Health and Welfare Canada
Canada has built a strong health care system, and has achieved for its people a level of health of which we are all proud. We want to continue in this tradition. While it is true that the prospects for health of the average Canadian have improved over recent decades, there nevertheless remain three major challenges which are not being adequately addressed by current health policies and practices:
The times in which we live are characterized by rapid and irreversible social change. Shifting family structures, an aging population and wider participation by women in the paid work force are all exacerbating certain health problems and creating pressure for new kinds of social support. They are forcing us also to seek new approaches for dealing effectively with the health concerns of the future.
This paper proposes an approach that is intended to help Canadians meet emerging health challenges. We are calling this approach "health promotion". It is an integration of ideas from several arenas of public health, health education and public policy ■ and it represents an expansion of the traditional use of the term "health promotion". We regard health promotion as an approach that complements and strengthens the existing system of health care.
In the past, when infectious disease was the predominant cause of illness and death, health was defined in terms of the absence of disease. By the mid 1900s, however, we had reduced the incidence of many of these infections, and health had come to mean more than simply not being ill. It was now defined as a state of complete physical, mental and social well-being. In 1974, a federal publication entitled A New Perspective on the Health of Canadians put forward the view that people's health was influenced by a broad range of factors: human biology lifestyle, the organization of health care, and the social and physical environments in which people live. `This representation of the factors contributing to health legitimized the idea of developing health policies and practices within a broader context.
Today we are working with a concept which portrays health as a part of everyday living, an essential dimension of the quality of our lives. "Quality of life"in this context implies the opportunity to make choices and to gain satisfaction from living. Health is thus envisaged as a resource which gives people the ability to manage and even to change their surroundings. This view of health recognizes freedom of choice and emphasizes the role of individuals and communities in defining what health means to them.
Viewed from this perspective, health ceases to be measurable strictly in terms of illness and death. It becomes a state which individuals and communities alike strive to achieve, maintain or regain, and not something that comes about merely as a result of treating and curing illnesses and injuries. It is a basic and dynamic force in our daily lives, influenced by our circumstances, our beliefs, our culture and our social, economic and physical environments.
This new vision of health does not represent a sudden or dramatic shift in our thinking. It is a view which revisits and embraces earlier ideas, and seeks to make them relevant to contemporary problems.
As we broaden and deepen our understanding of health, we begin to perceive with greater clarity the importance and magnitude of the challenges now looming in the field of health. We also draw the conclusion that our system of health care as it presently exists does not deal adequately with the major health concerns of our time.
The challenges we face today are not new. They have been identified separately on various occasions in the past. However, looking at these challenges together enables us to discern certain trends. These trends suggest that we move toward the approach we call health promotion.
Before exploring the practical meaning of health promotion, let us examine in more detail the nature of the health challenges facing Canadians. For the purposes of this document, we shall confine our attention to those challenges deemed to be of national importance. It is anticipated, however, that some communities may find these generic national challenges overridden by problems of a uniquely regional or local character.
The first challenge we face is to find ways of reducing inequities in the health of low-versus high-income groups in Canada.
There is disturbing evidence which shows that despite Canada's superior health services system, people's health remains directly related to their economic status. For example, it has been reported that men in the upper income group live six years longer than men with a low income. The difference is a few years less for women. With respect to disabilities, the evidence is even more startling. Men in upper income groups can expect 14 more disability-free years than men with a low income; in the case of women, the difference is eight years.
Among low-income groups, people are more likely to die as a result of accidental falls, chronic respiratory disease, pneumonia, tuberculosis and cirrhosis of the liver. Also, certain conditions are more prevalent among Canadians in low-income groups; they include mental health disorders, high blood pressure and disorders of the joints and limbs.
Within the low-income bracket, certain groups have a higher chance of experiencing poor health than others. Older people, the unemployed, welfare recipients, single women supporting children and minorities such as natives and immigrants all fall into this category More than one million children in Canada are poor. Poverty affects over half of single-parent families, the overwhelming majority of them headed by women. These are the groups for whom "longer life but worsening health" is a stark reality.
So far, we have not done enough to deal with these disparities. As we search for health policies which can take this country confidently into the future, it is obvious that the reduction of health inequities between high- and low-income groups is one of our leading challenges.
