Health studies: The Ottawa charter for health promotion
HEALTH STUDIESTHE OTTAWA CHARTER FOR HEALTH PROMOTION IMPLICATIONS IN PHYSICAL ACTIVITY: Taking the first charter to global health Westerberg, V.M. Date: 3 May 2010 THE OTTAWA CHARTER FOR HEALTH PROMOTION
WESTERBERG, VM Page 2 of 15 IMPLICATIONS IN PHYSICAL ACTIVITY: Taking the first charter to global health. “Health can be judged by which people take two at a time - pills or stairs” (Welsh, as quoted in Housman, 1994)The first International Conference on Health Promotion was held in Ottawa,Canada, in 1986, as a response to growing expectations for better public health.The purpose of the conference was to continue to identify action to achieve theobjectives of the World Health Organization (WHO) “Health for All by the Year2000” initiative, launched in 1981. The Ottawa Conference was preceded by theAlma Ata Primary Health Care Conference in 1978, and followed by furthersimilar conferences in Adelaide (1988), Sundsvall (1991), Jakarta (1997), Mexico(2000) and Bangkok (2005). Each conference continues to strengthen healthpromotion in an effort to overcome inequities.The promotion of health focused on physical activity is an issue of social concernbecause many of the non-communicable diseases that lead the causes of death indeveloped countries are preventable and one key determinant of prevention isprecisely physical activity, a cheap, cost-effective, everyday resource available forall (Ministry of Health [MOH], 2003).Sedentarism has established itself in today´s societies. Individuals who are notphysically active are usually blamed for choosing the wrong kind of lifestylewithout taking into account limitations which range from those emanating frommacro (sociopolitical, environmental, cultural) levels of intervention tointermediate levels (communities) to micro levels (age, diseases) .
WESTERBERG, VM Page 3 of 15“Healthy Eating - Healthy Action” is New Zealand’s Ministry of Health’s (MOH)nutrition, physical activity and healthy weight strategy (MOH, 2009). It focuseson five priority areas: environments, children, lower socioeconomic groups,workforce and communication, and takes into account the contents of the OttawaCharter for Health Promotion, which defines health promotion as: The process of enabling people to increase control over, and to improve their health. To reach a state of complete physical, mental and social well- being, an individual or group must be able to identify and to realise aspirations, to satisfy needs, and to change or cope with the environments. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to wellbeing (WHO, 1986).The key features of the Ottawa charter include eight pre-requisites ordeterminants of health (WHO, 1986), which are the sine qua non conditions forthe development of the charter contents. The three most important ones are:income, employment and education, the remaining ones are: peace, shelter, food,social justice, a stable ecosystem and equity (Baum, 2008).The Ottawa charter aims to reduce inequities in health and for that reason specialattention must be paid to indigenous population´s health, people with disabilities,the poor, the diseased, the elderly, the unemployed, that is, people at the lowerend of the social ladder, who are most at risk of having bad health outcomes andwho tend to ignore health promotion messages (WHO, 1986).
WESTERBERG, VM Page 4 of 15The Ottawa Charter for Health Promotion identifies five areas of priority: 1. Build healthy public policy: Health promotion policy combines multiple, complementary approaches, including legislation, fiscal measures, taxation and organisational changes action (WHO, 1986). Health promotion requires the identification of obstacles to make healthy choices for people easy to achieve by policy makers and the development of ways to remove those obstacles. Examples of building healthy public policies are: Launching information campaigns about the benefits of incorporating physical activity as part of daily life, pointing out the dangers of inactivity, promote physical activity at home (housework as a fitness activity, gardening), at schools (with incentives like “take part in sport competitions or sports summer camps and get a free ticket to see the All Blacks play”), at work (with incentives like: “take 30 minutes of your lunch hour to practice your favourite indoor exercises at work and get one more day of paid holiday per month), provide funding for community-based initiatives to promote physical activity, ensure action across institutions (councils, education and health ministries, etc.), promote social protection against impoverishment, isolation, malnutrition, disease and addictions that hamper or limit the practice of physical activity (SPARC, 2010).The 1988 Adelaide Conference on Healthy Public Policy, in which 42 countriestook part, continued in the direction set at Alma Ata and Ottawa, and the severalstrategies for healthy public policy action were proposed (WHO, 1988): Healthmust be regarded as a social investment by governments and institutions, equity,access and development are to be promoted for risk populations (indigenouspeoples, ethnic minorities, immigrants, women and dependent people) with
