Health Promotions and Social Determinants of Health (SGHPROSDH) v2.pdf
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Health Promotions and Social Determinants of Health (SGHPROSDH) SY 2023 -24 Term 2 Helena Marie Lagon Alvior, MD SESSION 1: 1. THE EPIDEMIOLOGICAL TRIANGLE INTRODUCTION TO HEALTH PROMOTION AND...
Health Promotions and Social Determinants of Health (SGHPROSDH) SY 2023 -24 Term 2 Helena Marie Lagon Alvior, MD SESSION 1: 1. THE EPIDEMIOLOGICAL TRIANGLE INTRODUCTION TO HEALTH PROMOTION AND The Epidemiological triangle is a conceptual framework SOCIAL DETERMINANTS OF HEALTH used in public health to understand the interplay LEARNING OUTCOMES between three key factors in disease transmission: 1. Broad understanding of how social, economic and the host (a person or organism susceptible to political factors influence health and health the disease) inequalities (Social Determinants of Health or SDH) the agent (the pathogen or cause of the 2. Foundational understanding on global and local disease), and perspectives on the goals and scope of health the environment (the context in which the promotion (HP) disease spreads). 3. Analysis and application of SDH and HP concepts to These three elements interact and influence each health issues encountered within the students’ local other, ultimately leading to the occurrence and spread context of diseases in populations. A. EVOLVING PARADIGMS ON DISEASE CAUSATION, HEALTH, AND WELL BEING 1 of 26 2. THE BIOPSYCHOSOCIAL MODEL 3. THE SOCIOECOLOGICAL MODEL The Biopsychosocial model of health is a holistic The socioecological model of health is a framework that framework that recognizes the complex interplay recognizes the multiple levels of influence on between biological, psychological, and social health outcomes, ranging from individual factors in determining an individual's overall health characteristics to broader social, community, and and well-being. environmental factors. It highlights the importance of considering biological It emphasizes the interconnectedness and factors (such as genetics and physiology), interdependence between these levels, highlighting psychological factors (such as thoughts, emotions, and the need for comprehensive interventions that address behaviors), and social factors (such as socioeconomic health determinants at multiple levels to promote status, culture, and social support) when assessing health and well-being. and addressing health issues. Example: 2 of 26 B. THE CSDH FRAMEWORK In an international conference held in 1978 in Alma-Ata in what used to be the USSR, Primary Health Care was recognized as the key to the attainment of "Health for All" by the year 2000. A key lesson from history is that international health agendas have tended to oscillate between: 1a focus on technology-based medical care and public health interventions, and 2an understanding of health as a social phenomenon, requiring more complex forms of intersectoral policy action. In this context, the Commission’s purpose was to revive the latter understanding and therein WHO’s constitutional commitments to health equity and social justice. HEALTH = SOCIAL JUSTICE HEALTH EQUITY (described by the absence of 4. HEALTH SYSTEM BUILDING BLOCKS unfair and avoidable or remediable differences in The health system building blocks are a framework that health among social groups) becomes a guiding provides a comprehensive view of the essential criterion or principle. components needed for a functional healthcare The framing of social justice and health equity, points system. towards the adoption of related human rights These building blocks include health service delivery, frameworks as vehicles for enabling the realization health workforce, health information systems, access of health equity to essential medicines, financing, and Wherein the STATE is the primary responsible leadership/governance, all of which are critical for duty bearer. effective and sustainable healthcare provision. Frameworks and instruments associated with human rights guarantees are also able to form the basis for ensuring the collective well-being of social groups. Having been associated with historical struggles for solidarity and the empowerment of the deprived they form a powerful operational framework for articulating the principle of health equity. Video 1: https://youtu.be/8PH4JYfF4Ns WHO Social Determinants of Health video (https://youtu.be/ES1IX3Mam20), and the TED talk by Sir Michael Marmot, one of the main authors of the 2008 WHO Social Determinants of Health Report: https://youtu.be/xjED0uLaQgk 3 of 26 Social, economic and political mechanisms give rise to a set of socioeconomic positions. Whereby populations are stratified according to income, education, occupation, gender, race/ethnicity and other factors; Socioeconomic positions in turn shape specific determinants of health status (intermediary determinants) reflective of people’s place within social hierarchies; based on their respective social status, individuals experience differences in exposure and vulnerability to health-compromising conditions. “CONTEXT” is broadly defined to include all social and political mechanisms that generate, configure and maintain social hierarchies. The contextual factors that most powerfully affect health are the welfare STATE and its redistributive POLICIES (or the absence of such policies). STRUCTURAL MECHANISMS are those that generate stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources. ─ Structural mechanisms are rooted in the key institutions and processes of the socioeconomic and political context. ─ The most important structural stratifiers and their proxy indicators include: Income, Education, Occupation, Social Class, Gender, Race/ethnicity. Together, context, structural mechanisms and the resultant socioeconomic position of individuals are “structural determinants” and in effect it is these determinants we refer to as the “social determinants of health inequities.” ─ The underlying social determinants of health inequities operate through a set of intermediary determinants of health to shape health outcomes. The main categories of intermediary determinants of health are: ─ Material circumstances include factors such as housing and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment. ─ Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof). ─ Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological also include genetic factors. 4 of 26 HEALTH SYSTEM SOCIAL COHESION/SOCIAL CAPITAL The role of the health system becomes particularly The concepts of social cohesion and “social capital” relevant through the issue of access, which occupy an unusual (and contested) place in incorporates differences in exposure and vulnerability, understandings of SDH. and through intersectoral action led from within the Influential researchers have proclaimed social health sector. capital a key factor in shaping population health. The health system plays an important role in Putnam defines SOCIAL CAPITAL as “features of mediating the differential consequences of illness social organization, such as networks, norms and in people’s lives. social trust, that facilitate coordination and cooperation for mutual benefit” Adoption of social capital as a key for understanding and promoting population health is part of a broader, radically depoliticizing trend. It is clear that the concept of social capital has not infrequently been deployed as part of a broader discourse promoting reduced state responsibility for health, linked to an emphasis on individual and community characteristics, values and lifestyles as primary shapers of health outcomes. Logically, if communities can take care of their own health problems by generating “social capital”, then government can be increasingly discharged of responsibility for addressing health and health care issues, much less taking steps to tackle underlying social inequities. The CSDH adopts the position that the state possesses a fundamental role in social protection, ensuring that public services are provided with equity and effectiveness. Such discussions highlight the role of political institutions and public policy in shaping opportunities for civic involvement and democratic behavior. In this context, while remaining alert to ways in which notions of ‘social capital’ or community may be deployed to excuse the state from responsibility for the well-being of the population we can also look for aspects of these concepts that shed fresh light on key state functions. 