Health Promotions and Social Determinants of Health (SGHPROSDH).docx

session 1: Introduction to Health Promotion and Social Determinants of Health Learning outcomes 1. Broad understanding of how social, economic and political factors influence health and health inequalities (Social Determinants of Health or SDH) 2. Foundational understanding on global a...

session 1: Introduction to Health Promotion and Social Determinants of Health Learning outcomes 1. Broad understanding of how social, economic and political factors influence health and health inequalities (Social Determinants of Health or SDH) 2. Foundational understanding on global and local perspectives on the goals and scope of health promotion (HP) 3. Analysis and application of SDH and HP concepts to health issues encountered within the students' local context A. Evolving Paradigms on Disease Causation, Health, and Well Being  1\. The Epidemiological Triangle - The Epidemiological triangle is a conceptual framework used in public health to understand the interplay between three key factors in disease transmission: - the **host** (a ***person or organism susceptible to the disease***) - the **agent** (the ***pathogen or cause of the disease***), and - the **environment** (the ***context in which the disease spreads***). - These three elements interact and influence each other, ultimately leading to the occurrence and spread of diseases in populations.  2\. The Biopsychosocial Model - The Biopsychosocial model of health is a holistic framework that recognizes the ***complex interplay between biological, psychological, and social factors in determining an individual\'s overall health and well-being***. - It highlights the importance of considering biological factors (such as *genetics* and *physiology*), psychological factors (such as *thoughts*, *emotions*, and *behaviors*), and social factors (such as *socioeconomic* *status*, *culture*, and *social* *support*) when assessing and addressing health issues.  3\. The Socioecological Model - The socioecological model of health is a framework that ***recognizes the multiple levels of influence on health outcomes***, ranging from individual characteristics to broader social, community, and environmental factors. - It emphasizes the ***interconnectedness and interdependence between these levels***, highlighting the need for comprehensive interventions that address health determinants at multiple levels to promote health and well-being.  - Example:  4\. Health System Building Blocks - The health system building blocks are a framework that **provides a comprehensive view of the essential components needed for a functional healthcare system**. - These building blocks include health service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance, all of which are ***critical for effective and sustainable healthcare provision***.  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: ^1^**a focus on technology-based medical care and public health interventions**, and ^2^an **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 unfair and avoidable or remediable differences in health among social groups*) becomes ***a guiding criterion or principle***. - The framing of social justice and health equity, points towards the adoption of related **human rights frameworks** as ***vehicles for enabling the realization of health equity**.* - Wherein the **STATE** is the ***primary responsible duty bearer***. - ***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: - WHO Social Determinants of Health video (), and the TED talk by Sir Michael Marmot, one of the main authors of the 2008 WHO Social Determinants of Health Report: - 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.   Health system - The role of the health system becomes particularly relevant through the issue of access, which incorporates differences in exposure and vulnerability, and through intersectoral action led from within the health sector. - The ***health system*** plays an important role in **mediating** the differential consequences of illness in people's lives.  social cohesion/social capital - The concepts of social cohesion and "social capital" occupy an unusual (and contested) place in understandings of SDH. - Influential researchers have proclaimed social capital a key factor in shaping population health. - Putnam defines **[SOCIAL CAPITAL]** as "features of ***social*** ***organization***, such as networks, norms and 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 ^1^***reduced state responsibility for health***, linked to an ^2^***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.    policy action - In turning to policy action on SDH inequities, three broad approaches to reducing health inequities can be identified. - These may be based on: - \(1) **targeted programs for disadvantaged populations**; - \(2) **closing health gaps between worse-off and better-off groups**; and - \(3) **addressing the social health gradient** **across the whole population** - Policy development frameworks can help analysts and policymakers to identify levels of intervention and entry points for action on SDH, ranging from policies tackling underlying structural determinants to approaches focused on the health system and reducing inequities in the consequences of ill health suffered by different social groups. - The **[single most significant lesson of the CSDH conceptual framework]** is that ***interventions and policies to reduce health inequities** **must not limit themselves to intermediary determinants**, **but must*** ***include* policies** specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups. - *To tackle structural, as well as intermediary, determinants require **intersectoral policy approaches***. - A key task for the CSDH will be: 1. To **identify successful examples of intersectoral action on SDH** in jurisdictions with different levels of resources and administrative capacity; and to characterize in detail the political and management mechanisms that have enabled effective intersectoral programs to function sustainably. 