CAPACITY BUILDING |
Integrated health promotion strategies: a contribution to tackling current and future health challenges
1 Centre for Health Promotion, University of Toronto, Canada 2 Street Health Community Nursing Foundation, Toronto, Canada 3 Health Issues Centre, Adelaide, Australia 4 Thai Health Promotion Foundation, Bangkok, Thailand
Address for correspondence: Suzanne F. Jackson, Ph.D. Director Centre for Health Promotion, University of Toronto, 155 College St. Suite 400 Toronto, Ontario M5T 3M7, Canada. E-mail: suzanne.jackson{at}utoronto.ca
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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This paper was presented as a technical background paper at the WHO sixth Global Conference on Health Promotion in Bangkok Thailand, August 2005. It describes what we know about the effectiveness of four of the Ottawa Charter health promotion strategies from eight reviews that have been conducted since 1999. The six lessons are that (i) the investment in building healthy public policy is a key strategy; (ii) supportive environments need to be created at the individual, social and structural levels; (iii) the effectiveness of strengthening community action is unclear and more research and evidence is required; (iv) personal skills development must be combined with other strategies to be effective; (v) interventions employing multiple strategies and actions at multiple levels are most effective; (vi) certain actions are central to effectiveness, such as intersectoral action and interorganizational partnerships at all levels, community engagement and participation in planning and decision-making, creating healthy settings (particularly focusing on schools, communities, workplaces and municipalities), political commitment, funding and infrastructure and awareness of the socio-environmental context. In addition, four case studies at the international, national, regional and local levels are described as illustrations of combinations of the key points described earlier. The paper concludes that the four Ottawa Charter strategies have been effective in addressing many of the issues faced in the late 20th century and that these strategies have relevance for the 21st century if they are integrated with one another and with the other actions described in this paper.
Key words: integrated health promotion; multiple strategies; Ottawa Charter; effectiveness
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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This paper describes what we know about the effectiveness of health promotion strategies and makes suggestions for the emphasis that is required as we move into the 21st century. The strategies are four of the five key health promotion action areas identified in the Ottawa Charter—building healthy public policy, strengthening community action, developing personal skills and creating supportive environments. Re-orienting health services is a very important strategy that has not been addressed consistently over the last 20 years. However, it was not addressed here because it was addressed independently by another background paper presented at the WHO sixth Global Conference on Health Promotion.
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EFFECTIVENESS OF HEALTH PROMOTION INTERVENTIONS, STRATEGIES AND ACTIONS |
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TOPSUMMARYINTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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In this section, we outline some of the key findings of eight reviews written in the last 6 years, which have assessed the effectiveness and cost-effectiveness of health promotion interventions. There is a significantly larger body of published evidence assessing the effectiveness and cost-effectiveness of chronic disease and particularly non-communicable diseases and their risk factors. We chose this selection of reviews because together they reflected health promotion interventions addressing chronic disease (i.e. mental health and injury), other health issues (i.e. HIV/AIDS and maternal and child health) and various social determinants of health (i.e. poverty, food security and nutrition).
The eight reviews consulted for this paper are described briefly in Table 1. All reviews used established criteria for ascertaining quality of the studies reviewed. Although several of these reviews aimed to be international in focus, or to focus on specific regions of the world other than North America and Europe, the majority of the reviews outlined in Table 1 relied solely or heavily on evidence of the effectiveness of health promotion interventions in North America and Europe. Many of the authors of these reviews noted that, although they attempted to find evidence from other parts of the world, little or no evidence, at least in English literature, was available.
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KEY LESSONS ABOUT THE EFFECTIVENESS OF HEALTH PROMOTION INTERVENTIONS, STRATEGIES AND ACTIONS |
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TOPSUMMARYINTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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The cited reviews of evidence for the effectiveness of health promotion interventions showed that interventions using a combination of health promotion strategies and actions are effective and cost-effective at preventing and addressing a wide variety of chronic diseases and their associated risk factors, as well as health determinants. One strategy in particular, ‘strengthening community action’, showed the need for more evidence of effectiveness. In Table 2, the strategies are grouped according to the level of action and linked to the key actions that are required for success based on this review.