Our second challenge is to find new and more effective ways of preventing the occurrence of injuries, illnesses, chronic conditions and their resulting disabilities. Prevention involves identifying the fac tors which cause a condition and then reducing or eliminating them. Immunization and the chlorination of drinking water are prime examples of measures introduced to prevent and reduce the incidence of infectious disease. In the last century, through the efforts of public health, the practice of prevention gained wide acceptance. In fact, many prevention measures we take for granted today were initiated during the 19th century
In recent years, the preventive effort has been extended into the area of individual lifestyle and behaviour. The realization that smoking, alcohol consumption and high-fat diets were contributing variously to lung cancer, cirrhosis of the liver, cardiovascular disease and motor vehicle accidents, led us to turn our attention to reducing risk behaviour and trying to change people's lifestyles.
Unfortunately, the causal relationships between behaviour and health are not nearly as clear-cut as they are between "germs" and disease. Today's illnesses and injuries and the disabilities to which they give rise are the result of numerous interacting factors. This means that prevention is a far more complex undertaking than we may at one time have imagined.
In spite of this, there is considerable scope for prevention. Already, children have been among the main beneficiaries. In prenatal and neo- natal care, preventive measures have brought about a marked reduction in infant mortality Notable progress has also been achieved in preventing learning disabilities, and preventive measures are helping, for example, to overcome the difficulties associated with dyslexia, hyperactivity and speech and hearing impairments. With regard to adults, it is estimated that the use of preventive measures can lead to a future 50 per cent reduction in the incidence of lung cancer and heart disease.
In this century, chronic conditions and mental health problems have replaced communicable diseases as the predominant health problems among Canadians in all age groups. Our third challenge is to enhance people's ability to manage and cope with chronic conditions, disabilities and mental health problems.
Conditions such as arthritis, hypertension, respiratory ailments, dependence on drugs and chronic depression can all limit people's capacity to work, to take care of themselves, to perform the activities of daily living and to enjoy life.
Canada is experiencing an "age boom", and the number of older people in this country will more than double within the next thirty-five years. Thus, for Canada's older population, coping with chronic conditions and the disabilities to which they give rise, is a particular concern. It is often hard for those seniors who are incapacitated by disabilities to function independently Everyday tasks, such as taking a shower or opening a jar, become difficult or even unmanageable.
It is particularly important to ensure that people are supported in the area of mental health. Obviously, we cannot afford to diminish our efforts to assist those who are suffering from serious mental illness; however, it is essential that we assign equal priority to helping people remain mentally healthy
Surveys indicate that many Canadians find their lives stressful. Women are more vulnerable in this regard. The fact that women are prescribed tranquillizers and anti-depressants more than twice as often as men is a telling sign of the emotional strain women are experiencing. For some, it may be the changing and uncertain nature of their role that is unduly stressful. Others may be overwhelmed by the burden of caring for family members, particularly those who are chronically ill or disabled. For both men and women, job burnout is taking an increasing toll. The changing nature of social roles and factors such as unemployment have also had a bearing on the emotional well-being of men, who may encounter health problems including ulcers, dependence on alcohol and depression.
We know that anxiety, tension, sadness, loneliness, insomnia and fatigue are often symptoms of mental stress which find expression in many forms, including child abuse, family violence, drug and alcohol misuse and suicide. Problems associated with mental stress may occur in times of crisis, or be the result of accumulated life circumstances.
Our challenge is to provide the skills and the community support needed by people with disabilities and mental health problems if they are to manage effectively lead stable lives and improve the quality of their lives. We must also recognize the importance of ensuring that informal care-givers have access to the support they need. Many people, especially women, care for others on a regular basis. The health and capacity of these individuals to manage is no less important than the health of those for whom they care. Homemakers, home care nursing, respite care and postal alert are services which enhance the coping capacity of both those with disabilities and their care-givers.
Reducing inequities, widening the prevention effort and enhancing people's ability to cope are the principal challenges confronting us as Canada enters the 21st century. It is toward these challenges that we must dedicate our efforts and resources.
