthy aging.” They were also asked to read and respond to questions about passages related to health to test their skill levels in relation to aspects of health literacy. The widely used Rapid Estimate of Adult Literacy in Medicine (REALM) Test was administered as well (Davis et al., 1993). Based on the analysis to date, it appears as if there is little or no relationship between self-perceived health literacy and health literacy as measured by skill tests and that the elements defining health literacy are strongly related to one another. The findings of this study will be used to revise the existing instrument, which will be tested with other samples of older adults and ultimately will be used as a prototype for measuring health literacy in different population groups. Hopefully, the instruments that are developed will be of use to others and will lead to studies examining the determinants and consequences of health literacy in Canada and perhaps elsewhere.

Another contribution to research on health literacy made in Canada is the project carried out in rural Nova Scotia mentioned earlier. Rather than defining health literacy the investigators and their collaborators asked respondents to tell them what they thought health literacy was. This approach led to a rich discussion about the concept as viewed through the eyes of adults with limited literacy, health and literacy practitioners, and community leaders. This experience thus suggests the value of another approach to the study of health literacy that could be used or adapted to other circumstances (see Web site noted below). From these examples, it should be clear that Canadian health promotion researchers have begun to make a contribution to research on health literacy and are likely to continue to do so for the foreseeable future.

Contributions to Practice and Policy The research projects noted above have also contributed to practice and policy related to health literacy within a literacy and health


framework. For example, the Nova Scotia project led to action related to an initiative by one of the partner organizations in the project to increase awareness and support of literacy as a determinant of health and well-being, and awareness of literacy issues among service providers. The activities have included: conducting an environmental scan to identify best practices, policies, and training materials that address literacy and health; organizing awareness sessions on health literacy for 185 primary health care providers at five sites and via Telehealth; drafting a health literacy policy; developing a health literacy assessment tool; and developing a health literacy standard for accreditation. The project also led to a provincial consultation sponsored by the Nova Scotia Department of Health in 2004 as well as to the launch of a Nova Scotiawide Health Literacy Initiative and a video on health literacy in 2005. The provincial consultation has been used as a prototype for a provincial consultation in British Columbia and the project is likely to be used as a model for other projects across the country. In addition, the topic of health literacy featured strongly in the Second Canadian Conference on Literacy and Health in October 2004 and led to the articulation of a set of recommendations for policy development in Canada. Specifically, a paper based on the conference suggested, among other things, that governments and others: • support integrated policy and program development across sectors by enabling collaboration among health, education, and other sectors • encourage and fund knowledge translation initiatives about literacy and health that reach practitioners, policy makers, and researchers • support strategies that bring together literacy practitioners and health professionals with adult learners through

participatory research and program development (Chiarelli & Edwards, 2006, p. S-41). The authors concluded by arguing that “this approach to policy development will lead us to a uniquely Pan-Canadian strategic policy agenda that addresses literacy as a determinant of health and health literacy as an important factor in improving the health of all Canadians” (Chiarelli & Edwards, 2006, p. S-42).

ISSUES IN HEALTH LITERACY AND HEALTH PROMOTION It should be clear from this chapter that the concept of health literacy has, in a very short period of time, made significant inroads into research, practice, and policy in health promotion in Canada and elsewhere. It has indeed become a “new frontier” for health promotion. There are, however, a number of issues that remain to be addressed in relation to the concept within health promotion. They include: Is it a useful concept in health promotion? What should be included in the concept in order to measure it? How does it relate to theory? Practice? Policy? How should the concept be developed? With regard to the first question, we obviously have two camps within health promotion: the camp that rejects the use of the concept (as exemplified by Tones) and the camp that accepts it enthusiastically (as exemplified by Kickbusch and Nutbeam). The arguments on both sides have been presented above and it appears as if for the time being at least, the enthusiasts are on the ascendancy. However, given the strong argument presented by Tones (2002), we need to be somewhat guarded in our enthusiasm. At minimum, we need to acknowledge that the


concept of health literacy is not the answer to all of our problems as a field, but is perhaps a useful tool for addressing some of them. A related issue has to do with whether or not we should frame our interest in “health literacy” as an independent area of interest for health promotion or within the context of the larger concept of “literacy and health,” which is how we have tended to look at it in Canada. One advantage of this larger framing is that it more strongly draws our attention to the importance of the determinants of health in health promotion. However, this too is a matter for further debate. In addition, we need to be clear what we are talking about when we use the term “health literacy.” At this point, all people interested in its development need not use the same definition of health literacy, but at the very least need to specify what definitions they are using. This is especially important when trying to develop measures of the concept. In this regard, it is important that the definitions used explicitly identify the elements of the concept that it is intended to measure. Thus, in the case of the British Columbia Health Literacy Research Team, we intend to measure people’s abilities to “access, understand, assess, and communicate” health information and these elements are therefore part of our definition (see Box 5.1). We see these as the core elements of health literacy, which, in turn, may be related to knowledge, use of information, decision making, health, or other outcomes. In contrast, the recent definition put forward by Kickbusch and her colleagues appears to emphasize decision making as the core element of health literacy (see Box 5.1). Both views are legitimate options, the merits of which could be debated. Some of the criteria to consider in this debate are the relationships of the different views to theory, practice, or policy. One might argue, for instance, that a particular view of

what health literacy is fits better with certain theoretical perspectives in health promotion such as “empowerment theory” or “information processing theory.” In this case, we would suggest that the Kickbusch and company definition fits better with the former, and the Canadian Health Literacy Team definition fits better with the latter. Similarly, a particular approach may be more helpful for practice or policy. With regard to how the concept should be developed, there is an evident need for work that will move health literacy beyond the “conceptual.” This can be achieved by systematically moving through a series of interrelated levels. At a “conceptual” level there remains a need to better map the universe of potential items related to the “concept” of health literacy. Next, there is a need to move from the “concept” to a “construct” of health literacy. That is, we need to operationally define “health literacy” and invoke the elements of validity and reliability that would yield a satisfactory level of “construct validity.” Tests of construct validity would make the notion of health literacy measurable. Following from construct validity, there is a need to develop measures or indicators of health literacy. In parallel, there is a need for new strategies/tests that can be used to measure or assess a given person’s level of health literacy in a specific context. Finally, there is a need to evaluate the relevance and utility of data on health literacy. The above steps yield a set of testable research questions: 1. Is it possible to achieve a measure of health literacy that possesses adequate validity and reliability? 2. What is the general level of health literacy in the Canadian population? 3. Does the level of health literacy vary by factors such as age, gender, education, ethnicity, and income?


4. Is a person’s level of health literacy malleable, i.e., can it be improved through interventions? 5. Does a person’s level of health literacy predict or relate to his or her health status, use of health services, and quality of life?

CONCLUSIONS This brings us to the question of where we go next as a field in the new frontier of health literacy. Our view is that we continue our efforts to define and measure health literacy and actively engage in sharing our progress with one another and in an open debate

around the issues that we have noted as well as others that may arise. To this end, members of the British Columbia Health Literacy Research Team have applied for funding from CIHR to develop a dialogue with our international colleagues about health literacy as well as cross-border collaborations. It is expected that this dialogue and collaboration will continue through many means, including the 19th International Union for Health Promotion and Health Education (IUHPE) World Conference on Health Promotion where this book will be launched.

REFERENCES Ajar, D., Fortin, J., Kaszap, M., Ollivier, É., Vandal, S., & Viens, C. (1999). Recherche-action visant l’identification des besoins d’éducation à la santé chez une clientèle âgée faible-lecteur présentant une problématique cardio-vasculaire. (Rapport de recherche préliminaire.) Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. American Medical Association. (1999). Health literacy: Report of the Council on Scientific Affairs. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs, American Medical Association. Journal of the American Medical Association, 281, 552–557. Baker, D.W., Parker, R.M., Williams, M.V., Clark, W.S., & Nurss, J. (1997). The relationship of patient reading ability to self-reported health and use of health services. American Journal of Public Health, 87, 1027–1030. Breen, M.J. (1993). Partners in practice: Literacy and health project phase two. Toronto: Ontario Public Health Association and Frontier College. Canadian Index on Adult Literacy Research in French/Répertoire canadien des recherches en alphabétisation des adultes en français (Récraf). From www.alpha.cdeacf.ca/recraf/ Chiarelli, L., & Edwards, P. (2006). Building healthy public policy. Canadian Journal of Public Health, 97(Suppl. 2), S37–S42. Council of Chief State School Officers. (1998). Assessing health literacy: Assessment framework. Santa Cruz, CA: ToucanEd Publications. Davis, T.C., Long, S.W., Jackson, R.H., Mayeaux E.J., George, R.B., Murphy, P.W., et al. (1993). Rapid estimate of adult literacy in medicine: A shortened screening instrument. Family Medicine, 25, 391–396. Dubois, L., Viens, C., Vandal, S., Kaszap, M., Beauchesne, É., Ollivier, É., et al. (2001). Rapport de recherche. Évaluation d’un nouveau lieu d’alphabétisation: l’épicerie-santé. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Fortin, J., Viens, C., Kaszap, M., & Ajar, D. (2002). Les perceptions des personnes âgées peu alphabétisées navigant dans le système de santé. Dans à lire, 9, 40–44.

CHAPTER 5: Health Literacy ■ 71 Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington: National Academies Press. Kaszap, M., Viens, C., Ajar, D., Ollivier, É., Leclerc, L.-P., & Bah Yayé, M. (2002). Rapport de recherche. Évaluation de l’applicabilité des nouvelles technologies de l’information et de la communication dans le domaine de l’éducation à la santé des adultes peu alphabétisés atteints de maladies cardio-vasculaires. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Kaszap, M., Viens, C., Fortin, J., Ajar, D., Ollivier, É., & Vandal, S. (2000). Rapport de recherche. Besoins d’éducation à la santé chez une clientèle âgée peu alphabétisée atteinte de maladies cardio-vasculaires: Une étude exploratoire. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Kickbusch, I. (1997). Think health: What makes the difference? Health Promotion International, 12, 265–272. Kickbusch, I. (2001). Health Literacy: Addressing the health and education divide. Health Promotion International, 16, 289–297. Kickbusch, I. (2002). Health Literacy: A search for new categories. Health Promotion International, 17, 1–2. Kickbusch, I., Maag, D., & Sann, H. (2005). Enabling healthy choices in modern health societies. Paper presented at the European Health Forum Bagastein. Kwan, B., Frankish, J., & Rootman, I. (2006). Final report: The development and validation of measures of “health literacy” for different population groups. Victoria: Centre for Community Health Promotion Research. Levin-Zamir, D., & Peterburg, Y. (2001). Health literacy in health systems: Perspectives on patient selfmanagement in Israel. Health Promotion International, 16, 87–94. Nutbeam, D. (1998). Health promotion glossary. Health Promotion International, 13, 349–364. Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st Century. Health Promotion International, 15, 259–267. OPHA & Frontier College. (1989). Literacy and health project phase one: Making the world healthier and safer for people who can’t read. Toronto: Ontario Public Health Association and Frontier College. www.opha.on.ca/resources/literacy1summary.pdf. Perrin, B., et al. (1989). Literacy and health—making the connection: The research report of the literacy and health project phase one: Making the world healthier and safer for people who can’t read: Ontario Public Health Association and Frontier College. From www.opha.on.ca/resources/literacy1research.pdf. Ratzan, S.C. (2001). Health literacy: Communication for the public good. Health Promotion International, 16, 207–214. Ratzan, S.C., & Parker, R.M. (2000). Introduction. In C.R. Selden, M. Zorn, S.C. Ratzan, & R.M. Parker (Eds.), Library of medicine current bibliographies in medicine: Health literacy (vol. NLM Pub. No CBM 2000-1). Bethesda: National Institutes of Health, US Department of Health and Human Services. Renkert, S., & Nutbeam, D. (2001). Opportunities to improve maternal health literacy through antenatal education: An exploratory study. Health Promotion International, 16, 381–388. Roberts, P., & Fawcett, G. (1998). At risk: A socio-economic analysis of health and literacy among seniors. Statistics Canada Cat. no. 89-552-MPE, no. 5. Ottawa: Statistics Canada. Rootman, I. (2000). A framework for health literacy research and practice. Paper presented at the First Canadian Conference on Literacy and Health, Ottawa. Rootman, I., & Ronson, B. (2005). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(Suppl. 2), 62–77.