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Six key lessons can be drawn from the common findings and conclusions of these reviews.
1. Investment in building healthy public policy is a key strategy
Reviews of health promotion interventions addressing several issues and determinants identified the creation of healthy public policy as a key strategy. Relevant actions include investment in government and social policy, the creation of legislation and regulations and intersectoral and interorganizational partnerships and collaboration. In some cases, reviews suggested that the creation of healthy public policy was the strategy for which the most evidence of effectiveness exists (e.g. legislation for road safety and social policy for income security and poverty reduction).
Ross' review of programmes aimed at alleviating poverty and improving the health of people experiencing poverty found that little research existed on the effectiveness and cost-effectiveness of programmes addressing poverty and health inequities. A major challenge for determining the effectiveness of programmes targeting poverty and health inequities is that many interrelated risk factors are involved, which poses difficulties for both the implementation and determining the effectiveness of interventions. Ross was, however, able to find some modest evidence regarding the effectiveness of government policies. The extent to which poverty is reduced at a country-wide level is directly related to how much is spent. In a study of 12 countries, poverty was reduced by 30% to 80%, depending on government spending levels. Because this did not take into account the inequitable distribution of benefits within certain subgroups, Ross also stated that creating broad policies requires attention to implementation strategies. Regardless, it is action at the healthy public policy level, specifically through government development and spending in social policy areas such as income security and employment, that can begin to be effective in reducing poverty (Ross, 2003
).
In Svanstrom's review of injury prevention and safety promotion interventions, it was found that in preventing road injuries, educational activities alone were not very effective. Legislation has been shown to be the most efficient way to prevent some injuries such as making bicycle helmets mandatory (Svanstrom, 1999).
Hoffman and Jackson's review found legislation and enforcement around tobacco use, advertising and sales, to be key parts of successful tobacco programmes, and taxation was shown to be the most cost-effective for reducing smoking (Hoffman and Jackson, 2003).
2. Supportive environments need to be created at all levels
Several reviews point to creating supportive conditions and environments as a strategy that is essential in order to ensure that other strategies are effective. This includes implementing a variety of actions that represent supportive conditions at the structural (policy), social (including community) and individual levels (Table 2).
Warren's review found that successful youth health promotion strategies addressing high-risk behaviours must address the social and economic conditions that lead youth to be at high risk. Key to the success of interventions was making behaviour change accessible, including the availability of instrumental supports such as condoms, and psychosocial and emotional supports such as counselling, peer counselling, outreach and life skills training. Effective interventions not only aimed to change behaviour among at-risk youth, but also addressed societal perceptions of youth by targeting a variety of stakeholders, including parents, professionals and community leaders (Warren, 1999).
Hosman and Jane Lopis' review found that mental health promotion interventions have improved maternal and child health and reduced pre-term delivery and low birth weights, as well as reducing teen pregnancy. Central to effective mental health promotion is the creation of positive individual, social and environmental conditions (Hosman and Jane Lopis, 1999). Ross' review of poverty-related interventions found that several programmes focusing on pre-natal nutrition were effective at reducing low birth weights. Key activities created supportive environments at a variety of levels by providing instrumental supports such as food vouchers or supplements, group support, nutritional education, counselling and home visits (Ross, 2003). That supportive environments are required for success for all three other health promotion strategies is illustrated in Table 2.
3. Effectiveness of community action is unclear and requires further evidence
The eight literature reviews included as part of the Hills et al. paper on ‘Effectiveness of Community Initiatives to Promote Health’ agreed that community interventions have had mixed results. Although their impact in terms of behaviour change has ranged from modest to disappointing, they have achieved success in terms of community and systems change (Hills et al., 2004).
In Svanstrom's review of injury prevention and safety promotion interventions, it was found that in preventing road injuries, educational activities alone were not very effective, but community programmes that involved local participation and policy and legislative change actions have been very effective (Svanstrom, 1999).
