Week 6

Health Promotion
What is health promotion?
• The process of enabling individuals and communities to increase
control over the determinants of health and thereby their health
• Health field concept (Lalonde 1974)- human biology, environment
(physical and social), lifestyle, and health care.
• Realization that advances in health care and medicine could not
improve the public’s health in the absence of changes in
environmental factors
• Initially, the greatest opportunity to influence people’s health was seen
to be in the area of lifestyle and behaviour
• Ottawa Charter for Health Promotion 1986
• Principles:
• Build healthy public policy
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Reorient health services
• Like Health Studies, Health Promotion is an interdisciplinary field that
emphasizes multiple levels of factors that influence health.
Public Health and Health Promotion
• 1800s Sanitary phase (clean water, sewerage, OHS) social
infrastructure
• Early 1900 Personal hygiene – cleanliness, health habits, shift to
personal responsibility, health education
• Mid 1900s Therapeutic – prevention of disease using medical
intervention – vaccination, family planning, antibiotics, medical care
• Late 1970s Health promotion –Brings together individual and
population health, healthy public policy. Shifts from battling disease
to creating health.
Public Health/Epidemiology Health Promotion
• Focused on more proximal factors • More focused on distal “upstream”
with a stronger causal relationship factors -- “Determinants” (eg poverty)
to health problem (eg smoking) rather than risk factors or causes
• Emphasizes prevention of • More focused on positive health and
disease/injury capabilities for a healthy life
(salutogenic)
• Relies more on “experts”,
• More empowering and less “top down”
biomedical model of health care
relationships • Focused on health in all policies (not just
health policy) (eg changes to food
• Pursues targeted public health allowances from social assistance)
measures (eg restrictions on • More open to qualitative, participatory
smoking areas) methods
• Laboratory & statistical science
• Medical/prevention model - prevention of disease/illness with a
focus on health system interventions and compliance with medical
advice
• Educational model - prevent disease and improve health by
informing or educating people about healthy lifestyles and as
rational human beings they will respond accordingly
• Social (critical) model - health is determined by the social/cultural
and physical environment, so solutions are at the community and
society level, and political policies and programs should protect
people from factors that are not in their control
• Public health associated with Public
health
Health
promotion
prevention from within the health
system (nutritional supplementation, education
post natal care, oral and dental
hygiene, immunization)
biomedical
• Health promotion tends to take place prevention Social/
in the community and involves policy
intersectoral action (education,
community kitchen, social supports)
• Lots of overlap – use all 3 models
Health education
• WHO: learning experiences that help people improve their health, by
increasing their knowledge or influencing their attitudes
• Traditional educational approaches – give information and assume
people will change their behaviour
• Assumes free choice (not constrained by other factors)
• Assumes people have autonomy and control over their lives
• May emphasize the characteristics
of the sender and be more
persuasive or even coercive
• Assume people respond to
expert/authority
Objectives of health promotion
Planned change in health-related lifestyles and life conditions through a
variety of individual and environmental strategies (O-Neill & Stirling,
2007).
• Education, social marketing/communications
• Planned change in skills and competencies (health literacy)
• Action on social determinants of health
• Community organization
• Political action
• Focus on settings, issues, or policies
Health communication
• Makes use of communications theories
• Mass media campaigns, education and influencing strategies in
schools or community groups
• Recognizes that a person’s response to health messages is mediated
by norms and social group influences
• 'symbolic' meaning (language); 'iconic’ (picture or imagery)
• Concerns not just who is sending the message, but who is receiving it.
'enactive’ - active involvement of the audience
Behaviour change approaches
• Make use of health psychology theories
• Encourage people to analyze their attitudes and beliefs and adopt
changes to behaviour - aimed at individual, group or society level
• Behaviour change models:
• Health beliefs model
• Theory of planned behaviour
• Stages of change
• Social cognitive theory, etc
• To be effective narrow down audience, tailor message, involve people
from the target group, give a specific action
Why don’t people change?
• Motivation: Don’t contemplate
change because are not worried
about risk
• Behaviour is rewarding
• Don’t feel control over changing
behaviour (problem is too big,
sometimes addiction)
• Feedback from networks/social
groups
• Are not opportunities in the
environment
Social models
• To get behavioural outcomes, also need:
• availability of required services and products
• availability of community-based programmes
• policies that support behaviour change
• Empowerment approaches – work with people on getting more
control over factors and events that influence their lives
• Individual – capacity, skills, coping
• Community – identify and address community development needs
• Policy initiatives
• Social activism
Empowerment
• Key concept of health promotion
• Psychological empowerment: a sense of power and control over one’s
own life is associated with ability to change health behaviour
• Community empowerment: participation in collective action to
change some distribution of resources or influence decision-making
favourable to the community (also creates psychological
empowerment) – political action and policy objectives
• Organizational empowerment: in between individual and political
action – ability and resources to improve quality of life
Power in health promotion
• On a scale, efforts to change people’s behaviour can be authoritarian
(top down approach) or negotiated with/proposed by the affected
people or community (bottom up approach)
• Health promotion can also intervene in different settings, from the
individual (person or family) to the collective (institution,
neighbourhood, nation)
 Authoritarian

