CNUR240 Week 3 Module Introduction PDF

Week 3 Module Introduction This module provides an overview of the historical development, underlying assumptions, and key characteristics of primary healthcare. It compares and contrasts the concepts of primary care and primary healthcare, as well as the levels of prevention (pr...

Week 3 Module Introduction This module provides an overview of the historical development, underlying assumptions, and key characteristics of primary healthcare. It compares and contrasts the concepts of primary care and primary healthcare, as well as the levels of prevention (primary, secondary, and tertiary). The module highlights the differences between population health and health promotion approaches and introduces the population health promotion model, which bridges the gap between these perspectives by integrating their key concepts. Additionally, it includes a discussion of the Declaration of Alma-Ata, which outlines the values and principles of primary healthcare. The module presents primary healthcare as defined by the Declaration of Alma-Ata, a milestone conference organized by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). This declaration marked a significant turning point in the global approach to public health and healthcare, emphasizing primary healthcare as crucial for achieving the goal of “Health for All” by the year 2000. This goal aimed to make healthcare universally accessible to all individuals and families in a community through acceptable, affordable, and sustainable means. We will then explore health promotion strategies and theoretical frameworks that promote health equity and social justice. The module reviews major health promotion approaches developed since the early 20th century, focusing on enhancing population health and well-being through prevention strategies, education, and interventions. These approaches empower individuals and communities to take greater control over their health. Health promotion strategies can be categorized into several types, each with distinct focuses and methodologies, ranging from educational and behavioural change approaches to client-centred, social change, and ecological approaches. Educational approaches involve imparting knowledge and information to influence health behaviours positively, such as school-based health education, public health campaigns, and workshops highlighting the risks of unhealthy behaviours and the benefits of healthier lifestyles. Ecological and social change approaches aim to identify and modify social and environmental factors influencing health, advocating for interventions that address multiple layers of influence from individual to societal levels. Examples include policy advocacy, community development, and legislative changes that facilitate healthier environments, such as creating smoke-free zones, improving access to healthy food, and enhancing public spaces for physical activity. Health promotion approaches also employ empowerment strategies that enable individuals and communities to take control of their health determinants. These strategies involve community organizing, participatory action research, and building community capacities to address health and social issues. The module will also delve into theoretical and analytical frameworks such as critical social theories. These include feminist theory, which critiques patriarchal structures marginalizing women and other gender minorities; critical race theory (CRT), which focuses on race and racism’s intersection with law and power; post-colonial theory, which analyzes the impact of colonialism on societies and advocates for reclaiming local histories and identities; and intersectionality theory, which examines how multiple forms of social inequity (e.g., race, class, and gender) intersect to shape experiences of oppression and privilege. We will discuss how shifting our vision of society from one centred on dominant groups’ voices and experiences to those of marginalized and excluded individuals can alter our understanding of the world. Topics Health discourses (biomedical, behavioural/lifestyle, socio-environmental and empowerment) Primary healthcare, primary care, and health promotion and population health Health promoting and population health approaches (educational, behavioural, client centred, social change, ecology, multi strategy approaches) Critical social theoretical frameworks relating to community health nursing. Community development and community-based participatory research Learning Objectives By successfully completing this module, you should be able to: Examine critical theory, social justice, and intersectionality as the theoretical frameworks in community health. Analyze critically the “‘ideology of choice” and “victim-blaming”. Examine population health promotion approaches to community health. Explore how different health promotion approaches and frameworks, e.g., biomedical, behavioural/lifestyle, socio-environmental and empowerment, are used in community health nursing practice. Compare and contrast upstream and downstream approaches and their implications for community health and community health nursing. Required 1. Lind, C., & Baptiste, L. (2020). Health promotion. Chapter 8 in L. L. Stamler, L. Yiu, A. Dosani, J. Etowa and C. Van Daalen- Smith (Eds.) Community health nursing: A Canadian perspective (5th ed.). Toronto: Pearson Prentice Hall (137–167). *Note-1: Health promotion approaches pp. 150-154. 