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Continue to Site. Other We hope to make GovTrack more useful to policy professionals like you. Email address where we can reach you:. While health promoters have often reflected deeply on health inequity, much of the appeal has been to an intuitive basis for supporting the elimination of inequity. We argue that this stance is no longer good enough. More recently this debate has been expanded to consider how we are to think of justice in the global context Nussbaum Health promoters should pay close attention to what is at stake in these debates for two reasons.
First, without an awareness of these important arguments, health promotion is liable to accept a default utilitarianism that it inherits from public health, which in turn the latter shares with orthodox economics.
It is argued here that this unacknowledged utilitarianism is in direct contradiction to two profound moral p. Second, important developments in these debates are directly relevant to concerns with acting on the social determinants of health.
Recent arguments have been refined concerning why and how we should address the issue of health inequity, both within and between societies Anand et al.
As health promoters, charged with the responsibility to advocate, enable, and mediate for equity in health, we should be armed with the very best arguments supporting our position. It cannot be assumed that arguments for equity in health are unassailable and intuitively obvious for two reasons. Second, differing conceptions of what is just will lead to different outcomes in terms of actions to promote health.
As we will see below, how we conceive of social justice has a profound impact on the types of actions we can imagine as solutions to the gross inequities in health we find across the world. Specifically, it has become apparent that the goals of health promotion are intimately related to the goals of a socially just global development agenda. Next we focus on an important element that tends to be lost in much of the discourse on health equity: what are the political, economic and social mechanisms by which the social determinants of health are reproduced as unequal resources for health?
This is followed by considering one emerging global initiative aimed at policy solutions in this area: the Health in All Policies agenda.
In this subsection, we outline a different question: what is it about our contemporary political and economic structures that vitiates against the implementation of health promotion strategies and actions as they are conceived in the Ottawa Charter? To begin to answer this question, we need to consider the three fundamental dimensions to health promotion: empowering communities and individuals, building health public policy, and creating supportive environments.
As has already been argued, empowerment is a key dimension of health promotion. By its very nature, empowerment aims to rebalance existing power arrangements by enabling those currently without power to gain access to the resources necessary to live fulfilled and happy lives.
In order to do this with any success, health promoters must do two things: they must have a clear-headed view of existing power structures and relations; and, they must recognize, as professionals, how they themselves fit into those power relations and how they help, often unconsciously, to reproduce them.
One way of seriously addressing this issue is to pay more attention to the concepts of class and status mentioned on the section on social justice and health promotion. Health promotion, to be successful, must rely on concerted action by governments around the world, both within their own territories and in cooperation to address needs that require global action, such as on climate change. However, while these wishes are often articulated WHO , seldom are we offered an analysis of the structure and dynamics of the contemporary state system in a global context.
A more reflective perspective is important here, as theorists of the state argue that certain issues and certain groups, using specific strategies, are more or less likely to be successful changing the nature of hegemonic projects and reversing the direction of state policies Jessop Finally, creating a supportive environment is even more wrapped up in the dynamics of global capitalism than all the other areas combined.
The fundamental prerequisites for health as outlined in the Ottawa Charter are: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity.
These are the elements that, when in adequate supply, make up many of the properties of a supportive environment for health. Yet, each of these elements is in large part determined by the particular structure and dynamics of our global socioeconomic system. It is necessary to develop an awareness of the fundamental political and economic drivers behind the dynamics of contemporary societies in both the developed and developing worlds.
If equity in health relies on the fundamental fairness of social, political, and economic institutions, then ignoring these basic realities is no longer an option for a serious approach to health promotion.
These important insights should no longer be gained in an ad hoc way but should be seen as part of what should constitute core knowledge for competent health promoters. Recently, particularly following the report of the WHO Commission on Social Determinants of Health , there has been a raft of activity by both academia and governments aimed at developing knowledge about the social determinants of health.
There has also been a marked and needed shift of emphasis to what types of action societies need to take to address the consequences of the iniquitous distribution of resources that support health. Less prominent are attempts to confront theoretically the p. While there have been recent attempts by some health promotion researchers to re-engage with fundamental debates in social theory McQueen et al. The key elements of social theory that should be at the forefront of debate in health promotion circles are considered more extensively in two recent sources McQueen et al.