So far, we have described a global, positive vision of health and outlined three health challenges of major national importance. Our ultimate responsibility is to ensure that the health of Canadians is preserved and enhanced, a goal which can only be achieved if each of us can be assured of equitable access to health. It is clear, however, that existing policies and practices are not sufficiently effective to ensure that Canadian men and women of all ages and backgrounds can have an equitable chance of achieving health.
In our quest for solutions to this problem, we asked ourselves two questions: "What mechanisms are needed to effectively respond to the emerging challenges?" and "What strategies or processes can we implement in order to meet these challenges?"
We conclude that these questions can best be answered by a wider application of health promotion. A health promotion approach would, with the necessary effort and resources, integrate easily into the present health system. We believe that just as health care is acknowledged as a cornerstone of the Canadian health system, health promotion is positioned to become another, equally important cornerstone of that system.
People often associate health promotion with posters and pamphlets. This is a simplistic view akin to associating medical care with white coats and stethoscopes. In the words of the World Health Organization, "health promotion is the process of enabling people to increase control over, and to improve, their health". It "represents a mediating strategy between people and their environments, synthesizing personal choice and social responsibility in health to create a healthier future".
It is quite true that, until recently, health promotion has relied heavily upon the dissemination of health information, targeting health messages to the public in the expectation that this would somehow bring about the desired changes in people's lifestyles. Although this approach did produce some shifts in attitudes and health behaviour, these have been slight and slow. It became increasingly evident that to be effective, information campaigns should not take place in isolation; they had to be combined with a variety of other activities. Health promotion became a multifaceted exercise which included education, training, research, legislation, policy coordination and community development. This perspective gained fairly wide acceptance with many professionals and the voluntary community By the mid 1970s, health promotion activities were becoming more visible in schools, community health service s, drug and alcohol commissions and in the workplace.
Less than a decade later, several programs of national scope were in operation. Covering a variety of themes, these major initiatives were the result of cooperative efforts among several levels of government and the voluntary sector. They included Dialogue on Drinking; the Breast- Feeding Program; It's Just Your Nerves, a program on women's use of alcohol and tranquillizers; Time to Quit, a smoking-cessation program; Stay Real a drug information program; and Break Free, a recent collaborative initiative aimed at reducing smoking among young people.
Communities and voluntary groups committed to undertaking health promotion activities at the local level were able to tap into financial resources, including federal funding through New Horizons, sustaining grants for voluntary associations, and the Health Promotion Contribution Program. Across Canada, organizations and groups as diverse as the Canadian Institute of Child Health, the Disabled Individuals' Alliance, Le Centre des Femmes de l'Estrie, the Alzheimer Society of Canada and many more contributed significantly to this country's growing record of achievement in health promotion.
The experience of the past ten years has confirmed our view that health promotion provides an avenue for dealing with emerging challenges, an approach which supports Canadians in improving the quality of their health. In summary, it offers a means of achieving health for all Canadians.
We have taken a backward glance at our efforts in health and assessed our progress. We have looked ahead and seen trends toward serious inequities in health, particularly for disadvantaged groups and coming generations of seniors. We have reviewed ten years of experience in health promotion. Our conclusion is that the health promotion approach offers considerable potential and scope to meet the complex health challenges that face Canadians.
The Framework for Health Promotion described here provides a means of linking the ideas and actions we regard as fundamental to the achievement of health for all, the aim to which we aspire.
Earlier, we identified the national health challenges which need to be overcome as we pursue this aim. Other key components of the framework are a set of health promotion mechanisms and a series of implementation strategies. We now present these mechanisms and strategies, elaborating on their relationship to each other and to the health challenges within the Framework for Health Promotion.
For a visual representation of all these components and the relationships among them, the reader is referred to the diagram entitled `A Framework for Health Promotion"
We believe that the three mechanisms intrinsic to health promotion are: - self-care, or the decisions and actions individuals take in the interest of their own health; - mutual aid, or the actions people take to help each other cope; and - healthy environments, or the creation of conditions and surroundings conducive to health.
