Health Promotion: A Literature Review

Full text

Manuja Perera
With
Nalika Gunawardena
Duminda Guruge
Kalana Pieris
health prom tiono
a literature review

Health Promotion – A Literature Review
ISBN 978-955-0189-05-2
© Manuja Perera with Nalika Gunawardena, Duminda
Guruge, Kalana Pieris 2012
Published by
HaPAN
Health Promotion Advocacy Network,
Rajarata University of Sri Lanka
Supported by
Plan SL
Cover Design
Rohana Ranasinghe
All rights reserved. No part of this publication may be
reproduced, stored in a retrieval system or transmitted in
any form or by any means, electronic, mechanical,
photocopying or otherwise, without prior written
permission of the authors.
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Foreword
Any new field of study or strategy for action nowadays
has to be built on what has gone before. This applies to
the 'health promotion approach' too. As a result, those
who are not particularly familiar with its unique
elements dismiss it as the same as what has gone before,
with which they are quite comfortable. Those who are
familiar with its principles and capable of applying
these in real practice, on the other hand, tend to dismiss
earlier strategies. This is based on a failure to recognize
or respect the developments that preceded and led to
this approach, which in fact gave birth to the new
package labeled 'health promotion'.
As a result, those who think it is all the same old stuff in
a new dressing fail to learn or apply the specific benefits
that the new approach offers. This is unfortunate, as it
does offer useful innovations in action to improve
public health. Committed advocates of the new
approach feel resentful at what they see as dismissal of
the evidence of the improved effectiveness that the new
approach offers. They also tend at times to alienate the
rest of the health field as they want to emphasize its
uniqueness.
Dr Perera's review of the literature here is good for both

these groups – those who are convinced of the
usefulness of the health promotion approach as well as
those who tend to dismiss it. This easy-to-read work
should help reduce the misunderstanding between
adherents and sceptics. They will both gain from
recognizing how health promotion strategy has evolved
from its roots in the public health effort to go beyond the
biomedical model to its present form – which goes
beyond the scope of the health sector as well.
Diyanath Samarasinghe

INDEX
Chapters Pages
1 Introduction 01
2 1970's 07
3 1980's 11
4 1990's 21
5 The new Millennium 27
6 Concepts in Health Promotion 35
7 Knowledge Competencies in Health Promotion 51
8 References 59

Chapter 01
INTRODUCTION
From the beginning of civilization, communities
have searched for strategies to prevent diseases
and untimely deaths with the aim of prolonging
lives. The concept of health was perceived by different
communities in different perspectives in the past and
since the World Health Assembly held in 1948, it
evolved in a more positive dimension. Constitution of
World Health Organization (WHO) has identified that
“Health is a state of complete physical, mental and
social well-being and not merely the absence of disease
or infirmity” (WHO, 2006a).
From the beginni n g of civili z a tion,
communities have searched for strategies to
prevent diseases and untimely deaths with the
aim of prolonging lives.
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The concept of 'Health for All by the year 2000', that
emerged with the 1977 World Health Assembly and
reaffirmed by Alma-Ata International Conference on
Primary Health care stressed the need for the change of
policies and strategies that promote health to provide
equitable health care (Park, 2009). The field of public
health felt the need to be reoriented in this new
perspective of health, and different approaches were
tried out throughout the world, in search of a solution for
this perceived need.
The first attempt to document the concepts of health
promotion as an organized approach is seen in the paper
'A new perspective of the health of Canadians',
published by Marc Lalonde, in 1974 (Rootman et al,
2001). Lalonde, then Canadian Health Minister,
introduced a new concept based on health equity and
this document opened up Canada and the rest of the
world to a new low cost approach to promote health
(MacDougall, 2007).
The first International Conference on Health Promotion
was held in Ottawa, Canada in 1986, and Ottawa Charter
for Health Promotion came into light as a result. Ottawa
Charter defines health promotion as “the process of
enabling people to increase control over, and to
improve, their health” (WHO, 1986b). Since the first
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02

International Conference on Health Promotion, six
more were held, connecting the experts in the field
throughout the world, sharing their experiences and
adding substance to the framework laid by the Ottawa
Charter for Health Promotion (WHO, 2009a). The latest
international conference on health promotion held at
Nairobi, Kenya in 2009 recognized it as a timely and a
well needed approach and as an essential component of
health care systems (WHO, 2011).
Thus health promotion has evolved through the years as
an organized approach accepted by many policy
ma kers, imple menters and community b ased
organizations working for population health all over the
world.
In the recent past, health promotion had become a
popular approach among health and non-health
professionals concerned about cost effective strategies
to promote health in communities. Many projects were
implemented throughout the world, in which, basic
concepts of health promotion approach were tried out in
practical dimensions. Healthy cities, villages,
municipalities and islands that focused on community
settings and health promoting schools, hospitals,
workplaces and healthy marketplaces that focused on
occupational and educational settings are examples for
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such projects. Many action plans were also formulated
by WHO, guided by the principles of health promotion
such as plans for control of alcohol and tobacco, active
living and healthy ageing. ((Nutbeam, 1998).
Many nationwide projects that aimed at promoting
health in populations were implemented in several
countries. One example for such a project is Healthy
People 2020, in United States of America which was
implemented to find a solution for the perceived need of
addressing determinants of health at all levels to
overcome modern health issues (US Department of
Health and Human Services, 2010).
However, as the approach gained popularity, many
activities that did not fit the criteria of health promotion
such as immunization, programmes for screening
diseases, etc. were also seen to be implemented under
the banner of 'health promotion' (Rootman et al, 2001).
This trend of labeling any activity used in promoting
health with the caption of health promotion is a global
phenomenon and denotes lack of comprehension of
principles of the approach by policy makers,
programme managers and implementers.
Sri Lanka, with a well organized structure to deliver
primary health care and relatively better health
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04

