Global Health Promotion

Twenty years have passed since the central document of health promotion, the Ottawa Charter, was constituted. Health was seen as the process enabling individuals and communities to increase control over their determinants of health, thereby improving their health and enabling an active and productive life, that is, a good quality of life. One main strategy was the making of a healthy public policy. At the same time Aaron Antonovsky developed the salutogenic theory and its core concepts the sense of coherence and the generalized resistance resources. This paper integrates Antonovsky's salutogenic theory and a salutogenic model of quality of life into the core principles of the Ottawa Charter and exemplifies how to make healthy public policy the salutogenic way. A process-oriented coherent health promotion research model integrating an ecological, a salutogenic and a resilient approach is shown. The objective of this theoretical model is to bring together the whole spectrum of risk factors, protective factors and promotion factors in one model. Further, individual, group and society level are considered. The model suggested aims to contribute to the creation of sense of coherence. This is exemplified in practice in a case study of a Nation, that is, on a national level. The case study of the “Nation” is partly masked. The principles behind these processes are explained in detail while the case study of the “Nation” only includes parts of the process explaining some core issues. The overall aim of this paper is to stimulate health promotion activities along the lines presented and invite the readers to comment and continue the discussion. (Global Health Promotion, 2009; 16 (1): pp. 17—28)

The perinatal period (shortly before and after birth) is a particularly significant stage, providing a sound base for healthy development. Primary health care should accompany the individual through the entire life cycle, and mental health problems constitute a public health threat that calls for the development of mental health promotion initiatives in primary health care. Responding, in 2004 our team initiated an action research project with the aim of reorganising primary health care during pregnancy and the first year of life. The aim is to enable health professionals to support families in the transition to parenthood, thereby promoting children's mental health.

In order to plan this reorganisation, we developed a two-step decision-making process: 1. assessment of antenatal health care; 2. joint reflection concerning the priorities for change. The study goal was to assess the particular characteristics and needs of families during the perinatal period as well as the kind of care they were actually receiving. We designed a cross-sectional quantitative—qualitative study that collected data from users and health professionals using questionnaires and semi-structured interviews. The reflection step took place during a workshop that aimed to analyse the results and discuss priorities. The study confirmed the need to search for mental health problems during pregnancy, particularly to prevent a disturbed mother/child bonding process, and the importance of emphasising issues such as communication, information provision and the adequate availability of health professionals for antenatal care.

The findings led to the following conclusions: 1. risk and needs assessment regarding mental health and options for family support should be included in the protocols of antenatal care; 2. primary health care professionals should be enabled to undertake diagnostic work and problem solving related to mental health; 3. collaboration between different levels of health care and between health sector and community resources should be increased.

The highly participative decision-making process used led to a selection of priorities and strategies that was meaningful to users and health professionals and should contribute to the implementation and sustainability of changes for mental health promotion. (Global Health Promotion, 2009; 1 (1): pp. 29—38)

Health and well-being are the result of a series of complex processes in which an individual interacts with other people and the environment. A systematic approach ensures incorporation of individual, ecological, social and political factors. However, interactions between these factors can be overlooked within a systematical approach. A systemic approach can provide additional information by incorporating interactions and communication. The opportunities of a systems thinking perspective for health promotion were investigated for this paper. Although others have also made attempts to explore systems thinking in the field of health promotion, the implications of systems thinking in practice need attention. Other fields such as agricultural extension studies, organizational studies and development studies provide useful experiences with the use of a systems thinking perspective in practice. Building on experiences from these fields, we give a theoretical background in which processes of social learning and innovation play an important role. From this background, we derive an overview of important concepts for the practical application of a systems thinking perspective. These concepts are the structure of the system, meanings attached to actions, and power relations between actors. To make these concepts more explicit and reduce the theoretical character of systems thinking, we use an illustration to elaborate on these concepts in practice. For this purpose, we describe a health promotion partnership in The Netherlands using the concepts structure, meaning and power relations. We show how a systems perspective increases insight in the functioning of a partnership and how this can facilitate processes of social learning and innovation. This article concludes by identifying future opportunities and challenges in adopting systems thinking for health promotion practice. A systems perspective towards health promotion can help projects reaching a more integral and sustainable approach in which the complex nature of health promotion processes is supported. Practical applications of systems thinking are necessary to adapt this perspective. (Global Health Promotion, 2009; 16 (1): pp. 39—47)

Our society is facing a crisis with escalating mental health disorders, long-term sick leaves and a health care system not provided with the appropriate healing tools. Combined with the global environmental degradation this could be a very depressive scenario.