WESTERBERG, VM Page 5 of 15particular attention to the impact of new technologies on health outcomes, publichealth promotion policies should have a positive health impact on developingcountries, governments and all other controllers of resources (macro-leveldecision-makers) are ultimately accountable to their people for the healthconsequences of their policies or lack of policies and must find multi-levelalliances (with institutions, corporations, NGOs, trade unions, academicassociations and religious leaders) to provide the impulse for health action.The promotion of physical activity has been recognized as a key public healthpolicy issue by the international community (Pate et al., 1995). Great concern isbeing shown in developed countries in this regard given the alarming rate atwhich non-communicable diseases are growing, namely: cardiovascular diseases,type II diabetes mellitus, some cancers like colon and breast, osteoarthritis,osteoporosis, obesity, anxiety and depression (MOH, 2003). Additionally, Harrisand Cale (1997) consider that the success of strategies for promoting physicalactivity resides in their effectiveness to provide equality, opportunities,incentives and reinforcements for all people, especially young people.Looking at New Zealand, one in three adults is not physically active at levelssufficient to benefit their health (MOH, 2009). Physical inactivity is second tosmoking as a modifiable risk factor for poor health and it is associated with 8 %of all deaths, with over 2000 deaths per year. Improving the level of participationin relevant physical activity so as to almost reach the maximum heart rate for age(220 - age) for at least 30 minutes a day is a priority health objective for the NewZealand government in cooperation with Sports and Recreation New Zealand(SPARC) and District Health Boards (DHBs). Target populations are inactiveadults, children, adolescents, women, elderly people, Maori people and riskpopulations (people with chronic diseases, dependent people) (MOH, 2003).
WESTERBERG, VM Page 6 of 15Physical activity does not lack risks, which range from musculoskeletal lesions toheart failure, but the risk / benefits ratio is overwhelmingly in favour of thebenefits (SPARC, 2009).2.- Create supportive environments: The relationship between people andtheir environment is the basis for a socio-ecological approach to healthpromotion. Protection of the environment (natural and built), the conservation ofnatural resources, safe, satisfying and stimulating living and workingenvironments and the impact of rapidly changing technological, working,urbanisational and energy production environments must be addressedstrategically. Having an adequate supporting environment, individuals may find iteasier to select healthier options for healthier living (WHO, 1986). Someexamples have been mentioned in the previous point, as the development ofpublic health policies is closely related to the creation of supportingenvironments. Examples in this line include the improvement of conditions andinfrastructures, building sport facilities near or in / at schools, malls or officebuildings, reducing environmental hazards to outdoor sport practice, the creationof safe walking areas in parks and forests, the creation of an extensive bicyclelane network with a good amount of strategically located parking places forbicycles, and the presence of information offices handing out maps indicating“exercise friendly zones”.The Third International Conference on Health Promotion: SupportiveEnvironments for Health, the 1991 Sundsvall Conference, reflected the result ofthe growing public concern about sustainable development in view of theincreasing threats to the global environment. Representatives from 81 countriestook part in it. Many approaches were identified for creating supportiveenvironments that should be used by policy-makers, decision-makers and
WESTERBERG, VM Page 7 of 15community activists in the health and environment sectors (WHO, 1991). TheConference recognized that everyone has a role in creating supportiveenvironments for health and urge powerful influential organizations like WHO,UNEP, the World Bank and International Monetary Fund to strengthen theirefforts to develop codes of conduct on the trade and marketing of substancesharmful to health and the environment (WHO, 1991). Social and economicalinequity is regarded as unacceptable and industrialised nations are compelled tohelp developing countries meet the eight pre-requisites for health mentioned inthe Ottawa charter (WHO, 1986). Action to create supportive environments hasmany dimensions: physical, social, spiritual, economic and political. Action mustbe coordinated at local, regional, national and global levels to achieve solutionsthat are truly sustainable. The Sundsvall Conference says that proposals toimplement the Health for All strategies must reflect two basic principles: Equityand public action. Empowerment of people, specifically women, is emphasized askey to social health development. Worldwide action based on global partnershipis regarded as the way to ensure the future of our planet, ourselves and ourhealth (WHO, 1991).3.-Strengthen community actions: Community development focuses on pre-existing human and material resources to increase self-help and social support,developing flexible systems to strengthen public participation in health issues.This requires complete and continuous access to information and learningopportunities for health, as well as support regarding funding (WHO, 1986).Community fun runs, physical activity groups and classes, school based programs(walk-a-thons, walking or cycling school buses), and community awarenessmeetings are but a few examples of how to strengthen community actions. In amulticultural society like New Zealand´s, the creation of community traditional