indicators compared to its neighbour countries, has
recognized the need of a new approach to achieve the
full potential of health as a nation. An approach that can
address health issues that cross the traditional
boundaries of health, correct the regional disparities and
improve the stagnating health indicators such as under
nutrition and low birth weight. National Health
Promotion Policy has recognized health promotion as
an efficient and cost effective approach to promote
health and a prospective solution for issues mentioned
above. Ministry of (Ministry of Health Sri Lanka, 2009).
Health has recognized empowering the communities
towards more active participation in maintaining and
promoting their health as a main objective in the
National Health Master Plan for 2007 – 2016 –(Ministry
of Health Sri Lanka, 2007b).
The above objective was reflected in the health policies
and programmes designed by the Ministry of Health, as
the National Nutrition Policy and the National Policy
for Prevention of Non Communicable Diseases have
community empowerment and health promotion as
identified strategies (Ministry of Health Sri Lanka,
2009; 2010a). There are programmes that use health
promotion as the main approach to promote health in
villages (Healthy Villages) and schools (Health
Promoting Schools) implemented via grass root level
health workers.
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Chapter 02
1970's
1974 - Canada
The concept of health promotion is traced back
to 1974, the year in which the Canadian
Minister of National Health and Welfare, Marc
Lalonde, presented a report to the parliament named 'A
new perspective on the health of Canadians: A working
document'. Later renowned to the world as 'The Lalonde
Report', it “helped to diminish the dominance of the
medical model for health systems” (Pinder & Rootman,
1998). It introduces the 'health field concept', a
proposition with the aim of making the Canadians
“The Lalonde Report helped to diminish the
dominance of the medical model for health
systems” (Pinder & Rootman, 1998).
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healthier while reducing the government expenditure on
health.
The report stresses the fact that even with a well
established, sophisticated and a high cost health care
system, the health of the Canadians is deteriorating due
to the limitations of the traditional views of health. “The
consequence of the traditional view is that most direct
expenditures on health are physician-centered,
including medical care, hospital care, laboratory tests
and prescription drugs. When one adds dental care and
the services of such other professions as optometrists
and chiropractors, one finds that close to seven billion
dollars a year are spent on a personal health care system
which is mainly oriented to treating existing illness”
(Lalonde, 1981, p.11).
Lalonde identifies four 'elements' that affects health in
his report.
1. Human biology
2. Environment
3. Life style
4. Health care organization
He stresses that if to make the nation healthy, all four
elements should be considered in equal importance
without putting the main focus on the health care
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organization element. He also suggests that the pre-
eminence held in health by the health sector should be
shared with all who contribute to health and recognizes
it as a “radical step” (Lalonde, 1981, p.33).
Lalonde declares that this 'new perspective of health'
will make the individuals, governments, health
professionals and institutions realize the importance of
each other's roles in health. This recognition in turn will
prevent implementation of imbalanced, ineffective
strategies that narrowly focuses on fields of interest of
individuals in health profession (Lalonde, 1981).
Lalonde report was revolutionary in that era and led to
'The New Public Health' concept that focused on
interplay of society and social environmental factors
with health.
1978 - Alma-Ata
The concept of primary health care came to light in this
background and the first International Conference on
Primary Health Care was held in the former Kazak
Soviet Republic in September 1978. The Declaration of
Alma-Ata, declared the importance of providing
comprehensive, affordable, universal and equitable
th
health care in all countries. In the 34 World Health
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Assembly, WHO adopted the Global Strategy for Health
for all by the year 2000 on the concepts declared in the
Alma-Ata Declaration (WHO 1981).
Within the context of the 'Health for All by the year
2000' strategy, countries were searching for approaches
that can reduce inequities in health and Canada, with its
background of health field concept, led the world to a
new approach which began to evolve in the 1980s and
gained wide international interest. Health promotion
developed as an active form of new public health, in
which the health is identified positively as intended by
the WHO and communities are motivated to actively
reach for the highest possible levels of their health
(Leeder, 2005).
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Chapter 03
1980's
1984 - Copenhagen
In mid 1984, a working group met in the European
Regional office of WHO to discuss about principles
and concepts of health promotion policies and
programmes. Its description of the process of health
promotion as “the process of enabling people to increase
control over, and to improve, their health” has later been
adopted by the Ottawa Charter and the Health
Promotion Glossary as the definition of the approach.
“the process of enabling people to increase
control over, and to improve, their health”
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The document consolidated based on the discussion,
identified five principles that later guided the world to
organize and integrate various approaches used in the
context of new public health to formulate a new
approach. The five principles stated in this document
are that health promotion,
1. focuses on populations in the context of
everyday life rather than on at risk
individuals for diseases
2. is directed towards acting on determinants or
causes of health
3. combines diverse but complementary
methods and strategies against health
hazards
4. aims at community participation and is
not a medical service but a health and
social activity
improves health by integrated action at different levels
on economic, environmental, social and personal
factors influencing health
The above proposed integrated actions were classified
under five subject areas;
1. reduce inequalities of health
2. developing supportive environments for
health
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3. strengthening of social networks and social
supports
4. promoting positive health behaviours
5. improving knowledge on health and
influencing factors to make informed choices
One can clearly identify how this Copenhagen
discussion document had influenced the first charter of
action on health promotion produced two years later.
Ottawa 1986
Ottawa Charter is the charter for action produced at the
First International Conference on Health Promotion
held in Ottawa, Canada in 1986. It is considered the
foundation document of health promotion approach.
Even though the document itself declares that it is for
the purpose of achieving health for all by the year 2000
and beyond, Ottawa Charter had been widely used for
development of many conceptual frameworks since its
origin.
Identifying health as a resource for life, it lists out basic
pre-requisites needed for improvement in health. The
pre-requisites mentioned in the document are: peace,
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shelter, education, food, income, a stable eco-system,
sustainable resources, social justice and equity.
The Ottawa Charter speaks about three main strategies
in health promotion:
1. advocate to make conditions (political,
economic, social, cultural, environmental,
behavioural and biological) that affect health
favourable
2. enable people to control the determinants of
health
3. mediate between different sectors and
interests to fulfill pre-requisites for health
Ottawa charter further classifies action in health
promotion into five broad action areas.
1. Build healthy public policy
2. Create supportive environments
3. Strengthen community actions
4. Develop personal skills
5. Reorient health services
The action 'build healthy public policy' aims to make the
healthier choice the easier choice for policy makers in
health and non-health sectors. Healthy public policies
give people the control of decisions and circumstances
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which affect their lives and for governments they set out
the accountability frameworks. Primary outcome of
healthy public policies is 'creating supportive
environments', the second action area of health
promotion.
Creating supportive environments aims to generate
safe, stimulating, satisfying and enjoyable living and
working conditions as well as equitable access to
resources for health, and opportunit ies for
empowerment. The environment includes both the
natural environment and socio-cultural environment.
Conservation of natural environment, protecting all its
species, conservation of resources and reducing
environmental pollution as well as creating a socio-
cultural environment in which people regain the control
over the determinants of health is considered an
important action in the Ottawa Charter.
The third action, 'strengthen community actions' is
strengthening public participation in issues related to
health and motivating collective actions to improve
self-help and build social networks that support health.
It is a process that empowers communities to own and
gain control of the strategies and interventions aimed to
promote their own health.
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Develop personal skills' is the fourth action mentioned
in the Ottawa Charter which goes beyond the traditional
life skills building in individuals. By providing
opportunities to continuously expand one's own life
goals and aspirations throughout the life, it aims to
enable individuals to develop more control over their
health and make healthy choices, as well as to
disseminate these skills to others.
The last action area, 'reorient health services' means
placing a more explicit concern about the population
health outcomes and was subjected to many
controversies, as the implied intention was to
reconstruct the health care systems to suit the concepts
of new public health.
The Ottawa Charter also identified the settings
approach to implement health promotion activities by
declaring that “health is created and lived by people
within the settings of their everyday life; where they
learn, work, play and love” (WHO, 1986b).
There were many driving forces behind the Ottawa
Charter as Leeder (2005) suggests in his paper, The
New Public Health. The unpopularity of the Health for
all by the year 2000 concept among industrialized
countries was clearly evident by that time.Traditional
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approaches such as behavioural and lifestyle
approaches were stretched to their maximum limits in
trying to meet the demands of modern diseases. Thus the
need for a statement integrating many concepts of health
promotion to a more organized approach was urgently
felt in that era for the betterment of the global public
health arena. Thus “the spirit of Alma-Ata was carried
forward in the Charter for health promotion” (WHO,
1988).
1988 - Adelaide
The Second International Conference on Health
Promotion was held in Adelaide, South Australia in
April 1988. Australia is known as the second leading
nation that took up the new approach in promoting
health and their interest in healthy public policies was
clearly evident by the resulting document from the
conference. The main point highlighted in the document
is that the other four actions on health promotion will
only be possible if the healthy public policies are made.
According to this document, there are two main
characteristics of a healthy public policy.
1. Concern for health and equity
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2. Accountability for the impacts made on health
They identify the main reason behind the inequalities in
health in communities as the societal inequities. Their
recommendation for closing the existing health gap
between the socially advantaged and disadvantaged is
building healthy public policies to improve accessibility
of goods and services and create supportive
environments for health.
The participants also recommend linking the policies
with integrated actions so that the social, economical
and health related factors will be effectively addressed
to promote health in populations. The Adelaide
Recommendations also include building new alliances
between partners in the policy process such as central
and local governments, corporate and business sectors,
nongovernmental and community based organizations,
commerce and industry, trade unions, academic
associations and religious leaders.
The conference identified women's health, food and
nutrition, tobacco and alcohol and creating supportive
environments as the key action areas within which the
building of healthy public policies should happen.
The main challenge the Adelaide document has
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identified for building healthy public policies is
developing partnerships between various sectors, levels
and factors that influence health (WHO, 1988).
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Chapter 04
1990's
1991 - Sweden
Sweden was the hosting country of the Third
International Conference on Health Promotion
in 1991 and the main focus of the conference
was supportive environments for health. It was co-
sponsored by the United Nations Environment
Programme, the Nordic Council of Ministers and the
WHO.
Supportive Environments for Health goes
beyond its physical component to include
social, economic and political components
that encompass the variety of settings of
everyday life.
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The meaning of the word 'environment' in the Sundsvall
Statement on Supportive Environments for Health goes
beyond its physical component to include social,
economic and political components that encompass the
variety of settings of everyday life, places where people
live, learn, work and play. The document recognizes that
health and environment are two entities that cannot be
separated from each other as they are interdependent.
The main environmental issues influencing health
identified in the document are rapid population growth,
po verty, lack of access to basic educa tion,
discrimination against women and inadequate access to
essential health care that create inequalities in health
and widen the gap.
According to the statement, the solution for these issues
goes beyond the traditional health system to social
action for health by communities using their resources
and creativity. To release this potential, a change in the
perception on health and the environment and a strong
political commitment for effective policies are needed
in all local, national and global levels.
The statement describes that social dimension includes
norms, customs and social processes and the need to
identify the ways and trends in which they influence
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22