2. To demonstrate how **participation of civil society and affected communities in the design and implementation of policies** to address SDH is essential to success. - **Empowering social participation** ***provides*** ***both ethical legitimacy and a sustainable base to take the SDH agenda forward*** after the Commission has completed its work. 3. Finally, SDH policies *must be crafted with careful attention to **contextual specificities***, which should be rigorously characterized using methodologies **developed by social and political science**. DOH'S Health Promotion Framework Strategy 2020-2030            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: - **[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](https://inst-fs-sin-prod.inscloudgate.net/files/6a3e7a3a-1eb3-424b-9f82-892c4d697a90/World%20Health%20Organization.%20%E2%80%9COttawa%20and%20Bangkok%20Declarations%20on%20Health%20Promotion.%E2%80%9D%20%20Milestones%20in%20Health%20Promotion%20%E2%80%93%20Statements%20from%20Global%20Conferences.%20%20WHO%20Press%202009%2C...-1.pdf?download=1&token=eyJ0eXAiOiJKV1QiLCJhbGciOiJIUzUxMiJ9.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.GRAzyikfnTj0nOVvnfGUMXImDMAo38vcJphXkJeHvbBDPny8AKR8RLFCDtArqEnT2iMGvxVtWei0eejN99GSww) B. Prevailing Models of Health Promotion - Over time, there have been several theories, strategies, and models that have been be used to inform health promotion and disease prevention programs. - These theories, strategies, and models have been used to develop and implement programs that empower and motivate people to improve and better manage their health. - Health promotion and disease prevention programs often integrate components of different theories and use more than one strategy to achieve their goals 1\. Socio-Ecological Models (SEM) - [Theory at a Glance: A Guide for Health Promotion and Practice](http://www.sbccimplementationkits.org/demandrmnch/wp-content/uploads/2014/02/Theory-at-a-Glance-A-Guide-For-Health-Promotion-Practice.pdf) - frames the ecological perspective as - "*\...the interaction between, and interdependence of, factors within and across all levels of a health problem. It highlights **people's interactions with their physical and sociocultural environments***." - Socio-ecological models recognize multiple levels of influence on health behaviors, including: 1. **Intrapersonal**/**individual** factors, which influence behavior such as *knowledge*, *attitudes*, *beliefs*, and *personality*. 2. **Interpersonal** factors, such as *interactions with other people*, which can provide *social support or create barriers to interpersonal growth* that promotes healthy behavior. 3. **Institutional** and **organizational** factors, including the *rules*, *regulations*, *policies*, and *informal structures* that constrain or promote 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.  ### ### ### ### ### Examples of Ecological Models - [Project HEART (Health Education Awareness Research Team)](https://www.cdc.gov/pcd/issues/2012/11_0100.htm) used an ecological model to design a health promotion and disease prevention program to address cardiovascular disease risk factors. The project uses a community health worker (CHW) [promotora model](https://www.ruralhealthinfo.org/toolkits/community-health-workers/2/layhealth) to provide services. - CDC\'s [Colorectal Cancer Control Program (CRCCP)](https://www.cdc.gov/cancer/crccp/about.htm) was designed to address multiple factors of influence on colorectal cancer prevention, using ecological model components. - The [Healthy People 2020 framework](https://www.healthypeople.gov/sites/default/files/HP2020Framework.pdf) addresses the importance of ecological models in health promotion and disease prevention. - Programs are most likely to be effective when they are designed to address the multiple levels of influence on health behaviors. ### Considerations for Implementation - The ecological perspective is a useful framework for understanding the range of factors that influence health and well-being. - It is a model that **can assist in providing a complete perspective of the factors that affect specific health behaviors**, including the social determinants of health. - Because of this, ecological frameworks can be used to integrate components of other theories and models, thus ***ensuring the design of a comprehensive health promotion or disease prevention program or policy approach***. 