5 of 26 READING ACTIVITY 1- THE CSDH IN MORE DETAIL Read the Executive Summary only, pages 1-23: https://www.who.int/publications/i/item/WHO-IER- CSDH-08.1 DAY 1: FORUM ACTIVITY 1 - WHY 'SOCIAL' DETERMINANTS OF HEALTH? In preparation for this class and this course, please read H.K. Heggenhougen (2009) Planting "Seeds of Health" in the Fields of Structural Violence: The Life and Death of Francisco Curruchiche (attached). From Global Health in Times of Violence. School for Advanced Research Press. pp. 181-199. https://ateneo.instructure.com/courses/39666/files/ 6967037?wrap=1 6 of 26 POLICY ACTION A key task for the CSDH will be: In turning to policy action on SDH inequities, three 1. To identify successful examples of intersectoral broad approaches to reducing health inequities can be action on SDH in jurisdictions with different identified. levels of resources and administrative capacity; These may be based on: and to characterize in detail the political and ─ (1) targeted programs for disadvantaged management mechanisms that have enabled populations; effective intersectoral programs to function ─ (2) closing health gaps between worse-off sustainably. and better-off groups; and 2. To demonstrate how participation of civil society ─ (3) addressing the social health gradient and affected communities in the design and across the whole population implementation of policies to address SDH is Policy development frameworks can help analysts and essential to success. policymakers to identify levels of intervention and entry Empowering social participation provides points for action on SDH, ranging from policies tackling both ethical legitimacy and a sustainable underlying structural determinants to approaches base to take the SDH agenda forward after focused on the health system and reducing inequities the Commission has completed its work. in the consequences of ill health suffered by different 3. Finally, SDH policies must be crafted with social groups. careful attention to contextual specificities, which The single most significant lesson of the CSDH should be rigorously characterized using conceptual framework is that interventions and methodologies developed by social and policies to reduce health inequities must not limit political science. themselves to intermediary determinants, but must include policies specifically crafted to tackle the social DAY 1: FORUM ACTIVITY 2 - PUBLIC HEALTH mechanisms that systematically produce an inequitable AND ITS DOWNFALL distribution of the determinants of health among population groups. https://ateneo.instructure.com/courses/39666/files/ To tackle structural, as well as intermediary, 6967056?wrap=1 determinants require intersectoral policy approaches. Slides: https://ateneo.instructure.com/courses/39666/files/ 6966872?wrap=1 Recording: https://drive.google.com/file/d/1Pdx- PuxL4haKXxF1Qc97IvKDjRgdl1FK/view?usp=shar ing 7 of 26 DOH’S HEALTH PROMOTION FRAMEWORK STRATEGY 2020-2030 8 of 26 9 of 26 SESSION 2: MEASURING PROGRESS IN HEALTH LEARNING OUTCOMES 1. Understand how the scope and practice of health promotion has evolved over time 2. Familiarize with the prevailing models, approaches, and strategies to health promotion 3. Understand how health promotion is envisioned to contribute to the achievement of Universal health care A. REDEFINING HEALTH PROMOTION Health Promotion has evolved significantly from the traditional understanding of communicating health information through posters, brochures and the use of other media, to one that is very encompassing. The very first International Conference on Health Promotion that was held in Ottawa, Canada in 1986 defines health promotion as: “Enabling people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure.” Video: https://youtu.be/G2quVLcJVBk DISEASE PREVENTION differs from health promotion because it focuses on specific efforts aimed at reducing the risk factors contributing to the development and severity of chronic diseases and other morbidities. HEALTH PROMOTION includes disease prevention, but also addresses the wider social determinants of health. Reading 10 of 26 B. PREVAILING MODELS OF HEALTH PROMOTION Examples of Ecological Models Over time, there have been several theories, strategies, Project HEART (Health Education Awareness and models that have been be used to inform health Research Team) to an external site. used an ecological promotion and disease prevention programs. model to design a health promotion and disease These theories, strategies, and models have been used prevention program to address cardiovascular disease to develop and implement programs that empower and risk factors. The project uses a community health motivate people to improve and better manage their worker (CHW) promotora model to provide services. health. CDC's Colorectal Cancer Control Program (CRCCP) to Health promotion and disease prevention programs an external site. was designed to address multiple often integrate components of different theories and factors of influence on colorectal cancer prevention, use more than one strategy to achieve their goals using ecological model components. The Healthy People 2020 framework addresses the 1. SOCIO-ECOLOGICAL MODELS (SEM) importance of ecological models in health promotion Theory at a Glance: A Guide for Health Promotion and and disease prevention. Practice - frames the ecological perspective as Programs are most likely to be effective when they “...the interaction between, and interdependence of, are designed to address the multiple levels of factors within and across all levels of a health influence on health behaviors. problem. It highlights people’s interactions with their physical and sociocultural environments.” Considerations for Implementation Socio-ecological models recognize multiple levels of The ecological perspective is a useful framework for influence on health behaviors, including: 1. Intrapersonal/individual factors, which understanding the range of factors that influence health influence behavior such as knowledge, attitudes, and well-being. It is a model that can assist in providing a complete beliefs, and personality. 2. Interpersonal factors, such as interactions with perspective of the factors that affect specific health other people, which can provide social support behaviors, including the social determinants of health. Because of this, ecological frameworks can be used to or create barriers to interpersonal growth that promotes healthy behavior. integrate components of other theories and models, 3. Institutional and organizational factors, thus ensuring the design of a comprehensive including the rules, regulations, policies, and health promotion or disease prevention program or informal structures that constrain or promote policy approach. healthy behaviors. 4. Community factors, such as formal or informal social norms that exist among individuals, groups, or organizations, can limit or enhance healthy behaviors. 