Population Health Promotion:

An Integrated Model of Population Health and Health Promotion

Why Are We Doing This

With the increased interest in population health across the country, many are asking how population health and health promotion are related. Health promotion is commonly defined as a process for enabling people to take control over and improve their health. Population health is an approach that addresses the entire range of factors that determine health and, by so doing, affects the health of the entire population. Many people think that population health is no different from public health and community health. Others believe that it is a new paradigm, while others believe that the concepts and principles of population health and health promotion are essentially the same. Rather than engage in a debate over the similarities and differences, this paper combines the ideas to provide an integrated Population Health Promotion Model. It presents the model and illustrates how this model can be used to operationalize a population health promotion approach.

How Did We Get Here

It 1974, the internationally acclaimed document A New Perspective on the Health of Canadians explored how factors other than health care contribute to the health of a population. This was a serious attempt to re-evaluate how health is created. It identified human biology, lifestyle, the environment and the availability of health services as the critical factors that influence health status. Of these, attention initially focused on the influence of lifestyle.

In the '70s, a number of government and non-governmental organizations established health promotion programs mainly designed to help people adopt healthy lifestyles. Programs were primarily preventive in nature and focused on the reduction of health-related risk behaviours. Principal strategies included the delivery of health education programs and public awareness campaigns combined with legislative changes to further discourage the identified risk behaviours.

During the '80s, discussion began to turn to the other health determining factors, in particular the influence of the environment (social, physical, economic and political) on health. The discussion also became global through the Alma Ata Declaration and the development of a Health For All Strategy by the World Health Organization. This culminated in 1986, when Canada hosted the First International Conference on Health Promotion. At this conference, two key documents (The Ottawa Charter on Health Promotion and Achieving Health for All: A Framework for Health Promotion) were released. These documents called attention to the underlying conditions within society that determine health. Consequently, they have been instrumental in focusing policy and program discussions on how health is created and how health can be achieved equitably by society as a whole.

Achieving Health for All: A Framework for Health Promotion called attention to three key health promotion challenges: reducing inequities in health; increasing the prevention of disease; and enhancing the capacity to cope with chronic disease and disability. The Framework also proposed mechanisms (self-care, mutual aid, and creation of healthy environments) and strategies (fostering public participation, strengthening community health services, and coordinating healthy public policy) for addressing these challenges. In proposing these strategies, Achieving Health for All acknowledged the important role of health care providers in preventing disease and promoting health. It also recognized the need for working with other sectors to ensure that the collective policy environment is one that supports health.

The Ottawa Charter on Health Promotion took a comprehensive view of health determinants, referring to them as pre-requisites for health. It defined the fundamental prerequisites for health as peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice and equity. It also recognized that access to these prerequisites cannot be ensured by the health sector alone. Rather, coordinated action is required among all concerned, including governments (health and other social and economic sectors) non-governmental organizations, industry and the media.

The Ottawa Charter called for action in five areas:

1. Build Healthy Public Policy to ensure that policy developed by all sectors contributes to health-promoting conditions (e.g., healthier choices of goods and services, equitable distribution of income).
2. Create Supportive Environments (physical, social, economic, cultural, spiritual) that recognize the rapidly changing nature of society, particularly in the areas of technology and the organization of work, and that ensure positive impacts on the health of the people. (e.g., healthier workplaces, clean air and water).
3. Strengthen Community Action so that communities have the capacity to set priorities and make decisions on issues that affect their health (e.g., healthy communities).
4. Develop Personal Skills to enable people to have the knowledge and skills to meet life's challenges and to contribute to society (e.g., life-long learning, health literacy).
5. Reorient Health Services to create systems which focus on the needs of the whole person and invite a true partnership among the providers and users of the services (e.g., homecare, child development services).

The Ottawa Charter has been translated into over 40 languages and serves as a guidepost for health promotion around the world. Implementing its calls for action, however, has been a challenge. While there are a number of reasons for this, perhaps one of the most important has been the need to show how action directed at the underlying prerequisites or determinants can affect health. The challenge is to show a relationship between these factors and health so that there is sustained commitment to action in a variety of health-determining sectors. Recently, there have been significant contributions to help meet this challenge.

What Are We Learning Now

Given that the factors which influence health are multiple and interactive, the knowledge around health determinants is complex. Contributions have been made from several disciplines and have recently been drawn together in the book Why Some People Are Healthy and Others Are Not. It is a compelling synthesis of the available evidence on the key factors and conditions that determine health status. The findings have been summarized in the following diagram.

Figure 1

What Makes Some People Healthy: Determinants of Health

The ideas emanating from the various sources have been formulated in a document Strategies for Population Health: Investing in the Health of Canadians which was approved by the Federal/Provincial/Territorial Ministers of Health in 1994. This document presented the following framework for population health.

The document Strategies for Population Health identifies health determinants as:

1. Income and Social Status: It is not the amount of wealth but its relative distribution which is the key factor that determines health status. Likewise, social status affects health by determining the degree of control people have over life circumstances and, hence, their capacity to take action.
2. Social Support Networks: Support from families, friends and communities is important in helping people deal with difficult situations and maintaining a sense of mastery over life circumstances.
3. Education: Education, that is meaningful and relevant, equips people with knowledge and skills for daily living, enables them to participate in their community, and increases opportunities for employment.
4. Employment and Working Conditions: Meaningful employment, economic stability, and a healthy work environment are associated with good health.
5. Physical Environment: Factors such as air and water quality, the type of housing and the safety of our communities have a major impact on health.
6. Biology and Genetic Endowment: Recent research in the biological sciences has shed new light on "physiological make-up" as an important health determinant.
7. Personal Health Practices and Coping Skills: Personal health practices are key in preventing diseases and promoting self-care. Just as important, are peoples' coping skills. Effective coping skills enable people to be self-reliant, solve problems and make choices that enhance health.
8. Healthy Child Development: Positive prenatal and early childhood experiences have a significant effect on subsequent health.
9. Health Services: There is a relationship between the availability of preventive and primary care services and improved health (e.g., well baby and immunization clinics, education programs about healthy choices).