The International Institute for Health Promotion



Conferences, Training, and Seminars Health Promotion: Global Perspectives" Country Profiles IIHP Committees IIHP Archives		"Health Promotion - An International Phenomenon" by Wolf Kirsten - National Center for Health Fitness American University Introduction Very few causes engender more universal interest and appeal than the issue of health. The concern for the health of individuals transcends the boundaries of race, religion, culture, and national origin. Over the past decade, there has been an increased focus in the international community on the importance of maintaining or improving one's health status through the practice of health-enhancing activities. The rising popularity of the promotion of wellness and healthy lifestyles has been spurred by the participation of institutions from many different fields. Academic institutions, government authorities, private corporations, insurance companies, hospitals, medical groups, community groups as well as other significant individuals in health promotion have joined the universal effort to improve the quality of life. While health promotion has emerged as a respected field of study in the United States and a few other select countries, many other countries are also displaying considerable momentum for advancement and recognition of the field. These developments have generated a global desire for intense networking and international collaboration in the area of health promotion. I The concept of health promotion In order to draw an accurate picture of the evolution of health promotion, one needs to define the concept. This is not an easy task since the promotion of health means different things to different people, especially in different countries. Disease prevention, health education, wellness, quality of life, and health promotion are some of the terms commonly used in the international community, often times depending on the translation. In spite of the confusion around terminology, this paper will highlight some of the most frequently used and inclusive models of health promotion at this time. Definition of health First, it is essential to examine what the terms "health" and "promotion" literally mean. Health has been defined in many different ways over history. The ancient Greek physicians believed health to be a condition of perfect body equilibrium. For the New World Indians being healthy was considered as being in harmony with nature. The ancient Chinese believed that health was a reflection of a vital body force called "Qi" (Edelman, 1986). In contrast, Western medicine attempted to understand the construct of health by analyzing its single components rather than the interconnection of the various parts. The Western approach has been advocated throughout the world for years which led the medical field to primarily focus on disease and disability. Only recently has this medical outlook begun to gradually change towards a more holistic view. As far back as 1946, the World Health Organization (WHO) introduced a positive dimension of health to its definition: "Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Dubos (1968) took a similar perspective: "Health is a quality of life involving social, emotional, mental, spiritual and biological fitness on the part of the individual, which results from adaptations to the environment." These definitions refer to health as a state of well-being. From this understanding the now common term "wellness" originated. To underline the difference between the traditional and the more holistic approach to health it is helpful to consider Travis' (1975) health continuum model (Fig. 1). The left side of the health continuum represents a state of extreme illness or premature death, whereas the right side of the health continuum represents a state of optimal health. In between the left and right side of the health continuum lie many different degrees of illness or wellness. Traditional Western medicine has almost exclusively focused on the left or illness side. Health promotion has traditionally focused on the right or optimal health side of the continuum, targeting overtly healthy people, but at risk of becoming ill (O'Donnell, 1986). However today, health promotion programs are designed to transcend the full spectrum of the health continuum. For example, health promotion targets the left side of the health continuum by facilitating the recovery of ill patients (e.g., cardiac rehabilitation). Promotion is defined as "the act of furthering the growth or development of something" (Webster's 9th Dictionary, 1984). Evolution of health promotion In the many existing definitions of health promotion, the "promotion" component has been included by emphasizing the act of encouraging the growth and development of health. The following WHO definition of health promotion originated at the Ottawa Conference (first international conference on health promotion) in 1986: "Health promotion is the process of enabling people to increase control over, and to improve, their health." This definition has its roots in earlier initiatives such as the Alma Ata declaration (WHO, 1978). The declaration, which was developed as an outcome of the WHO 1978 conference held at Alma Ata, introduced political action, social understanding, and economic policy to the concept of health promotion. The notion was that the promotion of healthy lifestyles cannot be accomplished unless resources are distributed more equally and health policies developed. Therefore all individuals and communities were encouraged to take part in the planning of health care policies and the implementation of health programs (Weston, 1995). The Alma Ata declaration