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