Health education/ Legislation

public health programs

Individual Collective

Personal support Community

Development

Negotiated

Health promotion tends to favour bottom up versus top down (or a

combination) and strengthening agency rather than only changing structure.
 Social change model
• Health education to raise critical consciousness of issues
• Explicit outcome of education should be social and policy action

Critical Get on policy Public pressure,

consciousness agenda coalitions, lobbying

Improved
Health Individual Healthy Public
education empowerment HEALTH conditions of
life & work Policy

More appropriate
health services

Adapted from Tones and Tilford, 1994

Principles of Health Promotion
• Build healthy public policy
• Create supportive environments
• Strengthen community action
• Develop personal skills
• Reorient health services
Dahlgren and Whitehead, 1991
Policy rainbow
• Dahlgren and Whitehead (1991) 'Policy Rainbow’ describes the
layers of influence on an individual's potential for health
• Non modifiable factors in the middle, Potentially modifiable factors
expressed as a series of layers
• Includes lifestyle, conditions of living and working, and wider socio-
economic, cultural and environment conditions (social ecological)
• Needs complementary actions to influence linked factors
• Intersectional: Disadvantages often affect the same people, and
their effect is cumulative
World Health Organization
Ecological Perspective on Health Promotion : Systems, Settings and Social Processes
Take-aways
• Health promotion addresses health behaviour – but tries to avoid a “victim
blaming” approach that places more emphasis on individual action. Health
promotion also seeks to change the social and economic context that
influences and constrains behaviour
• Focus on determinants or upstream causes of disease
• Seek co-operation between sectors, as well as government responsibility,
and acknowledge how non-health policies and structures affect health
• Combine methods or approaches including individual communication and
education, legislation, social programs, community development, etc
• Prioritize community participation and empowerment
Research assignment
• Part 1 – Outline
• Part 2 – Research Report
• Part 3 – Poster and Peer Assessment
PART 1: OUTLINE (10%)
• Read all the instructions for assignment #2
• Select a topic and study population, and start doing your research
• Based on your initial research, complete the template for Assignment
#2 – Part 1: Outline
• Print out the template and fill it in by hand
• Hand it in during class October 24, 29 or 31
PART 2: RESEARCH REPORT (30%)
• Intro: Select your topic and identify a segment of the population for study.
Describe the characteristics of the population and how seriously it is affected by
this problem (250 – 500 words)
• Body: Describe the main individual, social and eco-system factors that influence
the issue in this population. Use several appropriate and current research
materials (with proper referencing) to help you identify and explain determinants
(about 1000 - 1200 words)
• Recommendations: Describe 2 actions at different levels that might improve
outcomes for the population, and explain where the proposed actions would
intervene and how they work (250 – 500 words)
• Reflection: Summarize your analysis, and reflect on your preferred solution with
reference to course concepts (250 words).
PART 3: POSTER AND PEER ASSESSMENT (10%)
1. Create your poster using the template provided
2. Capture an image of your poster (or attach a file) and upload it in the Poster
Presentations Peer Assessment activity in Week 11 – deadline November 22.
3. Review 3 posters that are assigned to you – deadline November 29.
• Start out with an observation about a Host factors
problem
• Describe the problem
• Describe the population you want to
study. Why is it relevant to study them?
Environment
• Collect information about the causes of factors
Agent factors