underlined the WHO strategy for "Health for All by the Year 2000" (1977). The Ottawa Charter in 1986 (WHO 1986) further legitimized health promotion as it emphasized the need for intersectoral collaboration and equity in health. The call for health promotion action referred to five categories: building healthy policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services. The Ottawa conference is often regarded as a milestone in the field of health promotion because a vision and a strategy to advocate health promotion were developed and effectively brought to the public's attention. Having a prestigious body in the health field, like the WHO, endorse the concept of health promotion was extremely significant to the credibility of the emerging field. However, many renowned health promotion professionals, particularly in the United States, expanded on the traditional approach of public health reflected in the WHO declarations. The concept of individual responsibility and adoption of healthy lifestyles has been increasingly articulated. Michael O' Donnell, Editor-in-Chief of the American Journal of Health Promotion, defines health promotion (1986) as "the science and art of helping people change their lifestyle to move toward a state of optimal health." Reductions in morbidity and mortality have been generated through the application of behavioral strategies and promotion of healthy lifestyles. The task of health promotion is to help the individual move towards the right side of the health continuum, i.e. toward a state of optimal health, through lifestyle changes. As an autonomous person one is able to guide one's own conduct in terms of values. This means if a person knowingly follows an unhealthy lifestyle, it cannot be counted as an expression of autonomy, unless other values are involved (Downie, Fyfe, and Tannahill, 1990). In his classic analysis of the field of public health and medicine (1975), Ivan Illich emphasizes the significance of personal accountability with regard to health by stating that medical intervention or hygienic characteristics of the environment can enhance but never replace personal autonomy. Many national and international initiatives have followed this approach of linking individual responsibility to health status. In 1991, the U.S. Department of Health and Human Services released "Healthy People 2000", a report generated through the nationwide input of more than 10,000 experts. The report lists detailed goals and objectives for health promotion programs in the priority areas of physical activity and fitness, nutrition, tobacco use, and alcohol and other drugs for the year 2000. The U.S. Surgeon General's Report on Physical Activity and Health is a landmark review of the research on physical activity and health published in 1996 in the U.S. by a panel of leading experts in the field. This report stresses the significance of physical activity with regard to good health. The Victoria Declaration on Heart Health (1992) articulated the importance of healthy living in order to reduce risks for cardiovascular disease. The global scientific community involved in investigating cardiovascular disease and other non- communicable diseases has recognized the need to address individual responsibility, along with supportive environments, in order to make a visible difference in morbidity and mortality trends, and thereby create healthier nations. This approach is not limited to the United States, many distinguished scientists and health professionals from other countries have found similar results in their studies. For example, the Tokyo Metropolitan Health Center asks the Tokyo citizens to be aware of the concept "I am responsible for my own health" and offers educational programs about practical health promotion activities (1993). In May 1995, high ranking officials and professionals from over 100 countries assembled in Quebec City, Canada for the First World Forum on Physical Activity and Sport. The World Forum concluded with a uniform statement about the potential positive impact of physical activity and sport on health. The philosophy of advocating healthy lifestyles is not restricted to physical behavior but corresponds to the complex nature of human beings. The Optimal Wellness Model, developed by American University's National Center for Health Fitness, illustrates the various components a comprehensive health promotion program must address. Optimal wellness can only be obtained if individuals assume responsibility for the continual development and maintenance of the physical, spiritual, emotional, social, intellectual, and environmental components of their health, consistent with the culture in which they reside (1983). Self responsibility resides in the middle of the model because it is the driving force behind improvement in any of the six surrounding fields. The adoption and maintenance of healthy lifestyles holds an enormous potential with regard to creating healthier and more productive nations. For example, a nationwide increase in participation in regular physical activity would lead to enormous benefits for society, such as the decline of morbidity and mortality numbers, the increase of productivity and overall well-being. The inherent economic gains make this strategy very attractive to public and private sector decision makers. Health promotion - an interdisciplinary field In comparison with other established fields such as medicine, psychology, or sociology, the field of health promotion has only recently evolved. Health promotion has its roots in many different disciplines. As the field has developed, more and more components have become incorporated in it. Many of these components have existed