2. Porr, Caroline J., Kearney, A.J., & Dosani, A. (2020) Public Health Nursing. Chapter 4 in L.L. Stamler, L. Yiu, A. Dosani, J. Etowa and C. Van Daalen-Smith (Eds.) Community health nursing: A Canadian perspective (5th ed.). Toronto: Pearson Prentice Hall (59–87). 3. Betker, C., Hill, M., Kirk, M., & MacDonald, M. (2020). Theoretical foundations of community health nursing. Chapter 7 in L. L. Stamler, L. Yiu, A. Dosani, J. Etowa and C. Community health nursing: A Canadian perspective (5th ed.). Toronto: Pearson Prentice Hall (102–136). Videos 1. Health Promotion (3:50) Greg Martin 2. In-depth: What is Critical Race Theory and how might it look in classrooms (3:08). ABC Action News. 3. Postcolonialism: WTF? An Intro to Postcolonial Theory (17:22). Tom Nicholas. 4. What is Postcolonialism? A Short Introduction to Postcolonial Theory (6:59). Armchair Academics – Dr. Alexander.K. Smith. 5. Postcolonialism explained for beginners! Paul Gilroy Media Representation Theory Revision (6:24). Key Terms Critical Social Theories Health promotion documents o Declaration of Alma-Ata Primary healthcare, primary care o Ottawa Charter o Bangkok Charter o The Lalonde Report Health promotion and population health approaches o biomedical o behavioural/lifestyle o harm reduction o socio-environmental o empowerment Population health promotion mode What Is Theory? Well-substantiated explanations of some aspect of the natural or social world based on a body of knowledge that has been repeatedly confirmed through observation and experimentation. A theory provides a structured way to understand complex phenomena, much like a roadmap helps in understanding the layout of a region. Theories guide researchers on where to look for new information and how to interpret data, similar to how a roadmap directs travellers on where to go and how to navigate. Key Point Theories can predict outcomes under certain conditions, akin to how a roadmap can predict the best route to reach a destination. Importance of Theory Theory, research, and practice are reciprocal: Theory provides roots that anchor both practice and research in the nursing discipline. Practice and research in diverse settings contribute to development of new theories. Theory assists practitioners, decision makers, educators, and researchers to explain what they experience, inform their actions and decisions, and articulate possible outcomes. How Does Theory Relate to Nursing It helps to: Guide the nurse in the assessment Map the process of data collection Interpret the data in a clear and organized manner Identify the appropriate problem/s Find the means to address these problems Core Public Health Concepts Key public health concepts include social justice, population health, epidemiology, health promotion and prevention, ethics, commitment to community and health equity. Community health nursing concepts include health equity, determinants of health, capacity building, a strengths-based approach, caring, cultural safety, and collaboration. Health equity is achieved when all people have the opportunity to reach their full health potential regardless of age, race, ethnicity, gender, or social class. Historical Development of Nursing Theory Nursing theories focusing on illness in clinical settings are not always easily adapted to practice of community health nursing and theories specifically about CHN are lacking. In 1987, Schultz argued that nursing tends to represent individual problems as isolated events rather than a pattern of responses in a community. Critical Social Theory (CST) Critical social theory is the scientific study of social relationships in a society. CST is a subset of social theory  Does not adhere to one singular theory Derived from a variety of perspectives; e.g., racism, feminism, colonialism CST is Concerned with critically examining and reflecting on existing social institutions and ideologies and exposing the way domination and oppression are reinforced and normalized. Provides a way of looking at the world; e.g., analysis of root causes. CST addresses underlying power differentials and inequities that may exist offering insights into the mechanisms of social injustice and advocating for transformative change. Critical A process of asking questions Unpacking ideological implications Identifying constraints Determining risks of health damage (both intended and unintended effects) Joining WITH vulnerable groups Develop strategies to secure the conditions for health and well being Assumptions All research, theory, and practice is political Oppressive power relations and subjugation are common (insidious) but are frequently not questioned