Population Health Promotion:

An Integrated Model of Population Health and Health Promotion

Developing a Population Health Promotion Model

In building a model that can help guide our actions to improve health, three questions are critical. "On WHAT should we take action?" "HOW should we take action?", and "WITH WHOM should we act?" The documents discussed above help answer these questions. Strategies for Population Health points out that action must be taken on the full range of health determinants (the WHAT). The Ottawa Charter on Health Promotion calls for a comprehensive set of action strategies to bring about the necessary change (the HOW). Both documents affirm that, in order for change to be accomplished, action must be taken at various levels within society (the WHO). Taking these questions and the answers as a starting point, we can begin to construct an action model.

Figure 1

Figure 1, Text Equivalent

The Population Health Promotion Action Model figure is a cube which addresses three critical questions, which are identified on the three visible faces of the cube. The action model can help guide our actions to improve our health.

The question of "what" should be done to improve population health is addressed on the front face of the cube. The response to the question of "what" should be done to improve population health, is to take action on the full range of health determinants

The question of "how" should we take action is on the side face of the cube. The Population Health Promotion cube directs that action should be taken using on comprehensive action strategies, as laid out in the Ottawa Charter for Health Promotion.

The third question of "who" (with whom should we act) appears on the top face of the cube. This face provides guidance on the various levels to which interventions can be directed from individual, through to societal levels.

For the purposes of this image, it should be noted that although a square does have more than three sides, the image only uses three sides to address their questions of "what", "how" and "who".

To develop the details of the three dimensions in the model, we can turn to Strategies for Population Health for a summary of the evidence on the range of health determinants and The Ottawa Charter for a description of comprehensive action strategies. We can also turn to communication theory for an explanation of the various levels within society at which action can be taken: the individual; family and friends; community (people linked by a common interest or geographic setting such as a neighbourhood, school or workplace); sector/system (education, income support, housing, etc.); and society as a whole. For example, to promote the health of school-aged children we can help young people develop a positive self-image; involve families in the education of their children; ensure that schools, as communities, are healthy places to be; develop polices within the educational system that support the realization of one's full potential; and promote the value of learning and education throughout the society as a whole.

Using the findings of these documents, which have been accepted nationally and internationally, the model has been completed as shown below. We are calling the model a Population Health Promotion (PHP) model because it explains the relationship between population health and health promotion. It shows how a population health approach can be implemented through action on the full range of health determinants by means of health promotion strategies.

Figure 2

Figure 2, Text Equivalent

Population Health Promotion (PHP) model is a full cube shape image, which explains the relationship between population health and health promotion. This model identifies how population health approach can be implemented through action on the full range of health determinants by means of health promotion strategies.

The full cube includes 12 determinants of health on the front of the cube, followed by the 5 strategies for health promotion on the side and then the levels of intervention on the top of the cube.

The front of the cube outlines the social determinants of health, including:

  • Income and Social Status;
  • Social Support Network;
  • Education;
  • Working Conditions;
  • Physical Environments;
  • Biology and Genetics;
  • Personal Health and Practices and Coping Skills;
  • Health Child Development; and
  • Health Services.

The strategies of health promotion are outlined on the side of the Population Health Promotion Model, which include:

  • Strengthen Community Action;
  • Build Healthy Public Policy;
  • Create Supportive Environments;
  • Develop Personal Skills; and
  • Reorient Health Services.

Figure 3

Figure 3, Text Equivalent

The corresponding image is an evidence-based decision making model. Evidence based decisions are required to ensure that policies and programs focus on the right issues, take effective action and produce sound results. When assembling the evidence based decisions, the three sources as outlined in the model (outlines research, experimental learning and evaluation), should be consulted.

This model also illustrates the need for evidence-based decision-making to underpin the development of population health promotion activities. Evidenced-based decisions are required to ensure that policies and programs focus on the right issues, take effective action and produce sound results. When assembling the evidence required, three sources should be consulted:

  • Research studies that have systematically studied health issues, the underlying factors, the interventions and their impact, both intended and unintended.
  • Experiential knowledge that has been gained through practice and synthesized in ways that can guide practice and policy-making.
  • Evaluation studies (formative and summative) of policies, programs and projects.

These sources provide evidence based on an examination of past activities. In addition, trends can be analyzed to identify emerging issues and visioning can be done to create preferred scenarios for the future. Evidence-based decision-making is thus, an art and a science where collective wisdom and vision, along with empirically derived knowledge, play worthwhile roles.

The decision-making process must be made explicit. It must draw upon a broad base of evidence, involve all the key stakeholders, clarify who exercises the final decision-making authority and be supported by effective technological support systems. Information technologies are increasingly available to assist with decision-making processes. Technologies can help gather and synthesize information, conduct stakeholder consultations and perform meta-analysis across studies to help us reach key conclusions. Such decision support systems, in conjunction with explicit assumptions underpinning the decision-making process will help us reach the best possible decisions as to what to act on, how to act and with whom.

