Promoting health where the people are

4 World Health • SOth Year, No. 3, Moy-June 1997 Promoting health where the people are Ilona Kiekbusch & Desmond O'Byrne The garlic cultivated by a women 's movement in Indonesia will enable them lo finance health pro;ecfs, such as providing safe wafer to villagers. Photo WHO/H. Anenden The "Settings for Health" approach to health promotion hos led to projects focused on Healthy Cities, Healthy Villages, Healthy Islands, Health-Promoting Hospitals, Healthy Schools, Healthy Market Places, Healthy Companies, Healthy and Sof e Workplaces, and even Health in Prisons. decade has now passed since the Ottawa Charter, the first international charter for health promotion, was signed in November 1986 (see page 6). In that period, it has significantly influenced policies and programmes around the world, and it now constitutes a major com- ponent of WHO's renewed strategy for health for all. The Charter, which has been a central guide for those who seek to implement strategies that focus on health creation and supportive envi- ronments for health, defined health promotion as: "the process of en- abling people to increase control over and to improve their health." It identified five action areas: • Build health public policy. • Create supportive environments. • Strengthen community action. • Develop personal skills. • Reorient health services. But how can initiatives, projects, programmes and interventions be based on a process definition? A practical answer is offered by the Settings for Health approach . This builds in turn on the premise that there is a health development poten- tial in practically every organization or community which needs to be fostered through a series of defined strategies and applied across a range of settings. The health of an organi- zation or community is more than the aggregate health of its citizens. This stretches the measurement of progress beyond the health of popu- lations to include the health of sys- tems. It is also clearly a way of working for sustainability: the con- stant influx of new populations into the system calls for intervention at the environmental level. "Setting" projects have in com- mon: - a policy or strategy perspective; actions at the political and techni- cal levels; focus on organizational develop- ment and institutional change; building alliances and collab- oration between sectors, disci- plines and political or executive decision-makers; - community involvement and community empowerment. In the settings approach it is argued that certain environmental factors indicate the likelihood of people getting sick, but not what disease they would get. The appro- priate public health response is a health-promoting setting which builds health potential and creates buffers as well as intermediary sup- port and protection. Settings for Health projects are now being imple- mented all over the world, some linked officially to WHO networks, others working independently in the spirit of a new public health approach. Over 1000 cities worldwide are working on the Healthy Cities princi- ples today, while many communities, small towns and localities have adapted the approacp to their needs. Healthy Village initiatives are being developed in Africa with the support of the WHO Regional Office, as are the comparable Healthy Island pro- jects in the Caribbean and the Western Pacific. World Health • SOth Year, No. 3, Moy-June 1997 Health-Promoting Hospitals have spread from Europe throughout the world, with a network of several hundred hospitals. These projects focus on developing hospital hy- giene, developing healthy work- places for health care workers, improving patient well-being, improving the quality of hospital services, reorganizing wards and functional units, and health education. Healthy Schools projects involve parents, teachers and pupils in im- proving water supply and toilet facilities , making safer playgrounds and brighter classrooms, and devel- oping a medical service which em- phasizes prevention. These projects were recommended by the WHO Expert Committee on Comprehensive School Health Education and Health Promotion in 1995, and all WHO regional offices are committed to contributing to a global WHO school health initiative. Partners in this are organizations as diverse as the Council of Europe, the European Union, UNESCO, UNICEF, Education International, the World Bank, the Centers for Disease Control and Prevention in Atlanta, USA, and many more, particularly at the national and local level. Other projects are aimed at Healthy Market Places, Healthy Companies, Healthy and Safe Workplaces, and even at Health in Prisons. Several "How to " guides have been prepared, such as 20 Steps to developing a healthy city and The practitioners' guide to healthy cities. Many more very practical "tool- boxes" are in preparation. The Settings for Health approach means asking "What creates health in our settings?" The approach is oriented towards well-being and improved performance. The first step towards solutions is usually organizational rather than linked directly to health behaviour - a change of shift plans in the hospital, for instance, or a change of pupil- teacher interaction in schools. If the health development process is not participatory it is doomed to failure. Health-promoting schools are there- fore as much about teachers' health as about developing the health skills of children; health-promoting hospi- tals are as much about nurses' health as about reduced hospital infections. Where people live, love, work and play "Health is created where people live, love, work and play." What seems like a statement of the obvious is actually a revolution in health think- ing. It was pioneered by Aaron Antonovsky, who insisted that the key question which health research must ask is: "What creates health?" It is the interaction between environ- ments and people in the process of everyday life that creates a pattern of health - of the individual , the family, the community, the nation and the globe. Antonovsky went on to de- velop a scale which he called "the sense of coherence," or SOC, which links a person's sense of comprehen- sibility, manageability and meaning- fulness to health status. His research indicated that a high SOC tends to correlate with good health. We need to look at both positive and negative influences on health status, and improve our understand- ing of the factors promoting, protect- ing and maintaining health. It is from these health determinants that healthy public policy - the first strategic component listed in the Ottawa Charter - needs to take its starting point. Research results consistently indicate that systems interventions are more efficient than individually oriented prevention programmes. Therefore health promotion must prioritize healthy public policies. This knowledge s goes back to many of the public health pioneers around the globe who understood clearly the influence of economic, political and social factors on health, but it has as yet gained only minor acceptance in a health system dominated by a biomedical paradigm. Unfortunately, in many countries the "production" of health is seri- ously neglected in the health reform debate. Decisions and debate focus on the financing and organization of the curative services - that is, the consumption of medical care. But there are a few instances where the importance has been recognized of creating social environments that are supportive of health as the essence of a new public health approach: the Quebec policy on health and well- being in Canada, the Copenhagen healthy cities policy, and the empha- sis on a settings approach enshrined in the United Kingdom 's Health of the Nation document. In sum, health promotion action should seek: to encourage the rein- forcement of the indi vidual's poten- tial ; to provide support in social settings and develop healthy and safe environments; to improve living conditions and act for and with groups at ri sk; to coordinate public policy and action so as to promote health and well-being; and to orient the health and social services system towards the most effective and least costly solutions. • Dr 1/ono Kiekbusch is Director of the Division of Heolth Promotion, Education and Communication and Dr Desmond O'Byrne is Chief of the Health Education and Health Promotion Unit, World Health Organization, 121 1 Geneva 27, Switzerland. Two ways among many of promoting health A great number of places throughout the world are carrying out " Healthy Cities" projects. World Hea lth Day 1996 - held on 7 Apr il 1996 - celebrated W HO's worldwide initiative to improve the health and environment of people. The January-February 1996 issue of World Health described many aspects of the global Heal thy Ci ties movement. W HO is launching a global School Health Initiative to help all schools become "Health-Promoting Schools" . The July-August 1996 issue of World Health reported on the development of this initiative and provided examples of schools throughout the world which are striving to become "health-promoting".