Scientific and usual ways of thinking and getting things done are ideally open to systematic questioning and criticism Social, economic, and political conditions have a history We can better understand health by looking at history, oppressive social arrangements, economic inequities, and political disenfranchisement View of Health from This Perspective Related to empowerment – liberation Recognizes that health is complex Oppression creates ill health -- liberation is an indispensable part of any group’s pursuit for well being and integrity Health of communities depends on: o integrity of the physical environment o humanness of social relations Acceptance of diversity Equitable distribution of health risks Availability of resources to sustain life and manage illness Attainable employment and education Sense of empowerment and hope Connection with Health Promotion Recognition of the Social Determinants of Health Entire theoretical framework is based on: o understanding root causes o implications of differences in access to determinants of health View of Illness: o illness based on inequity and oppression o illness not simply a physiological occurrence o looks at the structures of society Empowerment through populations engagement in a dialectic (i.e., argument, debate, discussion): o enabling reflection to understand their oppression o developing meaningful strategies for change Recognition of the Social Determinants of Health Entire theoretical framework is based on: o understanding root causes o implications of differences in access to determinants of health View of Illness o illness based on inequity and oppression o illness not simply a physiological occurrence o looks at the structures of society Empowerment through populations engagement in a dialectic (i.e., argument, debate, discussion) o enabling reflection to understand their oppression o developing meaningful strategies for change “Bottom Up” Approach Health promoters work with the group  Part of the group Consciousness raising, liberation, and empowerment – helping groups understand the political, social, historical, and economic impediments to health Action Is Viewed As Informed, deliberate, meaningful behaviour by those experiencing health damaging constraints Based on political amd historical insights, reflection, and dialogue Upstream vs Downstream Upstream approaches are often prevention and promotion strategies focused on policy interventions that benefit the whole population. PHC interventions that focus on people’s well-being by addressing and taking action on the root causes of preventable diseases and injuries. Acute care services are usually tertiary prevention measures, are focused on individual treatment and cure, and are considered downstream interventions. Upstream approaches extend beyond addressing individual behaviours and identify programs, policies, and environmental changes. Strategies Analysis of issues Community development and/or community-based participatory action research Political action Self help and mutual aid, to achieve a process of creating consciousness Coalition building The aim is “empowerment,” “healthy” social change and social justice for all. Implications for Nursing Roles: Nurses as facilitators and consultants Nurses as a member of the group, “bottom up” approach Nurses not the expert: community members have expert knowledge of the situation Nurses help people to articulate that which they know but have not yet named Nurses acknowledge lived experience Shifting the Centre How might we see the world differently if we shifted our vision of society? Shifting one’s centre of thinking: from one often centred in the voices and experiences on dominant groups to the lives and thoughts of those who have been devalued, marginalized, and excluded include previously silenced voices as a starting point for analyzing the complex interrelationship of race, class, and gender in society, and for thinking about social relationships, actions, experiences, and institutions in new ways (Andersen & Collins, 2004, p. 15) Anderson and Collins Social Analysis 1. Shift the centre and reconstruct knowledge 2. Conceptualize race, class and gender in analytical terms a. make visible the continuing effects of race, class, and gender on peoples’ experiences b. draw attention to the interconnections and interrelationships between these constructs 3. Rethink how race, class and gender shape the social organization of social institutions a. how these institutions affect group experience b. how social institutions are constructed through race, class, and gender relations 4. Analyze social issues (e.g., violence and sexuality) using this inclusive perspective 5. Work toward social change and the politics of empowerment a. people are not just victims b. they are creative and visionary c. people actively resist oppression and make liberating social changes Key Point Social analysis should be the primary framework in all the community health studies. Social Justice Refers to fair and equitable distribution of resources, opportunities, and