72 ■ PART I: Conceptual Perspectives Rudd, R. (2000). Health literacy research: Current work and new directions. Paper presented at the First Canadian Conference on Literacy and Health, Ottawa. Simonds, S.K. (1974). Health education and social policy. Health Education Monographs, 2(Suppl. 1), 1–10. St. Leger, L. (2001). Schools, health literacy, and public health: Possibilities and challenges. Health Promotion International, 16(2), 197–205. Tones, K. (2002). Health literacy: New wine in old bottles? Health Education Research, 17, 287–290. United States Department of Health and Human Services. Office of Disease Prevention and Health Promotion. (2000). Healthy People 2010. Washington, DC: U.S. Government Printing Office. Viens, C., Fortin, J., Kaszap, M., Vandal, S., Ajar, D., & Ollivier, É. (2000). Rapport de recherche: Rechercheintervention visant l’élaboration d’une trousse d’éducation à la santé pour personnes âgées peu alphabétisées et insuffisantes cardiaques. Québec: Groupe de recherche Alpha-santé Éditeur, Université Laval. Viens, C., Fortin, J., Kaszap, M., Vandal, S., & Bourdages, J. (1999). Alpha-Santé à l’écoute de l’information transmise aux usagers, une question d’alphabétisation. L’Appui Québec, 12(4), 48. Williams, M.V., Parker, R.M., Baker, D.W., Parikh, N.S., Pitkin, K., Coates, W.C., et al. (1995). Inadequate functional health literacy among patients at two public hospitals (comment). JAMA, 274(21), 1677–1682. Zacadoolas, C., Pleasant, A., & Greer, D.S. (2005). Understanding health literacy: An expanded model. Health Promotion International, 20, 195–203.

CRITIC AL THINKING QUESTIONS 1. What are the main roles that new concepts play in a field? 2. Is the concept of “health literacy” a valuable one from a health promotion point of view? Why or why not? 3. What in your opinion, should be done with the concept of “health literacy” in health promotion? Why? 4. What are the differences between “health literacy” and “literacy and health”? 5. What are the factors that determine whether or not new concepts will be adopted by a field?

FURTHER READINGS Canadian Public Health Association. (2006). Staying the course: Literacy and health in the first decade. Canadian Journal of Public Health, Supplement, pp. S1-S48. This supplement contains a series of articles that attempt to put the proceedings of the Second National Conference on Literacy and Health into a larger perspective, drawing from the literature and other sources. It is a good overview of current thinking on literacy and health in Canada. Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington: National Academies Press. This report of the IOM Committee on Health Literacy presents a conceptualization of health literacy, reviews current literature and practice in relation to health literacy, and recommends directions for future action. Although written primarily for a US audience, it contains much that is relevant for other countries.

CHAPTER 5: Health Literacy ■ 73 Kickbusch, I., Maag, D., & Sann, H. (2005). Enabling healthy choices in modern health societies. Paper presented at the European Health Forum, Bagastein. This background paper written for the European Health Forum contains a discussion of the rapidly changing environment into which health literacy fits, the dimensions and definition of health literacy, and its relationship to key current issues (obesity and migrant health). Although directed at Europe, it contains information relevant for other countries as well. Rootman, I., & Ronson, B. (2005). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(Suppl. 2), 62–77. This paper, originally prepared for an international conference on health disparities, describes the development of interest in literacy and health in Canada, presents a conceptual framework for literacy and health research, summarizes literature in relation to the framework, and makes recommendation for research and practice. Shohet, L. (2002). Health and literacy: Perspectives in 2002. Available at www.staff.vu.edu.au/alnarc/ onlineforum/AL_pap_shohet.htm. This paper discusses the links between literacy and health as they are currently represented in the discourse communities of the medical profession and of adult literacy. After comparing the positions taken by the medical field and the adult literacy field, and examining some selected government policies, the author outlines some directions for the future.

RELEVANT WEB SITES Canadian Index on Adult Literacy Research in French/Répertoire canadien des recherches en alphabétisation des adultes en français (Récraf) www.alpha.cdeacf.ca/recraf/

The Canadian Index on Adult Literacy Research in French contains information on more than 146 research projects on literacy or adult literacy written in French and published in Canada since 1994. Some projects are still underway. CPHA Literacy and Health Program www.nlhp.cpha.ca

This Web site describes the National Literacy and Health Program and its associated services and projects, including the National Literacy and Health Research Program. Harvard School of Public Health, Health Literacy Studies www.hsph.harvard.edu/healthliteracy

This site contains introductions to health literacy, PowerPoint presentations, videos, literature reviews, annotated bibliographies, research reports, health education materials, guidelines on creating and evaluating written materials, curricula, highlights of talks and presentations, news items, insights, and links to related Web sites.

74 ■ PART I: Conceptual Perspectives Health Literacy in Rural Nova Scotia Project www.nald.ca/healthliteracystfx/

This Web site provides a description of the health literacy in the Rural Nova Scotia Project as well as findings, activities, and reports related to it. National Adult Literacy Database www.nald.ca

This Web site describes the National Adult Literacy Database, lists literacy organizations in Canada, presents information about what’s new and events in the field, as well as awards and contacts. It also provides access to literacy discussion groups and to expert advice, newsletters, a literacy collection, full-text documents, a resource catalogue, links to internal resources and to data. National Literacy and Health Research Program www.nlhp.cpha.ca/clhrp/index_e.htm

This Web site provides a description of the National Literacy and Health Research project and access to various reports produced by the project.

CHAPTER 6

A D D R E S S I N G D I V E R S I T Y I N H E A LT H P RO M OT I O N : I M P L I C AT I O N S O F WO M E N ’ S H E A LT H A N D I N T E R S E C T I O N A L T H E O RY Colleen Reid, Ann Pederson, and Sophie Dupéré INTRODUCTION ritish feminist sociologists Daykin and Naidoo (1995) have criticized health promotion practice for reproducing dominant discourses and practices toward women by failing to recognize the social position of women, adopting a traditional approach to women’s health by focusing on women’s reproduction, and by designing programs and interventions that hold women responsible for the health of others through targeted messages and campaigns directed at women’s caregiving activities. They also suggest that health promotion fails to deal with the diversity of women because while all women are affected by health promotion’s reproduction of gender inequalities, women are “also divided by other dimensions of inequality structured by class, ethnicity, sexuality and disability. Both the common characteristics and the divisions between them need to be recognized in health promotion. The current vogue for addressing women as consumers able to exercise personal choice over lifestyles and health care services is inappropriate, given the constraints on most women’s lives” (Daykin & Naidoo, 1995, p. 69). This chapter attempts to update the dialogue between feminist theory and health promotion by addressing the challenge of diversity within health promotion—both in general and as it affects women. Many have argued that health promotion’s theoretical base is still largely dominated

B

by biomedical, psychological, and behavioural models and call for the development of more social theories (Potvin et al., 2005; see Chapter 4). It has been suggested that health promotion should also expand its academic alliances to enrich its theoretical base (Mittlemark, 2005; Ziglio, Hagard, & Griffiths, 2000). Hilary Graham (2004) argues that to be able to tackle health inequalities, we need to build an interdisciplinary science through integrating research on health inequalities, which is mainly based in social epidemiology with research in social sciences and policy that focuses on social inequalities. This chapter argues for greater integration of contemporary theorizing about gender and diversity into the field of health promotion in Canada. Specifically, we argue that health promotion could learn from more dialogue and exchange with feminist scholarship by presenting intersectionality as an important theoretical contribution from women’s studies and other fields (McCall, 2005; Weber & Parra-Medina, 2003). We review some of the links between women’s health, gender and health, and health promotion in Canada, recognizing that while considerable work has been done (e.g., Denton et al., 1999), there has been less theoretical interaction between the fields of health promotion and women’s health than one would expect, given that the Canadian women’s health movement has a long history of recognizing the determinants of health to 75


understand women’s health (Thurston & O’Connor, 1996). We propose intersectionality as a contemporary theoretical approach that could increase the theoretical rigour and enhance health promotion practice. Finally, we argue for an integrated approach to thinking about health promotion in relation to gender and other dimensions of social experience and suggest some implications for practice in order to improve women’s health.

WOMEN’S HEALTH AND GENDER AND HEALTH IN C ANADA Women’s Health There is a lengthy history of women’s health activism in Canada that is beyond the scope of this chapter to discuss in detail (see, for example, Dua et al., 1994; Morrow, in press). However, it has been suggested that the women’s health movement and health promotion share important core values, priorities, and approaches to practice. Moreover, Thurston and O’Connor (1996) argue that the women’s health movement in Canada, as elsewhere in the world, had embraced health promotion and disease prevention before health promotion became a mainstream activity in Canada. They suggest that this is because women’s health activists and scholars have always recognized the link between the social location of a person or a group and health, as well as advocating individual and community empowerment as processes for improving health. They also observe that those in the women’s health field have long embraced a positive conceptualization of health, one that was formalized in the Platform for Action developed out of the 4th United Nations World Conference on Women held in Beijing in 1995:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Women’s health involves women’s emotional, social, cultural, spiritual and physical well-being, and it is determined by the social, political and economic context of women’s lives as well as by biology. (From www.un.org/ womenwatch/daw/beijing/platform/health.htm)

This definition recognizes that health is socially constructed rather than simply biologically determined or technically produced. This broad definition recognizes the validity of women’s life experiences and women’s own beliefs about and experiences of health in identifying priorities for action and determining the boundaries of what constitutes health. Women’s health is perceived as a continuum that extends throughout the life cycle and that is critically and intimately related to the conditions under which women live. According to some researchers, examinations of women’s health require a social model of health that puts women’s health needs at the centre of the analysis and focuses attention on the diversity of women’s health needs over the life cycle. The traditional oppression and disempowerment of women must also be addressed at both personal and societal levels, thus broadening the approach (Reid, 2004). “Every woman should be provided with the opportunity to achieve, sustain and maintain health as defined by that woman herself to her full potential.” (Ontario Women’s Health Interschool Curriculum Committee; cited in Cohen, 1998, p. 188) Following the Beijing conference, Canada adopted the UN Platform for Action and introduced its own national policy to advance women’s equality, the Federal Plan for Gender Equality (1995–2000), which stated that all subsequent federal legislation and policies were to include, where appropriate, an analysis of the potential differential effects on women and

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men (Hankivsky, 2005, p. 17). “Where appropriate” has turned out to be a sticking point in the implementation of the plan. However, the federal government did commit to a women’s health strategy, which was published in 1999 (Health Canada, 1999), and the creation of five Centres of Excellence for Women’s Health in 1996 (Health Canada, 1996), four of which continue to operate in 2006. Federal government departments, including Health Canada, supported the implementation of the plan by preparing topic-specific guides to assist their staff with understanding gender equity and in implementing gender-based analysis in their own policy arena (see, for example, Health Canada, 2003). Despite these commitments, most federal policies and programs remain genderblind or gender-neutral; that is, policies and programs are developed and articulated in ways that fail to examine or address meaningful differences in their impact on women and men. A number of important concerns persist in Canadian society as a recent report on gender equality shows (Canadian Feminist Alliance for International Action, 2003). Examples include: the high percentage of Canadian women who live in poverty and report poor health status; the persistence of violence against Canadian women; the diminished status of immigrant and refugee women; the vulnerability of Aboriginal women who are the “poorest of the poor,” to name a few. While we can appreciate the improvements in reducing overall inequality between men and women over the last decades, we have also witnessed the increased feminization and racialization of poverty in Canada, which reflects gender-based and racial discrimination (Galabuzi, 2004). An entire industry has arisen to develop and prepare gender-based analyses of key health (and other) policy areas, including wait times (Jackson, Pederson, & Boscoe, 2006),

mental health (Salmon et al., 2006), and health research (see Greaves et al., 1999) and/or responding to federal government documents that fail to incorporate gender considerations into their work (e.g., National Coordinating Group on Health Care Reform and Women, 2003). These analyses consistently demonstrate the myriad ways that gender matters.

Gender and Health Integral to the development of the Federal Plan for Gender Equality was the recognition that gender, as a key concept, needed to be differentiated from focusing specifically on women’s issues. The concept of gender is related to how women and men are perceived and expected to think and act because of the way society is organized, not because of their biological differences (World Health Organization, 1998). Gender is a complex concept that includes: understanding that men and women are typically thought of as different types of social actors with different types of bodies; awareness that power is differentially associated with men and women in any given society; and an appreciation that these differences have led to important differences in the kinds of work that women and men typically do, their roles in the household and with respect to children, their access to social resources such as income and decision making, and to differences in their health. These differences determine differential exposure to risk, access to the benefits of technology, information, resources, and health care, and the realization of rights, all of which can influence health. Indeed, women’s everyday experiences must be understood within the context of the larger social organization and ideological structures generated from outside experience. Paradoxically, gender inequality translates not into increased mortality but into increased


morbidity for women (Aïach, 2001; Denton, Prus, & Walters, 2004). As McCall (2005) suggests, we should ask ourselves if all women are better off than all men, and then question the differences that exist among women. McCall presents the results of a study conducted in several locations in the United States and shows that when gender inequality is broken down by social class and race, we see the emergence of other patterns of inequalities that also vary across different geographical and social contexts. Others have also highlighted the dynamic and complex relationships between gender inequality and health and the diverse intersections with many other factors such as class, ethnicity, sexuality, age, and disability (Aïach, 2001; Denton, Prus, & Walters, 2004; Doyal, 2000). This prompts us to look for theoretical tools, research designs, and methods that will permit us to seize the complexity and intertwined nature of social inequalities affecting not only women but other groups and individual as well.

