Health is more than just the absence of disease—it’s a state of physical, mental, emotional and social well-being. More than a goal that we try to reach in life, it’s a resource we use to facilitate everyday life.
Health promotion, then, is not only about preventing disease but also about helping people to embrace health so they can reach their full potential. Or, as the World Health Organization puts it, it’s "the process of enabling people to increase control over their health and its determinants, and thereby improve their health" (WHO, 2005).
But how does it work? How do we “promote health” in a way that measurably improves people’s lives? According to WHO, effective health promotion mediates “between people and their environments, synthesising personal choice and social responsibility in health” (WHO Regional Office for Europe, 1986), as opposed to putting the onus of good health on the individual alone. In other words, it forces us beyond an individual, disease-oriented, behaviour-change model by focusing attention on behavioural, social and environmental factors in play at different levels of society—from the individual, through family and community, to a national or global scale.
Because of its depth and breadth, the health promotion perspective can be applied to a variety of settings such as workplaces, markets, neighbourhoods, cities, schools or campuses. Unfortunately, for a variety of political, social and philosophical reasons, the implementation of health promotion hasn’t kept up with the rhetoric.
The history of health promotion has deep roots in Canada. The Lalonde Report (1974) explored how factors other than health care contributed to the health of a population, and popularized the concept of the “health field” as consisting of four equally weighted parts: human biology, environment, lifestyle, and health services.
By offering this comprehensive and unified view of health—and by highlighting factors beyond medical care in influencing health outcomes—the report laid the groundwork for health promotion. However, the Lalonde Report’s heavy emphasis on the concept of “self-imposed risk” and its tendency to shift the burden for change from government to the general public contributed to a victim-blaming tone and approach (Hancock, 1986).
Following the Lalonde Report, North America saw a policy distinction emerge between health promotion (focused mainly on individual health behaviours and lifestyle issues) and health protection (concerned more with the physical environment). Interestingly, Europeans were at this time arguing that both physical and social environmental factors lay within the purview of health promotion.
As a consequence, most of the early health promotion programs in Canada were primarily preventive in nature and focused on lifestyle modification and the reduction of health-related risk behaviours. Key strategies were the delivery of health education programs and public awareness campaigns.
In a similar way, health promotion research and evaluation in North America tended to focus on discovering alterable risk factors and related strategies for eliminating or at least reducing those risks. Factors such as socioeconomic status were controlled for as immutable independent variables or givens, and therefore were not the subject of study, let alone of intervention efforts (Minkler, 1989). Policy and legislative changes were used primarily as tools to discourage the identified behavioural risk factors.
The fact that governments (and others) chose to target primarily individual lifestyle factors, rather than the environmental factors cited in the Lalonde Report, occurred for reasons that are complex and deeply embedded in western ideologies of individualism and personal responsibility for one’s successes or failures (Becker, 1986). The dominance of the health care industry in defining health and directing government investments in the field, no doubt, also played a role.
The emphasis on individual responsibility for health was often unaccompanied by attention to individual response-ability, or the capacity of the individual for responding to his or her personal needs or the challenges posed by their environments. Few of the early health promotion programs, for example, addressed such issues as the economic health of the target group, or access to transportation or affordable alternatives to the “risk behaviour.” Yet when the response-ability of the individual is compromised by such factors, his or her likelihood of responding favourably to health promotion programs aimed at personal behaviour change is likely limited at best.
During the 1980s, greater attention began to be given to the way environmental (social, physical, economic, political) factors influenced health. The discussion culminated in 1986 when Canada hosted the First International Conference on Health Promotion. At the conference, two key documents that drew attention to the underlying conditions within society that determine health were released.
One of them was the Ottawa Charter for Health Promotion (WHO, 1986), which defined the prerequisites for health as peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. It also recognized that these prerequisites could only be ensured through the coordinated action of governments, civil society and businesses.
The other was the Epp Report (Epp, 1986), a health promotion framework released by the Canadian government that set forth three challenges aimed at reaching the goal of “health for all,” namely to reduce inequities, increase prevention and enhance coping abilities. These challenges were to be addressed through both a series of health promotion mechanisms—self-care, mutual aid and promotion of healthy environments—and a series of implementation strategies based on fostering public participation, strengthening community health services and coordinating healthy public policy.