privileges among all members of the community. It involves the recognition and dismantling of systemic inequalities and injustices that affect marginalized and disadvantaged groups. Goal To create a society where all individuals have the same access to social, economic, and political rights, and where diversity is respected and valued. Feminist Theories  Centred around understanding and addressing the social, political, and economic inequalities between genders Analyze the structures and systems that perpetuate gender-based oppression Advocate for the rights and empowerment of women and other marginalized genders Includes the perspectives and methods committed to political and social changes that improve the lives of women A movement to end sexism, sexist exploitation and oppression Is focused on equity, oppression, and justice, which are central concerns in public health Postcolonial Theories Explores the cultural, political, and economic impacts of colonialism and imperialism on former colonies and their people Examines how colonial histories have shaped the present and continue to influence identities, power structures, and social dynamics A view reflecting dominant discourse and culture and to give “voice to subjugated and Indigenous knowledge, especially non- Western voices” Understanding how continuities from the past shape the present context of health and healthcare Understanding of historical influences Analyzing how colonial powers established and maintained control through knowledge production, such as the creation of certain narratives and the suppression of others It challenges our assumptions through self-reflection and exploration of the forms of oppression at play within any given nurse- client relationship Intersectionality Theory Provides a way to understand how multiple social identities such as gender, race, disability, SES, and other inequalities intersect at the level of the individual Examines difference and influence of power A framework that accounts for synergistic or amplifying influence of multiple forms of oppression Creating and Maintaining Health – What Works and What Does Not? Past (pre-Alma Ata: Primary Health Care [PHC]): Primary focus on treatment of ill health Personal blame for ill health often the focus (victim blaming) Current (post-Alma Ata and Ottawa Charter): Research: 50% of population’s health due to social and economic factors (plus political and cultural factors [WHO, 2008]) 25% of “health” attributable to illness care Therefore: promotion of conditions and activities that help people create and maintain their health and the health of their families and communities is essential. “Taking action on health inequities is a matter of social justice” – “it is the right thing to do.” (Marmot, 2009, p. 23; WHO, 2008) How Do We Promote Health? What Is Health Promotion? Health Promotion – WHO definition (1986): “A process of enabling people to increase control over and improve their health” Broadly: describes a relationship between The state: which regulates health opportunities Market economies: which creates both health opportunities and health hazards Community groups: which, through individual choices or collective action, influence both the state and market economies as well as their own health HP works to create some change in those relationships; e.g., improving the ability of marginalized groups to voice their concerns and influence political decision-making (Laverack, 2004, pp. 6–7). Important health promotion documents Declaration of Alma-Ata (Primary Healthcare) First international conference on primary health care (PHC) The declaration emerged as a major milestone of the 20th century in the field of public health, and it identified primary healthcare as the key to the attainment of the goal for health for all (WHO, 1978) The conference called for urgent and effective national and international action to develop and implement PHC throughout the world and particularly in developing countries The Declaration of Alma-Ata noted that monitoring and surveillance were not creating healthier societies (i.e., epidemiological approaches). Therefore, a set of principles – a roadmap – was created to achieve better health for all populations The Declaration Has 10 Points 1. Definition of health 2. Equality 3. Health as a socio-economic issue 4. Human right to participate 5. Role of the state 6. Primary healthcare defined 7. Components of PHC 8. Called on all governments to incorporate PHC approach in their health systems 9. International cooperation in better use of world resources 10. Acceptable level of health for all by the year 2000 Primary Health Care (WHO, 1978) Primary healthcare (PHC): “A set of principles guiding a vision for community health that focuses on empowered citizens making informed decisions for health and harmony with the environment” (McMurray, 2007, p. 26) PHC principles are based on a social justice approach to health promotion Human rights and individual and community choice are at the heart of healthy communities Developing