Garrard et al.'s review of health promotion interventions targeting cardiovascular disease and diabetes prevention identified that although specific large-scale programmes using multi-faceted community-based interventions were often effective, they generally failed to produce substantial change over improvements occurring in the general population (Garrard et al., 2004).
Before deciding that community action is not as effective as a health promotion strategy, it is necessary to remove other possible explanations, such as a lack of consistent definitions, appropriate indicators, evaluation protocols and qualitative systematic review criteria for assessing community interventions. This is an area that requires further investigation and is the target for intensive efforts in Latin America, Canada, Europe, and the Cochrane Collaboration, to name a few.
4. Personal skills development must be combined with other strategies for effectiveness
Many reviews of health promotion effectiveness showed that developing personal skills (including the actions of health education, health communications and training and skills development) was an ineffective strategy if implemented in isolation from other strategies, particularly with disadvantaged groups and communities of low socio-economic status. Central to the effectiveness of personal skills development is the need to also implement strategies that create structural-level conditions to support health and increase access to goods, products and services.
Hoffman and Jackson found that people of low socio-economic status are unlikely to participate in lifestyle interventions and are more likely to participate in initiatives that will lead to a noticeable improvement in their quality of life in the short term. For example, interventions aiming to improve indoor air quality in homes or to increase food access and quality are more likely to be effective with low-income groups. In addition, non-communicable disease interventions using a variety of diverse strategies and actions to address socio-environmental conditions were shown to be more cost-effective than those focusing solely on individual behaviours and lifestyles. For example, taxation was shown to be most cost-effective for reducing smoking, and increased access to better stoves or cleaner fuel was cost-effective to improve indoor air quality (Hoffman and Jackson, 2003).
Both Schuit et al.'s review of food and nutrition programmes in Europe and Hoffman and Jackson's review of food security interventions found evidence that food security and nutrition interventions that focus on the most disadvantaged groups are most effective, but that it is essential in these interventions that the life realities of people, including the barriers to accessing nutritious food, are considered and addressed. According to both reviews, food interventions are more likely to be effective when they produce tangible short-term benefits such as increasing access to food (through income generation or food access activities) or better-tasting food (Schuit et al., 1999; Hoffman and Jackson, 2003).
Warren's review of health promotion strategies addressing high-risk behaviours that put youth at risk for contracting HIV/AIDS and other health issues found that successful interventions address not only the health issues, but also the social and economic conditions that lead youth to be at high risk. Key to the success of interventions was the provision of motivations to change behaviour (including peer education, communications strategies, support and training) and making the products and services needed to achieve the behaviour change accessible (such as providing free access to condoms, counselling and clean needles) (Warren, 1999).
5. Interventions employing multiple strategies and actions at multiple levels and sectors are most effective
Reviews of health promotion interventions working on a wide range of health issues and health determinants conclude that the most effective interventions employ multiple health promotion strategies, operate at multiple levels (often including all of the structural, social group and personal levels), work in partnership across sectors and include a combination of integrated actions to support each strategy.
Reviews of interventions focused on non-communicable disease provide a strong case for employing multiple strategies and actions at multiple levels. Garrard et al.'s review of health promotion interventions targeting cardiovascular disease and diabetes prevention asserts that the most effective non-communicable disease prevention and health promotion approaches operate at all levels, involve the collaboration and partnership of organizations in multiple sectors and use multiple strategies (Garrard et al., 2004). Similarly, a key finding of Hoffman and Jackson's review was that effective and cost-effective interventions for primary prevention of non-communicable disease used a combination of health promotion strategies at various levels in multiple settings (Hoffman and Jackson, 2003).
Specifically, Hoffman and Jackson found that interventions that were shown to be effective at reducing tobacco use, increasing physical activity, preventing cardiovascular disease and increasing food security involved a combination of health promotion strategies occurring at the personal, community and structural levels. For example, comprehensive tobacco programmes in several states in the USA have led to significant decreases in smoking in the population. These effective combinations of strategies included developing healthy public policy, creating structural and social conditions to support health and developing personal skills. Key health promotion actions that were part of these strategies included policy development, legislation, taxation, increasing access to food, increasing opportunities for physical activity, health education, health communications, lifestyle and skill-building. These comprehensive approaches used multiple strategies at multiple levels and included actions such as legislation and enforcement around tobacco use and sales, media campaigns, supporting local public health agencies, community-based prevention programmes and school-based education for youth (Hoffman and Jackson, 2003).