beforehand in their own isolated and limited sphere of influence: health education in schools or primary health care settings, public health programs such as immunizations or screenings, or occupational health measures aimed at preventing disease or accidents at the workplace. These activities involve education, prevention, protection and legislation and all relate to the concepts of positive health, well-being and lifestyle. The health promotion model developed by Downie, Fyfe, and Tannahill (1990) demonstrates the wide range of possibilities for health promotion by incorporating prevention, health education, and health protection in overlapping spheres. Prevention (1) focuses on services such as immunizations, cervical screenings, hypertension case-finding, the use of nicotine-containing chewing gum to aid smoking cessation, etc. Health education (5) is aimed at influencing behavior on positive health grounds and seeks to help individuals, groups, or whole communities to develop positive health attributes which are central to the enhancement of true well-being. Health protection (6) deals with regulations and policies such as the implementation of a workplace smoking policy in the interests of providing clean air or the commitment of public funds to the provision of accessible leisure facilities in order to promote positive health. Health promotion not only incorporates all of the domains described above, but also the overlapping areas. Preventive health education (2) includes educational efforts to influence lifestyle in the interests of preventing ill-health, as well as efforts to encourage the uptake of preventive services. Preventive health protection (3) addresses policies and regulations of preventive nature, such as fluoridation of water supplies to prevent dental caries. Health education aimed at health protection (7) involves raising awareness of, and securing support for, positive health protection measures, among the public and policy-makers. All three dimensions come together as health education, prevention, and health protection overlap (4) in efforts to stimulate a social environment conducive to the success of preventive health protection measures, e.g., intensive lobbying for seat-belt legislation. The categories are not rigidly separate compartments but are in reality often combined. For example, most health promotion measures are of preventive nature and aimed at empowering individuals to adopt healthy lifestyles. Further, the model underlines the necessity to include other disciplines such as psychology, sociology, public administration, business and economics, communications, politics, etc. Downie, Fyfe, and Tannahill (1990) describe health promotion as comprising efforts to enhance positive health and prevent ill-health, through the overlapping spheres of health education, prevention, and health protection. II Universal need for health promotion The social and humanistic value of health promotion provides a compelling argument in favor of supporting and advancing the field. An additional incentive to initiate health promotion programs is the positive economic impact. Over the last few years health care costs have been rising in many countries throughout the world. Most industrialized countries face the problem of an aging population contributing significantly to the increase of health care costs. Many of the current lifestyles in most industrialized countries, and in a rising number of developing countries, have been linked to the majority of morbidity and mortality causes. Diseases like cancer, cardiovascular and cerebrovascular disease are considered "lifestyle" diseases. A great number of studies have illustrated a correlation between smoking and cancer, smoking, inactivity, obesity and heart disease, stress and stroke, etc. Some of these correlations are stronger than others with a growing number of scientific studies with various populations supporting the findings. It is known that the leading causes of mortality in most Western industrialized nations are cardiovascular disease and cancer (in the U.S., these two causes make up over 50% of all deaths). However, even in China, accounting for one fourth of the total world population, the leading death causes are cerebro- and cardiovascular disease (37% of total deaths in urban areas), respiratory disease (26% in rural areas), and cancer (22% and 17% respectively in urban and rural areas). Lifestyle diseases such as heart disease, cancer, alcohol and drug use, etc. make up 43% of all hospital admissions in the U.S. annually (Chapman, 1995). With lifestyle changes a great number of these admissions are preventable. One only needs to take note of the profound effects of such a high-risk habit as smoking. It is estimated that 400,000 (19%) of all deaths in the U.S. can be attributed to tobacco consumption making it the number one cause (McGinnis & Foege, 1993). The task for the field of health promotion is to slow the onslaught of chronic disability and shift the direction towards a healthier and more productive society. III Health promotion programs The portrayed developments have spurred the establishment of new strategies, changes in the health care system, and the interest in more preventive measures. The corporate sector has played a leading role in the advancement of wellness programs because of the potential cost savings. The increasing documentation of the economic impact of quality worksite health promotion programs has caused more and more companies to adopt these programs. The public sector has also recognized this trend and implemented worksite programs. Health promotion programs at the worksite have been producing tangible and intangible benefits. Most