HEALTH PROMOTION AND WOMEN’S HEALTH: MISSED OPPORTUNITIES, POSSIBLE CONNECTIONS? Both the Ottawa Charter (1986) and the Bangkok Charter (2005)—the first and most recent international charters on health promotion respectively—mention gender, but they refer to it in distinctly different ways. The Ottawa Charter observes that the aims of health promotion itself, namely, to enable people to achieve their fullest health potential by increasing control over those things that determine their health, “must apply equally to women and men,” whereas the Bangkok Charter observes that “women and men are affected differently” by the economic and demographic changes that affect “working conditions, learning environments, family patterns, and

the culture and social fabric of communities” (World Health Organization, 1986, p. 2). Moreover, the Ottawa Charter calls for women and men to become “equal partners” in the planning, implementation, and evaluation of health promotion activities—a clear call for gender equality in health promotion. These contrasting references to gender and gender differences reflect important changes that have occurred in the past 20 years. From an acknowledgement of power as a function of gender relations, we have shifted to a discourse about gender that focuses on difference. In so doing, the field of health promotion has followed mainstream health research and policy making, but reduced some of the impact that a gendered analysis could have on the field. By adopting the discourse of gender as “difference,” health promotion is contributing to downplaying the challenge of addressing important social cleavages that constrain individual and collective action to improve health, and minimizes the role of power in gender relations. Health promotion is an interdisciplinary field in which diverse disciplines meet and borrow concepts from each other. These exchanges could be potentially enriching; however, these “concept transfers” from one field to another frequently occur and are operationalized without an in-depth understanding of the theoretical and epistemological basis underlying the concepts. In the public health literature, the concept of “social capital” is a recent example (Forbes & Wainwright, 2001). Krieger and Fee (1994) point out that although gender and sex are two distinct concepts, they have been used interchangeably in public health literature. There is a tendency to treat gender as a biological category instead of a social one that leads to reductionist and individualist explanations (Krieger & Fee, 1994). Krieger also argues that the public requires a better understanding of the concept of gender

CHAPTER 6: Addressing Diversity in Health Promotion ■ 79 BOX 6.1: D I S T I N G U I S H I N G S E X A N D G E N D E R

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alongside a clear differentiation between how sex and gender affect health (Krieger, 2003). In the early years of the women’s health movement, health concerns were seen to be so fundamental to women that they cut across race and class lines. Health was conceptualized as a powerful link that could unite all women into a strong and unified social movement. However, in time criticisms came to be levelled against White, middle-class feminists for generalizing the needs of dominant groups of women to all women, which resulted in race and class being identified as the second and third “axes” of domination. Extensive theorizations about the “additive,” “multiplicative,” or “interwoven” nature of the gender, race, and class triumvirate resulted (Reid, 2004). More recently, some feminist researchers argue that “any naming or categorizing tends to call attention to similarities and to neglect differences, and any human or social phenomena can be understood in countless different ways.” Although feminists affirm diversity, it remains difficult to be certain that this means gender, race, and class to all women. How do we know that diversity does not mean being fat, religious difference, involvement in an abusive relationship, disadvantage at the workplace, or

decisions made by girls in high school that attract them to female-dominated, lower paying jobs? The very categories we have assumed a priori (race and class) to be definitive of our differences may in fact be less significant than some others. Indeed, feminists continue to grapple with the substantial theoretical challenge of how to honour and appreciate diversity, while also recognizing how difference is constructed. Some researchers argue that gender is distinct from but interactive with other social features like social class or race/ethnicity. All these social factors combine to determine power relations in society that lead not only to inequalities between women and men, but also to inequalities within different groups of women and different groups of men (Ostlin, George, & Sen, 2003). Intersectional theory is based on the idea that “different dimensions of social life cannot be separated into discrete or pure strands.” When attempting to understand social inequalities, an intersectional analysis focuses on social relationships of power instead of focusing on differences in resources. An intersectional analysis examines social experiences and how they intersect at multiple forms of oppression, and what


happens at these intersections. Intersectional theory was developed most prominently by Black feminist social scientists emphasizing the simultaneous production of race, class, and gender inequality, such that in any given situation, the unique contribution of one factor might be difficult to measure (Collins, 1989; Fonow & Cook, 1991). This approach— an advance over earlier models that assumed that advantage and disadvantage simply accumulate to produce “double jeopardy”—suggests that the content and implications of gender and race as socially constructed categories vary as a function of each other (Mullings & Schulz, 2006). For example, whiteness and blackness are gendered, and masculinity and femininity are “raced” within particular cultural contexts. It is often difficult to pinpoint how the interaction, articulation, and simultaneity of race, class, and gender affect women and men in their daily lives, and the ways in which these forms of inequality interact in specific situations to condition health (Mullings & Schulz, 2006). Intersectional theory suggests that we need to move beyond seeing ourselves and others as single points in some specified set of dichotomies, male or female, White or Black, straight or gay, scholar or activist, powerful or powerless. Rather, “we need to imagine ourselves as existing at the intersection of multiple identities, all of which influence one another and together shape our continually changing experience and interactions.” According to Weber (2006), feminist intersectional scholarship, driven foremost by the pursuit of social justice, takes a researcher stance of engaged subjectivity and reflexivity, critically reflecting throughout the research process on the impact of the social locations of the researchers and the researched. A collaborative relationship more closely resembling a partnership between researchers and researched is seen as ideal.

Research methods focus less on measurement and quantification and more on identifying and holistically representing meanings in the lives of the researched and in institutional arrangements. Multimethod approaches are valued, often mixing ethnographic, historical, and community-based qualitative approaches with surveys and other tools. Inequalities are conceived as social constructions situated in social contexts and structures beyond the individual—in societies, institutions, communities, and families—and are characterized as power, not simply resource, differences between dominant and subordinate groups (Weber, 2006). Intersectional scholarship arose primarily to understand and address the multiple dimensions of social inequality (class, race, ethnicity, nation, sexuality, and gender) that manifest at both the macro-level of institutions and the micro-level of the individual experiences of women who live at the intersections of multiple inequalities. The focus is on identifying the meanings of multiple inequalities in these women’s lives and in institutions. Intersectional scholarship is not limited by typical disciplinary boundaries that examine these inequalities in separate studies and generate different theories about each dimension (Weber, 2006). Nor is it restricted by the methodological conventions dominant in health research that require large sample sizes in order to examine multiple dimensions of inequality in the same study. “By seeking social justice for those situated in multiply subordinated locations, intersectional scholars have looked for ways of facilitating liberatory dialogue across race, class, gender, and sexuality divides” (Weber, 2006, p. 31).


IMPLIC ATIONS FOR HEALTH PROMOTION PRACTICE What remains is the challenge of “operationalizing” an intersectional analysis to further and enhance how health promotion is practised. In order to consider this challenge, we asked: “What would interventions look like, or how would they be different, if we applied an intersectional analysis? What might this mean for health promotion practice?” We developed the following insights that intersectionality theory brings to the practice of health promotion, and invite women’s health, gender and health, and health promotion researchers and practitioners to join this conversation. • Shift the focus of intervention: An intersectional analysis invites us to target not only the individual but to take into consideration and even address explicitly social structures, social processes, and the underlying relationships of power. From this perspective we can better understand health from the framework of power and oppression and conceptualize alternative health interventions. This would involve developing more upstream inter-

ventions (i.e., taking action on the macro determinants of health such as poverty) (see Chapter 4); adopting ecological approaches (see Chapter 17); and ideally implementing approaches that seek to transform gender roles, reach equity, and empower women and men. • Change outlook on individual characteristics: An intersectional analysis would shift our focus from “immutable” individual characteristics (i.e., sex, ethnicity) to “mutable social realities” (i.e., those that can be targeted by intervention). Gender and race are not simply biological categories but also are social ones (Krieger, 2003). • Reframe the concept of health: This is consistent with contemporary reflections on the health promotion field (see Chapter 2) as well as intersectional analyses. An expanded conception of health would include refocusing on a broad framework of social relations and would locate health in families and communities and not only in individual bodies. • Utilize community-based and participatory approaches: Research methodologies that

BOX 6.2: I M P L I C AT I O N S O F I N T E R S E C T I O N A L I T Y T H E O RY F O R P RO G R A M S

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privilege the perspectives of oppressed and marginalized groups will further intersectional analyses. These kinds of approaches will also facilitate increased forms of activism that see activism for social justice as part of the knowledge acquisition process. • Adopt a holistic approach: A holistic approach invites us to look into the areas of intersection among multiple oppressions and to address them. An intersectional analysis examines social experiences and how they intersect at multiple forms of oppression, and what happens at these intersections (McCall, 2005). This approach would also involve necessarily intersectoral practice (i.e., bridging research, community, organizations, etc.) • Encourage reflexive practice: Intersectional theory invites us to pay attention to social processes, social dynamics, and the role of power in producing and sustaining social inequalities. As Poland (1998) has argued, failing to address the root causes of social inequalities in health promotion research, practice, and policy could lead us to unwittingly reproduce these inequalities. This perspective encourages reflexive practice (see Chapter 16) because it invites the researcher-practitioner to connect her or his personal and political identities, and to become aware of her or his own power and privilege. Adopting a reflexive practice can help prevent health researchers from unknowingly perpetuating, sustaining, and reinforcing harmful stereotypes (Reid & Herbert, 2005).

CONCLUSIONS With the mounting critiques of the atheoretical nature of health promotion research

and practice (see Chapter 4) and calls for health promotion, public health, and health science researchers to increase the theoretical rigour of their work in order to better inform and direct practice and policy, we advocate intersectional theory as a sophisticated and nuanced way toward addressing these gaps because it challenges us to think about conceptualizations of the content, context, and boundaries of social groups (Mullings & Schulz, 2006). However, there has been little discussion about its methodology. Intersectional analyses understand gender, race, and class as social relationships reproduced within local contexts, though methodological questions remain about how to accomplish this due to the complexities involved (McCall, 2005). According to Hankivsky et al. (2005), methods of doing research, and even the research questions themselves, too often fall short of creating genuinely inclusive, safe, and unbiased spaces of relevance for people whose life experiences are generally considered marginal. Health promotion and intersectional analyses are marginalized in mainstream health science venues and institutions, including academia, health care, and the community. The challenge is twofold—to push health promotion researchers, practitioners, educators, and advocates to understand the complexity and diversity of health through an intersectional analysis, and to develop strategies for moving a more theoretically informed health promotion into the mainstream. There is an opportunity and appetite for the reinvigoration of health promotion, though for this reinvigoration to be successful, it needs to pay attention to the more nuanced and complex understandings of women’s health that have been recently advanced by many feminist and intersectional scholars. An intersectional analysis of women’s health could enrich health promotion. In

CHAPTER 6: Addressing Diversity in Health Promotion ■ 83 BOX 6.3: I N C O R P O R AT I N G A N U N D E R S TA N D I N G O F G E N D E R I N TO H I V / A I D S P RO G R A M S

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many ways, there are already strong synergies, for example, their mutual commitment to an ecological approach to understanding health and developing health programs (see Chapter 17; also Krieger & Fee, 1994) and the commitment to multiple methods. But intersectional analysis reminds health promotion researchers, theoreticians, and practitioners that we must have a theory of power if we are to understand health inequalities and redress them. Indeed, a recent review of program evaluations in reproductive health demonstrated improved outcomes from programs that explicitly addressed both issues of gender equity and health (Interagency Gender Working Group, 2004) (see Box 6.3). This brings us to the question of what health promotion offers women’s health. We

suggest that it is the importance of being explicit about the need to empower people to change themselves, their lives, and their communities that health promotion can contribute to advancing the health of women and girls. Health promotion, as described thoroughly in this book, is fundamentally a practical endeavour. As such, it has a tradition of action and engagement that can be useful to those in the women’s health field who may get caught up in critique and theorizing at the expense of practice. By learning from one another, the fields of health promotion and women’s health (informed by intersectional analysis) can both contribute to reducing health disparities and improving the health of girls and women.