Hosman and Jane Lopis found that effective mental health promotion interventions operate at the personal and social/group levels, involving multiple activities and addressing multiple life factors, to create positive individual, social and environmental conditions, thereby enabling people to enjoy positive mental health and enhanced quality of life (Hosman and Jane Lopis, 1999).
6. Certain actions are required for effectiveness for all four Ottawa Charter strategies
Key health promotion actions were identified in several reviews as being central to the effectiveness of interventions. These critical actions are represented as cross-cutting actions in Table 2: actions that need to occur at the structural, social and personal levels and that need to be implemented in conjunction with all of the major health promotion strategies of the Ottawa Charter. These actions include the following.
- Intersectoral collaboration and interorganizational partnerships at all levels:
For example, in Svanstrom's review of injury prevention interventions, it was found that the most effective programmes involved multiple sectors and organizations, including various government departments and non-governmental organizations (NGOs) and groups, as well as local stakeholders (Svanstrom, 1999). See also the case examples described later in this paper.
- Community participation and engagement in planning and decision-making:
For example, Warren found that in order for youth health promotion strategies addressing high-risk behaviours to be effective and relevant, interventions need to engage at-risk youth to participate in the development and delivery of interventions and need to target a variety of stakeholders, including parents, professionals and community leaders (Warren, 1999). The engagement of youth and community leaders as part of the decision-making process was listed as a critical factor in the success of the ‘Youth for Health’ project in Ukraine (Canadian Society for International Health, 2004).
- Creating healthy settings, particularly focusing on the settings of schools, workplaces and cities and communities/municipalities:
For example, Hoffman and Jackson found schools, workplaces and municipalities to be effective settings for many interventions addressing non-communicable diseases and their risk factors, because they provide opportunities to effectively reach large numbers of people with sustained interventions. Schools can reach many children directly at a critical time in their lives, whereas workplaces can reach adults on a daily basis over a long period of time and have been shown to be cost-effective settings for interventions for both employers and employees. Municipalities offer great potential to effectively address a variety of health issues and determinants on the basis of the municipal governments' responsibility for key areas that affect people's lives, including urban planning, recreation, transportation and aspects of health. The healthy cities and communities movement offers examples and important lessons on how municipalities can address multiple health determinants, risk factors and health issues through a settings' approach (Hoffman and Jackson, 2003). A key component of the settings' approach is the formation of collaborations, partnerships and coalitions.
- Political commitment, funding and infrastructure for social policies:
For example, Ross' review finds that government development and spending in social policy areas, such as income security, play a role in reducing poverty (Ross, 2003). Government commitment to engage citizens and change policies to promote health in Bogota was a key to its success (Caballero, 2004; Edmundo, 2004; Silva, 2004).
- Awareness of the socio-environmental context is essential:
Most reviews used for this paper stressed that health promotion interventions are only effective when they are relevant to the context in which they are being used. This includes awareness of the social, cultural, economic and political context; the capacity and development of infrastructures and systems in key sectors such as health, education and government and the life realities of particular target populations or communities. Contextual differences are particularly important to consider in developing countries, as the majority of the reviews discussed earlier relied solely or heavily on evidence of the effectiveness of health promotion interventions in North America and Europe. Many reviews stressed that the goals, strategies and actions of any intervention be relevant and appropriate to the people they aimed to reach and the systems they aimed to work within. In addition, reviews pointed to the active participation and engagement of community members in planning and decision-making as a key health promotion action that could help to ensure that an intervention was appropriate to its context.
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CASE EXAMPLES OF CURRENT INITIATIVES |
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TOPSUMMARYINTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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To further illustrate the power of integrating several health promotion strategies at the structural, social and personal levels, some case studies were drawn from different parts of the world and focus on different topics or audiences. These particular cases were selected because evaluation information was available or because the process and outcomes were well documented. Key to the success in all case studies was partnership development. They are described very briefly below and each case demonstrates the effectiveness of partnerships at a different level—international, national, regional and local.