the problem for this population using a

multilevel analysis – direct/proximal
causes as well as indirect/distal causes
• Analyze some actions
• Summarize your analysis and describe
your preferred intervention
Determinant analysis approach
• Consider proximal and distal
influences on health problems
(not just the obvious)
• Look outside your own
disciplinary perspective
• Identify intervention points
based on analysis
• Think about what other
disciplines or sectors should be
involved in your action/research
Micro analysis
• Personal behaviour and lifestyle
• Health beliefs (protective like self-esteem, motivation, coping skills, or
damaging like denial, external locus of control)
• Individual-level social networks (positive or negative)
• Home/Family
• Friends, peers
• School, work
Meso analysis
• Material conditions and access to resources
• Food, water, housing
• Education
• Employment
• Access to health services
• Exposure to environmental stressors
• Characteristics of neighbourhood or environment (built, social,
physical)
Macro analysis
• Broader social and cultural norms
• Government programs – provide, protect, maintain order &
economic stability
• Human rights
• Social equity and inclusion
• Policy environment: support for economic, family, education,
social services, justice
• Environment
Practice 1: COVID in New York
In the COVID-19 pandemic, New York City (NYC) had among the highest infection
rates worldwide. Data from the New York City Department of Health and Mental
Hygiene (NYCDOHMH) showed higher rates of COVID-19 deaths among Latinos and
Blacks in comparison to Whites and Asians who reside in the City’s five boroughs.
Even though 76% of Queens’ residents self-reported their physical and mental
health to be ‘very good’ or ‘excellent’, and only 14% reported to be smokers, 7
underlying medical chronic conditions continued to be an issue. However, these
diseases alone did not explain the disproportionately higher levels of infections and
deaths observed in certain neighborhoods. The purpose of this study is to provide a
descriptive analysis of communities severely impacted by COVID-19, compared to
less-affected communities, with an emphasis on the social determinant factors.
Harlem, G., & Lynn, M. (2020). Descriptive analysis of social determinant factors in urban communities affected by COVID-
19. Journal of Public Health.
COVID in New York: Research and Analysis
• Individual
• comorbidities
• Micro
• Large families, higher rates of obesity, less health-seeking behaviour,
environmental stress (leading to comorbid conditions)
• Meso
• Crowded housing conditions, low education, poverty, more un-insured
• Macro
• Racism, structure of health services
COVID in New York: Recommendations
• More emphasis should be placed on their social distancing behaviors
in homes (education)
• Community programs to assess needs for basic resources such as
food, medication, personal protective equipment and other essential
supplies needed to socially distance during a pandemic
• More focus on the underlying factors that put people at risk (racism,
discrimination in health care system, health insurance)
Research and Analysis
• Biological (non-modifiable)
• Micro (individual)
• Meso (community – includes
conditions of life and work)
• Macro (economic, social,
cultural, environmental
conditions)
• Recommendations
Connect to course material
Case Analysis Q and A
• If you still have questions or you want more
information, please post your questions in the class
forum, so everyone can benefit
Week 6
Geography
Health Geography Host factors

