At 17.32 1996-06-13 EDT, you wrote:

>As part of the International Symposium on the Effectiveness of Health
>Promotion being held at the University of Toronto, Toronto Canada, June 17 -
>June 19th, 

*****


CREATING HEALTHY ENVIRONMENTS  
will be one of the themes during the above conference 


We are all intuitively familiar with the idea of a supportive environment.
It simply means favourable conditions for.... Thus supportive environments
is one of the crucial means of promoting health. The words signify that
health cannot be seen in a vacuum; it is determined to a great extent by
environmental conditions. Environments are not just the visible structures
and services surrounding us but have spiritual, social, cultural, economic,
political and ideological dimensions as well. Furthermore, all these
different facets of life are interwoven and inseparable. Influencing one
will affect changes in the others, for better or for worse. Using the
concept of supportive environments we are able to backtrack and ask: what do
we have to do to get where we want to go? The concept of Supportive
Environments has been used in rehabilitation work for some time and its
importance for physical or mental recovery for individuals is obvious. It
takes many different elements to build supportive environments for health.
Some common conditions will be necessary, such as:
¨     peace and security in the country and region
¨     democracy/pluralistic exercise of power, with special emphasis on human
rights
¨     satisfactory living conditions
¨     decentralized decision making involving public participation/
        empowerment
¨     no parts of the population living in extreme poverty
¨     balance between population growth and resources
 ¨    access to clean water, fresh air, wholesome food and energy
¨     social/economic equity and justice between and within countries,
particularly for the    under-represented: women, elderly, children, disabled,
ethnic minorities, etc.
¨     equitable access to land and ecologically safe materials and technologies
¨     equal access to health and social services
¨     psycho-social conditions, that offer a sense of coherence, of mastery, of
meaningfulness

More specifically: what conditions are favourable if people are to improve
their health?

In contrast to the prevailing and increasing amount of litterature using a
hierarcy of evidenc to assess the effectiveness of means and results of
medical and other health care practices, the Sundsvall handbook summarizes
about thousand global case studies and experiences, and presents 171
"stories" as the basis for strategies for good health promotion praxis. The
stories offer inspiring examples of different ways to bring about changes
for a healthier environment.  Based on this analysis of the stories it was
found that some Key ingredients make health promotion work.  Important
common factors to increase both the quality of the steps taken and their
effectiveness were brought together to a formula for succesful health
promotion workin this Handbook 
where K is knowledge and I is insight and the quotient points towards the
needed balance between formal knowledge on the one hand and insight and
wisdom gained from extensive experience of change processes on the other. 
Success= K/I + 5 * I + T
The five I's stand for:

Information, in particular the importance of well-informed citizens,
Innovations, i.e. inspiring actions involving people,
Individuals, in the sense of dedicated people, often struggling against huge
odds. Such individuals can be found behind most of the projects and
activities in the Handbook. A lot remains to be done in order to identify
such people and give them the encouragement they deserve.
Integrated actions in people's everyday lives, where we live, work, play,
love and enjoy ourselves.
Indirect, by putting health and environmental issues in the context of
living conditions, empowerment and self-esteem instead of actions simply
directed towards e.g. simple risk factors.
Finally, the T-component stands for Training, emphasizing the importance of
developing practical skills. 

Of course, this is not the superior, definitive, or complete formula for how
to conduct successful health promotion. But, given that they are derived
from stories presented from all over the world, they should contain at least
some hints for us all to consider, when embarking upon new programmes and
projects.

Based on the examples presented the Sundsvall conference, in 1991,
identified four key public health action strategies as the Key ingredients
to promote the creation of supportive environments at community level:

        1. Strengthening advocacy through community action, particularly through
groups organized by women.

        2. Enabling communities and individuals to take control over their health
and environment through education and empowerment.

        3. Building alliances for health and supportive environments in order to
strenghten the cooperation between health and environmental campaign and
strategies.

        4. Mediating beteween conflicting interests in society in order to ensure
equitable acess to supportive environments for health .

The Health Promotion Strategy Analysis Model (HELPSAM), developed in the
Sundsvall Handbook ("We Can Do It!"), is an instrumental model, useful for
analyzing a health problem and working out solutions the HELPSAM-model
vertically lists the seven strategies derived from the Sundsvall stories
These are briefly the seven key strategies of the Health Promotion Strategy
Analysis Model:

1)      The policy development strategy is based on the intention of government
or policy-maker, founded on specific political and moral values. 
2)      The strategy of health regulation contains both written and unwritten
laws and norms affecting public health. 
3)      Initiatives for improving public health ultimately often involve a
reorientation of the organizations to achieve sustainability in the long
term. If this is achieved, the activities are often maintained by becoming
institutionalized.
4)      Change is usually preceeded by advocacy for improved health. 
5)      After identifying a health problem, a crucial next step is to spread the
word through information, education and communication for health. It is also
crucial to forge alliances with the many other actors involved, i.e.
business, non-governmental organizations, the mass media, etc.  
6)      It is difficult to change peoples' behaviour if there are no effective
alternatives available to enable us to change. This can involve innovation
and product development.
7)      The final action category of mobilizing/empowering addresses based on
the active involvement and participation by those directly or indirectly
affected by public health problems. 

Say for example there is a health problem in a community, e.g. ill health
due to drinking polluted water. How to clean up the water and/or get people
to stop drinking it? The problem can be tackled in one or several ways,
using different strategies. 

In the example given above, one may want to develop a clean water policy
(policy development), take legal action (regulation), transform a wildlife
protection club to include human health issues (reorienting organizations),
fight for change via the authorities, politicians, the media etc.
(advocacy), get the appropriate ministeries to cooperate (building
alliances), help supply safe drinking water (enabling), and organize the
residents to fence off the area, educate the people or facilitate these and
other possible measures (mobilizing/empowering).

However, it should be emphasized, that the seven types of strategies have
not been more or less arbitrarily imposed on the Sundsvall stories from some
theoretical viewpoint, but have instead been derived from these and other
real life examples of working for change. In other words, people's concrete
experiences have been compiled and destilled, yielding the same strikingly
common basic features.

Change won’t come easy. Advocating community participation means initiating
a process of decentralization. Such a process will be a fundamental
challenge in the face of the steady concentration of political and economic
power in the hands of small elites. Sundsvall highlighted such concrete
efforts! In terms of evaluation participatory approaches should be
highlighted and also focus for the evaluation methods.  

This handbook has thus shown how "we can do it", that people can make a
difference in creating more favourable conditions for health. But of course
this book can not bring about changes by itself. It needs  active
commitment. Every community is specific and has its own way of defining
problems, cultural norms etc. This book should be seen as a general model
that has to be adapted to local settings. People in different countries have
the opportunity of compiling national versions of this handbook based on
specific local conditions and needs. 

Similarly you can help and inspire other people by telling them stories from
your community. In the process of developing handbooks and in creating
supportive environments for health, there will be a continuous need of an
international clearing-house for collecting and exchanging experiences
worldwide.  To use Internet for the future evolvement of Health Promotion
is in this perspective a challenge.


yours


Bo J A Haglund
associate professor, director
WHO Collaborating Centre
Karolinska Centre on Supportive Environments for Health
Karolinska Institute
Dept of Public Health Sciences
Division of  Social Medicine
S-172 83 SUNDBYBERG, Sweden
tel: + 46 8 629 05 64  fax: + 46 8 28 95 00

Internet adress: [log in to unmask]

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Supportive Environments for Health is about where people live, love, work, 
and play - in short, about everday life
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