I suggest a new and dynamic thinking in order to create a more positive atmosphere, both literally and conceptually, into which diverse disciplines work together to reach a mutual goal — global health and environmental justice. It is time to accept that science cannot be dispensed from the dynamics of living, culture and nature, but on the contrary those belong together. Only by working with this premise as a point of departure, can former criteria and old traditions in science be challenged and subsequently ameliorated. (Global Health Promotion, 2009; 16 (1): pp. 49—52)

Globally, research on social determinants of health has built a considerable knowledge base over the last decade. Still, not much of this research has been carried out in the extremely poor areas of the world, like for instance Africa south of the Sahara. In very poor ruralities, classic indicators of socioeconomic status are not well suited. Few people have any education, monetary income is not a good measure of material standing and people cannot be classified by occupation as they make their livelihood from a variety of activities. For efforts towards health equity to benefit the poorest of the poor, more suitable indicators of social health determinants must be identified. Health research might benefit from knowledge developed in neighbouring fields like development research, anthropology and sociology. (Global Health Promotion, 2009; 16 (1): pp. 53—56)

This commentary describes a visit to the Female Genital Mutilation/Cutting project in Cairo. FGM/C is a very serious problem in Egypt and other countries in the North of Africa. Among girls between the age of 15—17, 77% have been cut, with very serious health consequences. In Egypt, there is a comprehensive strategy led by very enthusiastic employees of the National Council for Childhood and Motherhood with support of UNICEF. At a national level a broad coalition is being built that tries to mobilise the legal, medical and media communities to overcome the practice of FGM/C and realising adequate laws that criminalise FGM/C.

At a local level two community projects were started in 160 villages in Upper and Lower Egypt for raising community awareness and dialogue on FGM/C. That is the only way to create a growing social movement that can collectively abandon the practice of FGM/C. (Global Health Promotion, 2009; 16 (1): pp. 57—60)

This commentary summarizes the experience and learnings from a site visit in May 2008 to a drop-in centre for vulnerable women in downtown Cairo run by El-Shehab Institution for Comprehensive Development, which provides street outreach for the prevention of Sexually Transmitted Infection (STI). The Centre successfully provides services and support for women, many of who are displaced or refugees and are from the most marginalized areas in Cairo. Through a rights-based approach to the work, the Centre helps people living in the slums fight and win the right to access clean water, sewerage and electrical power in their communities. An individual-based approach to human rights is also used. In the last year El-Shehab have helped 67 women go to court and win their marriage rights from husbands who have abandoned them. Their approach is an example of a successful way to achieve access to basic health determinants. (Global Health Promotion, 2009; 16 (1): pp. 61—64)

This commentary follows up on a field visit made by the authors to a community development programme in Cairo supported by a local non-governmental organization called New Horizon Association for Social Development (NHASD). The people who comprise NHASD are dedicated to improving the conditions and quality of life of the most marginalized and underdeveloped communities. The paper describes the overall approach that community members, social workers and leaders use to tackle the underlying causes of poverty and the skills, resources and services they build using a rights-based and participatory community development approach. It also addresses ideas for IUHPE concrete action, which came from discussions stimulated by the visit, to support such community initiatives out of isolation. It ranges from complimentary membership of the NHASD to the organization of a specific health promotion network of extremely socio-economically vulnerable communities in urban areas worldwide, connected to the IUHPE Group on Settings-based Health Promotion, as well as sessions at the forthcoming IUHPE 20th World Conference on Health Promotion on the theme “Health, Equity and Sustainable Development”. (Global Health Promotion, 2009; 16 (1): pp. 65—68)

La tuberculose est une maladie chronique dont la prise en charge nécessite une approche multisectorielle: le social et le biomédical. Une étude socio-anthropologique retraçant les itinéraires thérapeutiques des malades a permis d'identifier les détenteurs d'enjeux dans la gestion de la maladie pour élaborer une « carte des acteurs » et encourager une interaction dynamique entre les membres. L'identification des acteurs clés et leur mise en réseau a permis d'entreprendre des actions contribuant à renforcer l'efficacité et l'efficience de la prise en charge des malades au Burkina Faso, par des actions collectives. Nous identifions ainsi des acteurs sociaux, alliés et confidents des malades; des acteurs biomédicaux, directement concernés par la prise en charge médicale de la maladie. A travers ces liens entre les acteurs, nous remarquons que les systèmes de santé sont caractérisés par des interactions sur fond d'incompréhension qui influence négativement la qualité des soins. La dynamisation du réseau d'acteurs a permis d'éprouver un mode de collaboration axé sur l'analyse collective des problèmes rencontrés par les prestataires de soins et les malades tuberculeux. Celle-ci a permis la mise en œuvre d'actions visant à améliorer la qualité de vie des malades. La dynamique de collaboration entre acteurs concernés par l'accès aux soins de santé a eu raison sur les situations problématiques qui entament les succès thérapeutiques et la qualité de vie des malades tuberculeux. (Global Health Promotion, 2009; 16 (1): pp. 72—80)