WESTERBERG, VM Page 8 of 15and indigenous dance groups in schools and communities would not onlyimprove physical condition of participants while having fun, it would alsostrengthen ties among community dwellers and neighbours. It should be notedthat it is not enough that people are kept active through participation in healthpromoting activities, people should be acknowledged as “the main healthresource, accepting the community as the essential voice in matters of its health,living conditions and wellbeing” (WHO, 1986). The strengthening of communityaction is conceived as a source of information, community (decentralised)decision capacity, and as a resource for implementing health promotion actions,so that health promotion is seen as something shared and not imposed in aunidirectional way (Spicer & Fleming, 2007).4.- Develop personal skills: Achieving personal and social development throughinformation, education and enhancement of life skills. People should be enabledto learn throughout life to prepare themselves for all of its stages and to deal withchronic illness and injuries (WHO, 1986). This has to be facilitated in school,home, work and community settings. Personal skills development is targetedthrough the widespread use of education and information through, for example,on-site classes or conferences (schools, work places, health centres, etc.),advertising, videos, books, etc., and, in so doing, promoting health equality andhealth access to all. A specific example would be to teach classes of rehabilitationmovements, yoga, tai chi or Pilates exercises, that people can practice at home, atwork or outdoors. No specific clothing, equipment or fitness levels are requiredfor the practice of these activities.5.- Reorient health services: The role of the health sector must move towards ahealth promotion direction beyond its micro, biomedical level of intervention,that is, the responsibility for providing clinical and curative services towards a
WESTERBERG, VM Page 9 of 15macro, social, holistic level of intervention. Reorienting health services alsorequires attention to health research, as well as changes in professionaleducation and training (WHO, 1986). Examples of reorientation of health servicesinclude: Increase the number of training facilities, ensure that target groups haveaccess to advice / information regarding what physical activity and level oftraining are adequate for their age and physical condition and characteristics(SPARC, 2009). This must lead to a change of attitude and organisation of healthservices, which refocuses on the total needs of the individual as a whole person. Itmoves the health sector beyond providing only medical/clinical services towardsmeeting the more holistic needs of people using a multi-sectoral, multi-culturalapproach. Examples in practice include encouraging and resourcing Maoriproviders to develop physical activity programmes by Maori with and for Maori(Health Promotion Forum of New Zealand, 2010)Motivators and barriers have been identified in relation with physical activity(MOH, 2003). Motivators: Awareness that physical activity is good for health,desire to keep in shape, encouragement from others and wanting to role modelphysically active behaviours. Barriers: Lack of time and/or energy, lack ofencouragement or support from others, health problems.The Ottawa charter identified three basic strategies for health promotion (WHO,1986):Advocate: Good health is essential to achieve social, economic and personaldevelopment, and an adequate quality of life. Political, economic, social, cultural,environmental, behavioural and biological factors can impact health eitherpositively or negatively. Health promotion aims to make these conditionsfavourable, through advocacy for health (WHO, 1986). Examples of advocacy for
WESTERBERG, VM Page 10 of 15physical activity include: Request that the city council construct clearway bicyclelanes in local communities so that people will be able to ride their bicycles safely,work with local educational and labour-related institutions to provide after-hours and weekend access to recreation facilities, gyms, and soccer, cricket,rugby fields and work with the city council to create or extend and keep cleanwalking paths in local community parks.Enable: Health promotion focuses on achieving equity in health. Healthpromotion action aims to reduce differences in health status and ensure theavailability of equal opportunities and resources to enable all people to achievetheir full health potential (WHO, 1986). This includes a supportive environment(availability of facilities for the practice of physical activity), access to information(where to practice sports, “physical activity friendly” premises: office buildings,malls, neighbourhoods), life skills and opportunities to make healthy choices easychoices. People cannot achieve their fullest health potential unless they are ableto control those things that determine their health. Building the capability ofhealth promoting partners with systems, processes and tools, providing expertsand research and providing sector training and development are all key to enablepromotion of health (SPARC, 2009).Mediate: The prerequisites and prospects for health cannot be ensured by thehealth sector alone. Health promotion demands coordinated action by allconcerned, including governments, health and other social and economic sectors,non-government and voluntary organisations, local authorities, industry,information technology companies and the media (WHO, 1986). The media play akey role in today´s society and government funded promotion of physical activityon TV and the internet could prove an effective mediator between health
