A framework for global health promotion: The Circle of Health

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An individual’s health is a
combination of many driving
internal and external factors. To
protect and to promote health, various
interventions have been developed but
often many factors are overlooked, and
these therefore lack sustainability. The
Circle of Health (COH) is a translational
tool and value-based framework that
effectively links together all these health
factors to provide effective education,
planning, collaboration and evaluation
in health promotion. By simplifying the
complexity of health into a usable tool,
it plays an important role in helping to
bridge gaps in health promotion and
disease prevention versus lifestyle and
social factors. The COH integrates the
concepts required to plan for health at an
individual, family, community, system and
societal level. The COH can also be used
to re-analyse ndings and provide the
whole picture for the dynamics of health.
Its particular strength compared to other
models is its relevance. Taking a holistic
approach, the framework incorporates a
complete understanding of health, health
promotion strategies, determinants of
health and six key values such as caring
and justice.
It is written in plain language text and
arranged as a multi-coloured tool with
moveable rings which reminds one of a
compass. Visual and kinetic learners nd
it easy to use. The COH is designed to
overcome barriers of low literacy, and is
structured to provide a holistic, ‘health in
all settings’ approach. Today, the COH is
used worldwide and has been validated
and internationally evaluated. The COH
is also delivered in a workshop format,
and is available in six different languages
and is transferable to diverse settings
in 20 countries.
The COH was developed in 1996
during health reforms in Prince Edward
Island, Canada. Originally created
to generate a shared understanding
of health promotion amongst many
sectors, COH was developed from
a consultative community-based,
community development process: a
collaboration involving individuals from
government and marginalised sectors.
Funding came via a partnership including
the Prince Edward Island (PEI) Health and
Community Services, Canadian Public
A framework
for global health
promotion:
The Circle of Health
The Circle of Health (COH) is
an interactive and exemplary
framework that bridges gaps
in health promotion and draws
together both the external
and internal factors that drive
our health. Spearheaded by
Patsy Beattie-Huggan, BN,
MScN, founder and president
of The Quaich Inc., this novel
tool was developed, rened
and evaluated through broad
consultation in PEI, Canada.
With collaborators Kirsten
Steinhausen and Stephanie
Harsch, the team is now focusing
on how it can be used to identify
translational gaps in WHO
declarations, and disseminated
more broadly.
Health and
Medicine Patsy Beattie-Huggan BN, MScN, Professor Dr. med. Kirsten
Steinhausen & Stefanie Harsch, MA Health Education
Elnur/Shutterstock.com
“The Quaich” is a
Scots rendering of the
Gaelic word meaning
“cup”. They date back
centur ies, and are a
symbol of friendship
and community.
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Health Association, Health Promotion
Network Atlantic and the PEI Women’s
Network. Patsy Beattie-Huggan, founder
and President of The Quaich Inc. has
been at the forefront of the development,
use and education of the COH since
the outset. Together with collaborators
Kirsten Steinhausen and Stefanie Harsch,
with the support of Luis Saboga-Nunes,
the team is now focused on using the
COH in different environments and for
diverse target groups to bridge the gap in
the release of World Health Organization
(WHO) declarations where translational
strategies are missing.
UPTAKE AND EVALUATION
Soon after the launch of the COH, it
was observed that there had been
a spontaneous uptake of the COH
in Canada and other countries. This
prompted an evaluation in 1997, which
reported that users in multiple settings
including education, research, and
planning rated both the concept and
design highly at 91%. Patsy Beattie-
Huggan explains: “The unanticipated
uptake of the COH internationally speaks
to a need for tools that focus on holistic
health and empower stakeholders in
multiple sectors to work together.” In
2004, international reviewers from the
UK, USA, Australia and Canada provided
positive feedback on the relevancy of
the COH. With further work, a website,
online workshops, facilitator manual and
supplemental knowledge translation tools
were developed.
The Quaich started delivering online
workshops in 2008. In 2014, the
evaluation of the online workshops
showed that 100% learned from the
online workshops; 91% regard the COH
as useful to engage others; and 83%
found it benecial to address social
justice and health equity. In 2018 the
online workshops were adapted and
delivered as credit courses for students at
Furtwangen University, Germany. Positive
evaluations were received from students
and it was concluded that implementing
online training is an ideal method to train
facilitators in different places.
As of 2018, over 10,000 English and
700 copies in other languages of the
COH have been distributed. Workshops
have also been held internationally and
many facilitators trained. Researchers,
practitioners, and academics have found
it to be clear, easy to use and all inclusive.
Some are introducing it to students and
encouraging them to use it as a planning
and assessment tool.
The tool has been utilized in contexts
where students’ rst language is not
English. A 2018 study conducted by
researchers in Freiburg, Germany
analysed existing health interventions for
refugees in Germany and assessed the
As a shared framework in addressing
complex organisational and global issues
[the COH] could ll the gap.
Rawpixel.com/Shutterstock.com
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to a range of different learning styles
and level of education, and has the
ability to inspire new approaches
to health promotion.
CONCLUSION AND
LESSONSLEARNED
The continued relevance of the COH
demonstrates that tools that employ
a holistic approach and are based on
values resonate with a wide range of
users. The COH has been successfully
applied across different languages and
cultures. It is relevant to practitioners,
educators, researchers, policy makers,
and the general public. Patsy Beattie-
Huggan explains: “This speaks to its
global potential as a useful framework
and tool for collaboration to address
complex issues.” Because of these
qualities, COH is well-placed to meet
the demand for translational tools
to implement WHO declarations.
health promotion. The COH promotes
the inclusion of values, the Ottawa
Charter, determinants of health and
the aboriginal medicine wheel. It has
been validated by multiple stakeholders
and demonstrates a holistic approach
to areas such as culture and literacy.