5. Public policy factors, including local, state, and federal policies and laws that regulate or support health actions and practices for disease prevention including early detection, control, and management. 11 of 26 2. THE HEALTH BELIEF MODEL Considerations for Implementation The Health Belief Model is a theoretical model that can The Health Belief Model can be used to design short- be used to guide health promotion and disease and long-term interventions. prevention programs. The five key action-related components that determine It is used to explain and predict individual changes the ability of the Health Belief Model to identify key in health behaviors. decision-making points that influence health behaviors It is one of the most widely used models for are: understanding health behaviors. Gathering information by conducting a health needs assessment to determine who is at risk and the population(s) that should be targeted. Conveying the consequences of the health issues associated with risk behaviors in a clear and unambiguous fashion to understand perceived severity. Communicating to the target population the steps that are involved in taking the recommended action and highlighting the benefits to action. Providing assistance in identifying and reducing barriers to action. Demonstrating actions through skill development activities and providing support that enhances self- Key elements of the Health Belief Model focus on efficacy and the likelihood of successful behavior individual beliefs about health conditions, which changes. predict individual health-related behaviors. To ensure success with this model, it is important to The model defines the key factors that influence health identify "CUES TO ACTION" that are meaningful and behaviors as: appropriate for the target population. Individual's perceived threat to sickness or disease (perceived susceptibility) 3. STAGES OF CHANGE MODEL Belief of consequence (perceived severity) (TRANSTHEORETICAL MODEL) Potential positive benefits of action (perceived The Stages of Change Model, also called the benefits) Transtheoretical Model, explains an individual's Perceived barriers to action readiness to change their behavior. Exposure to factors that prompt action (cues to It describes the process of behavior change as action) occurring in stages. Confidence in ability to succeed (self-efficacy) These stages include: Health Belief Model Examples The Michigan Model for Health™ is a curriculum designed for implementation in schools. It targets social and emotional health challenges including nutrition, physical activity, alcohol and drug use, safety, and personal health, among other topics. This model adapts components of the Health Belief Model related to knowledge, skills, self-efficacy, and environmental support. Health Belief Model: Behavioral Change Models: Boston University School of Public Health provides an overview of Health Belief Model in health promotion setting and includes examples for each stage and the limitations of using this model in public health. 12 of 26 Stages of Change Examples Social Cognitive Theory Examples CDC provides a “Talking about Fall Prevention with Healthy Relationships, a program implemented by Your Patients” fact sheet that describes how to use the Chattanooga CARES, is a small-group intervention for Stages of Change Model for fall prevention education. people living with HIV/AIDS. The program is based on the Social Cognitive Considerations for Implementation Theory and uses skill-building exercises to The Stages of Change Model describes how an increase independence and develop healthy individual or organization integrates new behaviors, behaviors among participants. goals, and programs at various levels. HoMBReS is a community-based intervention designed At each stage, different intervention strategies will help to reduce the risk of HIV and other sexually transmitted individuals progress to the next stage and through the diseases among Latino men living in rural areas of the model. United States. Individuals within a population will likely vary in their Based on the Social Cognitive Theory, the program readiness to change. trains “Navegantes” (Navigators) who provide In addition, it is important to recognize that movement information and risk reduction materials to the through this model is cyclical – individuals may target population. progress to the next stage or regress to a previous stage. Considerations for Implementation The Stages of Change model can be applied to health The SCT can be applied as a theoretical framework in promotion and disease prevention programs to different settings and populations. address a range of health behaviors, populations, and It is frequently used to guide behavior change settings. interventions. It may be an appropriate model for health promotion It may be particularly useful in rural communities for and disease prevention programs related to worksite examining how individuals interact with their wellness, tobacco use, weight management, surroundings. medication compliance, addiction, and physical The SCT can be used to understand the influence of activity, among other health topics. social determinants of health and a person's past experiences on behavior change. 4. SOCIAL COGNITIVE THEORY Social Cognitive Theory (SCT) describes the influence DAY 2: FORUM ACTIVITY 1 - APPLYING HEALTH of individual experiences, the actions of others, PROMOTION MODELS and environmental factors on individual health https://ateneo.instructure.com/courses/39666/discu behaviors. ssion_topics/1095797?module_item_id=1993175 SCT provides opportunities for social support through instilling expectations, self-efficacy, and using observational learning and other reinforcements to achieve behavior change. Key components of the SCT related to individual behavior change include: Self-efficacy: The belief that an individual has control over and is able to execute a behavior. Behavioral capability: Understanding and having the skill to perform a behavior. Expectations: Determining the outcomes of behavior change. Expectancies: Assigning a value to the outcomes of behavior change. Self-control: Regulating and monitoring individual behavior. Observational learning: Watching and observing outcomes of others performing or modeling the desired behavior. Reinforcements: Promoting incentives and rewards that encourage behavior change. 13 of 26 C. COMMON STRATEGIES IN HEALTH PROMOTION Examples of Health Communication Interventions Health promotion and disease prevention programs can Tobacco prevention and cessation programs often use improve health at every stage of life. health communication to reach a broader audience. To achieve this, several strategies have been Examples of mass-reach health communication implemented for integrating health promotion and interventions are available in the Rural Tobacco disease prevention perspectives into everyday practice. Control and Prevention Toolkit. Examples of communication and social marketing 1. HEALTH COMMUNICATION interventions related to HIV prevention and treatment Health communication, as define as “the study and are available in the Rural HIV/AIDS Prevention and use of communication strategies to inform and Treatment Toolkit. influence individual and community decisions that The Northeast Louisiana Regional Pre-Diabetes enhance health.” Prevention Project (RPDP) promoted prediabetes Health communication includes verbal and written screening and diabetes prevention information to strategies to influence and empower individuals, communities using multiple media outlets. populations, and communities to make healthier choices. Considerations for Implementation Health communication integrates components of When designing health communication or social the health promotion models to promote positive changes in attitudes and behaviors. marketing strategies, it is important to consider the Health communication is related to social overall communication goals of the intervention. It is also necessary to understand the target marketing, which involves the development of activities and interventions designed to population so that the content created is relevant to positively change behaviors. the target population. It is important to tailor messages to the Effective health communication and social marketing strategies include the following components: communication channel being used. Further, using multiple communication and media Use of research-based strategies to shape materials and products and to select the channels strategies will ensure a broader reach. Ensure that the target population has access to the that deliver them to the intended audience. Understanding of conventional wisdom, concepts, communication channels being used. language, and priorities for different cultures and settings. 