It is an attempt to reinvigorate the original emphasis in the Ottawa Charter on healthy public policy, and to follow up on the work done at the WHO conference in Adelaide, Australia in WHO, Since that meeting, there has been much reflection on both the details of how to implement healthy public policy and the particular challenges posed by integrated, coherent, intersectoral action for health.
This was followed by two important publications in , also focusing on governance Kickbusch and Gleicher ; McQueen et al. The central challenge of implementing HiAP has been the difficulty of managing the governance and accountability structures necessary to sustain both vertical levels of government, non-governmental and private sector and horizontal cross-ministry, inter-departmental intersectoral collaboration.
We are only now beginning in public health and health promotion circles to appreciate the different type of knowledge base required to assess the effectiveness of policy implementation. We are still largely stuck in an outmoded attempt to squeeze what are really matters for political science, economic sociology and the sociology of the state into the narrow methodological confines of standard epidemiological research designs.
Some emerging work Lawless et al. Clearly, HiAP is required to move forward on the intersectoral action agenda outlined in the Ottawa Charter ; however, there is a large knowledge gap concerning implementation and sustainability that needs to be addressed in the future. Since the last version of this chapter, little has changed in the field that might signify a shift in this direction.
Training in health promotion still lacks any real engagement with scholarly debates in the social science disciplines that have insight into these key problems. Complexity, context, and causality in health promotion research. Over the past 15 years, a series of publications have charted the specific methodological challenges for evaluating the effectiveness of health promotion interventions IUHPE ; Rootman et al.
There has been some scepticism about applying the methodological protocols of evidence-based medicine EBM and RCTs as the gold standard because of the problems of complexity and context McQueen One emerging alternative has been to use different methods for synthesizing evidence, such as the realist Pawson et al. Key to understanding the critique of EBM and some of the proposed alternative strategies is the different nature of how causality is conceptualized.
Some health promotion researchers have started to take seriously the potential for a complexity or systems approach to health promotion interventions Rickles et al. These emergent attempts to apply complexity science have yet to show fruit though systems thinking in public health has a longer pedigree , yet they hold much potential to transcend the current impasses in health promotion effectiveness research.
Finally, an important emerging issue, and one that has attracted much attention, is the potential role of social media in public health. The pervasive use and influence of the Internet and social media in nearly all parts of the world, presents new opportunities and challenges for health promotion and health education see Chapter 4. A key feature that differentiates social media from more traditional communication processes is its interactive nature, where communications are not a one-way process, and where users also play an active role.
This allows the formation of new online communities, which can enable virtual participation and collaboration among its members. In this way, social media can provide resources as well as social support for patients with specific diseases or individuals with specific needs. In view of this, social media is emerging as a key p. This can provide additional scientific information for individuals and communities, which can facilitate and enable greater public participation in the discussion about how the evidence base could be best used for the community.
However, there are risks too that social media platforms could be used as avenues of persuasion by industry and other players who have vested interests in promulgating specific points of view. Nevertheless, social media can also be used as a tool to listen to a much wider range of individuals and groups within the community and internationally. This can provide very useful inputs that could balance the traditional, more top-down, nature of public health programming.
As a corollary, social media provides a major platform for health advocacy and activism that could lead to the strengthening of community action, the transformation of personal skills, and draw attention to health issues arising from social inequalities. We have chosen not to give a technical survey of the health promotion field for which there are many excellent sources available Tones and Green ; Green and Kreuter Two global perspectives on health promotion have been published, covering substantive areas and technical research problems concerning health promotion effectiveness McQueen and Jones Instead, we have attempted to offer the reader a chance to reflect on a set of core conceptual issues that underlie the health promotion problematic.
The five key messages we want to impart about health promotion are listed here:. Health promotion finds its core values and principles in the Ottawa Charter which bears careful examination to comprehend the essence of health promotion. The revolution in health education practice is directly connected to the birth of health promotion but beyond this, health promotion has its roots in the deep history of public health and has been invigorated by contemporary social movements. Only secondarily is it about technical strategies for behaviour change.