When we speak of self-care, we refer to the decisions taken and the practices adopted by an individual specifically for the preservation of his or her health. An older person using a cane when the sidewalks are icy a diabetic self-injecting insulin, a person choosing a balanced diet, someone doing regular exercises: these are all examples of self-care. Factors such as beliefs, access to appropriate information, and being in surroundings that are manageable play an important role in such situations. Simply put, encouraging self-care means encouraging healthy choices.
The second health promotion mechanism, mutual aid, refers to people's efforts to deal with their health concerns by working together. It implies people helping each other, supporting each other emotionally and sharing ideas, information and experiences. Frequently referred to as social support, mutual aid may arise in the context of the family the neighbourhood, the voluntary organization, or the self-help group.
Informal networks are recognized as a fundamental resource in the promotion of health. There is strong evidence that people who have social support are healthier than those who do not. The value of such support lies in its emotional and practical nature: it enables people to live interdependently within a community while still retaining their independence. A parent with a handicapped child, an older person enduring arthritic pain, an adolescent using drugs: these are people who need not only professional services, but understanding and the sense of belonging that comes with being socially supported.
In Canada, the "self-help movement" provides us with an abundance of illustrations of mutual aid in action. Alcoholics Anonymous (AA), One Voice of Seniors, Block Parents, the Coalition of Provincial Organizations of the Handicapped (COPOH), and rape crisis centres are some examples. Through self-help, people come together to deal with the consequences of being unwell, overburdened, bereaved, disabled, or in a situation of crisis.
The third health promotion mechanism is the creation of healthy environment. This means altering or adapting our social, economic or physical surroundings in ways that will help not only to preserve but also to enhance our health. It means ensuring that policies and practices are in place to provide Canadians with a healthy environment at home, school, work or wherever else they may be. It means communities and regions working together to create environments which are conducive to health.
From this perspective, the environment is all-encompassing; the concept of boundaries is inappropriate when we speak of the promotion of health. The environment includes the buildings where we live, the air we breathe and the jobs we do. It is also, for example, the education, transportation and health systems. Because of the breadth and scope of the environment thus understood, environmental change becomes by far the most complex and the most difficult of the three mechanisms or kinds of action required for the promotion of health.
The public sector and others are already engaged, to varying degrees, in encouraging people to care for themselves, to come together for mutual support, and to change the circumstances and surroundings which act as barriers to the achievement of health. Yet, to the extent that there are in place policies and practices which support the concept of health promotion, these tend to be implicit rather than explicit. In most instances, they are not the result of deliberate strategic planning. In our view, it is time to clearly articulate a direction which is designed expressly to promote the health of Canadians.
To do so means establishing a set of strategies, the implementation of which will enable us to attain our aim of achieving health for all. At the 77th Annual Conference of the Canadian Public Health Association, we presented six strategies for health promotion: ensuring access to health information; encouraging consensus about particular health ideas; initiating research in support of health promotion; fostering public participation; advocating a strong role for the health care system, particularly for community health services; and coordinating policies between sectors.
Of these six strategies, there are three which provide a central focus, and under which the others can be subsumed. In our view, the leading strategies or processes whereby we can act decisively in response to the health challenges confronting Canada are: - fostering public participation; - strengthening community health services; and - coordinating healthy public policy
Let us explore the strategies which we are proposing as a basis for action in the field.
Health promotion means ensuring that Canadians are able to act in ways that improve their own health. In the national quest for health, people constitute a major resource, both individually and in groups. Our experience confirms that people understand and are interested in the circumstances and events that influence their health. We know that they are seeking opportunities to take responsibility
Encouraging public participation means helping people to assert control over the factors which affect their health. We must equip and enable people to act in ways that preserve or improve their health. By creating a climate in favour of public participation, we can channel the energy skills and creativity of community members into the national effort to achieve health.
The enduring impact of public participation on health is well documented. In the Vancouver "Be Well" program, a network of seniors established a self-help model to encourage participants to preserve their own health. Crocus Co-operative in Saskatoon offers programs and counselling for post-mentally ill adults. In Quebec, a multi-ethnic association provides information and assists handicapped children and adults in making use of services. The Canadian Sickie Cell Society has grown from a handful of volunteers into a national organization dedicated to educating, testing and counselling Canadians affected by sickie cell anemia. In a small rural Ontario community, seniors came together to organize meal services, friendly visiting and home help for their less able older neighbours.