frequently listed tangible benefits in the United States include reduced use of the health care system, injuries, and absenteeism. Some of the intangible benefits are increased productivity, employee morale, and employee loyalty. Many corporations, in particular multinational enterprises, regard health promotion as one of the necessary elements to stay competitive in the global marketplace. Reduced employee turnover and increased morale will considerably enhance a company's image. A highly regarded global health promotion program is the Live for Life (LFL) program of Johnson & Johnson. The LFL program aims at containing disease costs attributable to unhealthy behavior and lifestyles that are amenable to modifications in the work setting (Holzbach et al., 1990). The program targets the entire worksite population and solicits participation through a variety of promotional media sources and formats, individualized follow-up, feedback to management, and recognition and incentives to participants. Offered activities include (Holzbach et al., 1990): health screenings (measurement of blood pressure, blood lipid levels, height and weight, body fat, estimated maximum oxygen uptake from submaximal bicycle ergonony, and lifestyle questionnaire) a lifestyle seminar on health risks and opportunities for improvement formal lifestyle improvement programs (e.g., exercise, weight control, nutrition, smoking cessation, stress management, high blood pressure, alcohol use) environmental improvements (exercise space, program promotion, smoking policies, cafeteria/vending programs, incentives, newsletters, health fairs) Data from ongoing epidemiological studies (e.g., Wilbur and Garner, 1984) evaluating the LFL program have documented improvement in weight, exercise, blood pressure, percent body weight above ideal, cigarette smoking, self-reported sick days, and other characteristics. Direct economic effects were derived from decreases in absenteeism rates and health care benefit costs, indirect economic effects from increased job satisfaction, commitment to the organization, and other work-related attitudes (Fielding, 1994). The results suggest that a comprehensive worksite health promotion program can affect a number of employee behaviors and attitudes over a two to three year period. Health promotion programs at other major corporations such as Coca-Cola and Coors Brewing Company have produced similar benefits. An analysis of Coca-Cola's health care claims shows that from 1988 to 1990 health care claim costs were reduced among the 60% of employees who joined the company's fitness program resulting in a savings of $500 per associate per year (Worksite Wellness Works, 1995). Two thousand five hundred of the 4,000 executives at the Coca Cola Atlanta complex are involved daily in the exercise program. In addition, many more are participating in various wellness activities from smoking clinics to stress management seminars. Coors Brewing Co. calculated a $5.50 return on their $1 investment towards a wellness program (Naas, 1992). This number is derived from real and anticipated reductions in medical claims and costs, reduced absenteeism, and increased productivity. Users of the Coors Wellness Center in Denver (2.5 times or more per week) were 18% less absent than non users (Naas, 1992). Workers not employed in the Denver area receive $400 annually to use toward health promotion (e.g., fitness club membership). An eleven year worksite health promotion program at the Army Materiel Command (AMC), coordinated by American University's National Center for Health Fitness, documented a strong correlation between participation in the program and lowered health risk, sick leave, health care costs, and increased productivity. The main components of the health promotion program included fitness training weight control, stress management, and personal change. Participants with the most program exposure exhibited far less health care expenses with a yearly expenditure of US $945 versus US $1,438 being spent by the low program exposure group (American University NCHF, 1996). An increasing number of scientific studies demonstrating a direct correlation between health promotion and lower health care costs are being published, not only in the U.S. but in many other countries. Health promotion programs can be implemented conveniently and effectively at the workplace. A very large percentage of the population return to their workplace every day and can easily be addressed through established communication channels. The worksite is probably the single most effective setting to capture the attention of many individuals and influence health behavior. There are proven rewards for both employer and employee, and health promotion programs often make a perfect match with the company benefit program. Combined with health care providers eager to lower costs, which is the case in many countries, the worksite is an ideal site for health promotion. Further, this setting also provides an opportunity to reach out to dependents who are covered by the employer's insurance plan. The last few years have shown a considerable increase in worksite health promotion programs (81 % of companies in the U.S. offer at least one health promotion activity according to the Healthy People 2000 survey of 1992). The worksite is not the only setting to effectively implement health promotion programs. One of the fastest growing sectors in the U.S. with regard to health promotion is the hospital sector. More and more hospitals are building wellness centers and establishing health promotion programs to stay competitive and lower health costs in the long run. Community-based health promotion initiatives have