International level case example: WHO framework convention on tobacco control
The framework convention on tobacco control (FCTC) is the WHO's first convention and came into effect on 27 February, 2005. As of that date, 168 countries have signed the convention and it has been ratified by the national governments of more than 50 countries. The lengthy 12-year process to develop the FCTC required a partnership between WHO, UN bodies, governments, NGOs and academia. The country negotiating teams were examples of intersectoral collaboration by including members from a wide range of government departments, such as health, tax, finance, economics and trade, development and planning, foreign affairs, treaties and law, commerce, customs and sometimes the tobacco companies. The convention includes a range of policy measures such as legislation requiring health warnings on cigarette packets, creation of smoke-free areas, bans on tobacco advertising and promotion, provision of cessation services, increased tobacco taxes and a crackdown on smuggling. The process of developing the FCTC has had several advantages—governments were encouraged to take action ahead of the finalization of the convention, health ministries became more politically mature and awareness was raised among other government ministries (World Health Organization, 2003).
National level case example: the Canadian tobacco control strategy
The Canadian tobacco control strategy continues to involve preventing the uptake of smoking, facilitating smoking cessation among smokers and protecting the public from second-hand smoke. Key health promotion actions that continue to be part of this comprehensive programme include coalition-building; national policies to ban tobacco advertising on television and sponsorship of sports and arts events; legislation and enforcement around where tobacco can be sold, as well as its use and sales to minors; taxation and increasing the price of tobacco products; media anti-smoking and second-hand smoke campaigns; school-based education for youth; providing free access to cessation information, support and counselling as well as subsidizing nicotine replacement therapies in some areas and local municipal by-laws banning smoking in public places and workplaces. Such comprehensive tobacco programmes have shown that they are effective, as have specific aspects of these initiatives such as increasing tobacco prices through taxation (Health Canada, 2002).
Regional level case example: youth for health in Ukraine project
In 1998, the Youth for Health Ukraine–Canada project was launched, funded by the Canadian International Development Agency and managed by the Canadian Society for International Health. The initiative aimed to address the large and increasing percentage of youth in Ukraine, demonstrating at-risk behaviours by empowering youth, promoting healthier living and behaviours and emphasizing gender equity and youth involvement. The Ukrainian Institute for Social Research as the lead organization built partnerships with ministries of health, education and family and youth, another research institute, the Kyiv City Government and a youth NGO. When they adapted their project model in the regions, the institute worked mainly with different levels of government and youth NGOs. The mutual collaboration of all partners has been key to the success of the project model. The project's activities have included intersectoral partnerships; the development and implementation of an integrated health education curriculum in schools; developing a training programme for service providers who can promote youth health; involving youth and practitioners in designing educational materials, resources and programmes to promote healthy youth behaviour and evaluation of the strategies and research on youth behaviour, existing law and policy on youth health and media influence on youth. The work of the project has led to strong public and political support at the national level for a national health promotion policy and improvements in the quantity and quality of youth health promotion policies and programmes at national, regional and local levels (Canadian Society for International Health, 2004).
Municipal level case example: reforming Bogota, Colombia
To improve citizens' health and well-being and reduce rising crime rates, the Mayor of Bogota, Colombia, Dr Antonus Mockus, in 1995 initiated actions that required the involvement of all government departments and active citizen engagement. To make citizens feel safe, lighting in public places was enhanced, traffic in the centre of the city was reduced, ‘safe women only’ nights were organized and police officers were retrained in appropriate law enforcement practices. To reduce traffic, the cost of parking was increased, car free days were encouraged and a new public transport system was built. Other reforms included modifying hours of operation for bars and entertainment places and improvements to city water and sewerage services. In order to promote a culture of treating one another with respect, artists and street performers were involved, and positive behaviour by citizens was publicly rewarded and promoted (e.g. good taxi drivers were identified by citizens). Intersectoral collaboration under the leadership of the mayor was an important component. As a result of these actions and reforms, Bogota saw a reduction in homicide rates from 80 per 100 000 inhabitants in 1993 to 22 per 100 000 in 2003. Traffic fatalities dropped from an average of 1300 a year to 600. The cities' water consumption dropped, public transportation usage increased and driver behaviour improved (Caballero, 2004; Diaz, 2004; Silva, 2004).