2. HEALTH EDUCATION Health education provides learning experiences on Consideration of health literacy, internet access, health topics that are tailored for their target population. media exposure, and cultural competency of Health education presents information to target target populations. Development of materials such as brochures, populations on particular health topics, including the billboards, newspaper articles, television health benefits/threats they face, and provides tools to broadcasts, radio commercials, public service build capacity and support behavior change in an announcements, newsletters, pamphlets, videos, appropriate setting. Examples include lectures, courses, seminars, digital tools, case studies, group discussions, webinars, workshops and others. health fairs, field trips, and workbooks among Characteristics of health education strategies include: others media outlets. Participation of the target population. Using a variety of communication channels can allow health messages to shape mass media or Completion of a community needs assessment to interpersonal, small group, or community level identify community capacity, resources, priorities, and needs. campaigns. Health communication strategies aim to Planned learning activities that increase change people's knowledge, attitudes, and/or participants' knowledge and skills. behaviors; for example: Implementation of programs with integrated, well- Increase risk perception planned curricula and materials that take place in a Reinforce positive behaviors setting convenient for participants. Influence social norms Presentation of information with audiovisual and Increase availability of support and needed services computer-based supports such as slides and Empower individuals to change or improve their projectors, videos, books, CDs, posters, pictures, websites, or software programs. health conditions Ensuring proficiency of program staff, through training, to maintain fidelity to the program model. 14 of 26 Considerations for Implementation ENVIRONMENTAL CHANGE Materials developed for health education programs Environmental change strategies involve changing the must be culturally appropriate and tailored to the target economic, social, or physical surroundings or populations to ensure cultural competence. contexts that affect health outcomes. In rural communities, this means addressing cultural Best used in combination with other strategies. and linguistic differences, and addressing potential Examples: barriers to health promotion and disease prevention in Increasing the number of parks, greenways, and rural areas. trails in the community Installing signs that promote use of walking and 3. POLICY, SYSTEMS, AND ENVIRONMENTAL (PSE) biking paths CHANGE Increasing the availability of fresh, healthy foods in For health promotion and disease prevention strategies schools, restaurants, and cafeterias to be successful, policies, systems, and environments (PSE) must be supportive of health. Examples of PSE Change Interventions Policy, systems, and environmental change strategies Kentucky Homeplace is a community health worker are designed to promote healthy behaviors by making (CHW) initiative that addresses health through PSE healthy choices readily available and easily accessible changes. The initiative emphasizes care coordination in the community. and health coaching for diabetes, hypertension, and PSE change strategies are designed with tobacco cessation, among other health topics. CHWs sustainability in mind. provide health information, screenings, and health coaching. The initiative also supports reduced or no- POLICY CHANGE cost services and medications. Tool for achieving health promotion and disease Healthy Adams County is an organization created by prevention program goals. community members in rural Pennsylvania. The Policy decisions are made by organizations, agencies, organization includes community task forces such as and stakeholders. Policy approaches include legislative the Breast Cancer Coalition, Food Policy Council, advocacy, fiscal measures, taxation, and regulatory Behavioral Health, Health Literacy, Oral Health, and oversight. Tobacco Prevention, among others. Activities are Examples of health promotion and disease prevention implemented to drive PSE changes in the community. policy approaches include: In Ohio, School as a Hub for Health, a project of the Establishing policies for smoke-free zones and Athens Creating Healthy Communities Coalition, public events implements PSE changes within schools with the goal Establishing healthy food options in vending of achieving improvements in physical, mental, and machines in public places social health. Examples of the services offered through Adding a tax to unhealthy food options the program include healthy vending machine options; Requiring the use of safety equipment in a work dental sealants; integrated mental health services; and setting to avoid injury school-based gardens, food pantry, and community health clinics. SYSTEMS CHANGE Refers to a fundamental shift in the way problems Considerations for Implementation are solved. PSE change strategies have the potential to create Within an organization, systems change affects positive changes in different settings. organizational purpose, function, and connections by PSE change strategies are often complex, as they addressing organizational culture, beliefs, attempt to drive change at multiple levels (within an relationships, policies, and goals. organization, community, or state). Examples of systems change in health promotion and PSE change strategies are therefore useful in disease prevention include: addressing chronic diseases and other complex Developing plans for implementing new health problems, such as obesity and diabetes. interventions and processes Programs seeking to implement PSE change strategies Adapting or replicating a proven health promotion must have realistic expectations about the time and model barriers that may be involved. Implementing new technologies Because PSE strategies seek to influence multiple Creating training or certification systems that align factors and levels, it may be difficult to measure with policies PSE changes. 