health. The political dimension should involve
communities in making policies and be committed to
provide pre-requisites for health. The responsibility of
the economic dimension is to ensure the rechanneling of
resources and healthy transfer of technologies.
The statement also highlights the need to utilize the
skills of women in all stages of the processes of health
promotion.
The conference identified four strategies to create
supportive environments for health.
1. Strengthening advocacy through community
action
2. Enabling individuals with information and
empowerment
3. Building alliances with all partners involved
4. Mediating different sectors to ensure health
equity
In the final paragraph, the statement warns the world
that human development cannot be separated from the
environmental sustainability and stresses the need for
new mechanisms to ensure accountability for health and
environment in the global context (WHO, 1991).
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1997 - Jakarta
New Players for a New Era, the Fourth International
Conference on Health Promotion was held in Jakarta,
Indonesia in 1997, on the verge of the new millennium.
The main focus of the conference was to find ways of
addressing the changing determinants of health of the
new millennium.
This conference denotes several 'firsts' in the history of
health promotion. It was for the first time an
international conference on health promotion was
hosted by a developing country in the South East Asia
region and the first in which the contribution from
private sector was seen. And for the first time, they have
openly declared “health promotion makes a difference”
by considering the evidence presented in the
conference.
The evidence based strategies for effective health
promotion stated in the document are,
1. adopting comprehensive approaches that
encompass all health promotion actions
2. conducting settings based interventions for
effective results
3. keeping communities at the center of the
inter v entio n s t o ensu r e s u staina b ility
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4. increasing access to education and heath
r el a t e d i n f o r m a t io n f o r c o m m u n it y
participation and empowerment
The conference also identified priority areas for health
st
promotion in the 21 century as stated below.
1. Promoting social responsibility for health,
great e r i nvestm ents on healt h and
r e c h a nneli n g ex i s t i n g i n v e s tment s
effectively
2. Breaking through traditional boundaries of
health to establish partnerships with all the
stakeholders involved
3. Capacity building of communities and
empowerment of individuals to make
healthier choices
4. Securing infrastructure (funds, resources,
training, documentation etc.) for health
promotion
The participants also pledged on making a global
alliance for health promotion to share resources and
expertise to facilitate progression of global health
promotion (WHO, 1997a).
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There were several follow up activities by WHO after
the Fourth Global Conference on Health Promotion
held in Jakarta. Initiation of Mega Country Health
Promotion Network, strengthening of Global School
Health Initiative, developing the concept of health
promoting workplaces and developing evaluation tools
to review health promotion activities are some of those
activities (Tissera & Damboragama, n.d.).
Mega Country Health Promotion Network included 11
countries that had more than 60% of the world's
population and the goal of this network was to promote
healthy lifestyles (Kennedy, 2002). The priority areas
recommended by the Jakarta Declaration were later
th
confirmed and recommended by WHO in their 55
World Health Assembly Resolution, based on the
evidence provided by 10 countries with a population
more than 100 Million (WHO, 1998a).
The Global School Health Initiative launched in 1995
later became one of the primary health promotion
efforts of the World Health Organization after
introduction of the approach following the Jakarta
International Conference on Health Promotion (WHO,
1998b).
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Chapter 05
The New Millennium
2000 - Mexico
The main objective of the Fifth Global
Conference on Health Promotion held in
Mexico was to address the increasing health
gap seen throughout the world. 'Mexico Ministerial
Statement for the Promotion of Health; from Ideas to
Action' was the statement signed by the Health
Ministers participated for this conference in June 2000.
The main objective was to address the
increasing health gap seen throughout the
world.
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The Ministers agree in that statement about the presence
of great amount of evidence on effectiveness of health
promotion approach and realize there is an urgent need
to address determinants of health by collaboration
between different sectors.
They also agreed to make health a priority in policies
formulated at all levels, to lead and collaborate other
sectors to promote health and to prepare countrywide
action plans for health promotion. The country plans
recommended were to have a basic conceptual model
that may vary within the context of country
requirements.
The action areas proposed for the framework of country
action plans in the statement are (WHO, 2000),
1. Formulating public policies to address health
priorities
2. Supporting research on health promotion
3. Mobilizing resources to build capacities for
implementing national health plans
4. Establishing supportive networks for health
promotion
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2005 - Bangkok
The Bangkok Charter for Health Promotion in a
Globalized World' expresses the views of experts in the
field of health promotion from all over the world who
participated in the Sixth Global Conference on Health
Promotion in the year 2005. A need for a new charter
was felt by those present as the global environment had
undergone massive changes since the first charter for
action on health promotion produced almost two
decades back.
Even though they recognize some progress had been
made in the field of health promotion, they stress the
need for speeding up the progress of its evolvement to
address the rapidly emerging health determinants in the
fast moving globalized world of the modern era. In the
mea n time impro v ement of info r matio n and
communication methods across the world, facilitating
sharing of knowledge and expertise was recognized as a
new opportunity for the evolving of health promotion
(WHO, 2005).
The experts in the Sixth Global conference strongly
recommend utilizing the proven effective strategies of
health promotion. Five required actions were identified
within these strategies.
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1. Advocating for health
2. I n v esting in p o l icies, actions and
development of infrastructure to address
determinants
3. Capacity building at all levels
4. Formulating rules and regulations to ensure
equity
5. Building partnerships with all the parties
involved so sustainability will be ensured
The Bangkok Charter describes four key commitments
to promote health in each level of action. Putting health
promotion in the center of the agenda of global
development so that the harmful effects of trades,
products, services and marketing strategies can be
addressed through global governance; making health a
core responsibility in governments at all levels and in all
different sectors within them are the first two key
commitments such identified.
The experts also identifies that empowered and well
organized communities have the potential to lead health
interventions effectively thus building capacities and
providing opportunities should be done in communities
and civil societies to make health their key focus. As the
corporate sector has gained more power in the
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30