The foundational principles of health promotion are equity, participation , and empowerment. This requires health promotion professionals to be critical and reflexive in their practice; they must acknowledge power imbalances that favour professional dominance and work to restore power to individuals and communities.
To do this it must engage more directly with contemporary arguments in political philosophy and it must be aware of the dynamics of the global political economy and its effect on the potential for health promotion. Some of these issues are well known, such as the problem of professional dominance; while others, such as the political economy of health promotion, or the engagement with political philosophy, are not addressed or require much deeper reflection.
We have argued that, at its heart, health promotion is about a radical shift in values for public health. However, these intuitive commitments were not sufficiently followed through when it came to not just what outcomes to change but how to change them. Too much of public health, for too long, was driven by a benevolent paternalism that, particularly when it came to dealing with chronic diseases and with vulnerable populations, ended up being counterproductive.
Indeed, not only was this paternalism ineffective in many areas, it was unethical. It assumed the authority of experts and professionals, not only to determine technical solutions, but to determine needs. If we are to take the concepts of equity and empowerment seriously, they have profound implications for how we do public health interventions. We have learned that by addressing needs without first establishing a participatory framework that enables individuals and communities to determine those needs for themselves, we fatally undermine one of the most crucial capacities for health: human dignity and self-respect.
This is particularly so in communities that have suffered historical social injustices. We hope to have demonstrated that there are many barriers to realizing this change in power relations; yet, there are also very important opportunities, such as with the Millennium Development Goals and the Commission on the Social Determinants of Health, where there is an increasing clamour for action to redress health inequities through empowering processes.
It is notable that even the World Bank, often the subject of brutal criticism for exacerbating inequalities Stiglitz , has made significant moves toward recognizing the importance of reducing inequity in human development and has integrated an empowerment approach World Bank It remains to be seen whether these gains can be translated into major policy changes and effective implementation; nevertheless, it is at this level where health promoters and all public health practitioners and researchers must have a strong advocacy position.
We hope that it is apparent that, in our interpretation, health promotion is much more than a set of technical public health interventions aimed at revamping traditional health education for the twenty-first century.
We cannot let go of the core competencies built up by health education and other contributing fields, but we cannot be limited in our vision either. Health promotion has to face up to the fact that, while it may only be a junior partner in the global struggle to develop a more just and equitable world, when it comes to a key human capability and resource, health , it must take a lead role in making the argument for equity, develop and present the evidence for what action is necessary to achieve equity in health, and finally, to hold the powerful accountable where they fail to live up to the demands of justice for health.
Embedded in health promotion is an imperative to act ethically and justly. In this case, unlike most, there is no choice. Text extracts from Hartrick, G. Family nursing assessment: meeting the challenge of health promotion, Journal of Advanced Nursing , Volume 20, Issue 1, pp. Anand, S. Public Health, Ethics, and Equity.
Oxford: Oxford University Press. Find this resource:. Aveneri, S. Communitarianism and Individualism. Baum, F. Cracking the nut of health equity: top down and bottom up pressure for action on the social determinants of health. Bhaskar, R. A Realist Theory of Science.
New York: Routledge. Carroll, S. Social theory and health promotion. Rootman, S. Pederson, and M. Health Promotion in Canada 3rd ed. Commission on the Social Determinants of Health Geneva: WHO. Craig, G. Conclusion: the rhizome and the tree.
Pederson, S. Rootman eds. Health Promotion in Canada , pp. Evans, R. Why are Some People Healthy and Others not? New York: Aldine de Gruyter. Producing health, consuming health care. Fraser, D. The Evolution of the British Welfare State. London: Macmillan Press Ltd. Freire, P. Pedagogy of the Oppressed. Harmondsworth: Penguin. Godin, G. Has the individual vanished from Canadian health promotion?
Green, L. Health promotion. What is it? What will it become? Health Promotion International , 3 , —9. Greenhalgh, T. Storylines of research in diffusion of innovation: a meta-narrative approach to systematic review. Hamilton, N. Hartrick, G. Family nursing assessment: meeting the challenge of health promotion. Journal of Advanced Nursing , 20 , 85— Hawe, P. Theorising interventions as events in systems. American Journal of Community Psychology , 43 3—4 , — Held, D.