Health Capacity Means For individuals: Becoming health literate Knowing where and how to access and maintain health knowledge and skills Feeling comfortable in participating in discussions or activities about health Having supportive, sustainable resources to support health and lifestyle choices For health professionals: Becoming a well informed partner and resource to members of the community Assisting community members in seeking out and using whatever resources and information are needed Helping community members to develop health capacity. Those that created the declaration urged that essential healthcare: Be based on practical, scientifically sound and socially acceptable methods and technology Made universally accessible to individuals and families in the community through their full participation At a cost that community and country can afford to maintain At every stage of their development In the spirit of self reliance and self determination (WHO [& UNICEF], 1978) PHC Interconnected Principles Based on Access to Health and Healthcare Equity and community empowerment Accessibility Appropriate technology Increased emphasis on health promotion Intersectoral collaboration Public participation Criticisms and Reactions Some argued that “health for all by 2000” was not possible and the declaration did not provide clear targets Unrealistic Idealistic Result: A Year Later, Bellagio Conference, Resulting in “Selective Primary Healthcare” Presented the idea of obtaining low cost solutions to “very specific” and common causes of death. Targets and effects were clear, concise, measurable, and easy to observe [GOBI (growth monitoring, oral rehydration treatment, breast-feeding, and immunization), and later GOBI-FFF (adding food supplementation, female literacy, and family planning)]. Supporters of the comprehensive Alma-Ata declaration, others preferred Selective PHC. Ottawa Charter for Health Promotion First international conference on health promotion held in Ottawa 1986 Launched a series of actions among international organizations, national governments and local communities to achieve the goal of “Health For All” by the year 2000 and beyond It built on the progress made through the Declaration of Alma-Ata and the WHO’s targets for health for all document Defined 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 Health is a resource for everyday life, not the objective of living HP is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being  (WHO, 1986) The Fundamental Conditions and Resources Required for Community Health Are Peace Shelter Education Food Income A stable ecosystem Stainable resources Social justice and equity (WHO, 1986) Determinants of health Action areas for health promotion were identified in the charter as: Build “healthy” public policy Create supportive environments Strengthen community action Develop personal skills Reorient health services Translated into 50 languages Continues to be the guidepost for health promotion globally. Strategies for Health Promotion Were Prioritized As Advocate: good health is a resource for social, economic and personal development. Political, economic, social, cultural, environmental, behavioural, and biological factors, can all favour or be harmful to it. HP action aims at making these conditions favourable through advocacy for health. Enable: must be empowered to control the SDOH to be able to reach the highest attainable QOL. Achieving equity in health. Mediate: collaboration of all sectors of government (social, economical, etc.), as well as independent organizations (media, industry, etc.) Key Point The Ottawa Charter Led to healthcare reform Reduced inequities by enabling citizens to take action to improve health Bangkok Charter for Health Promotion in a Globalized World Purpose: It affirms that policies and partnerships to empower communities, and to improve health and health equality, should be at the centre of global and national development. It complements and builds upon values, principles, and action strategies of HP – established by the Ottawa Charter for Health Promotion and recommendations of the subsequent global health promotion conferences – which have been confirmed by member states through the World Health Assembly. 6th Global Conference on health promotion held in Bangkok 2005 Scope: identifies actions, commitments, and pledges required to address the determinants of health in a globalized world through health promotion Critical Factors Community and global contexts for health promotion has changed markedly since the development of the Ottawa Charter. The Bangkok Charter recognizes critical factors that are currently influencing health include: Increasing inequalities within and between countries Widening gap between rich and poor locally, nationally, and globally New patterns of consumption and communication Commercialization Global environmental changes Urbanization 5 Key areas of action for a healthier world (all sectors and settings must act to): 1. Advocate: for health based on human rights and solidarity 2. Invest: in sustainable policies, actions, and infrastructure to address determinants of health; e.g., violence 3. Build capacity: for policy development, leadership, health promotion practice, research, knowledge transfer (i.e., sharing), health literacy, and freedom; e.g., from violence 4. Regulate and legislate: to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people 5. Partner and build alliances: with public, private and international organizations, NGOs and civil society to create sustainable actions New Opportunities: What Is Possible?  