Local level case example: mobilizing men as volunteers in Southern Africa AIDS trust
The Southern Africa AIDS trust began as an initiative of the Canadian Public Health Association and the Canadian International Development Agency. It is now an NGO that aims to increase the HIV competence of communities through supporting community agencies. For example, Word Alive Ministries International is a church-based community organization in Malawi which found that as their home-based care for people with HIV/AIDS and TB developed, 40% of their home care clients were men but all their HBC volunteers were women and cultural barriers limited the ability of female volunteers to meet the needs of male clients. To address this, they had to use a combination of strategies that included breaking down myths and stigma about care work and HIV/AIDS for men by showing local men in action, involving community leaders to identify potential male volunteers and providing training, support and supervision to counteract gender stereotypes. Some of the preliminary additional benefits from this mobilization of male volunteers were that it reduced unhelpful gender stereotypes, increased the acceptance of condoms among men and decreased the stigma associated with volunteer care work for men (SAT Southern African AIDS Trust, 2002–2003).
In summary, these case studies are not in-depth analyses but brief illustrations of how multiple intersectoral strategies, especially including partnership building operating at the individual, community and structural levels, are critical for success.
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DISCUSSION AND CONCLUSIONS |
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TOPSUMMARYINTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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The evidence for the effectiveness of the four health promotion strategies from the Ottawa Charter is mixed. No strategy stands on its own as a clear success—they all need to act in conjunction with each other and certain supporting actions in order to be effective. The strongest evidence for effectiveness for one strategy is linked to building healthy public policies. Structural level change results in measurable change within the time frames of the studies reviewed. At the other end of the spectrum, strengthening community action has mixed evidence of success. As stated earlier, more research and evaluation is needed in relation to this strategy.
Although ‘creating supportive environments’ is a major strategy in the Ottawa Charter, attention needs to be given to the fact that it is actually three strategies at three different levels (Table 2). Its importance receives more emphasis if it is explicitly discussed in conjunction with each of the three other Ottawa Charter strategies, particularly at the structural level. It is also clear from the reviews that developing personal skills could not stand on its own to be effective and requires additional strategies, particularly in creating supportive environments and policy development.
Some of the strategies that are weakly referred to in the Ottawa Charter should be given more prominence given the evidence of their effectiveness. They exist as cross-cutting actions that are required at all levels of health promotion (Table 2), specifically:
- interorganizational partnership building and intersectoral collaboration at all levels;
- participation and engagement of all people in decisions that affect their lives;
- healthy settings as places where comprehensive strategies that involve multiple actions and partnerships that occur at multiple levels;
- political commitment, funding and infrastructure for a broad range of social policy and health promotion actions;
- multiple strategies in multiple settings at all three levels (structural, social and personal) and involving several sectors are required for success;
- all strategies require attention to the socio-environmental context.
The four health promotion strategies from the Ottawa Charter addressed in this paper have been effective tools to address many of the issues we faced in the 20th century when used in combination (e.g. addressing and preventing chronic and communicable diseases and addressing lifestyle determinants). It should be noted that the reviews used in this paper focused largely on evidence published in English, although most of the case examples originated in non-Western countries. This potential cultural bias in the effectiveness of health promotion strategies hopefully will be addressed in the future as more evaluation and research emerges, for example, through the global project on health promotion effectiveness sponsored by the International Union of Health Promotion and Education where each region of the world is gathering evidence of effectiveness with a progress report due in 2007. In addition, with respect to the lack of information about the effectiveness of community actions, the Public Health and Health Promotion field of the Cochrane Collaboration has identified community-building interventions as its first priority topic for review (Cochrane Collaboration, 2005).