Global Transformations. Cambridge: Polity Press. Hills, M. Student experiences of nursing health promotion practice in hospital settings. Nursing Inquiry , 5 , — Detels, J. McEwen, R. Beaglehole, and H. Tanaka eds. The Oxford Textbook of Public Health 4th ed. IUHPE Brussels: European Commission. Jessop, R. The Future of the Capitalist State. Kemm, J. Health impact assessment and Health in All Policies.
Wismar, E. Ollila, E. Lahtinen, and K. Leppo eds. Health in all Policies: Prospects and Potentials , pp. Helsinki: Ministry of Social Affairs and Health. Kickbusch, I. Health promotion: a global perspective.
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Effectiveness of health education and health promotion: meta-analyses of effect studies and determinants of effectiveness. Patient Education and Counseling , 30 , 19— Kymlicka, W. Contemporary Political Philosophy: An Introduction. Community development and partnerships. Canadian Journal of Public Health , 84 , — Death of program, birth of metaphor: the development of health promotion in Canada.
Critical Public Health , 7 1 and 2 , 7— Promoting health in a globalized world: the biggest challenge of all? Lalonde, M. A New Perspective on the Health of Canadians. Ottawa: Health and Welfare Canada. Langille, D. The political determinants of health. Raphael ed. Social Determinants of Health: Canadian Perspectives , pp. Lawless, A. Health in All Policies: evaluating the South Australian approach to intersectoral action for health.
These were quickly followed by a state hygienic laboratory in Ann Arbor, Michigan, and a municipal public health laboratory in Providence. These laboratories concentrated on improving sanitation through detection and control of bacteria in water systems. Sedgwick, consulting biologist for Massachusetts, was one of the most famous scientists in sanitation and bacteriologic research. In he identified the presence of fecal bacteria in water as the cause of typhoid fever and developed the first sewage treatment techniques.
Sedgwick followed his research on typhoid with many similar investigations of epidemics. Laboratory research was also applied to diagnosis of disease in individuals.
Theobald Smith, director of the pathology laboratory in the federal Bureau of Animal Industry, earned an international reputation for his identification of the causes of several diseases in animals and the development of techniques to produce artificial immunity against them.
Later, as director of a state laboratory in Massachusetts, Smith developed vaccines, antitoxins, and diagnostic tests against such diseases as smallpox, meningitis, tuberculosis, and typhoid. He established the principle of using biological products to produce immunity to a specific disease in the individual and argued that research on the process of disease in the individual as well as the cause of disease in the environment was necessary to develop effective interventions.
Rosenkrantz, In New York, the city health department laboratory also promoted diagnosis of contagious diseases in individuals. New York was one of the first health departments to begin producing antitoxins for physicians' use, and the department offered free laboratory analyses.
Starr, Hermann Biggs, pathologist and later commissioner of the New York City Health Department, suggested the application of bacteriology to detecting and controlling cholera.
Park, another pathologist in the laboratory, introduced bacteriological diagnosis of diphtheria and production of diphtheria antitoxin. Some of the comments of the time reveal the enthusiasm with which the public health workers embraced the new scientific foundation for their efforts. Scientific measures were seen as replacing earlier social, sanitary, moral, and religious reform measures to combat disease. Science was seen as a more effective means of achieving the same desirable social goals.
Sedgwick declared, "before we knew nothing; after we knew it all; it was a glorious ten years. Chapin believed that time spent on cleaning cities was wasted, that instead health officers should concentrate on controlling specific routes of disease transmission. The new methods of disease control were remarkably effective.
For example, prior to 17 American cities had death rates from typhoid fever of 30 or more per , population; 18 had death rates between 15 and 30 per , After water filtering systems were put in place, only 3 of the same cities had rates exceeding 15 per , Winslow, In another example, the number of deaths from yellow fever in Havana dropped from to 6 in a single year after a team of American military scientists led by Walter Reed identified mosquitoes as carriers of the yellow fever virus.