These examples illustrate how fostering public participation can help us respond to one of our leading challenges, that of enhancing people's capacity to cope. We could, in fact, take any of the national challenges and produce evidence that endeavours initiated by the public can provide effective responses to health concerns. The conclusion is inescapable: public participation is not only valuable, but essential to the achievement of health for all Canadians.
Community health services are already playing an indispensable role in preserving health. We believe that there should be an expansion of this role and that it should be expressly oriented toward promoting health and preventing disease. At the same time, we recognize that adjusting the present health care system in such a way as to assign more responsibility to community-based services means allocating a greater share of resources to such services.
A health promotion and disease prevention orientation means that community health services will have to focus more on dealing with the major health challenges we have identified. For example, it assumes that there will be a greater emphasis on providing services to groups that are disadvantaged. It further takes for granted that communities will become more involved in-planning their own services, and that the links between communities and their services and institutions will be strengthened.
In these ways, community health services will become an agent of health promotion, assuming a key role in fostering self-care, mutual aid and the creation of healthy environments. This will involve coordinating programs much more closely with those of social services in order to maintain momentum in the health promotion effort. Given the present range of their responsibilities, it is only logical that community health services should play this expanded role in promoting the health of communities.
We consider it especially important that community health services become more active in helping people to cope with disabilities. If people are to manage effectively, there must exist a continuum of care which is flexible enough to meet their needs for support ■ whether temporary or long term ■ without making unnecessary and perhaps unsettling changes in their lives. To accomplish this, it is vital that there be coordination of available services. Community health services provide a natural focal point for coordinating services such as assessment, home care, respite care, counselling and the valuable work of volunteers.
People who are trying to cope with mental health problems would also benefit from the strengthening of community health services. While psychiatric treatment services clearly remain appropriate for the seriously ill, those who are finding it difficult to manage because of life circumstances could be assisted and supported by community health services.
For all those seeking to take responsibility for their own health, whether in groups or as individuals, community health services are well situated to assume a far more prominent role in the health promotion effort.
The potential of public policy to influence people's everyday choices is considerable. It is not an overstatement to say that public policy has the power to provide people with opportunities for health, as well as to deny them such opportunities. All policies, and hence all sectors, have a bearing on health. What we seek is healthy public policy.
We believe that health promotion is an appropriate way of achieving our ultimate aim, that of equitable access to health. We know that self- care, mutual aid and healthy environmental change are integral to health promotion, and that they are mow likely to occur when healthy public policies are in place. Policies that are healthy help to set the stage for health promotion, because they make it easier for people to make healthy choices.
All policies which have a direct bearing on health need to be coordinated. The list is long and includes, among others, income security, employment, education, housing, business, agriculture, transportation, justice and technology It will not be an easy undertaking to coordinate policies among various sectors, all of which obviously have their own priorities. We must bear in mind that health is not necessarily a priority for other sectors. This means that we have to make health matters attractive to other sectors in much the same way that we try to make healthy choices attractive to people.
Conflicting interests may exist between sectors. Such conflicts are intrinsic to our society. Take the example of tobacco. We are proponents of a smoke-free environment. On the other hand, there are Canadian farmers who cultivate this product for their livelihood. Changes in tobacco policies have implications for farmers and smokers alike. In this instance the creation of healthy public policy necessitates responding to a situation with serious health as well as economic implications.
The federal government has already begun the process of creating a healthy public policy on tobacco. In October 1985, a cooperative national program to reduce smoking was endorsed by the federal and provincial/territorial Ministers of Health and seven non-government organizations. There have also been consultations with the federal departments responsible for agriculture, justice, transport, revenue, and with the Treasury Board. As a result, several of these departments are now reviewing their policies in relevant areas, such as smoking in the workplace, crop substitution, tobacco marketing practices and smoking on public transportation.
Impaired driving is another issue which is leading to inter-governmental coordination at the provincial and federal levels. From a health promotion perspective, the responsibility is to make it socially unacceptable for people to drive while under the influence of alcohol, and to reduce the often tragic consequences of doing so. Other equally important responsibilities include amending the criminal code, improving road safety, making police enforcement more efficient and controlling the availability of a lcohol. In this context, coordinated changes to public policy are being achieved through consultation and consensus among the federal departments of Health and Welfare, Justice, Transport and the Solicitor General, and their provincial counterparts.