2\. The Health Belief Model - The [Health Belief Model](https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories2.html) is a theoretical model that can be used to **guide health promotion and disease prevention programs**. - It is used to **explain and predict individual changes in health behaviors**. - It is one of the **most widely used models for** ***understanding health behaviors***. - Key elements of the Health Belief Model **focus on individual beliefs about health conditions**, which ***predict individual health-related behaviors***. - The model defines the key factors that influence health behaviors as: - Individual\'s *perceived threat to sickness or disease* (**perceived susceptibility**) - *Belief of consequence* (**perceived severity**) - Potential positive benefits of action (**perceived** **benefits**) - **Perceived barriers** to action - *Exposure to factors that prompt action* (**cues to action**) - *Confidence in ability to succeed* (**self-efficacy**) ### Health Belief Model Examples - The [Michigan Model for Health™](https://mishca.org/how/mmh/) 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](https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories2.html): 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. ### Considerations for Implementation - The Health Belief Model can be used **to design short- and long-term interventions**. - The five key action-related components that determine the ability of the Health Belief Model to identify key decision-making points that influence health behaviors are: - **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-efficacy* and the likelihood of successful behavior changes. - *To ensure success with this model*, it is important to identify \"**CUES TO ACTION**\" that are ***meaningful and appropriate for the target population***. 3\. Stages of Change Model (Transtheoretical Model) - The [Stages of Change Model](https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories6.html), also called the Transtheoretical Model, ***explains an individual\'s readiness to change their behavior***. - It describes the process of behavior change as occurring in stages. - These stages include:  ### ### ### Stages of Change Examples - CDC provides a "[Talking about Fall Prevention with Your Patients](https://www.cdc.gov/steadi/pdf/STEADI-FactSheet-TalkingWPatients-508.pdf)" fact sheet that describes how to use the Stages of Change Model for fall prevention education. ### Considerations for Implementation - The [Stages of Change Model](https://sphweb.bumc.bu.edu/otlt/MPH-Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories6.html) **describes how an individual or organization integrates new behaviors, goals, and programs at various levels**. - At each stage, different intervention strategies will help individuals progress to the next stage and through the model. - Individuals within a population will likely vary in their readiness to change. - In addition, it is important to recognize that ***movement through this model is* cyclical** -- *individuals may progress to the next stage or regress to a previous stage*. - The Stages of Change model can be applied to health promotion and disease prevention programs to address a range of health behaviors, populations, and settings. - It may be an ***appropriate model for health promotion and disease prevention programs related to*** **worksite** **wellness**, **tobacco** **use**, **weight management**, **medication compliance**, **addiction**, and **physical activity**, among other health topics. 4\. Social Cognitive Theory - **Social Cognitive Theory** (**SCT**) describes the **influence of individual experiences, the actions of others, and environmental factors on individual health behaviors**. - 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. ### Social Cognitive Theory Examples - [Healthy Relationships](https://www.cdc.gov/hiv/pdf/research/interventionresearch/compendium/rr/cdc-hiv-intervention-rr-best-healthy-relationships.pdf), a program implemented by [Chattanooga CARES](https://bettertennessee.com/partners/chattanooga-cares/), is a small-group intervention for people living with HIV/AIDS. - The program is based on the Social Cognitive Theory and uses skill-building exercises to increase independence and develop healthy behaviors among participants. - [HoMBReS](https://www.ruralhealthinfo.org/project-examples/767) is a community-based intervention designed to reduce the risk of HIV and other sexually transmitted diseases among Latino men living in rural areas of the United States. - Based on the Social Cognitive Theory, the program trains "Navegantes" (Navigators) who provide information and risk reduction materials to the target population. ### ### Considerations for Implementation - The SCT can be applied as a theoretical framework in different settings and populations. - It is frequently used to **guide behavior change interventions**. - It may be particularly useful in rural communities for examining how individuals interact with their surroundings. - The SCT can be **used to understand the influence of social determinants of health and a person\'s past experiences on behavior change**. C. Common Strategies in Health Promotion 1\. Health Communication - Health communication, as define as "***the study and use of communication strategies to inform and influence individual and community decisions that enhance health***." - Health communication includes ***verbal** and **written strategies*** to influence and empower individuals, populations, and communities to make healthier choices. - **HEALTH COMMUNICATION** integrates components of the health promotion models to **promote positive changes in attitudes and behaviors**. - Health communication is related to **SOCIAL MARKETING**, which involves the ***development of activities and interventions designed to positively change behaviors.