Values and Assumptions Underlying the Population Health Promotion Model

The PHP model is based on the following assumptions:

  • Policy and program decision makers agree that comprehensive action needs to be taken on all the determinants of health using the knowledge gained from research and practice.
  • It is the role of health organizations to analyze the full range of possibilities for action, to act on those determinants that are within their jurisdiction and to influence other sectors to ensure their policies and programs have a positive impact on health. This can best be achieved by facilitating collaboration among stakeholders regarding the most appropriate activities to be undertaken by each.
  • Multiple points of entry to planning and implementation are essential as demonstrated by the examples in the following section. However, there is a need for overall co-ordination of activity.
  • Health problems may affect certain groups more than others. However, the solution to these problems involves changing social values and structures. It is the responsibility of the society as a whole to take care of all its members.
  • The health of individuals and groups is a combined result of their own health practices and the impact of the physical and social environments in which they live, work, pray and play. There is an interaction among people and their surroundings. Settings, consisting of places and things, have a physical and psychological impact on people's health.
  • In order to enjoy optimal health, people need opportunities to meet their physical, mental, social and spiritual needs. This is possible in an environment that is based on the principles of social justice and equity and where relationships are built on mutual respect and caring, rather than power and status.
  • Health care, health protection and disease prevention initiatives complement health promotion. Comprehensive approaches will include a strategic mix of the different possibilities for action. Meaningful participation of people in the development and operationalization of policies and programs is essential for them to influence the decisions that affect their health.

How To Work with the Population Health Promotion Model: Some Possibilities

To operationalize the model, it is helpful to visualize it as consisting of many interior cubes each providing a potential blueprint for action. While the model may appear static, it becomes dynamic when used as a planning tool. Organizations may use the model from different entry points. For example, one can begin with the health determinant that one intends to influence, the action strategy to be used, or the level at which action is to be taken. Alternatively, the model can be used to plan a comprehensive range of actions on emerging health issues or issues related to the health of a particular priority group.

Example 1: If You Would Like to Focus on the Determinants of Health

Collectively, stakeholders should address the full range of health determinants in adopting a population health approach. Particular organizations, however, may wish to focus on specific determinants. This example shows how the model can be used to identify possibilities for influencing the various determinants:

Figure 4

e.g: Governments can assess the health impacts of income support policy options.
Figure 4, Text Equivalent

Building upon the population health model, the who, what and with whom descriptors can be used to identify possibilities for influencing various determinants.

  1. In order for governments to assess the health impacts of income support policy options, using the population health model, the who is identified as sectors, the what is identified as income and social status and the how is identified as healthy public policy.
  2. In order for industry to examine the effects of emerging technologies on working conditions and to adopt health enhancing options, using the population health model, the who is identified as sectors, the what is identified as working conditions and the how is identified as healthy public policy.

e.g: Governments can assess the health impacts of income support policy options.

Figure 5

e.g: Community clinics can make appropriate primary care services accessible to young families.
Figure 5, Text Equivalent

Building upon the population health model, the who, what and with whom descriptors can be used to identify possibilities for influencing various determinants.

  1. In order for governments to assess the health impacts of income support policy options, using the population health model, the who is identified as sectors, the what is identified as income and social status and the how is identified as healthy public policy.
  2. In order for industry to examine the effects of emerging technologies on working conditions and to adopt health enhancing options, using the population health model, the who is identified as sectors, the what is identified as working conditions and the how is identified as healthy public policy.

e.g: Community clinics can make appropriate primary care services accessible to young families.

Figure 6

e.g: Parents can create family environments that help children learn to develop positive social relations.
Figure 6, Text Equivalent

Building upon the population health model, the who, what and with whom descriptors can be used to identify possibilities for influencing various determinants.

  1. In order for governments to assess the health impacts of income support policy options, using the population health model, the who is identified as sectors, the what is identified as income and social status and the how is identified as healthy public policy.
  2. In order for industry to examine the effects of emerging technologies on working conditions and to adopt health enhancing options, using the population health model, the who is identified as sectors, the what is identified as working conditions and the how is identified as healthy public policy.

e.g: Parents can create family environments that help children learn to develop positive social relations.

Figure 7

e.g: Industry can examine the effects of emerging technologies on working conditions and can adopt health-enhancing options.
Figure 7, Text Equivalent

Building upon the population health model, the who, what and with whom descriptors can be used to identify possibilities for influencing various determinants.

  1. In order for governments to assess the health impacts of income support policy options, using the population health model, the who is identified as sectors, the what is identified as income and social status and the how is identified as healthy public policy.
  2. In order for industry to examine the effects of emerging technologies on working conditions and to adopt health enhancing options, using the population health model, the who is identified as sectors, the what is identified as working conditions and the how is identified as healthy public policy.

e.g: Industry can examine the effects of emerging technologies on working conditions and can adopt health-enhancing options.

Example 2: If You Would like to Focus on a Specific Health Concern

This example shows how the model can be used to intervene in a comprehensive manner in the area of nutritional health.

