In the first chapter of Marmot and Wilkinson "Social Dererminants of Health"
volume they have a model of determinants of health. They have lines that run
directly to health outcomes from various structural aspects of societies. They
also have lines that run from these same structural aspects of society to health
behaviours to health outcomes. The BC model and most others only have this
latter conceptualization. This allows policy makers and health workers to
assume that the "solvable" problems are at the behavioural level with a little
support from tinkering with the structural aspects. The former model indicates
that the structural aspects of society have direct (and strong) links to health
outcomes. Modifying risk behaviours -- difficult to do in any case -- will not
effect the structural-outcomes links and should direct attention to the need to
deal with these structrual determinants of health.
When one pulls back from the minutiae of programs and interventions (visit
Scandinavia or Northern Europe on vacation for example or think about Canada vs.
the USA scene ) it becomes even more apparent that lifestyle approaches to
health are really missing the health promotion boat. It has to be ideology that
is driving the emphasis we see in many of our HP programs. The following will
appear in a USA based newsletter and may be of interest.
Models of Illness, Models of Health, Models of Society
Dennis Raphael, Ph.D.
School of Health Policy and Management
York University, Toronto, Canada
Health promoters require frameworks for making decisions about their goals,
and choosing activities for reaching these goals. Health promotion is an
exceedingly ideological activity in which beliefs and values determine the
nature of problems, means for dealing with these problems, and means of
evaluating success. Contrary to common notions, such decisions are not usually
evidenced-based but rather based on shared frameworks of meaning.
A most interesting example of the role ideology plays in health promotion
can be seen in the form that health promotion has taken in Canada and the USA.
In Canada, government policies and documents have adopted the World Health
Organization
's definition as outlined in the Ottawa Charter for Health
Promotion: Health promotion is the process of enabling people to increase
control over, and to improve, their health. In contrast, policy makers and
practitioners in the US embrace the definition outlined by the American Journal
of Health Promotion: Health promotion is the science and art of helping people
change their lifestyle to move toward a state of optimal health. The
implications of adopting each of these approaches are profound and any one
familiar with the Canadian and US health promotion scene can see their results.
The former definition leaves the door open to consideration of the role that
structural aspects of society play in health and illness; the latter definition
reduces all of health and illness to individual choices made by individuals.
In Canada, there is another debate that has implications for health
promotion. This debate is concerned with the Canadian model of population health
that has captured the attention of health promoters in the US and elsewhere. The
term population health has a variety of meanings but in the Canadian context it
has come to signify an approach developed by the Canadian Institute for Advanced
Research (CIAR) that considers how system-level variables influence the health
of populations. Not only has the CIAR definition and approach profoundly
influenced the direction that health policy has taken in Canada, but there is
increasing evidence that it is poised to influence health policy in the USA.
The CIAR population health approach was first described in the Social
Science and Medicine paper Producing Health, Consuming Health Care and further
elaborated in the volume Why Are Some People Healthy and Others Not?: The
Determinants of Health of Populations. The most recent volume from the CIAR
group is Developmental Health and the Wealth of Nations considers the
relationship between early childhood development and population health.
CIAR has outlined ten health determinants that have achieved an orthodoxy
within Canadian government documents on population health. These are income and
social status, social support networks, education, employment and working
conditions, physical environments, social environments, biology and genetic
endowment, personal health practices and coping skills, healthy child
development, and health services. These factors are researched by CIAR through
large-scale epidemiologically-oriented surveys.
The idea of population health developed by the CIAR has challenged health
promotion as the dominant approach to Canadian public health policy. And there
are clear signs that USA policy makers are examining the value for US public
health policy of the CIAR idea of population health. The US National Committee
on Vital and Health Statistics of the Center for Disease Control's is working
with Canadians to consider the relevance of the CIAR approach to the US scene;
the National Policy Association commissioned CIAR fellow Clyde Hertzman to
contribute a chapter to a volume on income, socioeconomic status and health; and
the State of Minnesota identified health determinants that are clearly drawn
from the CIAR list.
But a critique of population health has emerged that questions its basic
commitment to principles consistent with health promotion. The CIAR version of
population health is embedded within epidemiological thought and methodology.
It eschews pluralism in methodology and discounts the value of ethnographic and
critical forms of knowledge. Little note is taken of the role that power and
politics play in health and illness within societies. These is also an emphasis
on increasing understanding rather than action. Population health researchers
are especially keen to carry out further research but strikingly silent on the
policy implications of their work. Finally, population health's lack of a
critical perspective and concern with societal structures and their influences
upon health limits understanding about how economic and social forces influence
health and illness within societies. It has the potential therefore to be
disempowering and impotent.
For those health promoters who wish to stop tinkering with individual and
community factors that have questionable influences upon health and illness and
wish to get to the heart -- through community-based research -- of what promotes
the health of populations, a critical understanding of these debates are
essential. The reference list below should assist in this important, but
daunting task.
Reading List
Coburn, D. & Poland, B. (1996). The CIAR vision of the determinants of
health: A critique. Canadian Journal of Public Health, 87, 308-310.
Hamilton, N. & Bhatti, T. (1996). Population Health Promotion: an
Integrated Model of Population Health and Health Promotion. Ottawa: Health
Promotion Development Division, Health Canada, 1996. On-line at
http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm
Health Canada (1998). Taking Action on Population Health: A Position Paper
for Health Promotion and Programs Branch Staff. Ottawa: Health Canada. On-line
at http://www.hc-sc.gc.ca/main/hppb/phdd/resource.htm.
Labonte, R. (1995). Population health and health promotion: What do they
have to say to each other? Canadian Journal of Public Health, 86, 165-168.
Labonte, R. (1997). The population health/health promotion debate in
Canada: The politics of explanation, economics, and action. Critical Public
Health, 7, 7-27.
Poland. B., Coburn, D., Robertson, A., & Eakin, J. (1998). Wealth, equity,
and health care: a critique of a population health perspective on the
determinants of health. Social Science and Medicine, 46, 785-798.
Raphael, D. & Bryant, T. (2000). Putting the population into population
health. Canadian Journal of Public Health, 91, 9-12.
Raphael, D., & Bryant, T. (2002) The limitations of population health as a
model for a new public health: A critical analysis. Health Promotion
International, 17, 189-199.
Robertson, A. (1998). Shifting discourses on health in Canada: From health
promotion to population health. Health Promotion International, 13, 155-166.
Zollner, H. & Lessof, S. (1998). Population Health - Putting Concepts into
Action. Copenhagen: World Health Organization European Regional Office. On-line
at http://www.hc-sc.gc.ca/phdd/report.html.
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