The world is much more interconnected at a global level than it was in 1986 when the Ottawa Charter was created, and the emerging issues of today are different than those that we faced in the past. However, on the basis of the past success of health promotion strategies in addressing social determinants and health issues, the multi-level and multi-faceted nature of these strategies and the attention to social context, it is possible that health promotion strategies have a great potential to address the emerging health issues of the 21st century. These four health promotion strategies from the Ottawa Charter are potentially still relevant and important in addressing the emerging health challenges of the 21st century, especially when they are strengthened and integrated with other actions, such as partnerships, community engagement in decisions, attention to socio-environmental context, political commitment and use of multiple strategies in many settings, levels and sectors.
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REFERENCES |
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TOPSUMMARYINTRODUCTIONEFFECTIVENESS OF HEALTH...KEY LESSONS ABOUT THE...CASE EXAMPLES OF CURRENT...DISCUSSION AND CONCLUSIONSREFERENCES |
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Caballero M. C. (2004) Academic turns city into a social experiment: mayor Mockus of Bogotá and his spectacularly applied theory. Harvard Gazette(Harvard University, Harvard) 11 March, 2004.
Canadian Society for International Health. (2004) Youth for Health Phase 2 Ukraine Project—Second Semi-annual Narrative Report (October 2003–March 2004). (CSIH, Ottawa).
Cochrane Collaboration. (2005) Cochrane Health Promotion and Public Health Field: Priority Review Topics. http://www.vichealth.vic.gov.au/cochrane/activities/priorities.htm.
Diaz O. E. (2004) Car free Bogotá: the response to the transportation challenge. The New Colonist http://www.newcolonist.com/bogota.html.
Health Canada. (2002) The Federal Tobacco Control Strategy (FTCS) A Framework for Action (Government of Canada, Ottawa).
Garrard J., Lewis B., Keleher H., Tunny N., Burke L., Harper S., et al. (2004) Planning for Healthy Communities: Reducing the Risk of Cardiovascular Disease and Type 2 Diabetes Through Healthier Environments and Lifestyles. (Department of Human Services, Victorian Government, Melbourne).
Hills M., O'Neill M., Carroll S., MacDonald M. (2004) Canadian Consortium for Health Promotion Research (CCHPR), Effectiveness of Community Initiatives to Promote Health. An Assessment Tool. Final Report to Health Canada.
Hoffman K. and Jackson S. (2003) A review of the evidence for the effectiveness and costs of interventions preventing the burden of non-communicable diseases: how can health systems respond? Unpublished: Prepared for World Bank Latin America and the Caribbean Regional Office.
Hosman C. and Jane Lopis E. (1999) The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe. Chapter 3 Political Challenges 2: Mental Health. A Report for the European Commission by the International Union for Health Promotion and Education.
Ross D. P. (2003) Policy Approaches to Address the Impact of Poverty on Health—A Scan of Policy Literature. (Canadian Institute for Health Information (CIHI), Ottawa) Canadian Population Health Initiative (CPHI).
SAT Southern African AIDS Trust. (2002–2003) Community Response 1, Mobilising Men as Home-Based Care Volunteers , Harare.
Schuit J, Seidell J, Jansen J., Burns C. (1999) The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe. Chapter 7 Social Challenges 1: Nutrition. A Report for the European Commission by the International Union for Health Promotion and Education.
Silva J. (2004) My 2003 discovery—a leader, a team and an effective multiple interventions program in Bogotá, Columbia. International Union of Health Promotion and Education Electronic Journal http://www.rhpeo.org/reviews/2004/20/index.htm.
Svanstrom L. (1999) The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe. Chapter 8 Social Challenges 2: Safety. A Report for the European Commission by the International Union for Health Promotion and Education.
Warren M. (1999) The Evidence of Health Promotion Effectiveness: Shaping Public Health in a New Europe. Chapter 4 Political Challenges 3: Out-of-School Youth. A Report for the European Commission by the International Union for Health Promotion and Education.
World Health Organization. ((2003)) Framework Convention on Tobacco Control (WHO Press, Geneva.).
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