Globalization can open up new opportunities for cooperation to improve health and reduce transnational health risks. Opportunities include: Enhanced information and communication technology/ies Improved mechanisms for global governance and the sharing of experiences, locally, nationally, and internationally Audience The Bangkok Charter reaches out to people, groups, and organizations that are critical to the achievement of health including: Governments and politicians at all levels Civil society The private sector International organizations Public health community The Lalonde Report The Lalonde Report is a 1974 report produced in Canada, formally titled “A New Perspective on the Health of Canadians.” It proposed the concept of the “health field,” identifying two main health-related objectives: the healthcare system; and prevention of health problems and promotion of good health. Revolutionary; reconceptualization of health promotion. Four DOH were identified in this report: Healthcare system Human biology Lifestyle Environment Health Promotion Approaches There are a number of established health promotion approaches in the literature. Drawing on Cohen (2012) & Wallerstein (2006) re: empowerment (2006), and Wilkinson (2012) we will consider 5 of these approaches. Medical Behavioural/lifestyle Socio-environmental Harm reduction Empowerment Medical Approach (Dominant) Views health as: An absence of disease or disease-producing conditions Treatment of illness Disease prevention, among high-risk individuals, etc., with a greater risk of disease (i.e., COVID-19 spread and vaccine programs) The “expert” knows best about health Programs delivered “top-down” Based on the “experts’” knowledge Physicians dominant (in the 1950s) – others try to emulate – power issues Behavioural/Lifestyle Approach (Also Dominant) Views health as behaviour/lifestyle of individuals Individuals’ behaviour/lifestyle can directly impact their own health and the health of others; e.g., smoking and secondhand smoke Education and awareness campaigns Inform people about their high risk behaviours Analysis: research indicates many educational campaigns alone do not succeed in changing behaviours Peoples’ lives are far more complex than just lifestyle and behaviour Individuals are not isolated from their social context Yet lifestyle approaches continue to focus on individuals versus their contexts; e.g., heart health campaigns (i.e., blame the victim) Socio-environmental Approach Views health as influenced by social and environmental conditions. Critique of medical and behavioural approaches: Structural issues indirectly and directly influence health; e.g., poverty, employment, gov’t policies – not recognized Expert vs. individual: power-struggle between: o healthcare professional and client o communities and health promotion organizations … re: who has the power to identify/name the health issue Socially excluded, marginalized, and/or at-risk populations in a more precarious position in relation to their health Analysis: focus on social, economic, political, and cultural context Strategies: focus on health equity, social justice, and ecological sustainability  First 3 Models of Health Biomedical Model Behavioural Model Socio-environmental Model cardiovascular diseases smoking poverty cancer poor eating habits unemployment HIV/AIDS physical inactivity powerlessness stroke substance abuse isolation diabetes poor stress coping environmental pollution obesity lack of life skills, etc. stressors hypertension, etc. hazardous living and working conditions, etc. Harm Reduction Approach Views Health as: An individual concept, which goes beyond the absence of disease One can maintain health by engaging in harmful behaviours responsibly “A Public health philosophy” (Wilkinson, 2012, p. 441) related to “A program or policy designed to reduce drug-related harms without requiring the cessation of drug use” (Beirness et al., 2008, in Wilkinson, 2012, p. 441). These types of programs “allow individuals to live with a certain level of dependency while minimizing risks and other disruptive effects to the person and community” Empowerment Approach Views health and ways that “disadvantaged people can work together to increase control over events that determine their lives” (Werner, 1988 in Laverack, 2004, p. 46). Empowerment is both an individual and group phenomena Empowerment must come from within a group and cannot be given to a group or community (Wallerstein, 2006) Community empowerment includes: individual (psychological) empowerment, organization empowerment broader social and political changes Dynamic energy between all 3 levels: Continual shifts in power between different groups and decision makers in the broader society Community Empowerment: 5 Point Continuum Personal action The development of small mutual aid groups Community organizations Partnerships Social and political action (Jackson et al., 1989; Labonte, 1990, in Laverack, 2004, pp. 47–48) Others argue – it is not so much a continuum but drawing attention to the many locations where community empowerment can take place – the community is primary – the more locations, the more possibilities for collective and empowering health promoting action. Empowerment: Significant Milestones WHO 1978: first articulated: goals of community participation and equity WHO 1986: Bringing together health and social and economic development UN (2000): Millennium Goals including women’s empowerment and health interventions World Bank: Poverty reduction strategy – empowerment of the poor Empowerment: “A process by which people, organizations, and communities gain mastery over their affairs.” Community empowerment: “A social action process by: o which individuals, communities, and organizations o gain mastery over their lives in the context of o changing their social & political environment o to improve equity and quality of life” Population Health Promotion Model This model can be used from different entry points; e.g. one can begin by the determinant of health one intends to influence, the action strategy to be used, or the level at which action is to be taken. This three-dimensional model combines the strategies for the health promotion outlined in 1986 Ottawa Charter on one side, the determinant of population health on the other side and various levels of potential intervention on a third side. Developed by Health Canada in 1996  Bridges the gap between population health and health promotion by integrating the concepts from both perspectives Examples Exploring the effect of food and housing insecurity on the health of low income families and writing a report that boards of health could submit to a government committee considering welfare reform: o Income and social status/sector/building healthy public policy Participating in a coalition of community groups and citizens who have a number of environmental health concerns about a factory that will be built in the area: o Physical environment/community/ Strengthening Community Action Assisting a group of seniors in a seniors’ housing complex to plan a social event in their building: o Social support network/individual/families/developing personal skills Health Canada: Hamilton Bhatti, (1996), in Cohen (2012, p. 95) Population health promotion (Hamilton & Bhatti, 1996) o On WHAT should we take action? o HOW should we take action? o With Whom should we take action? Think and act upstream (macro – broad scope) Looking beyond the individual to where the real problems lie Emphasizing variables that precede or play a role in; e.g., the development of the problem of violence; i.e., the causes of the causes (WHO, 2008) On WHAT should we take action? Focus action strategies on equity and the social determinants of health (WHO, 2008) Early childhood development Education Income and equitable distribution Employment and working conditions Social support networks Physical environment Biology and genetic endowment Food security Housing Personal health practices and coping skills Healthcare services Violence Social exclusion: gender, race, ethnicity, class, abilities, age, sexualities, religion Social safety nets Unemployment Aboriginal peoples, women; e.g., pre and post-natal women, women in military and war-torn communities, immigrants and refugees, separated and divorced women, and most importantly children of all genders, races, ethnicities – in culturally safe contexts HOW should we take action? 1. Approaches to enabling culturally safe healthy social change must be multi-level, comprehensive, critical, and proactive i. Take a clear stand with diverse, socially isolated, marginalized, and at risk groups ii. Ask critical questions: expose oppressive relations iii. Make meaningful connections with communities iv. Work with them to name and solve problems; e.g., violence in interpersonal relationships and in their communities v. Align with others working toward similar goals vi. Aim strategies primarily at the collective level, rather than the individual level (Stevens & Hall, 1992) 2. Develop and ensure cultural safety in health (NAHO, 2006) i. Developing cultural awareness: recognizing that, for example, a health relationship is unique, power-laden, and culturally dyadic (two-way) ii. Developing cultural awareness and cultural sensitivity: recognizing the inherent nature of cultural difference iii. Engaging in self-exploration of one’s own experience and realities and the impact this may have on others iv. Committing consciously to ensuring preservation and protection of other cultures  v. Analyzing power