REFERENCES Aïach, P. (2001). Femmes et hommes face à la mort et à la maladie, des différences paradoxales dans Femmes et hommes dans Aiach, Cèbe, Cresson et Philippe, Le champ de la santé: Approches sociologiques. Anderson, J.M. (1987). Migration and health: Perspectives on immigrant women. Sociology of Health and Illness, 9(4), 410–438. Bangkok Charter for Health Promotion in a Globalized World. (2005). Geneva: World Health Organization. Retrieved November 15, 2005, from www.who.int/healthpromotion/conferences/6gchp/ bangkok_charter/en/index.html Brah, A., & Phoenix, A. (2004). Ain’t I a woman? Revisiting intersectionality. Journal of International Women’s Studies, 5(3), 75–86. Brower, V. (2002). Sex matters: In sickness and in health, men and women are clearly different. European Molecular Biology Organization (EMBO) Reports, 3(1), 921–923. Brydon-Miller, M. (2004). The terrifying truth: Interrogating systems of power and privilege and choosing to act. In M. Brydon-Miller, P. Maguire, & A. McIntyre, Traveling companions: Feminism, teaching, and action research (pp. 3–19). Westport: Praeger. Canadian Feminist Alliance for International Action. (2003). Canada’s failure to act: Women’s inequality deepens. Ottawa: Canadian Feminist Alliance for International Action. Retrieved April 4, 2007, from www.fafia-afai.org/en/node/164. Celayir, S. (2002). Is there a “bladder sex”? The relation of different sex hormones and sex hormone receptors in bladder in childhood. Medical Hypotheses, 59(2), 186–190. Cohen, M. (1998). Towards a framework for women’s health. Patient Education and Counselling, 33, 187–196.

CHAPTER 6: Addressing Diversity in Health Promotion ■ 85 Collins, P.H. (1989). The social construction of Black feminist thought. Signs: Journal of Women in Culture and Society, 14(4), 745–773. Daykin, N., & Naidoo, J. (1995). Feminist critiques of health promotion. In R. Bunton, S., Nettleton, & R. Burrows (Eds.), The sociology of health promotion: Critical analyses of consumption, lifestyle, and risk (pp. 59–69). London and New York: Routledge. Denton, M., Hadjukowski-Ahmed, M., O’Connor, M., & Zeytinoglu, I.U. (Eds.). (1999). Women’s voices in health promotion. Toronto: Canadian Scholars’ Press Inc. Denton, M., Prus, S., & Walters, V. (2004). Gender differences in health: A Canadian study of the psychosocial, structural, and behavioural determinants of health. Social Science and Medicine, 58(12), 2585–2600. Doyal, L. (2000). Gender equity in health: Debates and dilemmas. Social Science and Medicine, 51(6), 931–939. Dua, E., FitzGerald, M., Gardner, L., Taylor, D., Wyndels, L. (Eds). (1994). On women healthsharing. Toronto: Women’s Healthsharing. Fonow, M.M., & Cook, J.A. (1991). Back to the future: A look at the second wave of feminist epistemology and methodology. In M.M. Fonow & J.A. Cook (Eds.), Beyond methodology: Feminist scholarship as lived research (pp. 1–15). Bloomington: Indiana University Press. Forbes, A., & Wainwright, S.P. (2001). On the methodological, theoretical, and philosophical context of health inequalities research: A critique. Social Science and Medicine, 53(6), 801–816. Galabuzi, G.E. (2004). Social exclusion. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Graham, H. (2004). Social determinants and their unequal distribution: Clarifying policy understandings. Milbank Quarterly, 82(1), 101–124. Greaves, L., Hankivsky, O., Amaratunga, C., Ballem, P., Chow, D., & De Koninck, M. (1999). CIHR 2000: Sex, gender, and women’s Health. Vancouver: Centre of Excellence for Women’s Health. Greenberger, P. (2001). News from the Society for Women’s Health Research: FDA doing poor job of monitoring drugs for sex differences. Journal of Women’s Health and Gender-Based Medicine, 10(9), 829–830. Hankivsky, O. (2005). Women’s health in Canada, Beijing, and beyond. Winnipeg: Canadian Women’s Health Network. From www.cwhn.ca Hankivsky, O., et al. (2005). Research methodologies in women’s health/gender and health research. Simon Fraser University, Vancouver. Health Canada. (1996). Centres of Excellence for Women’s Health Program. Fact sheet prepared for the Canada–USA Women’s Health Forum. Ottawa: Women’s Health Bureau. Health Canada. (1999). Health Canada’s women’s health strategy. Ottawa: Women’s Health Bureau. Health Canada. (2000). Health Canada’s gender-based analysis policy. Ottawa: Health Canada. Health Canada. (2003). Exploring concepts of gender and health. Ottawa: Women’s Health Bureau, Health Canada. Hunt, K., & Annandale, E. (1999). Relocating gender and morbidity: Examining men’s and women’s health in contemporary Western societies. Introduction to special issue on gender and health. Social Science and Medicine, 48(1), 1–5. Interagency Gender Working Group. (2004). The “so what?” report: A look at whether integrating a gender focus into programs makes a difference in outcomes. Washington: Population Reference Bureau. Jackson, B.E., Pederson, A., & Boscoe, M. (2006). Gender-based analysis and wait times: New questions, new knowledge. Prepared for the Federal Advisor on Wait Times. From www.hc-sc.gc.ca/hcs-sss/ alt_formats/hpb-dgps/pdf/pubs/2006-wait-attente/index_e.pdf.

86 ■ PART I: Conceptual Perspectives Krieger, N. (2003). Genders, sexes, and health: What are the connections—and why does it matter? International Journal of Epidemiology, 32(4), 652–657. Krieger, N., & Fee, E. (1994). Man-made medicine and women’s health: The biopolitics of sex/gender and race/ethnicity. International Journal of Health Services, 24(2), 265–283. Lockshin, M.D. (2001). Genome and hormones: Gender differences in physiology: Invited review: Sex ratio and rheumatic disease. Journal of Applied Physiology, 91(5), 2366–2373. Martin, J.R. (1994). Methodological essentialism, false difference, and other dangerous traps. Signs: Journal of Women in Culture and Society, 19(3), 630–657. McCall, L. (2005). The complexity of intersectionality. Signs: Journal of Women in Culture and Society, 30(3), 1771–1800. Mittlemark, M. (2005) Global health promotion: Challenges and opportunities. In A. Scriven & S. Garman (Eds.), Promoting health: Global perspectives (pp. 48–57). New York: Palgrave Mcmillan. Morrow, M. (in press). “Our bodies our selves” in context: Reflections on the women’s health movement in Canada. In M. Morrow, O. Hankivsky, & C. Varcoe (Eds.), Women’s health in Canada: Critical perspectives on theory and policy. Toronto: University of Toronto Press. Mullings, L., & Schulz, A.J. (2006). Intersectionality and health: An introduction. In A.J. Schulz & L. Mullings (Eds.), Gender, race, class, and health: Intersectional approaches (pp. 3–17). San Francisco: Jossey-Bass. National Coordinating Group on Health Care Reform and Women. (2003). Reading Romanow: The implications of the final report of the Commission on the Future of Health Care in Canada for Women. Winnipeg: Canadian Women’s Health Network. Ostlin, P., George, A., & Sen, G. (2003). Gender, health, and equity: The intersections. In R. Hofrichter (Ed.), Health and social justice: Politics, ideology, and inequity in the distribution of disease (pp. 132–156). San Francisco: Jossey-Bass. Poland, B. (1998). Social inequalities, social exclusion, and health: A critical social science perspective on health promotion theory, research, and practice. Conference presentation, Bergen, Norway. Potvin, L., Gendron, S., Bilodeau, A., & Chabot, P. (2005). Integrating social theory into public health practice. American Journal of Public Health, 95(4), 591–595. Rao Gupta, G. (2000). Gender, sexuality, and HIV/AIDS: The what, the why, and the how. In XIIIth International AIDS Conference, July 12, 2000, Durban, South Africa: International Center for Research on Women (ICRW). Retrieved July 18, 2006, from www.icrw.org/docs/ durban_hivaids_speech700.pdf Reid, C. (2004). The wounds of exclusion: Poverty, women’s health, and social justice. Edmonton: Qualitative Institute Press. Reid, C., & Herbert, C. (2005). “Welfare moms and welfare bums”: Revisiting poverty as a social determinant of health. Health Sociology Review, 14(2), 161–173. Ruzek, S.B., Clarke, A.E., & Olesen, V.L. (1997). Social, biomedical, and feminist models of women’s health. In S.B. Ruzek, A.E. Clarke, & V.L. Olesen (Eds.), Women’s health: Complexities and differences (pp. 11–28). Columbus: Ohio State University Press. Salmon, A., Poole, N., Morrow, M., Greaves, L., Ingram, R., & Pederson, A. (2006). Integrating sex and gender in mental health and addictions policy: Considerations and recommendations for federal policy development. Vancouver: British Columbia Centre of Excellence for Women’s Health. Thurston, W.E., & O’Connor, M. (1996). Health promotion for women: A Canadian perspective. Paper prepared for the Canada–USA Women’s Health Forum, August 9–11, 1996, Ottawa, Ontario.

CHAPTER 6: Addressing Diversity in Health Promotion ■ 87 United Nations. (1995). The Platform for Action. Division for the Advancement of Women, The United Nations Fourth World Conference on Women. Beijing, China: United Nations. Retrieved February 5, 2007, from www.un.org/womenwatch/daw/beijing/platform/health.htm. Weber, L. (2006). Reconstructing the landscape of health disparities research: Promoting dialogue between feminist intersectional and biomedical paradigms. In A.J. Schulz & L. Mullings (Eds.), Gender, race, class, and health: Intersectional approaches (pp. 21–59). San Francisco: Jossey-Bass. Weber, L., & Parra-Medina, D. (2003). Intersectionality and women’s health: Charting a path to eliminating health disparities. In M.T. Segal & V. Demos (Eds.), Gender perspectives on health and medicine: Key themes (pp. 181–230). London: Elsevier. Women’s Health Bureau. (2003). Exploring concepts of gender and health. Ottawa. Health Canada. World Health Organization. (1986). Ottawa Charter for Health Promotion. Health Promotion International, 1(4), 405. World Health Organization. (1998). Gender and health: Technical paper. Geneva: World Health Organization. Retrieved July 18, 2006, from www.who.int/reproductive-health/publications/ WHD_98_16_gender_and_health_technical_paper/WHD_98_16_table_of_contents_en.html World Health Organization. (2005). The Bangkok Charter for Health Promotion in a Globalized World. Retrieved November 15, 2005, from www.who.int/healthpromotion/conferences/6gchp/ bangkok_charter/en/index.html Ziglio, E., Hagard, S., & Griffiths, J. (2000). Health promotion development in Europe: Achievements and challenges. Health Promotion International, 15(2), 143–154.

CRITIC AL THINKING QUESTIONS 1. What is the difference between sex and gender? 2. Apply a “gender analysis” to understanding the prevalence of common health problems (e.g., heart disease, arthritis, and so on) through distinguishing it from an approach focused solely on “sex” differences. 3. Describe how gender interacts with health disparities, health inequalities, and social inequalities. 4. How has the “women’s health movement” or “women’s health activism” advanced understandings of gender and health and women’s health? 5. What can the women’s health movement and health promotion learn from each other?

FURTHER READINGS Andrew, C., Armstrong, P., Armstrong, H., Clement, W., & Vosko, L.F. (Eds.). (2003). Studies in political economy: Developments in feminism. Toronto: Women’s Press. This book brings together a collection of articles from Studies in Political Economy, a Canadian journal, to illustrate and explore the development of analyses regarding contemporary political economic theory and feminist theory. In particular, the articles look at the ways that class and gender intersect through studies of the workplace, long-term care for the elderly, the crisis in nursing in Canada, and violence against women. The collection was originally developed as a teaching aid and should help introduce students to the current theorizing and research.