As a shared framework in addressing
complex organisational and global
issues it could ll the gap.
VALIDATION AND REDESIGN
Multiple stakeholders have validated
the COH concept. These include
Aboriginal elders, self-help groups and
people with intellectual disabilities. They
recommended adding the Aboriginal
Medicine Wheel, determinants of
gender and culture and plain language
materials to the original prototype
design. As a model of best practice,
the COH has a global potential to be
the ‘people’s framework’. It appeals
feasibility of the COH as an analysing
tool. Over 150 interventions were
identied and analysed. Notably,
the COH helped to identify and
systematically organise the broad eld
of interventions, analyse the approaches
in general, explore gaps, raise
awareness of unaddressed areas (e.g.
critical health literacy) and of underlying
principles and inspire the development
of new interventions.
BRIDGING THE GAPS:
WHODECLARATIONS
It is vital to analyse the health
promotion approaches in a country
comprehensively, considering its most
relevant factors and how they link
together. The COH is therefore ideally
placed to bridge the theory to practice
gap in health promotion because it is
holistic. Importantly, the COH can also
assist policy makers and community
leaders undertake steps to promote
health at a system-level.
A gap in the release of the WHO
declarations (Ottawa Charter-Shanghai
Declaration) highlights that translational
strategies have been missing. There
are a number of reasons why the COH
can plug these gaps. It is already used
worldwide and is a translational tool for
The continued relevance of the COH
demonstrates that tools based on values,
validated with multiple stakeholders,
with a holistic approach resonate with a
wide range of users and can be applied
across different languages and cultures.
Circle of Health Wor kshop - EUPHA Conference
2018, Ljubljana, Slovenia.
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Behind the Research
E: patsy@thequaich.pe.ca T: +1 902-894-3399 W: www.thequaich.pe.ca
E: stefanie.harsch@ph-freiburg.de E: kirsten.steinhausen@hs-furtwangen.de
Stefanie Harsch, MA
Professor
Dr. med. Kirsten
Steinhausen
Patsy
Beattie-Huggan
BN, MScN
Detail
Research Objectives
To support knowledge translation and innovation in
applications of the Circle of Health© (COH). One of the
leading consulting tools in health promotion, the COH aims
to analyse, plan and implement programs and identify gaps.
The Quaich Inc., Charlottetown, PEI, Canada
www.thequaich.pe.ca
www.circleofhealth.net
Bio
Patsy Beattie-Huggan BN, MScN, founder and President
of The Quaich Inc. has provided leadership in nursing
education, health system redesign, health promotion
and development of the Circle of Health©, holding a
Bachelor of Nursing from the University of New Brunswick
and MSc in Nursing and Health Studies from the University
of Edinburgh.
Professor Dr. med. Kirsten Steinhausen holds the position of
Professor for Health Sciences and Vice Dean at The Faculty
of Health, Safety and Security, Furtwangen University.
She has experience of hospital project management where
she has implemented evidence-based guidelines. Her
research interests include public health, health policy, health
economics, evidence based practise and health promotion
in the workplace.
Stefanie Harsch, MA, Ph.D. student, works as a research
associate at the University of Education Freiburg, Germany
in a research project supported by the German Federal
Ministr y of Education and Research focussing on promoting
health literacy of people with migration and refugee histor y
in German as a second language course.
Funding
Funding for the development of the Circle of Health
came via a partnership including the PEI Government,
Canadian Public Health Association, PEI Women’s Network,
and Health Promotion Network Atlantic.
Collaborators
Gratitude is expressed to the many people who
contributed to the development, evaluation and
dissemination of the Circle of Health, with special thanks to
Luis Saboga-Nunes, President, EUPHA Health Promotion
Section for more recently encouraging its application in
the European context.
References
Beattie-Huggan, P. (2016). Circle of Health - A holistic and
systematic approach to health promotion research, education
and practice. SpiritualitéSanté, Vol. 9, No. 1 (Published in
French; available in English in (Health Promotion Preliminary
Research Report: Looking Back ... Moving Forward, p. 33-38,
Alliance for Health Promotion, Versoix, Switzerland (2016).
Beattie-Huggan, P. (2018). Circle of Health – a unique
knowledge transitional tool with global potential. European
Journal of Public Health, Volume 28, Issue suppl_4, November
2018, cky214.185, https://doi.org/10.1093/eurpub/
cky214.185.
Harsch, S., Beattie-Huggan, P., Steinhausen, K., Saboga-
Nunes, L., & Bittlingmayer, U. H. (2018). Applying the circle of
health to analyse health interventions for people with refugee
experiences in Germany. European Journal of Public Health,
28(suppl_4), cky213-823.
Mitchell, T., Beattie-Huggan, P. (2006). Bridging the distance
between lifestyle and determinants of health approaches:
The Circle of Health as a synthesis tool. International Journal
of Health Promotion & Education, Volume 44 (2): 78 – 82.
PEI Health and Community Services Agency. (1996). Circle
of Health©, Charlottetown (PE, Canada).
Rocha, D., Beattie-Huggan, P., (2016). Potential of distance
learning using a shared framework amongst a community
of dispersed learners across large geographic areas for
implementing a local, national, regional, and global strategy
Presented at 22nd IUHPE Conference, 2016, Curitaba, Brazil.
Personal Response
The Circle of Health has gone from strengt h tostrengt h.
What is next for the tool?
The potential for the Circle of Health to be used in
additional settings such as those working with children,
refugees and vulnerable populations is endless. The hope
is to expand its use internationally - and share stories
of its use to facilitate a shift to a more holistic approach
to promoting global health.
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