imbalances, institutional discrimination, colonization, and colonial relationships as they relate to health (NAHO, 2008) vi. Cultural safety: a type of advocacy informed by a recognition of self, the rights of others, and the legitimacy of difference (NCNZ 1996) 3. The Ottawa Charter for Health Promotion (WHO, 1986) i. Five areas for action [while ensuring cultural safety: 1. Develop personal skills 2. Create supportive environments (e.g., ensuring cultural safety) 3. Strengthen community action (e.g., partnership, participation, protection) 4. Build healthy public policy (e.g., cultural safety in policy and practice) 5. Reorient health (and social) services (e.g., cultural safety in theory, policy, curriculum, and practice) ii. But we need more to enable culturally safe healthy social change. 4. Bangkok Charter for Health Promotion in a Globalized World (WHO, 2005) i. Advocate: for health based on human rights and solidarity ii. Invest: in sustainable policies, actions, and infrastructure to address determinants of health; e.g., child poverty iii. Build capacity: for policy development, leadership, health promotion practice, research, knowledge sharing, health literacy and freedom from; e.g., life debilitating child poverty iv. Regulate and legislate: to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people, especially children v. Partner and build alliances: with public, private and international organizations, NGOs, and civil society to create sustainable actions; e.g., in reducing and eradicating child poverty All with attention to cultural safety. With whom should we take action? Working to enable culturally safe healthy social change; e.g., to eradicate child poverty, involves strategies at multiple levels – locally, nationally and globally. Individuals Family/relationships Groups Communities Populations Systems Institutions Government Corporations Civil Society Key Commitments Make a key commitment to health equity, cultural safety, social justice, and the promotion of health; e.g. related to child poverty and its eradication Central to the global development agenda A core responsibility for all of government A key focus of communities and civil society A requirement for good corporate practice (Bangkok Charter for Health Promotion in a Globalized World, WHO, 2005) And Evaluate: acting Locally in our communities, while thinking globally All efforts to promote health, health equity, and social justice need to be evaluated to ensure their effectiveness. Some Critical Questions for Health Promoters Where can people seeking better health access further knowledge and adequate support? How can community members become involved in promoting health in their communities? How can the conditions that enable empowerment at the individual, community, organization, and political levels be facilitated? How, when, where, why, and with whom should health promoting nurses work? What ethical considerations should guide nurses’ practices? What actions can health professionals take to participate in political processes that have an effect on health and well-being, health equities, and social justice? Module Summary In summary, the Declaration of Alma-Ata has had a profound and lasting impact on global health initiatives and policies. The commitment to primary healthcare has influenced numerous national health policies and international strategies, including the Sustainable Development Goals (SDGs) established decades later. The declaration remains a seminal and foundational document in discussions of global health policy and practice. Health promotion approaches focus on enhancing the health and well-being of populations through prevention strategies, education, and interventions. These approaches aim to empower individuals and communities to gain greater control over their health. Central to health promotion and the work of Community Health Nurses (CHNs) is the exploration of the social determinants of health – the underlying causal factors contributing to health and healthcare issues, such as poverty, unemployment, and environmental concerns. We have explored the historical development, underlying assumptions, and key characteristics of three dominant health promotion approaches: biomedical, lifestyle/behavioural, and socio-environmental. While all these approaches are employed at different times, the biomedical and lifestyle approaches have traditionally dominated the health promotion domain. However, focusing solely on individual factors and ignoring the root causes of poor health is problematic. By drawing on socio-environmental and empowerment health promotion approaches, CHNs can commit to reducing health disparities and promoting social justice and equity. Critical social theories provide a broad framework for analyzing and critiquing society as a whole, rather than merely understanding or explaining it. These theories take a critical approach to social structures and phenomena, emphasizing the need to understand the underlying power dynamics, inequalities, and ideologies that shape social relations.