Figure 8

e.g: The agriculture sector can provide information on the cost of a nutritious food basket to policy makers who are developing income support programs.
Figure 8, Text Equivalent

In order for community clinics to make appropriate primary services accessible to young families, using the population health model, the who is identified as community, the what is identified as healthy child development and the how is identified as reorienting health services.

e.g: The agriculture sector can provide information on the cost of a nutritious food basket to policy makers who are developing income support programs.

Figure 9

e.g: Women's groups can advocate for community support groups for breastfeeding mothers.
Figure 9, Text Equivalent

In order for community clinics to make appropriate primary services accessible to young families, using the population health model, the who is identified as community, the what is identified as healthy child development and the how is identified as reorienting health services.

e.g: Women's groups can advocate for community support groups for breastfeeding mothers.

Figure 10

e.g: Schools and workplaces can make nutritious foods available in their cafeterias.
Figure 10, Text Equivalent

In order for community clinics to make appropriate primary services accessible to young families, using the population health model, the who is identified as community, the what is identified as healthy child development and the how is identified as reorienting health services.

e.g: Schools and workplaces can make nutritious foods available in their cafeterias.

Addressing the Health Concerns of At Risk Groups

In addressing the question of risk, it is important to consider both risk factors and risk conditions. Risk factors are elements&emdashoften behaviour patterns&emdashwhich tend to predispose people to poorer health. Risk Conditions are general circumstances, over which people have little or no control, that are known to affect health status. An example of risk conditions would be a deprived neighbourhood where the housing is substandard, there are few recreational facilities, community spirit is weak and there are feelings of danger and insecurity. Risk conditions are usually a result of public policy and are modified through collective action and social reform.

The Population Health Promotion Model can contribute to the discussion of risk in three ways:

  • It moves the discussion away from victim blaming and calls for action on the full range of factors and conditions that determine health.
  • It provides an analytical tool to help develop a clearer picture of those likely to be most at risk. Who are they? People who, by virtue of their economic and social situation, are isolated and without access to resources and opportunities to participate in their communities. People with few life skills and, who consequently, feel little sense of control over their lives and their environments. People who, for a variety of reasons, engage in negative lifestyles and people who do not have access to appropriate primary care and preventive health services.
  • It provides a planning tool and may be used to address the health concerns of identified groups at risk, as illustrated in the next example.

Example 3: If You Would Like to Focus on a Group-at-Risk

The model may be used to address the health concerns of particular "at risk" groups such as in the prevention of AIDS.

Figure 11

e.g: Support community action to establish needle exchange programs.
Figure 11, Text Equivalent

In order for parents to create family environments that help children learn to develop positive social relations, using the population health model, the who is identified as family, the what is identified as social support and the how is identified as supportive environments.

e.g: Support community action to establish needle exchange programs.

Figure 12

e.g: Boards of Education can ensure that healthy sexuality is included in the school curriculum.
Figure 12, Text Equivalent

In order for parents to create family environments that help children learn to develop positive social relations, using the population health model, the who is identified as family, the what is identified as social support and the how is identified as supportive environments.

e.g: Boards of Education can ensure that healthy sexuality is included in the school curriculum.

Figure 13

e.g: Communities can make opportunities for HIV testing and counselling more available and accessible.
Figure 13, Text Equivalent

In order for parents to create family environments that help children learn to develop positive social relations, using the population health model, the who is identified as family, the what is identified as social support and the how is identified as supportive environments.

e.g: Communities can make opportunities for HIV testing and counselling more available and accessible.

Figure 14

e.g: Social marketing campaigns can heighten public awareness of the importance of safe sex practices.
Figure 14, Text Equivalent

In order for parents to create family environments that help children learn to develop positive social relations, using the population health model, the who is identified as family, the what is identified as social support and the how is identified as supportive environments.

e.g: Social marketing campaigns can heighten public awareness of the importance of safe sex practices.

Implementing the PHP Model

While the preceding section showed how the PHP model can be used to identify potential action strategies, it did not discuss how decisions are made regarding which strategies are selected, nor did it explore the roles required in implementing the various strategies.

The PHP model illustrates how many of the levers for influencing health lie outside the health sector. Thus, organizations within the health sector will need to adopt a number of roles. While they will still be required to provide direct service in the form of financial resources, knowledge and technology, they will increasingly be required to assume an "influencing" role where their role will be to work with other sectors whose programs and policies have an impact on people's health.

The PHP model shows how a comprehensive set of action strategies is required to improve health. While the PHP model can be used to identify specific actions, it is also helpful in showing how the actions can be combined to develop a comprehensive action strategy. Such a strategy often requires the co-operation of organizations working within a variety of sectors. For example, "Brighter Futures"&emdasha child development initiative designed to improve the health of young children and their families&emdashhas involved a high degree of inter-sectoral co-operation and has utilized a variety of policy instruments such as the child tax credit. It has also created opportunities for broadly-based public participation in decision making (e.g., in setting the Child Health Goals).

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