globalized, modernized world, Bangkok Charter
realizes its ability to influence health and suggests
making health promotion a requirement of good
corporate practice as its final key commitment (WHO,
2005).
2009 – Nairobi
'Nairobi Call to Action for closing the Implementation
Gap in Health Promotion' is the end product of the
Seventh Global Conference on Health Promotion, the
latest of the global conference series held at Nairobi,
Kenya in 2009.
The document identifies health promotion as the most
cost-effective strategy not only to promote health but
also to reduce inequities in health and poverty. By
making people healthy and creating just societies,
health promotion will help the governments to achieve
variety of global and national developmental goals.
The call states that there are implementation gaps in the
areas of evidence, policies, practice, leadership and
political commitment that prevent the approach to
achieve its full potential. These gaps will not only result
in adverse health impacts like disease and suffering but
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also will produce a wider range of adverse outcomes in
social and economical dimensions.
To make use of the full potential of health promotion,
The Call suggests advocating governments by
1. using existing evidence
2. revitalizing public health by community
centered strategies
3. using the maximum capacities and resources
available at community level
to address the double burden of communicable and non-
communicable diseases.
The experts in the conference also pointed out the
importance of putting health in the agenda of all policy
makers to reduce health inequities to increase the
quality of life of people and attainment of development
goals. They also requested to establish a global plan for
health promotion and a mechanism for sharing
resources and expertise.
Strategies and actions recommended in the Nairobi Call
to Action were categorized under five sub themes that
complement each other across their thematic
categorization.
1. Building capacity for health promotion
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2. Strengthening health systems, partnerships
and inter-sectoral action
3. Community empowerment
4. Health literacy
5. Health behaviours
The Call has also identified five urgent responsibilities
of partners and stakeholders involved in health
promotion. Strengthen leadership and workforces,
mainstream health promotion, empower communities
and individuals, enhance participatory processes and
build and apply knowledge are those urgent
responsibilities they immediately call for action (WHO,
2009b).
Thus health promotion has evolved as an approach since
its first global conference in Ottawa in 1986, following a
series of global conferences and documents. Many
concepts and key terms also evolved with the approach
and became widely popular among the health promoters
throughout the world. Some of those key terms and
related concepts will be described in the next section.
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34