*** - Effective health communication and social marketing strategies include the following components: - Use of ***research-based strategies*** to shape materials and products and to select the channels that deliver them to the intended audience. - Understanding of ***conventional wisdom***, ***concepts***, ***language***, and ***priorities for different* *cultures and settings***. - Consideration of ***health literacy***, ***internet access***, ***media exposure***, and ***cultural competency*** of target populations. - ***Development of materials*** such as brochures, billboards, newspaper articles, television broadcasts, radio commercials, public service announcements, newsletters, pamphlets, videos, digital tools, case studies, group discussions, health fairs, field trips, and workbooks among others media outlets. - Using a variety of communication channels can allow health messages to shape mass media or interpersonal, small group, or community level campaigns. Health communication strategies aim to change people\'s knowledge, attitudes, and/or behaviors; for example: - **Increase risk perception** - **Reinforce positive behaviors** - **Influence social norms** - **Increase availability of support and needed services** - **Empower individuals to change or improve their health conditions** ### Examples of Health Communication Interventions - **Tobacco prevention and cessation programs** often use health communication to reach a broader audience. Examples of mass-reach health communication interventions are available in the [Rural Tobacco Control and Prevention Toolkit](https://www.ruralhealthinfo.org/toolkits/tobacco/2/communities/mass-communication). - Examples of communication and social marketing interventions related to **HIV prevention and treatment** are available in the [Rural HIV/AIDS Prevention and Treatment Toolkit](https://www.ruralhealthinfo.org/toolkits/hiv-aids/2/prevent/social-marketing). - The [Northeast Louisiana Regional Pre-Diabetes Prevention Project (RPDP)](https://www.ruralhealthinfo.org/project-examples/857) promoted **prediabetes screening and diabetes prevention** information to communities using multiple media outlets. ### Considerations for Implementation - When designing health communication or social marketing strategies, it is important to ***consider the overall communication goals of the intervention***. - ***Understand the target population*** so that the content created is relevant to the target population. - It is important to ***tailor messages*** to the communication channel being used. - Further, ***using multiple communication and media strategies*** will ensure a broader reach. - ***Ensure that the target population has access to the communication channels*** being used. 2\. Health Education - Health education provides learning experiences on health topics that are tailored for their target population. - Health education presents information to target populations on particular health topics, including the health benefits/threats they face, and provides tools to build capacity and support behavior change in an appropriate setting. - Examples include lectures, courses, seminars, webinars, workshops and others. - Characteristics of health education strategies include: - ***Participation of the target population***. - Completion of a community needs ***assessment*** to identify community capacity, resources, priorities, and needs. - ***Planned learning activities*** that increase participants\' knowledge and skills. - ***Implementation of programs*** with integrated, well-planned curricula and materials that take place in a setting convenient for participants. - ***Presentation of information*** with audiovisual and computer-based supports such as slides and projectors, videos, books, CDs, posters, pictures, websites, or software programs. - Ensuring proficiency of program staff, through ***training***, to maintain fidelity to the program model. ### Considerations for Implementation - Materials developed for health education programs must be culturally appropriate and tailored to the target populations to ensure cultural competence. - In rural communities, this means ***addressing cultural and linguistic differences***, and addressing potential barriers to health promotion and disease prevention in rural areas. 3\. Policy, Systems, and Environmental (PSE) Change - For health promotion and disease prevention strategies to be successful, policies, systems, and environments (PSE) must be supportive of health. - [Policy, systems, and environmental change strategies](http://healthtrust.org/wp-content/uploads/2013/11/2012-12-28-Policy_Systems_and_Environmental_Change.pdf) are designed to promote healthy behaviors by making healthy choices readily available and easily accessible in the community. - PSE change strategies are designed with **sustainability** in mind. ### POLICY CHANGE - ***Tool for achieving health promotion and disease prevention program goals***. - Policy decisions are made by organizations, agencies, and stakeholders. Policy approaches include legislative advocacy, fiscal measures, taxation, and regulatory oversight. - Examples of health promotion and disease prevention policy approaches include: - Establishing policies for smoke-free zones and public events - Establishing healthy food options in vending machines in public places - Adding a tax to unhealthy food options - Requiring the use of safety equipment in a work setting to avoid injury ### SYSTEMS CHANGE - Refers to a ***fundamental shift in the way problems are solved***. - Within an organization, systems change affects organizational purpose, function, and connections by addressing organizational culture, beliefs, relationships, policies, and goals. - Examples of systems change in health promotion and disease prevention include: - Developing plans for implementing new interventions and processes - Adapting or replicating a proven health promotion model - Implementing new technologies - Creating training or certification systems that align with policies ### ENVIRONMENTAL CHANGE - Environmental change strategies involve ***changing the economic, social, or physical surroundings*** or contexts that affect health outcomes. - Best used in combination with other strategies. - Examples: - Increasing the number of parks, greenways, and trails in the community - Installing signs that promote use of walking and biking paths - Increasing the availability of fresh, healthy foods in schools, restaurants, and cafeterias ### Examples of PSE Change Interventions - Kentucky Homeplace is a community health worker (CHW) initiative that addresses health through PSE changes. The initiative emphasizes care coordination and health coaching for diabetes, hypertension, and tobacco cessation, among other health topics. CHWs provide health information, screenings, and health coaching. The initiative also supports reduced or no-cost services and medications. - Healthy Adams County is an organization created by community members in rural Pennsylvania. The organization includes community task forces such as the Breast Cancer Coalition, Food Policy Council, Behavioral Health, Health Literacy, Oral Health, and Tobacco Prevention, among others. Activities are implemented to drive PSE changes in the community. - In Ohio, School as a Hub for Health, a project of the Athens Creating Healthy Communities Coalition, implements PSE changes within schools with the goal of achieving improvements in physical, mental, and social health. Examples of the services offered through the program include healthy vending machine options; dental sealants; integrated mental health services; and school-based gardens, food pantry, and community health clinics. ### Considerations for Implementation - PSE change strategies have the potential to create positive changes in different settings. - PSE change strategies are often complex, as they attempt to drive change at multiple levels (within an organization, community, or state). - PSE change strategies are therefore useful in addressing chronic diseases and other complex health problems, such as obesity and diabetes. - Programs seeking to implement PSE change strategies ***must have realistic expectations about the time and barriers*** that may be involved. - Because PSE strategies seek to influence multiple factors and levels, it may be difficult to measure PSE changes. - To plan, develop, and implement PSE change strategies for disease prevention and health promotion, it may be important to: - ***Engage partners, stakeholders, and community members*** in the early stages of program development. - ***Understand the needs of the target population*** to identify appropriate PSE change strategies. - Use ***health impact assessments*** to demonstrate the rationale for PSE changes. - ***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 effectiveness and impact on population health outcomes. D. Integrating Health Promotion Models and Strategies - The Ottawa Charter - In 1986, the First International Conference on Health Promotion was held in Ottawa, Canada, to harmonize a global definition and approach to health promotion. - At that conference, the Ottawa Charter and Emblem for Health Promotion was launched. - Since then, WHO kept this symbol as the Health Promotion logo (HP logo), as it stands for the approach to health promotion as outlined in the Ottawa Charter.  3 basic strategies 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 program. - 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 including the use of the ***mass media*** and ***multi*-*media***, ***direct political lobbying***, and ***community*** ***mobilization*** through, for example, coalitions of interest around defined issues. - Health professionals have a major responsibility to act as advocates for health at all levels in society. 2\. mediate - A process through which the different interests (personal, social, economic) of individuals and communities, and different sectors (public and private) are ***reconciled*** in ways that promote and protect health. - Producing change in people's lifestyles and living conditions inevitably produces conflicts between the different sectors and interests in a population. - Such conflicts may arise, for example, from concerns about access to, use and distribution of resources, or constraints on individual or 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. 5 key actions 1\. Build Healthy Public Policy - Health promotion goes beyond health care. - It **puts health on the agenda of policy makers** in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. - Health promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. - It is coordinated action that leads to health, income and social policies that foster greater equity. - Joint action contributes to ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. - Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. - The aim must be to make the healthier choice the easier choice for policy makers as well.  2\. Create Supportive Environments - Our societies are complex and interrelated. - Health cannot be separated from other goals. - The inextricable links between people and their environment constitutes the basis for a socioecological approach to health. - The overall guiding principle for the world, nations, regions and communities alike, is the need to ***encourage* RECIPROCAL MAINTENANCE** - ***to take care of each other, our communities and our natural environment***. - The conservation of natural resources throughout the world should be emphasized as a global responsibility. - Changing patterns of life, work and leisure have a 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 - is essential and must be followed by action to ensure positive benefit to the health of the public. - The ***protection of the natural and built environments*** and the ***conservation of natural resources*** must be addressed in any health promotion strategy. 