As public health became a scientific enterprise, it also became the province of experts. Prevention and control of disease were no longer tasks of common sense and social compassion, but of knowledge and expertise. Health reforms were guided by engineers, chemists, biologists, and physicians. And the health department gained stature as a source of scientific knowledge in health.
It became clear that not only public and individual restraint were needed to control infectious disease, but also state agency epidemiologists and their laboratories were needed to direct the way. In the early twentieth century, the role of the state and local public health departments expanded greatly. Although disease control was based on bacteriology, it became increasingly clear that individual persons were more often the source of disease transmission than things. Massachusetts, Michigan, and New York City began producing and dispensing antitoxins in the s.
Several states established disease registries. In , Massachusetts passed a law requiring reporting of individual cases of 16 different diseases. Required reporting implied an obligation to treat. For example, reporting of cancer was later added to the list, and a cancer treatment program began in It also became clear that providing immunizations and treating infectious diseases did not solve all health problems.
Despite remarkable success in lowering death rates from typhoid, diphtheria, and other contagious diseases, considerable disability continued to exist in the population. There were still numerous diseases, such as tuberculosis, for which infectious agents were not clearly identified. Draft registration during World War I revealed that a substantial portion of the male population was either physically or mentally unfit for combat.
Fee, It also became clear that diseases, even those for which treatment was available, still predominantly affected the urban poor.
Registration and analysis of disease showed that the highest rates of morbidity still occurred among children and the poor. On the premise that a healthier society could be built through health care for individuals, health departments expanded into clinical care and health education.
In the early twentieth century, the New York and Baltimore health departments began offering home visits by public health nurses. New York established a campaign for education on tuberculosis. Winslow, School health clinics were set up in Boston in , New York in , Rhode Island in , and many other cities in subsequent years. Bremner, Numerous local health agencies set up clinics to deal with tuberculosis and infant mortality. By , there were more than tuberculosis clinics and baby clinics in America, predominantly run by city health departments.
These clinics concentrated on providing medical care and health education. Starr, As public agencies moved into clinical care and education, the orientation of public health shifted from disease prevention to promotion of overall health.
Epidemiology provided a scientific justification for health programs that had originated with social reforms. Public health once again became a task of promoting a healthy society. In the twentieth century, this goal was to be achieved through scientific analysis of disease, medical treatment of individuals, and education on healthy habits.
In , C. Winslow defined public health as the science of not only preventing contagious disease, but also of "prolonging life, and promoting physical health and efficiency. Federal activities in public health also expanded during the late nineteenth century and the early twentieth century. In , Congress passed the Food and Drug Act, which initiated controls on the manufacture, labeling, and sale of food. In , the Marine Hospital Service was renamed the U.
Public Health Service, and its director, the surgeon general, was granted more authority. Although early Public Health Service activities were modest, by they included administering physical and mental examinations of aliens, demonstration projects in rural health, and control and prevention of venereal diseases.
Interdepartmental Social Hygiene Board, a comprehensive venereal disease control program for the military, and provided funds for quarantine of infected civilians.
Brandt, Federal activities also grew to include promoting programs for individual health and providing assistance to states for campaigns against specific health problems.
The Children's Bureau was formed in , and the first White House Conference on child health was held in Hanlon and Pickett, The Sheppard-Towner Act of established the Federal Board of Maternity and Infant Hygiene, provided administrative funds to the Children's Bureau, and provided funds to states to establish programs in maternal and child health.
This act was the first to establish direct federal funding of personal health services. In order to receive federal funds, states were required to develop a plan for providing nursing, home care, health education, and obstetric care to mothers in the state; to designate a state agency to administer the program; and to report on operations and expenditures of the program to the federal board.
The Sheppard-Towner Act was the impetus for the federal practice of setting guidelines for public health programs and providing funding to states to implement programs meeting the guidelines. Although federally initiated, the programs were fully staterun. Bremner, As the federal bureaucracy in health grew and programs requiring federal-state partnerships for health programs were developed, the need for expertise and leaders in public health increased at both the federal and state level.
From the s through the s, local, state, and federal responsibilities in health continued to increase. The federal role in health also became more prominent.