Chapter 06
Concepts in Health
promotion
There are several concepts and key terms that
need to be understood by the health personnel
for them to effectively apply health promotion
approach in their work. Comprehension of the concepts
of health and health promotion is foremost.
....a positive concept emphasizing social and
personal resources, as well as physical
capacities
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Health
The definition of health currently accepted and widely
used is the definition stated in the Constitution of WHO,
“health is a state of complete physical, mental and social
well-being and not merely the absence of disease or
infirmity” (WHO, 2006).
In the era of its origin many controversies arose with it
for several reasons. The main argument was that it is an
unrealistic and idealistic view of health and is
unachievable in practical day to day life. Considering it
as a 'complete state' was also criticized as a concept that
link with life and nature will never exist in such a static
status but be dynamic. The facts that it is not measurable
and it fails to include the spiritual dimension of
wellbeing were also argued against (Tissera &
Damboragama, n.d.a).
The Ottawa Charter for Health Promotion identifies the
comprehensiveness of this idealistic definition but goes
beyond its abstract state to describe health in a new
positive dimension (Nutbeam, 1998).
It identifies that health is, “a resource for everyday life
rather than an objective of living….. a positive concept
emphasizing social and personal resources, as well as
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36

physical capacities” (WHO, 1986). In simple terms,
health is not an end state that we should aim to achieve
but a resource that must not be wasted and used
optimally.
Equity in health is one of the pre-requisites for health, as
mentioned in the Ottawa Charter. It is widely proven
that most of the inequalities in health are due to the
inequities as identified by the definition of equity in
health - “the absence of disparities in health (and in its
key social determinants) that are systematically
associated with social advantage/disadvantage”
(Braveman & Gruskin, 2003).
Evidence is abundant that great differences exist
between health statuses not only among different
countries but also between groups within the same
country.
The terms equity and inequality is not interchangeable
as all health inequalities may not necessarily reflect
inequities in health. Inequities in health refer to
unnecessary, avoidable, unfair and unjust differences in
health status among different groups.
It is widely accepted that equity in health is grounded in
ethical and human right principles as inequities place
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the socially disadvantaged in a deeper disadvantageous
state. Therefore creating equal opportunities for health,
with fair distribution of resources and processes
implemented to target reduction of health gaps between
socially advantaged and disadvantaged is necessary to
achieve equity in health (Whitehead, 2000).
Health goes beyond the physical dimension to
encompass social and other factors which may act as
resources as well as determinants of health. Thus,
Ottawa Charter identifies and describes an approach
with specific actions and strategies to promote
individuals and communities to achieve such a state of
health – health promotion.
Health Promotion
Health promotion is first described in the Copenhagen
Discussion Document on the Concept and Principles of
Health Promotion in 1984. The definition “the process
of enabling people to increase control over, and to
improve, their health” was later adopted by Ottawa
Charter for Health Promotion in 1986.
Nutbeam (1998) further elaborates it as “the process of
enabling people to increase control over the
determinants of health and thereby improve their
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38