WESTERBERG, VM Page 11 of 15promoting organizations and the general public, between governments andcommunities.But the Ottawa charter also has weak points. One of them is that it was designedto meet the needs for health promotion of industrialised countries and focuses onthe prevention of non-communicable diseases (NCDs). Developing countries arestruck by communicable (infectious) diseases instead, as the lifespan of people inthose countries is too short to develop NCDs.Another weakness of the Ottawa charter is that it may create rather thaneliminate inequities in society in favour of the middle classes, as lowersocioeconomic groups tend to ignore health promotion campaigns (WHO, 1986).Finally, the Ottawa charter does not take into account environmental threatscoming not from the physical but from the political, economic and socialenvironment. Neoliberal economics and the globalization of trade and economyhave led to a reduction in the degree of maneuverability of national and localgovernments to establish social, environmental and health standards, leading toincreasing inequities in income and health service distribution, with consequentenvironmental and social deterioration. Governments keep reducing the budgetfor the public sector, resulting in increasingly scarce resources dedicated togovernment funded health promotion (Arya, 2003). Old time and also indigenouspopulation values of solidarity and mutual aid that led people to seek collectivesolutions to shared problems are in danger of being replaced by US-styleindividualism with the help of the media (Arya, 2003). Clearly, the dichotomyindividual versus community interests and solutions to health creates tension.
WESTERBERG, VM Page 12 of 15Tension between the individualist health promotion programmes (IHP) and thesocial health promotion programmes (SHP) is almost inevitable. Aninterventionist government can be labelled as “nanny state” and some claim thatindividual choices are hampered by such governments (Jochelson, 2005).Conversely, some governments claim that citizens should decide, withoutimpositions or “counselling”, what is more convenient for them, thereforerelieving themselves of the burden of their responsibilities towards society. Thelatter situation means that governments will keep in good terms (collectingmoney) from large pharmaceutical and food industries that are, to a considerableextent, responsible for people´s bad health in developed countries, where thebiomedical model of health predominates and generates handsome amounts of“benefits”.Arguably, laypeople lack the critical knowledge, the overall view, the data todecide on something as complex as how different factors (medication, surgery,junk food, lack of exercise, etc.) can impact their health outcome (Wang, 2000).Governments and institutions have a global view of society and it is theirresponsibility to take action in order to promote and preserve its wellness (WHO,2000). Local communities and sociopolitical activists must claim their right tohealth education and to be informed about and to take part in decisions andactions involving their communities, more so when there are underprivilegedminorities in them.The concept of “stewardship state” (versus “nanny state”) introduced by theWHO (2000) states that governments should not press people or restrict theirfreedom without a reason. It also emphasizes that governments have aresponsibility to provide the conditions under which people can lead healthylives. The “stewardship state” also has a particular responsibility for reducing
WESTERBERG, VM Page 13 of 15health inequalities and protecting the health of vulnerable groups such aswomen, children and minorities (WHO, 2000).The Ottawa charter dream of “health for all by the year 2000” (WHO, 1986) stillremains a dream. Health promotion deterioration accelerated by environmentalhazards, sociopolitical inactivity and globalization of economies can producetrans-generational inequities even greater than those seen now among countries,regions, ethnic groups and classes. The physical, economical and social well-beingof the “health for all” society of the future will be affected by decisions madetoday by individuals, communities and governments. It is necessary to make surethat the policies advocated from the other sectors influencing health (transport,housing, finance, etc.) do not sacrifice the health of future generations for a short-term gain.Physical activity is a key factor in health promotion as it reduces the rate andimpact of non-communicable diseases, which are gradually becoming the leadingcause of death in developed countries (WHO, 2000). Solutions to thedevelopment, implementation and control of physical activity as part of healthpromotion initiatives should come in the first place from community level actionsdue to their proximity to individuals, coordinated with subsequent macro levelsof intervention from the highest instances of society (governments andinstitutions). Let’s get moving!
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