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Chapter 1 Part 1 Introduction to Health Promotion. © John Hubley & June Copeman 2008. Refocusing upstream.

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chapter 1 part 1 introduction to health promotion

Chapter 1 Part 1Introduction to Health Promotion

© John Hubley & June Copeman 2008

refocusing upstream
Refocusing upstream

"I am standing by the shore of a swiftly flowing river and hear the cry of a drowning man. I jump into the cold waters. I fight against the strong current and force my way to the struggling man. I hold on hard and gradually pull him to shore. I lay him out on the bank and revive him with artificial respiration.

Just when he begins to breathe, I hear another cry for help.

I jump into the cold waters. I fight against the strong current, and swim forcefully to the struggling woman. I grab hold and gradually pull her to shore. I lift her out on the bank beside the man and work to revive her with artificial respiration.

Just when she begins to breathe, I hear another cry for help.

I jump into the cold waters. Fighting again against the strong current, I force my way to the struggling man. I am getting tired, so with great effort I eventually pull him to shore. I lay him out on the bank and try to revive him with artificial respiration.

Just when he begins to breathe, I hear another cry for help.

Near exhaustion, it occurs to me that I'm so busy jumping in, pulling them to shore, applying artificial respiration that I have no time to see

who is upstream pushing them all in...."

A story told by Irving Zola - but is used in an article by John B. McKinlay in "A Case for Refocusing Upstream: The Political Economy of Illness" McKinlay, J.B. (1981)


healthy onset of advanced disability

person symptoms symptoms death

(reversible) (not reversible )

Primary Secondary Tertiary

prevention preventionprevention

screening rehabilitation

case finding

early prevention


Death rates from lung cancer (per 1000) by number of cigarettes smoked, British doctors, 1951-61

Annual lung cancer death rates

per 1000

Average number of cigarettes smoked per day

health field model
Health Field Model

Human Biology








human behaviours important for health promotion
Human behaviours important for health promotion
  • Community action- actions by communities to change their surroundings include community participation in health decision-making
  • Health behaviours– actions people undertake to be healthy
  • Utilization behaviours– utilization of health services
  • Illness behaviours- recognition of symptoms and prompt self-referral
  • Compliance (adherence)– following course of prescribed medicines
  • Rehabilitation behaviours– what people need to do after an illness/surgery to recover

Saving Lives – Our Healthier Nation (1999)This White Paper from the Department of Health for England set the agenda for health policy for the next decade. Lifestyle and human behaviour was given a prominent role through its “Ten Tips for Better Health”

  • Don't smoke. If you can, stop. If you can't, cut down.
  • Follow a balanceddiet with plenty of fruit and vegetables.
  • Keep physicallyactive.
  • Managestress by, for example, talking things through and making time to relax.
  • If you drink alcohol, do so in moderation.
  • Cover up in the sun, and protect children from sunburn.
  • Practise safer sex.
  • Take up cancer screening opportunities.
  • Be safe on the roads: follow the Highway Code.
  • Learn the First Aid ABC - airways, breathing, circulation

Mortality from Coronary Heart Disease

men aged 20-64 by social class, England and Wales, 1991-93

England and Wales = 100

Social Class



Non-manual skilled

Manual skilled

Partly skilled


Standardized mortality ratios

Source: Office for National Statistics (ONS), Health Inequalities



Perinatal Mortality Rate

By mother’s country of birth, England and Wales, 1997-99 combined

Rate per 1,000 live & still births





E Africa



The Rainbow model - The main determinants of health

Independent Inquiry into Inequalities in Health report Chairman: Sir Donald Acheson 1998

jason s story
Jason’s story

"Why is Jason in the hospital? Because he has a bad infection in his leg.

But why does he have an Because he has a cut on his leg and it got infected. infection?

But why does he have a cut Because he was playing in the junk yard next to his

on his leg? apartment building and there was some sharp, jagged steel there that he fell on. But why was he playing in Because his neighbourhood is kind of run down.

a junk yard? A lot of kids play there and there is no one to supervise them. But why does he live in that Because his parents can't afford a nicer place to neighbourhood? live.

But why can't his parents afford Because his Dad is unemployed and his Mom is

a nicer place to live? sick.

But why is his Dad unemployed? Because he doesn't have much education and he can't find a job. But why ...?"

Towards a Healthy future : second report on the health of the Canadians (1999)

causes of poor health
Causes of poor health


Social Injustice


Lack of empowerment

Tobacco use


Reckless risk-


Poor education

Low prestige


Excess illness

Low productivity

Early death

Proximal and distant causes of illness and premature mortality, JR Seffrin Journal of health education Sep – Oct 1997. Vol 28.No4.

an effective response should
An effective response should
  • Provide the information and power for the community to make decisions
  • Make the healthy choice the easiest option
  • Remove barriers to action
health promotion
Health Promotion

The process of enabling people to increase control over, and to improve, their health

Ottawa Charter 1986

ottawa charter for health promotion
Ottawa Charter for Health Promotion

Health Promotion - the process of enabling people to increase control over, and to improve, their health.




















Source: Canadian Public Health Association - An International Conference on Health Promotion - November 17-21 1986

promoting health
Promoting health



Improvements in

quality and quantity of services:


case management


patient education outreach

social marketing

  • Health Education
  • Communication directed at individuals, families and communities to influence:
  • Behaviour change
  • Determinants of behaviour change:
    • awareness/knowledge
    • decision-making
    • beliefs/attitudes
    • empowerment
    • community participation


Agenda setting and

advocacy for healthy public policy:

policies for health

income generation

removal of




gender barriers


Health education.‘A process with intellectual, psychological and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family and community well-being. This process, based on scientific principles, facilitates learning and behavioural change in both health personnel and consumers, including children and youth.’ (Ross and Mico, 1997)

Service improvement.Promoting change in services to make them more effective, accessible or acceptable to the community.

Advocacy.Activities directed at changing policy of organizations or governments.

  • Influencing policy makers, leaders and media to raise profile of health programmes
  • Addressing legal, financial and service obstacles to health action
  • Tackling discrimination and inequalities
service delivery
Service Delivery
  • Improvement in capacity of staff – training and support
  • Development of new activities
  • Reorienting existing activities to make them more effective/acceptable
  • Strengthening communication/health education within services
      • Improved patient education
      • Outreach to schools, community, workplace
      • Involvement of personnel in supporting community health promotion

Define health promotion strategy

  • Mix of health education, service improvement and advocacy?
  • Health Education approach?
  • Methods?
  • Settings?
  • Persons/groups involved in delivery?
  • Timing?
  • Targets?

Health promotion needs/situation analysis

  • Current situation?
  • Health needs?
  • Influences on health
  • Influences on health actions?
  • Target groups?

Health Promotion Planning Cycle

  • Implement
  • How to put it all together?
  • How do we overcome barriers?
  • How to monitor activities?
  • Evaluate, reflect, learn
  • Were our targets achieved?
  • What lessons were learnt?
  • How can we make our programmes better?
the ten areas of competencies in public health identified by faculty of public health
The ten areas of competencies in public health identified by Faculty of Public Health
  • Surveillance and assessment of the population's health and wellbeing.
  • Promoting and protecting its health and wellbeing.
  • Developing quality and risk management within an evaluative culture.
  • Collaborative working for health.
  • Developing health programmes and services and reducing inequalities.
  • Policy and strategy development and implementation to improve health.
  • Working with – and for – communities to improve health and wellbeing.
  • Strategic leadership.
  • Research and development to improve health and wellbeing.
  • Ethically managing self, people and resources to improve health/wellbeing.