also shown considerable success, e.g. the "Healthy Cities" project sponsored by the WHO. IV Health promotion initiatives in China Although China is still considered a developing country, it is confronted with many of the same health problems that other developed countries face. Chronic diseases, like cancer and cardiovascular disease, are the leading mortality causes and on the rise, especially in urban areas. The most serious problem China faces is tobacco consumption. It is only one of six countries in the world where per capita cigarette consumption is steadily rising. Richard Peto (as cited in Frankel & Mufson, Washington Post, 1996), a British research expert specialized in tobacco-related diseases, calculated that China is currently suffering a half-million deaths per year from tobacco-related disease, and projected that the figure would reach two million by 2025. In addition, the incidence of obesity has rapidly increased among Chinese urban children parallel to the development in many Western countries (Gao Da-an, personal communication, September 20, 1996). China is also challenged by rising health care costs, a side effect of the economic reforms. Between 1986 and 1993, health care spending per person increased by an average of 11 percent annually (Hsiao and Liu, 1996). Government financing of the health care system was reduced after economic reform, resulting in a greater burden for the patient. Only 25% of the population has health insurance, therefore fee-for-service programs have become more popular (Hsiao and Liu, 1996). With regard to health promotion, the budget cuts meant a reduction in preventive care and vaccinations. These new developments provide major challenges for the country. Naturally, specific cultural, social, and political characteristics require a unique approach to health promotion. In light of the recent establishment of the China Institute for Health Promotion and the increased focus on health and fitness, it is the logical consequence for China to become a more active player in the global health promotion community. One of the first steps to that end was the extensive involvement of several distinguished Chinese medical and educational professionals in the Inaugural Meeting of American University's International Institute for Health Promotion in Washington D.C. in July 1996. China is not a newcomer to health promotion programming aimed at improving the quality of life of the people. Nationwide physical tests on children and youth were conducted by the Chinese government in 1978. More recently, "Standards for the Physical Test of Chinese Adults" were developed, and "Standards for the Physical Test of Preschool Children" are currently being drafted. In 1995, the Chinese government launched the "National Fitness Program" which is designed to continuously track the fitness levels of the Chinese people. Epidemiological studies have been conducted on the health status of special groups, e.g., of Chinese intellectuals in 1984 and 1994. In addition, the Public Health Ministry and the National Institute of Health Education have been very active over the last few years with initiatives to curb the increase in smoking. In 1997, the WHO will stage its World Conference on Smoking and Health in Beijing. These multiple projects over the last 20 years combined with some of the traditional Chinese exercises, like Qigong and Tai Chi, make China a valuable partner for health promotion professionals throughout the world, in particular in light of the size of the population. IV Conclusion The recent developments with regard to health have generated a great interest in health promotion and a desire for intense networking throughout the world. This paper provides a rationale for the significance of health promotion and lists a number of successful projects. The investment in health promotion is regarded as an investment in human capital. Changes in lifestyle, expressed in learned individual and group behaviors, have an increasing impact on the improvement of health in many countries. In order to maximize the multiple efforts across the globe, three major goals have to be considered: To increase international communication and collaborative projects. To develop a global database on health and fitness indicators. To develop and support educational programs to train future health promotion professionals. All involved parties can benefit immensely if experiences are exchanged through regular communication and common projects are undertaken. A global and electronically stored database will provide immediate access to valuable information, even in remote areas, resulting in more effective programs worldwide. By providing quality educational experiences for future professionals all countries greatly increase the prospects for healthier citizens. However, in spite of the big strides taken in the right direction, there is a great need for all health promotion professionals to pool their resources and bring forth healthier and more productive nations. Note: Wolf Kirsten's area of expertise is the international health promotion field as he has visited with many health promotion leaders worldwide and given lectures in numerous countries such as China, Brazil, Germany, France, etc. and taught health promotion classes in Portugal and the United States. References American University National Center for Health Fitness. (1983). Optimal wellness model. Washington D.C: American University. American University National Center for Health Fitness. (1996). Annual management report for the headquarters, Army Materiel Command Health Promotion Program. AMC Health Promotion Project. Chapman, L.S. 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