88 ■ PART I: Conceptual Perspectives Doyal, L. (1995) What makes women sick? Gender and the political economy of health. London: Macmillan. In this classic volume, Lesley Doyal illustrates the value of a political economy approach to understanding and acting on women’s health. The book examines in detail the impact of sexuality, fertility control, reproduction, domestic labour, and waged work on women’s health and well-being by linking how gender divisions in economic and social life affect women’s experiences of illness, disability, and mortality. The final chapter draws from Professor Doyal’s extensive international experiences to illustrate how women around the world are meeting the challenges to their health. Morrow, M., Hankivsky, O., & Varcoe, C. (Eds.). (in press). Women’s health in Canada: Critical perspectives on theory and policy. Toronto: University of Toronto Press. Women’s health in Canada: Critical perspectives on theory and policy brings together an interdisciplinary group of scholars and practitioners who lay out the methodological and theoretical foundations for the interdisciplinary study of women’s health. The book emphasizes analytical and constructive directions in theory, practice, and policy from critical, feminist, and anti-racist perspectives. Ruzek, S.B., Clarke, A.E., & Olesen, V.L. (1997). Women’s health: Complexities and differences. Columbus: Ohio State University Press. This volume, from the United States, argues for integrated models of women’s health that address contributions of culturally and socially constructed concepts of caring and curing as well as health practices, medical care, and social investments in the prerequisites for health. These conceptualizations of health differ radically from narrow biomedical models that only acknowledge prevention, detection, and treatment of disease. This volume is divided into seven parts, including: (1) what is women’s health; (2) what we share and how we differ; (3) health practices, working and living conditions, and medical care; (4) culture and complexities; (5) intersections of race, class, and culture; (6) power and social control; and (7) challenges and choices for the 21st century. Schulz, A.J., & Mullings, L. (2006). Gender, race, class, and health: Intersectional approaches. San Francisco: Jossey-Bass. This volume aims to provide opportunities for dialogue or mutual exchange across the disciplines and paradigms that inform empirical efforts to understand and address inequalities in health. It brings together an interdisciplinary group of scholars from the social sciences and public health to examine the ways that gender, race, and class are mutually constituted and interconnected. The goal is to inform theory, research, and practice focused on the elimination of health disparities. The volume is divided into five parts: (1) intersectionality and health; (2) race, class, gender, and knowledge production; (3) the social context of health and illness; (4) structuring health care: access quality and inequality; and (5) disrupting inequality.

RELEVANT WEB SITES Bureau of Women’s Health and Gender Analysis www.hc-sc.gc.ca/ahc-asc/branch-dirgen/hpb-dgps/pppd-dppp/bwhgabsfacs/index_e.html

The Bureau of Women’s Health and Gender Analysis is the focal point for women’s health within the federal government. It provides policy advice and leads initiatives to


advance women’s health and to increase our understanding of how sex and gender affect health over the lifespan. It builds departmental capacity by coordinating the implementation of gender-based analysis and reports on the development of gender-sensitive legislation, policies, and programs at Health Canada. The bureau, through the Centres of Excellence for Women’s Health, Working Groups, and the Canadian Women’s Health Network, ensures policy-relevant research and information dissemination. The bureau maintains ongoing relationships with provinces and territories, major women’s organizations, health researchers, and others to promote women’s well-being. Centre for Social Justice www.socialjustice.org/

The Centre for Social Justice is an advocacy organization that seeks to strengthen the struggle for social justice. The centre is committed to working for change in partnership with various social movements and recognizes that effective change requires the active participation of all sectors of the community. Through the centre research, education and advocacy is conducted toward narrowing the gap in income, wealth, and power. It aims to bring together people from universities, unions, faith groups, and communities toward the pursuit of greater equality and democracy. Centres of Excellence for Women’s Health www.cewh-cesf.ca

Canada’s Centres of Excellence for Women’s Health are funded through Health Canada’s Women’s Health Contribution Program. The centres were established in 1996 as part of the women’s health strategy and conduct and/or facilitate research on the determinants of women’s health and its translation into policy and accessible health information. The centres are associated with the Aboriginal Women’s Health and Healing Research Group (www.awhhrg.ca/index.php), Women and Health Care Reform (www.cewh-cesf.ca/healthreform/index.html), Women and Health Protection (www.whp-apsf.ca/en/index.html), and the Canadian Women’s Health Network (www.cwhn.ca/). CWHN is a voluntary national organization dedicated to improving the health and lives of girls and women in Canada and the world by collecting, producing, distributing, and sharing knowledge, ideas, education, information, resources, strategies, and inspirations. In 2006, there were four Centres of Excellence: • • • •

Atlantic Centre of Excellence for Women’s Health (www.acewh.dal.ca) British Columbia Centre of Excellence for Women’s Health (www.bccewh.bc.ca) National Network on Environments and Women’s Health (www.yorku.ca/nnewh) Prairie Centre of Excellence for Women’s Health (www.pwhce.ca)


PA RT I I

NATIONAL PERSPECTIVES

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f we consider Canada as a whole, major actors or groups of actors have had a significant impact over the evolution of health promotion during the last 10-12 years. The federal government is clearly a significant force in health promotion from the perspective of funding, programming, and policy making. In Chapter 7, Pinder argues that although Canada’s federal government was the undisputed world leader from 1974 to 1994, it then abandoned the field for about a decade before beginning very recently to reclaim it, notably through the creation of the new Public Health Agency of Canada in 2004 and renewed interest and support for interventions on “healthy living.” In Chapter 8, Raphael illustrates how the policies of a national government have a major impact on the health of populations through the inequities that are produced or curtailed through such policies. Comparing Canada to other countries, notably the United Kingdom, Raphael shows that we are now lagging behind in addressing inequities, having been at the forefront of these issues at one time. Chapter 9 shows how another group of actors, Canada’s universities, have had an influential role over the last decade through training, capacity building, and the production and dissemination of knowledge related to health promotion. Rootman, Jackson, and Hills show how, in the absence of federal government leadership, the Canadian Consortium for Health Promotion Research became a major player in Canadian health promotion. By championing a certain vision of health promotion, however, the Consortium has created some debates within the research community that reflect some of the definitional dilemmas presented in the first section of the book. At the end of this section, the reader should thus be able to understand some of the major mechanisms that have operated within Canada as a whole from 1994 on and that had an impact on health promotion as a field and on the health of the population.

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CHAPTER 7

T H E F E D E R A L RO L E I N H E A LT H P RO M OT I O N : U N D E R T H E R A DA R Lavada Pinder

INTRODUCTION rom 1974–1994 the federal government played a prominent role in establishing Canada as a leader in health promotion. Internationally this reputation was undisputed. Closer to home there were reservations, but, even here, its contribution was acknowledged and respected. Beginning in 1994, however, the federal government appears to have quite willingly, even deliberately, given up its claim to leadership. At the federal level, it virtually vanished from the radar screen, replaced by the “population health approach.” Recently, there is reason to believe health promotion is beginning to regain its place as part of a renewed focus on public health. This raises many questions. Why was the leadership role given up? Were advances made with a new approach? Was the approach really new? Why is health promotion re-emerging at this point? Was health promotion operating under the radar, waiting for the right moment to resurface? The story of health promotion at the federal level needs telling. Writing about the role of the federal government in the first 20 years was relatively straightforward, drawing heavily on the first edition of this book (Pinder, 1994). It is the story of the third decade, however, that reads as a cautionary tale urging decision makers and practitioners alike to reflect, to acknowledge the past, and to build on successes. This chapter will attempt to tell this

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story by describing the development of health promotion and its rise to prominence, examining the policy shift from health promotion to population health, reviewing the impact of the population health approach, and, finally, discussing the renewed attention to health promotion as it is currently positioned within a public health context.

THE FIRST TWO DEC ADES Laying the Groundwork Action following the release of A New Perspective on the Health of Canadians (Lalonde, 1974) focused on lifestyles as applied through what would be known as the health promotion strategy, rather than dealing with all four elements of the health field concept presented by Lalonde. The first concrete indication of commitment was in 1978 with the establishment of a Health Promotion Directorate (HPD), thought to be the first of its kind in the world. Ron Draper, its first director general, brought together planning and research capacity, content knowledge (e.g., tobacco, nutrition, child health) and delivery skills (e.g., training education, social marketing) plus the community development expertise of five regional offices (Atlantic, Quebec, Ontario, Prairies, Western) to form program teams. This structure and approach to development and delivery was maintained, by and large, throughout the life of the HPD.

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In 1982 a submission to Cabinet by HPD sought a mandate for a comprehensive program focused on issues, target groups, and country-wide strategies that involved: (1) informing and equipping the public to deal with lifestyle issues; (2) promoting a social climate supportive of healthy lifestyles; (3) supporting self-help and citizen participation; and (4) promoting the adoption of health promotion programs within health care, social welfare, and other established programs (Draper, 1989). The program was approved with so few new resources, however, that its scope was reduced to tobacco, alcohol, drugs, and nutrition. The public face of health promotion, therefore, was associated with lifestyle programs. Few people were aware of the development of school and workplace health, heart health, child health, and a national health promotion survey. By the mid-1980s, growing criticism from within the HPD and from the field concerning the narrowness of the approach was captured by the term “victim-blaming” (Labonté and Penfold, 1981).

Redirecting Health Promotion At about the same time, a fundamental redirection in health promotion was articulated in Europe through Health Promotion: A Discussion Document on the Concept and Principles (World Health Organization, 1984). This little eight-page piece (also called the “yellow document” given the paper on which it was printed) defined health promotion as “a process of enabling people to increase control over, and to improve, their health” (p. 2)1 and introduced the principles of involving the population as a whole and directing action to the determinants of health. In 1985, these ideas found their way into a Canadian federal policy review initiated by bureaucrats and supported by the Honourable Jake Epp, the

minister of Health. As part of setting a new direction, the minister agreed to host the First International Conference on Health Promotion in Ottawa in collaboration with the World Health Organization (WHO) and the Canadian Public Health Association (CPHA). The conference produced the Ottawa Charter (World Health Organization, 1986) and the Canadian government released its own discussion paper, Achieving Health for All: A Framework for Health Promotion (AFHA) (Epp, 1986). The Epp Report (1986) was distributed and promoted throughout the country with a mixed response. While the conceptual framework of both AFHA and the Charter were welcomed by most, pragmatic souls raised doubts about capacity and political will to tackle healthy public policy. In fact, the skeptics were right. Efforts to obtain a mandate and resources to act on a broader view of health were not successful. Instead, HPD received significant new resources to undertake programs related to drug and alcohol abuse, tobacco use, nutrition, and AIDS. However, to their credit, the resulting strategies were designed to reflect many aspects of the new health promotion. They were intersectoral and involved partnerships with other federal departments, provincial and territorial governments, non-governmental organizations, and the private sector. Social marketing programs set a positive, non-judgmental tone; educational materials were developed to train professionals and augment school programs; qualitative research explored living and working conditions; and the regional offices of HPD delivered community action funds in response to locally defined needs. In an effort to balance the emphasis on these strategies, core funds were again directed to school and workplace health, and the Canadian Heart Health Initiative was launched in 1987 in collaboration with the

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National Health Research Development Fund (NHRDP). A knowledge development strategy, developed under the leadership of Dr. Irving Rootman, then a director in HPD, included negotiations with NHRDP and the Social Sciences and Humanities Research Council (SSHRC), resulting in a five-year support program for health promotion research centres in six universities. It is fair, then, to say that for two decades the federal government played a significant role in the development of Canadian health promotion. Documents redefining health and its determinants were written by bureaucrats and championed by ministers of health. A fledging infrastructure was put in place that reached beyond the federal level to the provinces and territories, universities, local public health units, and community health centres. An intersectoral, collaborative style of program development and delivery was pioneered. The federal government also took a prominent role internationally, hosting the First International Conference on Health Promotion and supporting subsequent conferences. Celebration of these achievements must be tempered, however, with the realization that health promotion never took its place as a cornerstone in the health system as envisioned in AFHA (Epp, 1986). It did not receive high-level support from either the federal government or federal/provincial/territorial committees. It did not acquire resources (beyond funds for risk reduction strategies) that would permit the research necessary to identify and explain the correlation between levels of socio-economic status and many measures of health status (Hayes & Glouberman, 1999). In fact, the work done equated health promotion with lifestyles. By the early 1990s, the popular view that health promotion was merely a series of lifestyle programs based primarily on social marketing was a perception that could not be shaken.2

Only keen observers appreciated health promotion as a set of values and action strategies designed to improve living and working conditions.

MOVING ON IN THE 1990S: PLUS ÇA CHANGE, PLUS C’EST PA R E I L ? In the early 1990s the work of the Canadian Institute for Advanced Research (CIAR) seemed more to the point. A respected group of researchers went beyond the concepts in the Lalonde Report (1974), the Epp Report (1986), and the Ottawa Charter (1986) to provide evidence needed to pursue a broader view of health. In masterful presentations to federal/provincial/territorial (F/P/T) meetings and publications such as Producing Health: Consuming Health Care (Evans & Stoddard, 1990) and Why Some People Are Healthy and Others Not (Evans, Barer, & Marmor, 1994), population health gained currency by providing a coherent set of analyses and priorities. The provinces of Quebec, British Columbia, Manitoba, Ontario, and Saskatchewan were the first to take up the notion of population health, and their influence on colleagues in F/P/T meetings gained support from the federal government. By 1992, the population health framework under development by the CIAR won the attention of the F/P/T Conference of Deputy Ministers of Health, which created an Advisory Committee on Population Health (ACPH) to reflect this new focus (Legowski & McKay, 2000).

Another Milestone Document? The ACPH got to work. A document outlining a national goals framework was prepared under contract in an effort to put a policy focus on population health (McAmmond, 1994).


