Hi everyone.

A) As an intro...

I cannot refrain from adding my own narrative to the fascinating ones of
others (Sam, Jane, Alison, Blake etc.) on what is health promotion. I have
been devoting a good bit of the last 20 years to figure out an answer I
find conceptually and politically satisfying for myself as well as usable
in the context of an academic environment mostly defined by classical
public health (epidemiology, biostats and medical care). Those of you out
there who know me have surely heard this many times; I carry the same
overhead with me for the last 4 years... Moreover, as Ann Pederson who
knows my work very well mentioned after a comment of mine on the
involvement of professionals in more political type of work in a CPHA
session last summer: "you wrote your dissertation on this 10 years ago"...
I am encouraged by the saying of S.M. Miller, who was one of my professors
at Boston University; according to him everyone has basically one idea and
keeps rediscovering it, refining it and reframing it. So if you want  more
detailed versions of my one idea, I can give you references. But in the
mean time, I think that the issues raised by the spirited discussion on
this listserv over the last couple of days (Liz, Alison and Sam, is this
archived somewhere ? It should be reposted at least to the swedish listserv
if not elsewhere) boils down to:

1) How do we define health promotion;
2) Who can undertake health promotion activities.


B) What is health promotion

About the nature of health promotion, what I think is the big problem is
that two different but complementary things are talked about under the same
concept, creating a lot of confusion. On the one hand lies THE VISION (i.e.
the philosophy or ideology) carried under the name of health promotion; as
I have argued with my colleague Lise Cardinal, this vision as promoted in
official documents like the Ottawa Charter, the Epp document, the WHO
yellow document,  the population health literature and in may other places
is by no means new. Basically is the old public health approach to health
issues (that we can trace back to the mid 19th Century, if not to the
godess Hygea of the old Greeks), accomodated to the end of the millenium
sauce given a different global situation. Consequently, I suggest to stop
refering to health promotion when this vision is put forward and to label
it the "new" or the "ecological" public health as many have suggested.

I consequently think it is crucial to limit the use of the word health
promotion to a specific set of practices aiming at working at the planned
change of human health related behavior. As mentioned by many, we have to
consider and work on a planned manner (I dont go into the real ethical
issues that are present here for the sake making my point short) BOTH on
individual behavior (through health education, social marketing and
persuasive communication among other strategies) AND on the environment
which helps or hinders the adoption of healthy individual  behaviors
(through political action, community organization and organisational
development). And obviously, environements influence individuals but the
reverse is also true. If human health related behavior becomes the specific
domain for health promotion, then it can be worked on at the primary,
secondary or tertiary levels of prevention, during acute episodes, to
change the behavior of professional or politicians, etc. etc. Health
promotion specialists thus become process specialists of planned change at
the individual or the structural levels and this is what they should be
trained for, more than on content issues.

If I ended up distinguishing between the vision and the practice and to
suggest to limit health promotion to the latter defined as I propose, it is
because otherwise, as very well described in one of the postings (the
physician from BC; sorry, I forget your name), there is no way to isolate
anything different in health promotion from the traditional important
efforts done for decades by public health. Health promotion then carries
the very high risk to be seen as a noble ideology, but just the relabelling
of an old one. Limiting health promotion to the technical know how,
scientifically grounded as much as possible, about individual and
structural change makes it more focused and different from other tasks done
by other people working for the public's health, hence legitimizing HPR
existence and giving a focus to its teaching and practice. In my viewpoint,
a good health promoter should thus be trained as a health related behavior
change specialist, either at the individual or the structural level
(ideally at both). This thus leads into the second issue:


C) Who should do health promotion.

Many people, in and out of the health or even the public health field can
work at the improvement (or the diminution...) of the health of populations
as long as their work has an impact on one or the other of the determinants
of health. I nevertheless think that there is a place for some kind of
health promotion specialist who has the technical skills, grounded in
science and practical knowledge accumulated out of the practice of
professionals and communities, needed to work on the planned change of
behavior and structures. Otherwise, promoting health becomes the vague and
unfocused task of everybody and nobody at the same time.

I know very well that the structural change side of the health promotion
skills are very likely to be less in demand these days than the individual
ones. I nevertheless think (this what my dissertation was all about...)
that even in state funded professional agencies, there are spaces and
margins of manoeuver available (admittedly becoming narrower and narrower)
to work for structural change which are often not taken up to their limits;
and some organisations at some point in time ( the Advocay service at the
city of Toronto public health departement for example) have more space than
others to do so.

Moreover, I think the major survival strategy remains alliances between
people in and out of the system pushing together on the same thing. It is
of use to nobody to have depressed professionals quitting or putting their
jobs at stake on well intended but foolishy risky political undertakings
when they can be of major use within the system as long as well connected
with people out there who can muster the political heat required at some
point.

As mentioned by (some) of the CIAR people and by our friend the BC
physician, we should look closely at our allies rather than fussing over
sometimes important but not fundamental points. Health promoters sometimes
remind me of extreme left groupuscules spending more time fighting one
another than their common ennemy...


D) In conclusion...

If we accept the need to separate the public health ideology from the
specific set of practices needed to work on the (individual and structural)
change of health related human behavior and to call the latter health
promotion, we then have a clear and focused field. And we need to train
people in the specific skills required to prompt and monitor these changes,
be they working in jobs specifically labelled health promotion (which I
dont think would be this bad an idea, despite all the risks of narrow
professionalism) or not. This obviously does not preclude other types of
interventions done by people in or out of the health field to promote the
health of populations; but it clarifies (once and for all ???) what
"professional" health promotors should do that others dont.


So this is my (too long) narrative. I could not resist...

Bonne journee !

Michel O'Neill, Ph.D.

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Professeur titulaire, Ecole des Sciences infirmieres;
co-directeur, GRIPSUL;
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Canada, G1K 7P4
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Co-directeur, Centre collaborateur quebecois de l'OMS pour le developpemement
de villes et villages en sante / Quebec WHO Collaborating Centre for the
development of Healthy Cities and Towns
2400 D'Estimauville
Beauport, Qc
Canada, J3G 4M4
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