health” in his second revision of the Health Promotion
Glossary.
The basic concept behind both these definitions is a
process which develops people's abilities to assume the
power that is due over conditions affecting their health.
Even though several definitions evolved since then,
definitions that vary in their level of specificity and
elements, few identify the above mentioned essence of
the approach – the process of empowerment.
Thus the activities that do not have 'empowerment' as
their fundamental concept cannot be labeled with the
'health promotion' title. Even though many diseases
could be prevented by health promotion, disease
prevention and health promotion are not synonymous
but complementary to each other (Rootman et al, 2001).
As outlined earlier, Ottawa Charter further classifies
action in health promotion into five broad action areas.
These are building healthy public policy, creating
supportive environments, strengthening community
actions, developing personal skills and reorienting
health services.
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1. Build Healthy Public Policy
While acknowledging the fact that health policies alone
cannot build supportive environments to promote health
as many determinants lie outside the traditional
boundaries of the health sector, all public policies
should be healthy.
The concept of Healthy Public Policies is discussed
comprehensively in the Adelaide Recommendations on
Healthy Public Policy (1988). The key features in a
healthy public policy are that the policy concerns about
health and equity at all levels and is accountable for the
health impact it generates.
As the term 'public policy' commonly denotes
legislative documents of governments, it is implied that
governments are accountable for their people's health
outcomes resulting from the presence or absence of
certain policies. This concept is closely linked with
investment for health as the decisions regarding public
investments are based on policies (Nutbeam, 1998).
As health promotion is a community centered approach,
it is not surprising to see the first action area building
healthy public policy commonly interpreted in a more
practical and community oriented terms. The policy
formulations at the levels of individual, family and
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40

community settings are sometimes used as a health
promotion strategy all over the world. As an example,
the Global School Health Initiative describes that a
school has to implement polices with concern about
students wellbeing if it is to be named as a 'Health
Promoting School' (WHO 1998b).
2. Create Supportive Environments
As described earlier, the term environment does not
mean only the physical environment around individual
an d communities. Thus, b uilding suppo rtive
environments for health not only offer opportunities for
enabling and empowering individuals and communities
to take control of health determinants but also
protection from threats to health (Nutbeam, 1998).
Some health promoters see this as the most important
action area because the immediate physical and social
environment has a considerable amount of influence on
the lifestyles of individuals, which in turn greatly
determines their health status. Therefore, if the
environmental factors can be changed to promote
people to obtain and sustain healthy lifestyles,
empowering them to achieve highest possible level of
health can be done without much difficulty
(Samarasinghe et al, 2011).
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The Ottawa Charter describes that “health is created and
lived by people within the settings of their everyday life;
where they learn, work, play and love” (WHO, 1986).
Nutbeam (1998) explains settings for health as a place
or social context in which people engage in routine
activities and in which determinants of health
(environmental, organizational and personal) interact
with each other and with individuals or communities to
influence their health.
This concept later led to establishment of health
promoting schools, villages, cities, islands, worksites,
market places and also health promoting hospitals.
A settings approach provides a framework to identify
the links between determinants of health and facilitates
integrated action on a wider range of health risks in a
given setting. It also helps the health workers to
establish working relationships with other sectors and
provides effective channels and mechanisms for
delivery of health promoting programmes making them
efficient in time and resources. In community settings, it
also mobilizes the community leaders to actively
involve and own the interventions making them
sustainable (WHO, 2003).
But Whitelaw and others (2011) argue that by using
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42

above mentioned large conventional settings, the
individuals who are not included in them and probably
who are socially disadvantageous compared to their
involved counterparts will miss the opportunities to
improve their health, widening the existing gaps and
creating inequities.
3. Strengthen Community Actions
Strengthening community actions for health was
evident throughout the history and it was recognized as
an effective strategy with the concept of primary health
care. But, utilizing that strategy was deliberately
forgotten especially by the industrialized countries who
did not believe in bottom up approaches.(Leeder, 2005).
Ottawa Charter identified strengthening community
actions for health as an action area and strongly
recommended to use it for setting priorities, planning,
implementing and reviewing interventions of health.
In the context of health promotion, community actions
for health refer to activities that are collectively
implemented by communities with the intension of
improving their health by controlling determinants
(Nutbeam, 1998).
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According to Preston and others (2010), it is described
as empowerment model of community participation –
one of the four conceptual models identified on the
subject. Ottawa Charter and most subsequent
documents regarding health promotion identified that
empowered communities acting towards promoting
health is a potential and a powerful resource that should
be utilized effectively.
4. Build Personal Skills
nd
Nutbeam (1998) in his Health Promotion Glossary; 2
Revision, describes personal skills as a set of skills
similar to the popular 'life skills', based on a publication
of WHO in 1993 on life skills education in schools.
Ability to identify and realize aspirations, satisfy needs
and ability to change or cope with the environments are
the skills identified by the Ottawa Charter as the skills
that a group or an individual should develop with a
process of health promotion.
Thus many health promoters do not agree with Nutbeam
and believe that the term 'personal skills' does not
denote a rigid set of skills and that the skills required
change with the environments and the communities
involved. Major actions that are required to develop
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44