These documents represented a key departure from the almost exclusive emphasis on individual responsibility that had dominated health promotion in North America. Recognition was now given to broader societal responsibility and, in particular, to the health inequities between low and high income groups. Self-care needed to be balanced with social responsibility and the creation of healthy environments within which positive personal health behaviours can flourish.
In 1989, the Canadian Institute for Advanced Research introduced a “new” concept called “population health.” And in 1994 the Canadian Ministers of Health adopted a population health framework (Federal, Provincial and Territorial Advisory Committee on Population Health, 1994).
In a nutshell, population health seeks to step beyond the individual-level focus of health care by addressing a broad range of factors that impact health on a population-level, such as environment, social structure, and resource distribution. In other words, it provides a corrective to the early narrow implementation of health promotion.
Population health draws attention to the complex interaction among determinants of health and provides a conceptual framework for thinking about why some populations are healthier than others. The “overall goal of a population health approach is to maintain and improve the health of the entire population and to reduce inequities in health between population groups” (Health Canada, 1998).
Unfortunately, the implementation of this perspective has been slow-going. Despite the investments in health promotion infrastructure and programs since the adoption of the Ottawa Charter, participants of the Global Conference on Health Promotion in Bangkok lamented that the development of healthy public policy had not kept pace with other issues. They concluded that “progress toward a healthier world requires strong political action, broad participation and sustained advocacy” and went on to “forcefully call on Member States of the World Health Organization to close the implementation gap” (WHO, 2005).
Today, we are beginning to understand that a community, like the people within it, is a living organism, and its health depends on all its systems functioning, both on their own and together. This renewed understanding of health promotion sees the community as a social environment where socioeconomic equity, social connectedness, and personal efficacy can and need to be nurtured. It also recognizes that health, social and economic policies need to be coordinated, and that communities can provide an atmosphere that supports policy makers to make the right choices.
CARBC uses a social ecological model—grounded in a broad health promotion vision—to articulate the various levels of action needed in a comprehensive approach to improving health outcomes among Canadians. This model forms the foundation of our resources for schools, post-secondary campuses and communities, aimed at addressing harms related to the use of alcohol and other drugs.
The social ecological model recognizes that each level is linked to the others through a complex network of interactions between the various determinants of health that operate within and across these levels. An equally complex network of interconnected action strategies is needed to maximize the health of communities, populations and individuals. Hamilton and Bhatti have proposed a three-dimensional integrated model to represent this complexity (1996).
Levels of action
Strategies and actions
Determinant of health
Becker, M. (1986). The tyranny of health promotion. Public Health Review , 14, 15-25.
Epp, J. (1986). Achieving health for all: A framework for health promotion. Report of the Minister of National Health and Welfare. Ottawa: Government of Canada.
Federal, Provincial and Territorial Advisory Committee on Population Health. (1994). Strategies for population health: Investing in the health of Canadians. Ottawa: Health Canada.
Hamilton, N., & Bhatti, T. (1996). Population health promotion: An integrated model of population health and health promotion. Ottawa: Health Canada.
Hancock, T. (1986). Lalonde and beyond: Looking back at " a new perspective on the health of Canadians". Health Promotion , 1 (1), 93-100.
Health Canada. (1998). Taking action on population health. Ottawa: Health Canada.
Kaplan, G., Haan, M., Syme, S., Minkler, M., & Winkleby, M. (1987). Socioeconomic status and health. American Journal of Epidemiology , 125 (6), 989-98.
Lalonde, M. (1974). A new perspective on the health of Canadians. Ottawa: Government of Canada.
Minkler, M. (1989). Health education, health promotion and the open society: An historical perspective. Health Education Quarterly , 16 (1), 17-30.
WHO. (1986). Ottawa Charter for Health Promotion. Geneva, Switzerland: World Health Organization.
WHO Regional Office for Europe. (1986). A discussion document on the concept and principles of health promotion. Health Promotion , 1 (1), 73-76.
WHO. (2005). The Bangkok Charter for health promotion in a globalized world. Geneva, Switzerland: World Health Organization.