There was, however, little appetite for health goals among politicians and senior bureaucrats and even fewer resources to support their development. Instead the goals framework became the basis for a discussion paper, Strategies for Population Health: Investing in the Health of Canadians (Federal, Provincial, & Territorial Advisory Committee on Population Health, 1994). In quick succession the paper was approved by the F/P/T Conference of Deputy Ministers of Health in June 1994 and by the F/P/T ministers of Health in September 1994. Three years later, in 1997, in response to a memorandum developed with participation from 18 departments, the federal Cabinet agreed to adopt the population health approach to guide health policy (Legowski & McKay, 2000). Strategies for Population Health (1994) identified nine determinants of health: (1) income and social status; (2) social support networks; (3) education; (4) employment and working conditions; (5) physical environments; (6) biology and genetic endowments; (7) personal health practices and coping skills; (8) healthy child development; (9) and health services—and outlined three strategic directions—strengthening public understanding of the determinants of health; building understanding of the determinants of health among sectors outside of health; and developing comprehensive intersectoral population health initiatives. There is no doubt this document was pivotal in the federal government’s move from health promotion to the “the population health approach.” With the exception of one reference to the Lalonde Report (1974), it made no mention of 20 years’ of work in health promotion. It also marks the point when intellectual ferment within the federal government ceased and policy development moved into the F/P/T arena. Whether it ranks with the Lalonde and Epp reports or

the Charter as a milestone document is not the issue. What is at issue, in this chapter, is its impact on the federal government’s role in health promotion, on federal programs, and on federal efforts to take action on the determinants of health.

Getting Things Done in the 1990s In hindsight, the federal government may have moved quickly to adopt the new approach without fully appreciating the challenges. Moving beyond rhetoric is difficult at the best of times, but the environment created by the massive structural changes and budget cuts that affected the federal governments of the 1990s made the task exceptionally difficult. Defending scarce resources and self-preservation became the order of the day. In the summer of 1993 the Department of National Health and Welfare became Health Canada, and welfare was moved to a new Human Resources and Labour Department. A change of government in the fall of 1993 was followed by Program Review in 1994–1995 and Business Lines in 1995–1996. Subsequently, there was a limited reorganization in 1995–1996 to reflect the need to “do more with less” and, as significant new funds became available in 1999–2000, a more far-reaching one occurred in 2000 (Health Canada, 2000). Program Review was an exercise in which every program in the federal government was examined to establish the core role of a modern and affordable government. Each program was assessed according to criteria that included public interest, the number of partnerships, and whether the program was more suitable to the provincial role. Many programs did not pass this test and were “allowed to sunset.” Health promotion programs, without a legislative base and suffering from an image of high-cost


social marketing activities, were either terminated or severely cut. Business Line working groups, established following program review, scrutinized health-related federal expenditures. A working group discussion paper, Population Health: From Rhetoric to Action (1996a) presented ideas on possible roles for Health Canada and contained a list of federal departments responsible for key determinants. It is a formidable list that in itself signalled how difficult it would be to turn rhetoric into action. Subsequent planning documents, while well crafted, were aimed at program officers and had little impact on policy development (Health Canada, 1998, 2001).

Impact on Health Promotion In March 1995, as part of reorganization, the Population Health Directorate was created to replace HPD. A Health Promotion Development Division in the new Directorate was ultimately reduced to one officer. With the champions gone, institutional memory fading, and no identifiable unit, health promotion began its descent as a policy and program focus, replaced by the “population health approach.” The health promotion field did not have a problem with the focus on the determinants of health. There were, however, concerns that promises to contribute to prosperity, to a vibrant economy, and to a reduction in health and welfare expenditures (Federal, Provincial, & Territorial Advisory Committee on Population Health, 1994) pandered to the hard-nosed approach demanded by the fiscal climate and avoided the importance of socioeconomic inequalities (Coburn & Poland, 1996). Moreover, the ideas seemed to support a top-down approach and stand to lose health promotion’s focus on community and advocacy. Ron Labonté (1995) suggested that health

promotion might possibly be “a stale concept in need of re-invention. [But if] population health is to be its phoenix, let it rise from the ashes of health promotion’s diversity in social critique and empowering practices” (p. 167). Unwilling to see health promotion reduced to ashes, Health Canada made a serious effort to integrate population health and health promotion into a common framework. A discussion paper, Population Health Promotion: An Integrated Model of Population Health and Health Promotion, was prepared by the Health Promotion Development Division (Hamilton & Bhatti, 1996). At a round table, following distribution of the paper, 26 participants, representing the who’s who of both fields, agreed there was common ground and expressed a willingness to work together (Health Canada, 1996b). Some years later Evans and Stoddard (2003) suggested the framework was useful and appropriate in its recognition of both health promotion and population health. Inside the bureaucracy in 1996, however, there was little traction. Health Canada had put its money on population health as the great leap forward and was not about to complicate matters. At the same time, Health Canada funded a Canadian Public Health Association (CPHA) project, Perspectives on Health Promotion. In 1995 CPHA established a working group, which commissioned a background document, undertook a key informant survey, held consensus-building workshops across the country and a national workshop at the CPHA annual meeting (Canadian Public Health Association, 1996a). The resulting Action Statement (1996b) contained strategic principles, confirmed health promotion concepts, and proposed a renewed emphasis on healthy public policy, strengthening communities and reorienting the health system. The process was important to a field that was feeling insecure with the ascendancy of population health, but,


by the time the action statement appeared, there were no funds to promote it. Efforts to support development of a health promotion training and research infrastructure, represented in the early 1990s by funding for selected university-based health promotion centres, became increasingly ad hoc later in the decade. This story is presented in detail in Chapter 9 of this book.

Impact on Programs The federal government may seem to have abandoned health promotion, but, having survived the deficit cutting of the mid-1990s, Health Canada did not stop producing and continues to produce a host of health-promoting programs (Health Canada, 2002). Some are a continuation of earlier health promotion programs; others are newer. The topics cover issues such as tobacco and HIV/AIDS, population groups such as children and seniors, and settings such as the workplace and schools. Even a little digging reveals that most are built on the foundation laid down in the first two decades of health promotion. Prime examples are the Federal Tobacco Control Strategy (FTCS) and the Canadian Diabetes Strategy. The Tobacco Strategy, for instance, renewed and improved many times over the years, is, in many ways, the gold standard for intersectoral, collaborative strategies. Smoking rates have declined dramatically since it was first launched in 1987, testifying to the fact that change takes time, a clear focus, and significant investment to make a difference (Health Canada, 2005b). New programs such as the Canadian Health Network (CHN) and the Pan-Canadian Healthy Living Strategy are also reminiscent of earlier programs, i.e., Health Promotion OnLine and the Health Canada-Participaction programVitality/Vitalité. The difference is they reach further, are better funded, more

technologically sophisticated, and, most important, have the support of governments at all levels. The CHN (Health Canada, 2004) is a bilingual, Web-based information service intended to help Canadians make healthy choices. It provides practical information through links to more than 17,000 Web-based resources and monthly features on current health issues. Information on a variety of topics, including health promotion, is provided by affiliates. The Centre for Health Promotion at the University of Toronto, for example, in partnership with the Ontario Prevention Clearinghouse, provides expertise and training in health promotion for CHN affiliates working in other subject areas The Integrated Pan-Canadian Healthy Living Strategy is the result of an agreement reached by the F/P/T ministers of Health in September 2002 to use a common approach to addressing the risk factors known to contribute to non-communicable diseases. Following cross-country consultations in 2003, the F/P/T ministers of Health approved a framework that included a Healthy Living Network, research, surveillance and best practices, options for an intersectoral fund, and further dialogue with Aboriginal stakeholders (Health Canada, 2005b).

Impact on Policy: The Determinants of Health In a recent book on the social determinants of health, Raphael (2005a) observes that, “strengthening social determinants of health would reduce health inequalities, thereby improving the population health of Canadians. This being the case, it would be expected that governments would be responsive to these ideas. This may not be the case.” Others agree that recently in Canada, it is difficult to find examples of policy shifts addressing the social


determinants of health carried through to implementation, although the National Children’s Agenda (1999) and the National Child Benefit (1998) are positive moves in that direction (Evans & Stoddard, 2003). The role of Health Canada in leading intersectoral strategies has been well honed over the years. Other sectors do not have a problem in collaborating on issues that are clearly health related, but tackling the social determinants where the policy changes clearly lie in sectors outside of health is quite another matter as well identified in Rebalancing at the Societal Level (a paper in volume II of the final report of the National Health Forum (1997b): The health sector can play a very effective role as an advocate or, a partner in, strategies which act on the basic determinants of health. But we must resist the temptation of taking on too broad of a mandate for achieving health objectives. We should not hold health authorities accountable for reducing inequities in health. But we should hold them accountable for identifying needs, clarifying connections, and telling the truth about why some people are healthy and others are not. (p. 18)

This seems simple enough until the idea is explored in terms of research needs, analysis, policy tradeoffs, mechanisms, and the tools necessary to conduct health impact analysis of relevant policies. In fact, strategies to act on the social determinants call on just as much, if not more, investment, strategic thinking, persistence, and long-term thinking as the tobacco strategy. Efforts to set up mechanisms such as the 1997 Interdepartmental Reference Group, made up of senior officials from several departments, were short-lived. Senior staff was quickly replaced with junior officers when it became clear that no real mandate would be given to such a structure.

PUBLIC HEALTH FINDS ITS RIGHTFUL PLACE Reports, Reports, but Finally Some Respect Had it not been for a SARS epidemic that had major economic consequences and recommendations from several commission reports, the decade of the 1990s that started out with a paper entitled, Producing Health: Consuming Health Care, could have closed with one called Producing Action: Consuming Rhetoric. But there is no question that the SARS outbreak of 2002–2003 and concern about mad cow disease (BSE) and West Nile Virus put public health front and centre in the public, political, and bureaucratic mind at the beginning of the new century, even more so than the reports of several federal commissions. Deliberations on health futures started with the National Forum on Health, launched by the Right Honourable Jean Chrétien in 1994. The 24 volunteer members went further than the provincial commissions of the 1980s in trying to find a balance between the national preoccupation with health care and the need to deal with other health determinants. For a year following the final report in 1997, the federal government monitored progress on the recommendations. Perhaps as a consequence of this special effort, there was significant institutional response to the recommendations concerning research, information, and Aboriginal health. The Population Health Initiative was created as part of the Canadian Institute for Health Information; a National Aboriginal Health Institute was established; and several of the 13 Canadian Institutes for Health Research, a new major funding mechanism for health research created in 2000, cover issues relevant to health promotion: population and public health, gender, aging, nutrition, and human development (National Forum on Health, 1997b).


Two highly anticipated reports had much less impact on public health. The Kirby Report, The Health of Canadian—The Federal Role (2002), devoted a section to health promotion and disease and recommended funds for prevention of chronic disease. The Romanow Report, Building on Values: The Future of Health Care in Canada (Health Canada, 2002) concentrated on health care, despite briefs from the public health community and several consultations From a health promotion perspective, however, the Naylor Report, Learning from SARS: Renewal of Public Health in Canada (Health Canada, 2003), was the most important document. First, it recommended the creation of a Canadian agency for public health and the appointment of a chief public health officer for Canada; and, second, in line with some work done for the Americas by the Pan-American Health Organisation, health promotion was identified as one of five essential public health functions, the others being health protection, health surveillance, disease and injury prevention, and population health assessment. These functions are also consistent with those outlined by the Institute of Population and Public Health and the Association for the Care of Children’s Health. It is worth noting that population health assessment is described as “the ability to understand the health of populations, the factors which underlie good health and those which create health risks. These assessments lead to better services and policies”(p. 47). The description of health promotion, on the other hand, is as follows: Public health practitioners work with individuals, agencies, and communities to understand and improve health through healthy public policy, community-based interventions, and public participation. Health promotion contributes to and shades into disease prevention

by catalyzing healthier and safer behaviours. Comprehensive approaches to health promotion may involve community development or policy advocacy and action regarding environmental and socioeconomic determinants of health and illness. (p. 47)

These descriptions are interesting on two counts. First, a clear distinction is made between population health and health promotion. The former is seen as having mainly a research/assessment role and the latter is seen as action-oriented, in line with the Ottawa Charter. Second, the description of health promotion comes with a footnoted warning that the more “expansive” aspects of health promotion—i.e., addressing the determinants of health—may be criticized as “health imperialism” or “social engineering.” It would be ironic, indeed, if health promotion, once accused of being limited to social marketing, would now take the rap for being too broad. The Canadian Coalition for Public Health in the 21st Century (the Coalition) complements the recommendations in the Naylor Report (Health Canada, 2003) and represents a non-governmental approach to strengthening public health. The Coalition is the result of a think tank on the future on public health sponsored by the Institute for Population and Public Health just prior to the annual meeting of the Canadian Public Health Association (CPHA) in May 2003. In its advocacy role it should be a force in sustaining the renewed federal government’s commitment to public health (Frank, DiRuggiero, & Moloughney, 2004).