Tobacco and impaired driving are only two examples of attempts to ensure that public policy is coordinated. The fundamental point is, however, that for public policies to be healthy, they must respond to the health needs of people and their communities. This is so whether they are developed in government offices, legislatures, board rooms, church halls, union meetings or centres for seniors.
The mutually-reinforcing strategies, taken together with the mechanisms, comprise the basic elements of the Health Promotion Framework. It is important to state that one strategy or mechanism on its own will be of little significance. Only by putting these pieces together, assigning resources, and setting priorities, can we be certain that health promotion carries meaning and comes alive. We believe the approach we propose allows us to respond effectively and ethically to current and future health concerns.
This, then, is our proposal for a health promotion framework: a vision of health as a dimension of the quality of life; an articulation of the current and future health challenges confronting this country; an understanding of health promotion as a process enabling people to increase control over their health; an identification of three mechanisms which can "energize" health promotion, and, finally, an elaboration of the three implementation strategies which we believe will make it possible for all Canadians to achieve equitable access to health.
In summary health promotion implies a commitment to dealing with the challenges of reducing inequities, extending the scope of prevention, and helping people to cope with their circumstances. It means fostering public participation, strengthening community health services and coordinating healthy public policy Moreover, it means creating environments conducive to health, in which people are better able to take care of themselves, and to offer each other support in solving and managing collective health problems.
There is a certain timeliness about health promotion. The signs are evident across the country. Regional boards of health, professional organizations, provincial and national councils and voluntary associations are all articulating policies that support the concept of health promotion. The most convincing evidence is the voice of public support. People everywhere are demonstrating a willingness to act on matters of health. Each year, for example, federal funding programs receive thousands of applications for resources to be used in community health projects. Low-income women, seniors, native people, the disabled, immigrant groups and many others are expressing their own ideas on the health needs of their communities, as well as their eagerness to find ways of meeting those needs.
We are aware that there are certain dilemmas inherent in health promotion. For example, we cannot invite people to assume responsibility for their health and then turn around and fault them for illnesses and disabilities which are the outcome of wider social and economic circumstances. Such a "blaming the victim" attitude is based on the unrealistic notion that the individual has ultimate and complete control over life and death.
Secondly, there is the question of allocating resources during times of scarcity. The availability of financing is obviously a critical question for each of us. Canada has performed fairly well in controlling the growth of health care costs; however, cost control is a matter of continuing concern. The pressures created by an aging population and the growing incidence of disabilities in our society will take a heavy toll on our financial resources. We believe, however, that the health promotion approach has the potential over the long term to slow the growth in health care costs.
Every day, individual Canadians face difficult situations. We see unhappy pregnant teenagers, abused children, women who are depressed, seniors who are lonely, men in midlife incapacitated by heart disease, and people suffering from incurable diseases such as multiple sclerosis or arthritis. There is, however, another side to this story We also see transition homes, family counselling, drug treatment centres, self-help groups, efforts in the workplace to hire the disabled and, above all, people moving voluntarily to help themselves and to reach out to others. This is what we want to see and this is what we want to encourage.
The Health Promotion Framework helps us formulate ways of dealing with day-to-day health issues. We can use it to visualize the kinds of mechanisms and strategies that are needed to support and encourage Canadians as they strive to live healthy, full lives. The framework links together a set of concepts, providing us with a particular way of thinking about and taking action toward achieving our aim of health for everyone in this country. Above all, health promotion is an approach which can develop alongside and be integrated into our sophisticated system of health care. Already, in our private and professional lives, many of us are thinking and behaving in ways that are consistent with the concept of health promotion.
It will take time to give meaning to health promotion. A vital element in the process will be nationwide discussion. This will enable Canadians to assess the implications of health promotion. The body of knowledge and experience is accumulating rapidly: individuals and groups in many parts of the country are already familiar with the approach we are calling health promotion.
We have the foundations upon which to build. Let us continue our efforts to achieve health and improve the quality of life of the people and communities of Canada.