personal skills are ensuring free exchange of
information and experiences on health and provision of
opportunities for lifetime learning.
5. Re-orient Health Services
The concept of re-orienting health services speaks
about changing the attitudes and structure of health
services to target population health outcomes rather
than individual disease prevention (Nutbeam, 1998).
Lalonde, (1981) in his report spoke about the need for
changing the perceptions of health sector to promote
health rather than treating ill health.
The health care sector itself is identified as a
determinant of health by many health promoters all over
the world as sometimes health services causes gaps in
health. Baum and others (2009) argues that health
services should be free from its narrow bio medical
imagination of health and concentrate on approaches
that generate health equity by addressing a wider range
of social determinants. Ontario Resource Team (n.d.) in
its online course teaches that health services should be
re-oriented to “work with people rather than for them”.
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Community Empowerment
Community empowerment can be thought as the heart
of the conceptual model of health promotion. The term
empowerment was first introduced in 1981 by Julian
Rappaport in his presidential address to the Division of
Community Psychology of the American Psychological
Association. It was defined as “the mechanism by which
people, organizations and communities gain mastery
over their lives” (Rappaport & Hess 1984).
Nutbeam (1998) redefines the term in the context of
health promotion – “empowerment is a process through
which people get greater control over decisions and
actions affecting their health” in his Health Promotion
Glossary. According to him, empowerment is achieved
mainly by the second and fourth actions of health
promotion; creating supportive environments and
developing personal skills.
Outcomes of community empowerment include (WHO,
2006b);
1. social capital and community bonding
2. neighbourhood cohesion and influence
3. sharing of capacities and resources within the
communities
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46

4. increased community participation
5. change of social norms
6. improved material conditions
7. equity in health
DARE criteria (D – community Determines the goals; A
– community Acts to achieve the goals; R – community
Receives the benefits from the action; E – community
participates in Evaluating the action) can be used to
assess the level of empowerment in health promotion
initiatives (Tissera & Damboragama, n.d. b).
Health promotion action aims at enabling people to
achieve their fullest health potential. Enabling is the
process of empowerment in the context of health
promotion. 'Enable' is identified as one of the main
three strategies for health promotion in the Ottawa
Charter (1986). It refers to acting in partnership with
individuals or communities to empower them by
mobilizing human and material resources necessary to
improve and maintain their health (Nutbeam 1998).
Emphasis lies on the words 'in partnership' that denotes
an active and participatory mechanism rather than a
passive process.
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Inter-sectoral Action for Health
The need for collaboration with other sectors to improve
population health came to light with the Alma-Ata
Conference, which declared that health sector alone
cannot improve people's health (WHO, 1978).
The conference on Inter-sectoral Action for Health held
in Canada in 1997 defined it as “a recognized
relationship between part or parts of the health sector
with part or parts of another sector which has been
formed to take action on an issue to achieve health
outcomes, (or intermediate health outcomes) in a way
that is more effective, efficient or sustainable than could
be achieved by the health sector acting alone” (WHO,
1997b).
Nutbeam (1998), in the Health Promotion Glossary
further elaborates on this definition and explains that to
achieve equity, intersectoral action is very much
important as the progress of processes that address
determinants outside the health sector depends on the
support from the relevant sectors. He further argues that
if an intervention that promotes health to be named as an
'intersectoral action for health', it does not always
require health sector as a partner.
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A major goal of intersectoral action is to move towards
healthy public policy by increasing awareness about
health consequences of policy decisions in different
sectors. Adelaide Statement on Health in All Policies;
Moving towards a shared governance for health and
well-being, stresses that health sector must learn to
work in partnership with other sectors, need to be open
minded and outward oriented with necessary technical
competence, skills and attitudes (WHO, 2010b).
Determinants of Health
Determinants of health are defined as “the range of
personal, social, economic and environmental factors
which determine the health status of individuals or
populations” (Nutbeam, 1998). They are multiple and
interactive in different levels and some are even non-
modifiable.
One of the fundamental principles of health promotion
approach is to address and modify determinants of
health that are beyond each individual's control (social,
economical, political etc.) to promote individual and
population health. The most popular among them are
the 'social determinants of health' which are believed to
be the main culprits of generating inequities of health
(WHO, 2008).
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The Commission of Social Determinants of Health in
their report 'Closing the gap in a generation: Health
equity through action on the social determinants of
health' gives evidence to this and as health promotion
approach is proven to be effective in addressing them,
the need for utilizing its maximum potential by the
strategies recommended is timely and much felt.
The presence of a comprehensive set of diverse
concepts and principles not only make the health
promotion approach unique but also widens the scope of
subject matter if one is interested in learning it to put
into practice. The following chapter describes what is
commonly identified as knowledge competencies in
health promotion.
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50