The Public Health Agency of Canada In September 2003, in the wake of the reports mentioned above, the F/P/T Conference of Ministers of Health recognized the need to


give public health top priority, improve public health infrastructure, and increase institutional, provincial, territorial, and federal capacity. In December 2003, a federal minister of state for public health was named, the Honourable Carolyn Bennett. By June 2004, the federal government had established the Public Health Agency of Canada (PHAC) and announced the creation of six National Collaborating Centres for Public Health dealing with the determinants of health (Atlantic), public policy and risk assessment (Quebec), public health methodologies and tools development (Ontario), infectious diseases (Manitoba), environmental health (British Columbia), and Aboriginal health (British Columbia) (Public Health Agency of Canada, 2004). In September of the same year Dr. David Butler-Jones, former chief medical officer in Saskatchewan and former president of the CPHA, was named Canada’s first chief public health officer (Public Health Agency of Canada, 2004). Further acknowledgement of the need to strengthen public health can also be found in The 10-Year Plan to Strengthen Health Care, a statement from the First Ministers’ meeting in September 2004. The Plan is perhaps best known for the $41 billion health care agreement with the provinces, but the careful reader can find a commitment to the creation of a new Public Health Network, continuing work on development of a Pan-Canadian Public Health Strategy, and the development of health goals and targets (Federal, Provincial, & Territorial First Ministers Conference, 2004). The PHAC is central to all of the recent and planned efforts to strengthen in public health, including again, in a significant way, health promotion without dismissing population health. With its mission “to promote and protect the health of Canadians through leadership, partnership, innovation and

action in public health” and a clear identity, the PHAC is firming up its leadership role (Public Health Agency of Canada, 2006). For example, it has led the federal government participation in developing the PanCanadian Public Health Network (the Network) and public health goals. The final report of the F/P/T Special Task Force on Public Health, Partners in Public Health (2005), outlines the role and structure of the Network. The role includes information sharing and dissemination, helping jurisdictions facing emergencies, and providing advice to the F/P/T Deputy Ministers of Health. Expert Groups made up of experts nominated by each of the jurisdictions report to a council of F/P/T representatives, who, in turn, report to the F/P/T Conference of Deputy Ministers. Health promotion is one of the six expert groups and it is expected the Ottawa Charter (1986) will frame its work. After 15 years of advocacy, particularly by the CPHA, a single phrase in the First Ministers’ 10-year plan, plus an enthusiastic Minister of State for Public Health, got the process underway and completed in less than a year. Roundtables with the provinces and territories and with experts took place from March–July 2005 and by October the goals were approved by the F/T/P ministers of Health (Public Health Agency of Canada, 2005). The goals, under the four headings— basic needs, belonging and engagement, healthy living, and system of health—are deliberately broad and obviously designed to achieve consensus. The idea is for each community, government, and individual to put them into effect, but, without promotion and monitoring, they will be easy to ignore and may never trigger specific objectives and targets given the never-ending complexities of federal-provincial relationships concerning these issues. The PHAC plans to discuss their


relevance to various sectors with government departments, but this, as has been mentioned before, will take a sophisticated process to avoid being a one-off exercise.

The Future of Health Promotion The federal government has been urged to reclaim its leadership role in health promotion (Law, Kapur, & Collishaw, 2004). “Health promotion” continues to be the term used internationally and the profile has recently been raised again in Canada with both Ontario and Nova Scotia having created ministries of health promotion. As the confusion about population health and health promotion dissipates, the PHAC is poised to begin, once again, to earn a reputation for leadership. One significant step is the change of name of its Centre for Human Development to the Centre for Health Promotion. This is more than a change in name. The intention is to use health promotion as an integrating and unifying concept to organize policies and programs. Internationally, there are opportunities to support health promotion and, at the same time, begin serious work on the determinants of health. The PHAC is funding the Canadian Consortium for Health Promotion Research to organize the 19th International Conference on Health Promotion and Health Education in Vancouver in June 2007. The conference could provide a platform for the federal government to present Canadian health promotion in the context of a renewed public health. Another opportunity is Canada’s participation in the World Health Organization Commission on the Social Determinants of Health. The Canadian representatives, Monique Begin and Stephen Lewis, are being supported by a Canadian Reference Group chaired by Dr. Sylvie Statchenko, deputy chief public health officer

(World Health Organization, 2005). The Canadian representatives to the Commission are also supported by Dr. Ron Labonté, University of Ottawa (globalization), and by Dr. Clyde Hertzman, University of British Columbia (child health). This work could provide a basis for the PHAC to secure its role both nationally and internationally in leading intersectoral action on determinants. In some respects this would be in line with the formation of a federal Social Determinants of Health Task Force proposed in the Toronto Charter for a Healthy Canada (2002) (Raphael, 2005b).

CONCLUSIONS One thing is clear. In the future, terms may come and go, but “the determinants of health” are here to stay. Health promotion laid down the foundation and the population health approach unequivocally put the determinants of health on the agenda. The policy implications remain unclear, but the need to strengthen the social determinants has been widely accepted. At the same time it needs to be said that introducing new policy ideas into government is not too difficult. Gaining acceptance is possible, but taking action is not so easy. Each in its turn—the Lalonde Report (1974), the Epp Report (1986), the Ottawa Charter (1986), and the Strategies for Population Health (1994)—was thought to be the turning point. Proponents promised a great deal, but delivered very little. In fact, there is remarkable similarity in the results achieved by each new wave—changes in language, reorganizations, a host of excellent programs, but little policy. Now there is a new opportunity to move ahead, with population health and health promotion having found their places within a public health framework. With secure and complementary roles, energy will be saved for the real task ahead—sustained and strategic


effort to pursue the policies that would strengthen the determinants of health. Things may have worked out for the best, but it is still a puzzle why, along the way, the federal government so readily gave up its national and international leadership role in health promotion. Why did thinking people buy the notion that health promotion was simply lifestyles/social marketing? Why was a decision not made to acknowledge some limitations in health promotion’s understanding of the determinants of health and to draw on population health research to

strengthen health promotion? Why was the argument not made that health promotion based on the Ottawa Charter (1986) would be the best way for the federal government to contribute to achieving population health? Yes, there were political and bureaucratic changes, different priorities, diminishing resources—hard times—but the lesson here is simple—“Don’t throw out the baby with the bath water”—particularly when the baby has earned Canada a worldwide reputation. Build and be seen to build.

ACKNOWLEDGEMENTS Thanks to Brian Bell, Tariq Bhatti, Carmen Connolly, Peggy Edwards, Heather Fraser, Lynn Hawkins, Suzanne Jackson, Jim Mintz, Ian Potter, Claude Rocan, Sylvie Statchenko, and Elinor Wilson for providing information and pointing the way to documents and Web sites.

NOTES 1

2

Nutbeam’s (1986) definition is an improvement: “the process of enabling individuals and communities to increase control over the determinants of health and thereby improve their health” (p. 114). The role of social marketing should be clarified. It is not health promotion; it is a health promotion tool representing one of the few ways government can reach Canadians directly. With the exception of the mid-1990s when social marketing budgets virtually disappeared, it has played a vital role in Health Canada strategies and been allocated significant funds.

REFERENCES Canadian Public Health Association. (1996a). Perspectives on health promotion: Final report. Ottawa. Canadian Public Health Association. (1996b). Action statement on health promotion in Canada. Ottawa. Coburn, D., & Poland, B. (1996). The CIAR vision of the determinants of health. Canadian Journal of Public Health, 87(5), 308–310. Commission on the Future of Health Care in Canada. (2002). Building on values: The future of health care in Canada. Retrieved July 16, 2006, from www.hc-sc.gc.ca/english/pdf/romanow/pdfs/ HCC_Final_Report.pdf. Draper, R. (1989, June 5–9). The WHO strategy for health promotion. Paper presented at the Community Participation Strategies in Health Promotion Workshop, Bielefeld, Germany. Epp, J. (1986). Achieving health for all: A framework for health promotion. Ottawa: National Health and Welfare. Evans, R.G., Barer, M.L., & Marmor, T.R. (1994). Why are some people healthy and others not?: The determinants of health of populations. New York: Aldine de Guyter.

CHAPTER 7: The Federal Role in Health Promotion ■ 103 Evans, R.G., & Stoddard, G.L. (1990). Producing health, consuming health care. Social Science and Medicine, 31(12), 1347-1363. Evans, R.G., & Stoddard, G.L. (2003). Consuming research, producing policy? American Journal of Public Health, 93(3), 371–379. Federal, Provincial, & Territorial Advisory Committee on Population Health. (1994). Strategies for population health: Investing in the health of Canadians. Ottawa: Health Canada. Federal, Provincial, & Territorial First Ministers Conference. (2004). The 10-year plan to strengthen health care. Ottawa: Online at www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/ 2004-fmm-rpm/index_e.html. Federal, Provincial, & Territorial Special Task Force on Public Health. (2005). Partners in public health. Ottawa: Public Health Agency of Canada. Online at www.phac-aspc.gc.ca/publicat/healthpartners/ pdf/partnersinhealthmainreport_e.pdf. Frank, J., DiRuggiero, E., & Moloughney, B. (2004). Think tank on the future of public health in Canada. Canadian Journal of Public Health, 95(1), 6–11. Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of health and health promotion. Ottawa: Health Promotion Development Division, Health Canada. Online at www. phac-aspc.gc.ca/ph-sp/phdd/php/php.htm. Hayes, M., & Glouberman, S. (1999). Population health, sustainable development, and policy future. Ottawa: Canadian Policy Research Networks. Health Canada. (1996a). Population health: From rhetoric to action, a discussion paper prepared by the Population health Steering Committee and Working Group. Ottawa. Health Canada. (1996b). Report of the roundtable on population health and health promotion. Ottawa: Health Promotion Development Division, Health Canada. Online at www.phac-aspc/ ph-sp/phdd/roundtable.htm. Health Canada. (1998). Taking action on population health: A position paper for health promotion and programs branch staff. Ottawa: Population Health Development Division, Population Health Directorate, Health Canada. Health Canada. (2000). Realigning Health Canada to better serve Canadians. Ottawa: Minister of Public Works and Government Services. Health Canada. (2001). The population health template: Key elements and actions that define a population health approach. Ottawa: Health Canada, Population and Public Health Branch. Health Canada. (2002). Promoting health in Canada: An overview of recent developments and initiatives. Ottawa: Strategic Policy Directorate, Population and Public Health Branch. Health Canada. (2003). Learning from SARS: Renewal of public health in Canada: A report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada. Health Canada. (2004). Canadian health network: Retrieved January 25, 2006, from www. canadian-health-network.ca/servlet/ContentServer?pagename=CHN-RCS/Page/ ShellCHNRResourcePagetemplate&cid=4266339&lang=E. Health Canada. (2005a). The integrated pan-Canadian healthy living strategy. Cat. no. HP 10-1/2005E, ISBN 0-662-41146-3. Ottawa: Minister of Health. Health Canada. (2005b). Federal Tobacco Control Strategy. Retrieved January 25, 2006, from www.hc.sc.gc.ca/hl-vs/tobac-tabac/about-apropos/role/federal/strateg/index_e.html. Kirby, M., & LeBreton, M. (2002). The health of Canadians—the federal role: Final report. Retrieved July 16, 2006, from www.parl.gc.ca/37/2/parlbus/commbus/senate/com-e/SOCI-E/rep-e/repoct02vol6-e.htm.