15 of 26 To plan, develop, and implement PSE change D. INTEGRATING HEALTH PROMOTION MODELS strategies for disease prevention and health promotion, AND STRATEGIES - THE OTTAWA CHARTER it may be important to: In 1986, the First International Conference on Health Engage partners, stakeholders, and community Promotion was held in Ottawa, Canada, to harmonize members in the early stages of program a global definition and approach to health promotion. development. At that conference, the Ottawa Charter and Emblem for Understand the needs of the target population to Health Promotion was launched. identify appropriate PSE change strategies. Since then, WHO kept this symbol as the Health Use health impact assessments to demonstrate the Promotion logo (HP logo), as it stands for the approach rationale for PSE changes. to health promotion as outlined in the Ottawa Charter. Assess individual and organizational readiness for change, (e.g., by using the Stages of Change (Transtheoretical Model) Provide education to the individuals (i.e., healthcare providers, administrators, or teachers) and organizations (i.e., healthcare facilities, worksites, or schools) who will be involved in implementing PSE changes. Foster partnerships and coalitions to support broader reach and sustainability. Ensure enforcement of new policies. Ensure regular review of PSE changes to evaluate The logo represents a circle with 3 wings. effectiveness and impact on population health The central circle stands for the three basic strategies outcomes. for health promotion, "enabling, mediating, and advocacy ", which are needed and applied to all health promotion action areas. The wings on the other hand represent five key action areas in Health Promotion. Upper wing that is breaking the circle represents that action is needed to "strengthen community action" and to "develop personal skills". ─ This wing is breaking the circle to symbolize that society and communities as well as individuals are constantly changing and, therefore, the policy sphere has to constantly react and develop to reflect these changes: a "Healthy Public Policy" is needed; Middle wing on the right side represents that action is needed to "create supportive environments for health" Bottom wing represents that action is needed to "reorient health services" towards preventing diseases and promoting health. 16 of 26 3 BASIC STRATEGIES 5 KEY ACTIONS 1. ADVOCATE A combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme. Such action may be taken by and/or on behalf of individuals and groups to create living conditions which are conducive to health and the achievement of healthy lifestyles. Advocacy is one of the three major strategies for health promotion and can take many forms 1. BUILD HEALTHY PUBLIC POLICY including the use of the mass media and multi- Health promotion goes beyond health care. media, direct political lobbying, and community It puts health on the agenda of policy makers in all mobilization through, for example, coalitions of sectors and at all levels, directing them to be aware of interest around defined issues. the health consequences of their decisions and to Health professionals have a major responsibility to accept their responsibilities for health. act as advocates for health at all levels in society. Health promotion policy combines diverse but complementary approaches including legislation, fiscal 2. MEDIATE measures, taxation and organizational change. A process through which the different interests It is coordinated action that leads to health, income and (personal, social, economic) of individuals and social policies that foster greater equity. communities, and different sectors (public and private) Joint action contributes to ensuring safer and are reconciled in ways that promote and protect healthier goods and services, healthier public health. services, and cleaner, more enjoyable Producing change in people’s lifestyles and living environments. conditions inevitably produces conflicts between the Health promotion policy requires the identification of different sectors and interests in a population. obstacles to the adoption of healthy public policies in Such conflicts may arise, for example, from non-health sectors, and ways of removing them. concerns about access to, use and distribution of The aim must be to make the healthier choice the resources, or constraints on individual or easier choice for policy makers as well. organizational practices. Reconciling such conflicts in ways which promote health may require considerable input from health promotion practitioners, including the application of skills in advocacy for health. 3. ENABLE Taking action in partnership with individuals or groups to empower them, through the mobilization of human and material resources, to promote and protect their health. The emphasis in this definition on empowerment through partnership, and on the mobilization of resources draws attention to the important role of health workers and other health activists acting as a catalyst for health promotion action, for example by providing access to information on health, by facilitating skills development, and supporting access to the political processes which shape public policies affecting health. 17 of 26 2. CREATE SUPPORTIVE ENVIRONMENTS 3. STRENGTHEN COMMUNITY ACTIONS Our societies are complex and interrelated. Health promotion works through concrete and effective Health cannot be separated from other goals. community action in setting priorities, making decisions, The inextricable links between people and their planning strategies and implementing them to achieve environment constitutes the basis for a better health. socioecological approach to health. At the heart of this process is the The overall guiding principle for the world, nations, EMPOWERMENT of communities - their ownership regions and communities alike, is the need to and control of their own endeavors and destinies. Community development draws on existing human and encourage RECIPROCAL MAINTENANCE - to material resources in the community to enhance self-help take care of each other, our communities and and social support, and to develop flexible systems for our natural environment. strengthening public participation in and direction of The conservation of natural resources throughout health matters. the world should be emphasized as a global This requires full and continuous access to responsibility. information, learning opportunities for health, as Changing patterns of life, work and leisure have a well as funding support. significant impact on health. Work and leisure should be a source of health for people. The way society organizes work should help create a healthy society. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable. Systematic assessment of the health impact of a rapidly changing environment - particularly in areas of technology, work, energy production and urbanization - 4. DEVELOP PERSONAL SKILLS is essential and must be followed by action to ensure Health promotion supports personal and social positive benefit to the health of the public. development through providing information, education for The protection of the natural and built health, and enhancing life skills. environments and the conservation of natural By so doing, it increases the options available to resources must be addressed in any health people to exercise more control over their own health promotion strategy. and over their environments, and to make choices conducive to health. Enabling people to learn, throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. This has to be facilitated in school, home, work and community settings. Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves. 18 of 26 5. REORIENT HEALTH SERVICES E. APPROACHES TO HEALTH PROMOTION The responsibility for health promotion in health services Readings: is shared among individuals, community groups, health A community-based system dynamics approach professionals, health service institutions and suggests solutions for improving healthy food governments. access in a low-income urban environment They must work together towards a health care system Applying the whole-system settings approach to which contributes to the pursuit of health. food within universities The role of the health sector must move increasingly in Revitalizing the Setting Approach - super settings a health promotion direction, beyond its responsibility for sustainable impact in community health for providing clinical and curative services. promotion Health services need to embrace an expanded mandate which is sensitive and respects cultural 1. COMMUNITY-BASED APPROACH needs. This approach to health promotion focuses on This mandate should support the needs of individuals engaging and empowering local communities to and communities for a healthier life, and open take ownership of their health by addressing their channels between the health sector and broader social, political, economic and physical specific needs and priorities through community-led environmental components. initiatives, education, and interventions. Reorienting health services also requires stronger attention to health research as well as changes in 2. WHOLE SYSTEM APPROACH professional education and training. The whole system approach considers health This must lead to a change of attitude and promotion as a comprehensive effort that involves all organization of health services which refocuses on sectors of society, including government, the total needs of the individual as a whole person. business, education, and civil society, to collaboratively create and implement policies, practices, and interventions that promote health and well-being at a systemic level. 3. SETTINGS APPROACH The settings approach targets specific environments where people live, work, learn, and play (such as schools, workplaces, neighborhoods, and healthcare facilities) to create supportive and health-promoting settings by implementing policies and practices that encourage healthy behaviors and lifestyles within those contexts. The three approaches to health promotion— DAY 2: FORUM ACTIVITY 1 - APPLYING HEALTH community-based, whole system, and settings—are PROMOTION MODELS not mutually exclusive; in fact, they are complementary Community-based Drug Rehabilitation Program and interconnected. Link: While each approach has its focus and strategies, https://ateneo.instructure.com/courses/39666/discu they overlap in many ways. ssion_topics/1095797?module_item_id=1993175 For example, community-based programs often operate within specific settings (e.g., schools or workplaces) and require cooperation from various sectors, aligning with both the settings and whole system approaches. 19 of 26 When combined, these approaches can amplify their SESSION 3: impact. MEASURING AND MONITORING THE SOCIAL For instance, a community-based program that DETERMINANTS OF HEALTH promotes healthy eating in schools can benefit LEARNING OUTCOMES from whole system support, such as government 1. Appreciate the utility of data in bringing to light policies on school nutrition standards, creating a health inequities and their underlying health synergistic effect. determinants. Health promotion is more likely to be successful 2. Gain a broad understanding of the importance and and have a lasting impact when it combines components of health impact assessment. individual behavior change (community-based), 3. Understand the importance of evaluating health systemic changes (whole system), and supportive initiatives in the context of social determinants of environments (settings). health This comprehensive approach addresses the multiple determinants of health effectively. A. MONITORING AND EVALUATION IN HEALTH MONITORING can be defined as the systematic Video: https://youtu.be/Wp_SaMtMSZM collection of data about an indicator or variable of F. HEALTH PROMOTION IN THE UHC LAW interest. To facilitate a productive and generative discussion, I EVALUATION, in contrast, involves a judgement also invite you to browse through the following about the value of or change in that variable. reference documents to further expand your HEALTH MONITORING is the process of tracking the knowledge of the Health Promotion Bureau's initiatives: health of a population and the health system that https://drive.google.com/drive/folders/1FPE1b0L9vXNJ serves that population. 1Ql2AWLpUfFiN-YVcG85 Monitoring and evaluation can focus on different aspects of health and health policy-making. For instance: CASE STUDY: POLITICAL ACTIVISM IN HEALTH Population health (e.g. incidence of disease and life PROMOTION Narrative: expectancy); https://ateneo.instructure.com/courses/39666/page Epidemiology (e.g. risk factors and exposure s/case-study-political-activism-in-health- levels); promotion?module_item_id=1993179 Determinants of health (e.g. income and living conditions); Answers: Health system performance (e.g. access and https://ateneo.instructure.com/courses/39666/discu quality of health services); and ssion_topics/1095833?module_item_id=1993180 Health policy (e.g. impact on health outcomes and health inequity). DAY 2: GROUP CHALLENGE - FIT FOR SCHOOL PROGRAM https://ateneo.instructure.com/courses/39666/assig nments/603616?module_item_id=1993181 Slides: https://ateneo.instructure.com/courses/39666/files/ 6967073?wrap=1 DOH HPB - Introduction to HPFS (2023) DOH HPB - Compilation of Relevant Health Promotion Issuances 20 of 26 FIVE STAGES OF THE CYCLE OF HEALTH B. HEALTH IMPACT ASSESSMENT MONITORING: Given many of the determinants of health and health inequities in populations have social, environmental 1. Selecting relevant indicators and economic origins that extend beyond the direct The process begins by identifying indicators that are influence of the health sector and health policies, it is relevant to the desired type of monitoring as mentioned important to monitor the activities of other sectors above. for significant health consequences. These measures can be quantitative or qualitative and As the WHO’s Commission on Social Determinants the appropriate selection can often be a complicated of Health recommends, routine consideration of task that requires consideration of what is easily health and health equity impacts in policy monitored, analytically robust and communicates the development is one way to achieve a reduction in issue to the public and other policy-makers. health inequalities. A common approach to achieve this is using a 2. Obtaining data health impact assessment. The next step, collecting data, should occur regularly. HEALTH IMPACT ASSESSMENT (HIA) is a The methodology for this collection will depend on the combination of procedures, methods and tools that purpose of the M&E and could include, for example, assesses the potential effects of a policy or project scientific research and trials, epidemiological studies, on the health of a population and the distribution of household surveys, analysis of policy processes, those effects within the population. interviews and project case studies. HIAs also identify appropriate actions to manage those effects. 3. Analyzing data HIA is an important and useful tool within HiAP as it This means interpreting the data and can involve provides a tangible way for government preparing summary statistics, modelling, literature departments to actually work together rather than reviews and political analysis of policy processes and just talking about working together. issues such as the social determinants of health and HIA can be used on projects, programmes (groupings barriers to health care access. of projects) and policies, though it has most commonly been used on projects. 