• Disease Ecology (role of environment in

life cycle of pathogens and people’s
exposure to them)
• Transition to study of complex ways that
Environment Agent
spatial context influences biological and factors factors
social factors that pattern disease
• Like epidemiology, looks at health-
related patterns in data – but organized
spatially
• Where? Why there?
“Place” in Social Epidemiology
• A place is more than just a collection of individuals in space. A place
(town, province, school, area, etc) reflects power and decision-
making and exerts independent influence over people’s health
• Pay attention to features of places that might influence health
outcomes, and the mechanisms by which they do so
• Quantitative and qualitative methods
• Identifies place/environmental level as a potential area for health
intervention
Geographic methods
• An assumption of geography/social epidemiology is that place is
linked to health of the people who live there
• Mapping spread of disease (John Snow) – maps help to visualize
patterns and potential connections
• Geographic information systems for integrating, mapping and
analyzing huge amounts of data
• Spatial analysis statistical techniques
• Clustering and spatial interpolation methods
Health mapping and GIS
• Provides astounding ability to
analyze distribution of disease and
health related factors
• Widely used in public health,
epidemiology
• Concerns with sensitive
information, privacy and
confidentiality
Health issues in natural environment
Things in the natural environment can harm people’s health or protect
their health.
• Environmental pathogens
• Natural influences on quality of air, water
• Weather conditions and events
• Climate
• Psychological/emotional connection to nature
Health issues in natural environment
Human development and decision-making also affects the natural
environment and may have an affect on people’s health.
• Changing exposures to environmental pathogens
• Man-made influences on quality of air, water
• Impact of climate change on food production & nutrition
• Equity of distribution of climate effects
Health issues in built environment
Built environment refers to things in our life and work that have been
planned or created by human activity.
• Sanitation and public safety
• Urban planning – recreation, transportation, industry
• Distribution of grocery stores, schools, services
• Housing and building maintenance
• Parks and green spaces, art and design
• Access to health care
Health issues in social environment
Social environment or human environment refers to the characteristics
of social capital that are present where people live and work.
• Social networks and participation
• Type of employment and organization of workplaces
• Degree of community control over local problems
• Policy environment (speed limits, no smoking regs, etc)
• Crime, policing, authority
• Neighbourhood culture
Example: Heavy guys
Obesity is a major determinant of a number of chronic conditions, and the direct
and indirect costs of health care expenditures and associated economic output lost
pose a huge economic burden on the Canadian society. Similar to other countries,
more Canadian males than females are overweight with national prevalence
reaching 23.0 %. Higher prevalence of obesity can be found with rural residents
living in the Maritimes and central Prairies where excess rates are higher than the
national average. In the 2004 Canadian Community Health Survey (CCHS) the
highest prevalence of obesity was primarily found in persons living in non-
metropolitan areas, and other studies find that both rural men and women living in
western Canada are more likely to be obese than their urban counterparts. In a
rural community of Saskatchewan, the prevalence of obesity has continued to rise
steadily during the past 3–4 decades.
Chen, Y., Rennie, D. C., Karunanayake, C. P., Janzen, B., Hagel, L., Pickett, W., ... & Saskatchewan Rural Health Study Group. (2015). Income
adequacy and education associated with the prevalence of obesity in rural Saskatchewan, Canada. BMC Public Health, 15(1), 700.
Impact of environment on obesity
(as per class discussion)

• Natural environment
• Chilly in winter, hot in summer
• Not very densely populated
• Ability to grow gardens
• Built environment
• Not as many options for groceries, exercise, sports in town
• People spend a lot of time in their cars driving to jobs/school/shop etc outside
the community
• Social/human environment
• Rural culture – eating and drinking associated with social activity
Impact of environment on asthma
• Natural environment

• Built environment

• Social/human environment
Health Geography
Host factors
• Pay attention to features of places
that might influence health
outcomes, and the mechanisms by
which they do so
• A place (town, province, school,
region, neighbourhood, etc) exerts a Environment Agent
unique influence over people’s factors factors
health (natural, built, social)
• Identifies place/environmental level
as a potential area for health
intervention
Take-aways
• Natural environment, built environment and social environment are
important influences on people’s health
• Social epidemiology looks at small area geographies, neighbourhoods
or places to study community-level social integration and conditions
of life and work
• Geographic information systems provide ways to collect data and
illustrate distribution of disease, determinants of health and other
factors of interest
• Mapping provides a way to combine different data sets and visualize
relationships
Climate change and epi transition
• Rising mortality due to climate change
Climate change as a social determinant
• Climate change -- heatwaves, wildfires, floods, tropical storms and
hurricanes etc in greater scale, frequency and intensity.
• Damage to infrastructure in health-determining sectors such as
agriculture and water, health care services, sanitation
• Effect on patterns of disease - malaria, diarrhoea, stress.
• Effects on people’s jobs, homes and livelihood
• Reverses much progress on public health in last 100 years!
• Inequity – effect on areas with weaker infrastructure, vulnerable
groups in any affected area.