Chapter 08
Knowledge Competencies
in Health Promotion
Ahealth promoter could be anyone. As Ontario
Health Promotion Resource System defines,
“a health promoter is someone who works to
promote health as defined in the Ottawa Charter,
regardless of professional designation. It includes
people, organizations, and groups from various sectors.
Health promotion work may be paid or voluntary”
(Ontario Health Promotion Resource System, n.d.).
However, there have been many efforts made by the
WHO as well as other agencies, who work on Health
Promotion, to identify a common set of competencies
for those who undertake health promotion globally.
...a health promoter is someone who works to
promote health as defined in the Ottawa
Chart e r, regar d l ess of profes s i onal
designation.
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Knowledge is identified as one of the five core
competencies in health promotion (Australian Health
Promotion Association, 2009).The knowledge
competencies that an entry level health promotion
practitioner needs to have are listed below as it appears
in that document.
Knowledge competencies (Australian Health
Promotion Association, 2009, p. 5-6)
“An entry level health promotion practitioner is able to
demonstrate knowledge of:
5.1the following concepts: definition of health
and health promotion, inequalities inequities
in health including the concept of social
gradient and relevance to practice, the action
areas for health promotion, as well as the
de t e r m i n an t s o f h e a lt h ( b i o l o g i ca l ,
behavioural and socio-environmental);
5.2of the biomedical, behavioural and socio
environmental models of health and their
relevance to health promotion practice in
general and needs assessment in particular;
5.3the history and development of health
promot ion ( including Alma Ata 19 78,
Ottawa Charter 1986, Sundsvall Statement
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52

1991, Jakarta Declaration1997, Mexico
Ministerial Statement 2000, and the
Bangkok Charter 2005);
5.4the health promotion principles of practice:
ev i d e n c e - b a s e d p r a c t i c e , e q u i t y,
mu l t i d i s c iplinary k n o w l e d ge b a s e ,
in ter sectoral collaboration,
population health approach, multi-
strategic i n t e r ven t i o n s ,
effective partnerships, c u lt u ra l
competence;
5.5stages of program planning, strategy
selection, implementation, evaluation and
sustainability of programs;and
sustainability of programs;
5.6relevant theories and models of behaviour
change, social and political
change, social m a r k e t i n g ,
organisational development;
5.7health promotion strategies to promote
health – health education, advocacy,
lobbying, media campaigns, community
d e ve l o p m e n t p r o c e s s es , p o l i c y
development, legislation;
5.8quantitative and qualitative evaluation
methods and uses;
5.9descriptive statistics and basic epidemiology
definitions and concepts;
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5.10literature searching and critical analysis;
how to access peer reviewed journals from a
variety of relevant disciplines such as health
promotion, public health, social
sciences, p u b l i c p o l i c y ,
c o m m u n i c a t i o n , m e d i a a n d
organizational change disciplines;
5.11the Australian health system and broader
systems that impact on health;
5.12the use of policy in promoting and
maintaining the health of populations;
5.13effective interpersonal, group and public
communication and effective written and
oral communication and media strategies;
and
5.14resource development and pre-testing
resources”.
The fifteen core competencies that should be built in the
regional health promoters which was identified by the
WHO South East Asian Regional experts in 2010, also
named knowledge and comprehension of health
promotion as a core competency (WHO, 2010a).
They further subdivided it into three categories:
1. “demonstrate knowledge of health system,
health promotion principles, practice
and determinants of health;
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54

2. apply the knowledge to improve the
wellbeing of people and the community;
3. disseminate knowledge and best practices”
In this meeting, most countries expressed that there was
a massive shortage of skilled manpower to carry-out
health promotion processes. They also identified that
health promotion training is unstructured and limited to
short in-service and post-service courses. Only a few
countries in South East Asia region had opportunities
for graduate and higher level trainings and only Sri
Lanka had a dedicated degree programme on health
promotion in the region at that time.
According to the experts in that meeting, the existing
short courses, including diploma courses, did not focus
on a particular set of competencies and the expected
outcomes were largely in cognitive terms (WHO,
2010a). This gap in meeting the training needs can be
clearly seen as a structural barrier for application of
health promotion.
Health Education Bureau of Ministry of Health Sri
Lanka conducted a workshop in 2002 to develop a
training manual on health promotion with the
participation of middle level health managers (Medical
heal th pr om t ion - a lit erature reviewo55

Officers of Health, Medical Officers of Maternal and
Child Health, Regional Epidemiologists, Health
Education Officers, Public Health Nursing Sisters and
Supervisory Public Health Inspectors).
The components of a training manual they identified
were: (Tissera & Damboragama, n.d.c, p. 10)
1. “holistic concept of health and determinants
of health;
2. concept and strategies for health promotion;
3. partnership building for health promotion;
4. advocacy for health promotion;
5. settings approach for health;
6. community development approach”
To gain effective population outcomes, a health
promoter has much to learn regarding the approach,
applying it in the real life setting and monitoring the
progress (or the lack of it). Many successful yet small
scale health promotion processes that can be seen in
various parts of Sri Lanka can be scaled up only if the
structural barriers are addressed at macro level.
As Ottawa charter describes, “Health is created and
lived by people in the settings of everyday life, where
they learn, work, love and play” (1986b). This is
applicable not only to the specific thematic area
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56

identified as Health Promotion, but also for every
discipline which talks and works about 'health'.
Therefore health interventions are unlikely to render
the health outcomes that they envision achieving unless
the intervention is not translated into better health that is
created and lived by all people in the settings of their
everyday life. For this reason, it is very important for Sri
Lanka to identify ways and means of building health
promotion competencies among those who can be
health promoters in a more systematic way while
appreciating the specificities and principles of health
promotion.
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58

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