4. Reporting results The flexibility of HIA allows these projects, programmes and policies to be assessed at either Reporting can come in many forms, ranging from a local, regional, national or international level – internal memos to press releases, technical reports making HIA suitable for almost any proposal. and academic publications, each including various A caveat: methods of presenting data (such as tables, graphs, HIAs are not simply for fault-finding. maps or text). ─ They look not only for negative impacts (to The goal should be to ensure that the results of the prevent or reduce them), but also for impacts monitoring process are communicated effectively, favorable to health. and can be used to inform policies, programmes ─ This provides decision-makers with options to and practice. strengthen and extend the positive features of a proposal, with a view to improving the 5. Implementing changes health of the population. Based on monitoring results, changes may be implemented that will improve health policy, maximize the net health benefits of activities outside the health sector and thus, enhance population health and reduce health inequities. 21 of 26 C. HEALTH LENS ANALYSIS QUIZ: SELECTING AND ALIGNING M & E The HiAP Health Lens Analysis (HLA) process builds INDICATORS ACROSS THE RESULTS CHAIN on traditional health impact assessment methodology INPUTS and PROCESSES – the resources needed by incorporating a suite of additional methods (e.g., and how they are used to initiate a policy or project; economic modelling) to allow the process to deliver OUTPUTS – products and services, or states (e.g., both rigor and flexibility that accommodates the readiness, accreditation, licensing) that immediately operational culture and policy imperatives of the result from the utilization of inputs or performance of processes; partner agency. OUTCOMES – short- to medium-term results of a As a consequence, the methodology employed for policy or project; and a health lens is modified for each target area. IMPACTS – long-term effects produced by a policy or EVALUATION, an essential component of the HiAP project. process, is built into each individual health lens. Example: The emerging methodology for the health lens analysis, consists of a series of steps that underpin its effectiveness and ability to deliver mutually beneficial outcomes: 1. Engage: establishing and maintaining strong collaborative relationships with other sectors. Determine agreed policy focus. 2. Gather evidence: establishing impacts between health and the policy area under focus, and identifying evidence-based solutions or policy options. 3. Generate: producing a set of policy recommendations and a final report that are jointly owned by all partner agencies. 4. Navigate: helping to steer the recommendations through the decision-making process. 5. Evaluate: determining the effectiveness of the health lens. 22 of 26 SESSION 4: 21ST CENTURY DETERMINANTS, GLOBALIZATION, AND CLIMATE CHANGE LEARNING OUTCOMES The 21st century brings many complex and interacting challenges. This module explores the major global challenges impacting health, reviews the contemporary burden of disease, and dives deeper into the influence of modern movements on the changing health landscape. A. CONTEMPORARY BURDEN OF DISEASE Of 56.9 million global deaths in 2016, 40.5 million, or Here's the bright side: The past 200 years actually brought dramatic 71%, were due to noncommunicable diseases (NCDs). improvement in life expectancy throughout the The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases. world, much thanks to significant advancements in The burden of these diseases is rising medicine, science and technology. disproportionately among lower income countries In the video episode below from ‘The Joy of Stats', and populations. Professor Hans Rosling tells the story of how the In 2016, over three quarters of NCD deaths -- 31.5 health status of 200 countries has progressed over million -- occurred in low- and middle-income 200 years using 120,000 numbers - in just four minutes! countries with about 46% of deaths occurring Link: https://youtu.be/ahp7QhbB8G4 before the age of 70 in these countries. Communicable, maternal, perinatal and nutrition ─ Plotting life expectancy against income for every conditions collectively were responsible for a quarter of country since 1810, Rosling captures quite well how the level of health and well-being we find global deaths, and injuries caused 9% of all deaths. ourselves now, though far from ideal, is B. IHME'S GLOBAL BURDEN OF DISEASE definitely leaps and bounds from how the world VISUALIZATION TOOL used to be. Link: https://vizhub.healthdata.org/gbd-compare/ ─ But as he has also outlined in the video, some huge disparities (or inequalities) in health remain. And depending on where you are and QUIZ: UNDERSTANDING TRENDS IN BURDEN OF DISEASE 'the circumstances by which you are born, Based on the 2019 Global Burden of Disease where you live, learn work, and age', the level Study, the 16 diseases listed below in alphabetical of your health (and overall life expectancy) may order were the most burdensome for Filipinos as also vary significantly across various socio- measured by disability-adjusted life years (DALYs). economic determinants. Communicable, maternal, neonatal and nutritional diseases are in red, Noncommunicable diseases BURDEN OF DISEASE' CONCEPT are in blue and Physical injuries are in green. The BURDEN OF DISEASE is a measurement of that The burden of disease has changed over time. For gap between a population’s current health and the this assignment, put the diseases in order from optimal state where all people attain full life most burdensome to least burdensome between expectancy without suffering major ill-health. 1990 to 2019. DISABILITY-ADJUSTED LIFE YEAR (DALY) is one Answer measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death. 23 of 26 C. GLOBALIZATION AND HEALTH The increased movement of people and other items The 21st century brings many complex and interacting creates a complex equation of advantages and challenges--all of which impact health in many ways. disadvantages for each society. The world is more and more economically and The health impacts of globalization are culturally interconnected than before. simultaneously positive and negative, and the Between 1950 and 2000, the volume of trade magnitude of these impacts to populations will vary between countries increased by a factor of nearly according to factors such as geographical location, 200. sex, age, ethnic origin, education level, and Trade as a share of economic activity is also socioeconomic status. increasing. ─ Between 1960 and 2007, the value of trade in DAY 4: FORUM ACTIVITY 1 - GLOBALIZATION goods and services as a share of global GDP AND HEALTH increased from 12% to 28%. DISCUSSION QUESTION: In your areas of work, The number of people travelling and migrating is what are some concrete examples of the positive also exponentially increasing between 1995 and 2012, and negative impacts of globalization to health? the number of international tourist arrivals annually Answers: doubled from 530 million to 1.1 billion. https://ateneo.instructure.com/courses/39666/discu In 2010, the number of international migrants was ssion_topics/1095828?module_item_id=1993201 214 million, and based on current trends could reach 405 million by 2050. Over the past several decades, global trade and DAY 4: FORUM ACTIVITY 2 - RAPID relationships have rapidly urbanized many low- and URBANIZATION AND HEALTH INEQUITY middle-income economies. DISCUSSION QUESTION: Using the lens of the In contrast to many high-income countries, this social determinants of health, how does rapid economic transition has been far more rapid with urbanisation increase further the disparities in more dramatic