A strong federal government and a strong government role in ensuring social welfare were publicly supported social values of this era. From Roosevelt's New Deal in the s through Johnson's Great Society of the s, a federal role in services affecting the health and welfare of individual citizens became well established.
The federal government and state and local health agencies took on greater roles in providing and planning health services, in health promotion and health education, and in financing health services.
The agencies also continued and increased activities in environmental sanitation, epidemiology, and health statistics. Federal programs in disease control, research, and epidemiology expanded throughout the mid-twentieth century. In , the Institute greatly expanded its research functions to include the study and investigation of all diseases and related conditions and the National Cancer Institute was established as the first of the research institutes focused on particular diseases or health problems.
In , Congress passed a second venereal disease control act, which provided federal funds to states for investigation and control of venereal diseases. In , the Federal Security Agency, housing the Public Health Service and national programs in education and welfare, was established. The Public Health Service also continued to expand. Federal programs supporting individual health services and state programs also continued to grow, both in number of health problems and types of citizens addressed.
The Social Security Act was passed in One title of the act established a federal grant-in-aid program to the states for establishing and maintaining public health services and for training public health personnel. Another title increased the responsibilities of the Children's Bureau in maternal and child health and capabilities of state maternal and child health programs.
This institute was also authorized to finance training programs for mental health professionals and to finance development of community mental health services in local areas, as well as to conduct and support research. The Medicare and Medicaid programs, titles 18 and 19 of the Social Security Act, were passed in These programs enabled federal payment for health services to the elderly and federal-state programs for payment for health services to the poor. Hanlon and Pickett, The Partnership in Health Act of established a "block grant" approach for a variety of programs, providing federal funding of state and county activities in general health, tuberculosis control, dental health, home health, and mental health, among others.
The block grant was used by the federal government as incentive to states and counties for further development of their health services.
Omenn, The Comprehensive Health Planning Act, passed in , established a nationwide system of health planning agencies and allowed development of community health centers across the country. Expansion of state activities in health paralleled the growth in federal activities.
Many of the changes on the federal level stimulated or supported state programs. States expanded their activities in health to accommodate Medicaid, health promotion and education, and health planning, as well as many other federally sponsored programs. Medicare and Medicaid in particular had a tremendous impact at the state level. To participate in Medicaid, states had to designate a single state agency to direct the program, setting up a dichotomy between public health services and Medicaid services.
Also, most states experienced a sudden growth in programs and program costs with the advent of Medicare and Medicaid. For example, federal funding for the institutionalized mentally ill became available for the first time through Medicaid, allowing expansion of these services and their costs in many states. Some federal programs of the s also inspired growth of health services in local health departments and in private health organizations.
Maternal and child health, family planning, immunization, venereal disease control, and tuberculosis control offered financial and technical assistance to local health departments to provide these services. Other federal programs developed at this time allowed funds and technical assistance to be provided directly to private health care providers, bypassing state and local government authorities. The Comprehensive Health Planning Act was an example of this trend. It allowed federal funding of neighborhood or community health centers, which were governed by boards composed of a consumer majority and related directly to the federal government for policy and program direction and finances.
The National Health Service Corps Program, in which the federal government directly assigned physicians to provide medical care to citizens in underserved areas, is another example of unilateral federal action for health care. By the s, the financial impact of the expansion in public health activities of the s through the s, including new public roles in the financing of medical care, began to be apparent.
During the same period, the public sector share of this sum rose from 25 percent to 37 percent. Anderson, The social values of earlier decades came under criticism. Containing health costs became a national objective. The Health Maintenance Act of , promoting health maintenance organizations as a less costly means of health care, and the National Health Planning and Resources Development Act of , setting up a certification system for new health services, are examples of this effort.
In the current decade, efforts toward cost containment continue. Although health needs and health services have not diminished, political and social values of the time encourage fiscal constraint. Current values also emphasize state responsibility for most health and welfare programs. Block grants were implemented in , consolidating the federal grants-in-aid to the states into four major groups and cutting back the amount of grant money some of the cuts were restored in Medicaid was altered to give greater leeway to the states in the design and implementation of the program, although the federal share of Medicaid financing was not changed.
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