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Foundations and principles of health promotion

A report on the health of the Canadian population (Lalonde 1974) and the Alma Ata Conference (WHO 1978) are widely cited as key contributions in setting the early agenda for health promotion. Certainly it is from this time that the term ‘health promotion’, although not a new term, began to be widely used. The foundations of health promotion were complex and differed between countries and regions of the world but three are widely noted.

The first was a change in perceptions of the key determinants of health. In Europe, and in other parts of the world, there was considerable optimism in the mid-twentieth century about the contribution that modern medicine could make to health and a widespread tendency to equate health with availability and access to health care. As a result other contributions to health were underrecognized. Gradually, however, this situation began to change. Lalonde refocused attention on the multiple determinants of health categorizing them into four interacting groups: health behaviours, social factors, biological determinants and health care. In the UK a seminal book by McKeown (1979) entitled, The Role of Medicine, examined the decline of infectious diseases in those countries which had moved through the epidemiological transition from infectious diseases to chronic diseases as the major causes of illness and death. He documented the relative contributions of different influences to the changes since the nineteenth century. He demonstrated that improvements in water and sanitation, and later in nutrition, were significantly more important than health care interventions in the decline of infectious diseases. McKeown’s work, and that of others at the time (McKinlay and McKinlay 1977) helped to remind people of the importance of basic aspects of public health in developing the health of populations. The shift to chronic diseases in higher income countries also highlighted the fact that people’s lifestyles were important in the causal pathways of such diseases which were mostly incurable. Prevention, therefore, assumed major importance. In the UK a number of documents (DHSS 1976, 1977) promoted the idea that prevention was everybody’s business and focused heavily on individual responsibility for health and the need to make changes in health related behaviours.

While the role of social determinants of health was acknowledged in these documents relatively little attention was given to them leading to allegations of ‘victim blaming’. At this time there were also developments of what was called ‘The New Public Health’ moving public health beyond public health medicine to action on the wider social and environmental determinants of population health. Health education was a second important foundation. While education for health is an integral part of lay cultures health education, as a formalized activity, expanded during the twentieth century. Typically this was as a component of other professional roles but also, in a few countries such as the UK, as a specialist role. It has been customary to make specific allegations about ‘traditional’ health education, describing it as narrowly focused either on behaviour change or on simple educational goals such as information provision (Rodmell and Watt 1986). From the 1970s there was awareness of these concerns and health education activities broadened. Educational activities for individuals extended to develop empowerment and informed decision-making. Education about the social determinants of health and radical actions to improve it also increased (Freudenberg 1981).

The third foundation was a growing awareness of the wide differences between the health of industrialized and developing countries. In 1977 the World Health Assembly considered these differences and initiated the slogan of Health For All by the Year 2000 and a series of targets were set (WHO 1998a) with targets focused not only on health care services but also on the determinants of public health. Although most low income countries had traditional systems of health care they lacked access to modern medicine. There was a widespread tendency to undervalue the contributions of the former, and overvalue those of the latter, to health care. The provision of primary care through ‘barefoot doctors’ in China and similar initiatives in other countries had been noted. In 1978 the Alma Ata Conference presented a new philosophy of primary health care. This addressed the provision of first line preventive and treatment services in low income countries within a context of actions directed towards key determinants of health such as water, sanitation and nutrition. Effective primary health care was to have health education as a core activity and be built on community participation.

Many countries went on to develop programmes of primary health care as laid out in Alma Ata but it became clear that the focus was often more strongly on the basic health services rather than the development of full primary care (Mull 1990). Although health in developing countries was the main focus of Alma Ata it was intended that its concept of primary care should be relevant to all countries (Kaprio 1979). Those, however, with established primary care medical services paid little attention to the idea (Green 1987). The rapid development of health promotion thinking and practice began in the early 1980s. A key early influence was a discussion paper in 1984 often referred to as the Copenhagen document (WHO 1984). This presented a socio-ecological model of health and considered the principles of health promotion, areas of action and priorities for the development of policies. Health was seen as a resource for everyday life, with an emphasis on social and personal resources, as well as physical capacities, and viewed positively rather than as the absence of disease. Health promotion was described as: ‘the process of enabling people to increase control over, and to improve their health’, a statement which was widely adopted.

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