consequences in terms of rural to health outcomes among population groups? urban migration, urbanization and socioeconomic Answers: change. https://ateneo.instructure.com/courses/39666/discu This globalization is impacting health in multiple ssion_topics/1095829?module_item_id=1993202 ways. On the positive side, the global connectedness of D. THE CHANGING ENVIRONMENT AND HEALTH transportation and the communications revolution In the Philippines, the state of the environment is a has enabled a more efficient exchange of health major cause and contributor to morbidity and mortality. information and resources. In 2006, 22% of reported diseases and 6% of A clear example is the international network of deaths in 2006 were found to be caused by institutions coordinated by the World Health environmental factors. Organization (WHO) via global telecommunications Lack of attention to environmental health which can readily detect and rapidly respond to exacerbates both communicable and non- changes in the influenza virus — such a capacity communicable diseases, and induces epidemics was unavailable after the First World War, when an and public health emergencies. estimated 20 million people died of influenza And as emerging issues on worsening pollution, worldwide. climate change and rapid urbanization usher in, On the other hand, the internationalization of trade, the gravity of environmental health issues facing migration and travel also increases the risks of Filipinos will only worsen if left unaddressed. global epidemics and the spread of health hazards Needless to say, the relationship between humans and through imports and exports of contaminated the environment is a close and intimate link. foods and products. Especially for high-income countries, the debate surrounding globalization and health tends to focus on the perceived threat, from low- and middle- income countries, of acquiring certain acute and epidemic infections, such as HIV/AIDS, tuberculosis, plague and, more recently, severe acute respiratory syndrome (SARS) and COVID- 19. 24 of 26 Human activity affects the environment which, in turn, QUIZ plays a role in the health and well-being of the 1. Advances in the identification of infectious population. disease agents and the development of vaccines The DPSEEA framework (below), adopted by the were the milestones of the 20th century and were World Health Organization (WHO) in 1992, pursued using what conceptual framework? illustrates well this environment-human connection: a. Biomedical Model or Paradigm b. Natural History of the Disease Model c. Social Determinants of Health Framework d. Determinants of Health Outcome 2. Under what conceptual framework do the Etiologic, Pre-clinical, Clinical and Post-Clinical phases of disease belong to? a. Bio-Medical Model b. Natural History of the Disease Model c. Social Determinants of Health Framework d. Wagstaff's Determinants of Health Outcomes Rationale: 3. Why was it necessary to develop new conceptual models of health, disease and health outcomes in The framework thus sees health impacts as originating the course of the past 2 decades? from driving forces (D), which lead to pressures on the a. New models are much more sensitive to the realities environment (P) in the form of production, of poor and developing countries compared to the consumption, waste generation etc, and their realities of developed countries. consequent releases into the environment. b. New frameworks offer a more nuanced These contribute to changes in the state of the understanding of the determinants of health and environment (S) - for example, as environmental wellbeing, based on research and empirical data. pollution or increased risks of natural hazards. c. New frameworks are the result of globalization. Exposures (E1) occur when humans come into contact d. Older frameworks have become obsolete and have with these hazards, leading to potential health effects lost their usefulness. (E2). Rationale: Policy and other actions (A) are taken to control adverse health effects. 4. Wrong fundamentals on health lead to These may be targeted at different points in the misconceptions, distortions and misallocations, and causal chain. eventually the disconnectedness of and within the Later interventions (aimed at reducing exposures or health sector. Examples of this disconnectedness mitigating the health impacts) may appear to be more include the following: directly effective and sometimes cheaper, because a. The desire of political leaders to set up structures like they can be targeted more directly at specific hospitals and health centers without an eye on the population groups and health outcomes. human resources required to run these facilities and the Preventive measures, in contrast, tend to involve sustainability of their operations. somewhat blunter tools - but with the major advantage b. All of these statements are manifestations of that they can control the problems at source, and often wrong fundamentals on health. offer a wide range of other environmental and social c. The building of a patronage system where benefits. constituents depend on political leaders for medicines and hospitalization expenses. d. The propensity to spend on medicines and to dispense them injudiciously. 25 of 26 5. What is the value of using the Social Determinants Framework in understanding health problems and in 9. Enumerate the advantages of the Wagstaff Matrix framing the response to these problems? over the Bio-Medical Framework in terms of a. The framework identifies contextual causes that understanding health and wellbeing. [Answer in determine the social standing and mobility of individuals, bullet form; four short bullet points expected.] families and communities. b. The framework underscores the need for inter- sectoral action on health and recognizes the important role of other stakeholders outside of the health sector. c. The framework demonstrates the need for multiple strategies needed to tackle the different determinants of health. d. All statements are correct. 6. Which of the choices below DOES NOT serve as proxy indicator in stratifying an individual’s socio- economic position or in defining one’s social mobility? a. Occupation b. Behavior c. Income d. Education e. Gender Rationale: Groups are stratified according to the economic status, power, and prestige they enjoy, for which we use social class, income levels, education, occupation status, gender, race or ethnicity, and other factors as proxy indicators. https://www.sciencedirect.com/science/article/abs/pii/B9 780123739605006730 7. In the conceptual framework of the Commission on Social Determinants of Health (CSDH), how is the health system viewed in relation to its impact on health and well-being? a. As part of the socio-economic and political context b. As a part of material circumstance c. As a determinant of social cohesion and social capital 10. In the SDH Framework, how does the health d. As an intermediary determinant of health system act as a mitigating factor in the health and well- being of individuals, families and 8. In the Brazil Bolsa Familia Program (BFP) and the communities? (Answer in 1-2 sentences only; 40 subsequent Proximo Passo, and in our own words) Pantawid Pamilyang Pilipino Program (4Ps), how does the conditional cash transfer improve the social position of the target group? a. Through an improved purchasing power and through skills-based education that can improve mobility b. Through government’s political will to carry out constitutionally mandated services on health and education c. Through investments on the health & educational structures of communities d. Through the immediate changes in behavioral circumstances 26 of 26