104 ■ PART II: National Perspectives Labonté, R. (1995). Population health and health promotion: What do they have to say to each other? Canadian Journal of Public Health, 86(3), 165–168. Labonté, R., & Penfold, S. (1981). Canadian perspectives in health promotion: A critique. Health Education, 19(3), 4–9. Lalonde, M. (1974). A New Perspective on the Health of Canadians. Ottawa: Minister of Supply and Services. Law, M., Kapur, A.D., & Collishaw, N. (2004). Health promotion in Canada 1974–2004: Lessons learned. Ottawa: Canadian Medical Association. Legowski, B., & McKay, L. (2000). Health beyond health care: Twenty-five years of federal policy development. Ottawa: Canadian Policy Research Networks. McAmmond, D. (1994). Analytic review towards health goals in Canada. Final report prepared for the Federal, Provincial, and Territorial Advisory Committee on Population Health. Ottawa: Health Canada. National Forum on Health. (1997a). Canada health action: Building on the Legacy: Final report. Ottawa: Minister of Public Works and Government Services. National Forum on Health. (1997b). Canada health action: Building on the Legacy. Vol. 2. Synthesis Reports and Issues Papers. Ottawa: Minister of Public Works and Government Services. Nutbeam, D. (1986). Health promotion glossary. Health Promotion, 1, 113–127. Pinder, L. (1994). The federal role in health promotion: The art of the possible. In A. Pederson, M. O’Neill, & I. Rootman (Eds.), Health promotion in Canada. Toronto: W.B. Saunders. Public Health Agency of Canada. (2004). News release. Retrieved January 30, 2006, from www.phacaspc.gc.ca/media/nr-rp/2004/index.html. Public Health Agency of Canada. (2005). Health Goals for Canada. Retrieved January 30, 2006, from www.healthycanadians.ca/NEW-1-eng.html. Public Health Agency of Canada. (2006). Web site. Retrieved January 15, 2006, from www.phac.gc.ca/about_apropos/index.html. Raphael, D. (2005a). Introduction to the social determinants. In D. Raphael (Ed.), The social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. Raphael, D. (2005b). Appendix: Strengthening the social determinants of health: The Toronto charter for a healthy Canada. In D. Raphael (Ed.), The social determinants of health. Toronto: Canadian Scholars’ Press Inc. World Health Organization. (1984). Concepts and principles of health promotion. Copenhagen: WHO Regional Office for Europe. World Health Organization. (1986). Ottawa Charter for Health Promotion. Geneva:Author. World Health Organization. (2005). Commission on social determinants of health. Retrieved February 3, 2006 from, www.who.int/social_determinants/en/.

CRITIC AL THINKING QUESTIONS 1. If it is accepted that risk reduction/lifestyle programs are important ways health promotion can contribute to improved health, how can this role be maintained without undermining efforts to influence determinants outside of the health sector? How can these roles be seen as complementary rather than competitive? 2. Governments change frequently. How can progressive policy work be sustained despite the fact that priorities and sometimes values change with new political masters? What is


the role of bureaucrats? What role can non-governmental organizations play in influencing the maintenance of positive policy change? 3. What are the fundamental building blocks in strengthening the social determinants of health? How can the basic research, tools, mechanisms, etc., be developed and maintained as a natural part of the way the health sector does its business? 4. It is important to have pan-Canadian leadership in health promotion. What role would the federal government ideally play? 5. How important is language clarity to the future of health promotion? What is the impact of terminology on policy, programs, training, and advocacy? Does it matter what an endeavour is called as long as it contributes to the improvement of health?

FURTHER READINGS Savoie, D.J. (2003). Breaking the bargain: Public servants, ministers, and Parliament. Toronto: University of Toronto Press. This book provides historical background on how the federal government works and the traditional roles of public servants and politicians in setting and implementing policies. It goes on to discuss current realities, emergent issues, and thoughts on how they might be resolved.

RELEVANT WEB SITES Canadian Consortium for Health Promotion Research www.utoronto.ca/chp/CCHPR

The Consortium, with 16 members, aims to enhance health promotion research through collaborative research projects, advocating funding for health promotion research, and acting as a focal point for international activity. Canadian Population Health Initiative (CPHI) www.cihi.ca/cphi

CPHI is a source of research information on the determinants of health. It was established in response to a recommendation from the National Forum on Health to foster better understanding of factors that affect individual and community health and contribute to policy development. Canadian Public Health Association www.cpha.ca/english/

CPHA is a national, independent, not-for-profit, voluntary association representing public health in Canada with links to the international public health community.

CHAPTER 8

A D D R E S S I N G H E A LT H I N E Q UA L I T I E S I N C A N A DA : L I T T L E AT T E N T I O N , I N A D E Q UAT E AC T I O N , L I M I T E D S U C C E S S Dennis Raphael INTRODUCTION ealth promotion is about improving the health of the population by increasing control over the determinants of health (Nutbeam, 1998). An important component of this agenda should be the reduction of inequalities in health and influencing the determinants of these health inequalities (Whitehead, 1998). Health promotion initiatives that fail to consider the source of health inequalities may actually increase inequalities by employing approaches that favour those already enjoying good health at the expense of those whose health is already poor (Graham, 2004).1 Profound health inequalities exist in Canada. These inequalities result from Canadians’ experiencing varying exposures to both health-enhancing and health-threatening living conditions (Raphael, 2002). These differential exposures are related to where Canadians live; the social classes and income groups in which they find themselves; whether they are of Aboriginal, European, or non-European descent; or male or female (Raphael, 2006a,b). These health inequalities are apparent in general health status, life expectancy, and in the incidence of, and mortality from, a wide range of medical conditions. Canada was one of the first jurisdictions to identify addressing health inequalities as important, but Canada now lags far behind many other developed nations in having

H

106

health inequalities on the public health and public policy agendas (Canadian Population Health Initiative, 2002). Not surprisingly, Canada also lags behind other developed nations in researching health inequalities and the sources of such inequalities, and developing and implementing means of reducing these inequalities (Raphael et al., 2005). The past few decades have seen a diminution of health inequalities among Canadians for certain conditions (Wilkins, Berthelot, & Ng, 2002).2 But these declines cannot be attributed to directed action by governments and public health agencies motivated by a health inequalities agenda (Sutcliffe, Deber, & Pasut, 1997; Williamson, 2001; Williamson et al., 2003). Instead, many recent governmental policies have widened known determinants of health inequalities among the population (Dunn, Hargreaves, & Alex, 2002; Raphael, Bryant, & CurryStevens, 2004). And Canadian public health action continues to be focused on issues that play a relatively little role in producing or reducing health inequalities (Raphael, 2003; Raphael & Bryant, 2006). There are troubling implications for the health of Canadians that result from these developments. In this chapter the extent and sources of health inequalities among Canadians is examined. The reason why addressing health inequalities is a marginal issue in Canada is considered by contrasting our situation with developments in other nations. To do so will

CHAPTER 8: Addressing Health Inequalities in Canada ■ 107

require political and institutional willingness to address key issues related to the societal or social determinants of health.

ADDRESSING HEALTH INEQUALITIES IN C ANADA AND ELSEWHERE Health Inequalities Elsewhere Health inequalities exist in every nation on the planet (Amick, Lavis, & Lopez, 2000). There are two primary discourses that have been applied to explain the existence of these inequalities. The cultural/behavioural explanation is that individuals’ behavioural choices (e.g., tobacco and alcohol use, diet, physical inactivity, etc.) are responsible for their developing and dying from a variety of diseases. The materialist/structuralist explanation emphasizes the material conditions under which people live (Raphael, 2006). These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others. Access to health-enhancing conditions is also related to the way governments behave (Ross et al., 2000). Evidence clearly favours the materialist explanation of the sources of health inequalities (Acheson, 1998; Gordon, Shaw, Dorling, & Davey Smith, 1999; Raphael, 2006a; Shaw, Dorling, Gordon, & Smith, 1999; Townsend, Davidson, & Whitehead, 1992). Jurisdictions differ profoundly to the extent that these inequalities are seen as a cause for concern requiring action to address them (Bryant, 2006). A recent review examined how 13 developed nations are addressing health inequalities. Some, like the UK countries, New Zealand, and Sweden, have undertaken systematic governmental efforts to identify the existence and magnitude of

health inequalities and their sources. In contrast, Canadian efforts are limited to reports on how poverty and income inequality influence health mostly by non-governmental organizations (Canadian Population Health Initiative, 2004; Phipps, 2002; Ross, 2002, 2004). Outside of governmental attention devoted to Aboriginal health, the extent of Canadian activity directed toward the issue of health inequalities is minimal and varies across provinces. Health promotion and population health discourses in Canada, for the most part, do not explicitly focus upon reducing health inequalities. As compared to developments in several European countries, reducing health inequalities in Canada takes a back seat to policy statements about improving social and physical environments (Health Canada, 2001). There has been no defining Canadian “Black Report” (Black & Smith, 1992) or “Independent Inquiry into Health Inequalities” (Acheson, 1998) focused on health inequalities, as was the case in the United Kingdom.

Health Inequalities in Canada: Income and Other Determinants In contrast to other nations where research and policy concern with health inequalities has a long-standing history such as the UK, few Canadian researchers explicitly focus on the extent and source of health inequalities (Raphael et al., 2005). And when these researchers do, many are likely to attribute such differences to behavioural risk factors such as tobacco use, physical inactivity, and diet. As one example, a report from Statistics Canada devoted most of its content to documenting how health behaviours (e.g., smoking, exercise, weight, etc.) and psychosocial variables (e.g., stress and depression) helped explain differences in health status among


health regions (Shields & Tremblay, 2002). This was done even though data from the same study showed that self-reported income was far and away the best explanation for these regional differences in health outcomes (Tremblay, Ross, & Berthelot, 2002). Such a fixation on individual behaviours and psychosocial risk conditions is surprising as Canada has been seen as a leader in developing health promotion and population health concepts that outline the importance to health of societal factors such as income and its distribution, employment security and working conditions, early childhood, and other social determinants of health (Restrepo, 2000). Nevertheless, there is Canadian research that identifies inequalities in health as being related to Aboriginal status, income and its distribution, geographic location, and gender. Somewhat less work examines how health inequalities result from early life experiences, inadequate housing, food insecurity, lack of access to health services, immigrant status, and social exclusion (Galabuzi, 2004, 2005; Raphael, 2004b; Raphael, Bryant, & Rioux, 2006). And important research focuses on the political economy of health inequalities and how changes in economic structures and processes associated with increasing economic globalization and the adoption of neoliberal public policies drive increasing inequalities in these social determinants of health (Coburn, 2000, 2004; Teeple, 2000). In this chapter, I focus on health inequalities related to income as it is the most studied factor; other chapters cover factors such as gender and Aboriginal status and the literature cited in this chapter provides ample additional information. Income is an especially important determinant of health inequalities as it is a marker of differential experiences with many social determinants of health.3 Income is a determinant of the quality of early life, education, employment,

and working conditions as well as food security (Raphael, 2001). Income also is a determinant of the quality of housing, the need for a social safety net, the experience of social exclusion, and the experience of unemployment and employment insecurity across the lifespan (Raphael, 2004a). Income level is the best predictor of just about every health indicator experienced by Canadians (Auger, Raynault, Lessard, & Choinière, 2004). The most definitive work in Canada on income and health is done by Wilkins and colleagues at Statistics Canada (Wilkins, Berthelot, & Ng, 2002). Essentially, his analyses are conservative estimates of the relationship between income level and mortality rates. In both 1986 and 1996, those Canadians living within the poorest 20 percent of urban neighbourhoods were much more likely to die from cardiovascular disease, cancer, diabetes, and respiratory diseases—among other diseases—than other Canadians (Wilkins, Berthelot, & Ng, 2002). In 1986, 21 percent of premature years of life lost for all causes prior to age 75 in Canada could be attributed to income differences and this estimate increased to 23 percent by 1996. This figure is obtained by using the mortality rates in the wealthiest quintile of neighbourhoods as a baseline and considering all deaths above that rate to be excess related to income differences. Figure 8.1 shows how excess mortality associated with income manifests itself in premature mortality associated with various diseases. Moreover, as shown in Table 8.1, the burden of ill health is concentrated in the lowest income quintile of neighbourhoods in urban Canada. For just about every cause of death, the richest neighbourhoods fare much better than the others. A recent study reinforces these findings. In this Ontario study, selfreported health status, as well as a functional measure of health, were examined in relation

CHAPTER 8: Addressing Health Inequalities in Canada ■ 109 TABLE 8.1: Age-Standardized Mortality Rates Per 100,000 Population, for Both Sexes, or for Males and Females When Rates Differ by Gender, for Selected Causes of Death by Neighbourhood Income Quintile, Urban Canada, 1996

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to both personal and area variables. Findings indicated that individual level of income was a primary determinant of both self-reported and functional health (see Figures 8.2 and 8.3). Income-related health inequalities are higher than would be expected from income distribution and health data derived from other nations (Humphries & van Doorslaer, 2000).

As mentioned earlier, we could have gone in great detail on many other determinants of health and would have seen reproduced the same patterns of health inequities between males and females, Aboriginal or not, immigrant or not, etc. Let us address now how this problem can be tackled.

FIGURE 8.1: INCOME-RELATED PREMATURE YEARS OF LIFE LOST (0–74 YEARS) ASSOCIATED WITH DISEASE ENTITY, URBAN CANADA, 1996

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FIGURE 8.2: REPORT OF FAIR OR POOR SELF-RATED HEALTH: ODDS RATIOS FOR INDIVIDUAL AND AREA FACTORS, ONTARIO, 1996

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CHAPTER 8: Addressing Health Inequalities in Canada ■ 111 FIGURE 8.3: POOR SCORES (

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