3\. Strengthen Community Actions - Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. - ***At the heart of this process is the*** **EMPOWERMENT** ***of communities*** - their ***ownership and control of their own endeavors and destinies***. - Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public participation in and direction of health matters. - This requires full and ***continuous access to information***, ***learning opportunities for health***, as well as ***funding support***.  4\. Develop Personal Skills - Health promotion supports ***personal and social development through providing information, education for health, and enhancing life skills***. - By so doing, it increases the options available to people to exercise more control over their own health 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. 5\. Reorient Health Services - The **responsibility** for health promotion in health services is **shared** among individuals, community groups, health professionals, health service institutions and governments. - They must work together towards a health care system which contributes to the pursuit of health. - The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. - Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. - This mandate should support the needs of individuals and communities for a healthier life, and **open** **channels** between the health sector and **broader social, political, economic and physical environmental components**. - Reorienting health services also requires stronger attention to **health research** as well as changes in professional education and training. - This must lead to a change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person.  E. Approaches to Health Promotion 1\. Community-based Approach - This approach to health promotion focuses on **engaging and empowering local communities** to take ownership of their health by addressing their specific needs and priorities through ***community-led initiatives, education, and interventions***. 2\. Whole System Approach - The whole system approach considers health promotion as a comprehensive effort that ***involves all sectors of society, including government, 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---community-based, whole system, and settings---are not mutually exclusive; in fact, they are complementary and interconnected. - While each approach has its focus and strategies, they overlap in many ways. - 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. - When combined, these approaches can amplify their impact. - For instance, a community-based program that promotes healthy eating in schools can benefit from whole system support, such as government policies on school nutrition standards, creating a synergistic effect. - Health promotion is more likely to be successful and have a lasting impact when it combines individual behavior change (community-based), systemic changes (whole system), and supportive environments (settings). - This comprehensive approach addresses the multiple determinants of health effectively. - Video: F. Health Promotion in the UHC Law - To facilitate a productive and generative discussion, I also invite you to browse through the following reference documents to further expand your knowledge of the Health Promotion Bureau\'s initiatives: session 3: Measuring and Monitoring the Social Determinants of Health Learning Outcomes 1. Appreciate the utility of data in bringing to light health inequities and their underlying health determinants. 2. Gain a broad understanding of the importance and components of health impact assessment. 3. Understand the importance of evaluating health initiatives in the context of social determinants of health A. Monitoring and Evaluation in Health - **[MONITORING]** can be defined as the ***systematic collection of data about an indicator or variable of interest***. - **[EVALUATION]**, in contrast, involves a ***judgement about the value of or change in that variable***. - **[HEALTH MONITORING]** is the process of ***tracking the health of a population and the health system*** that serves that population. - Monitoring and evaluation can focus on different aspects of health and health policy-making. For instance: - Population health (e.g. incidence of disease and life expectancy); - Epidemiology (e.g. risk factors and exposure levels); - Determinants of health (e.g. income and living conditions); - Health system performance (e.g. access and quality of health services); and - Health policy (e.g. impact on health outcomes and health inequity). five stages of the cycle of health monitoring: ### ### 1. Selecting relevant indicators - The process begins by **identifying indicators** that are relevant to the desired type of monitoring as mentioned above. - These measures can be quantitative or qualitative and the appropriate selection can often be a complicated task that requires consideration of what is easily monitored, analytically robust and communicates the issue to the public and other policy-makers. ### 2. Obtaining data - The next step, **collecting data**, should occur regularly. - The methodology for this collection will depend on the purpose of the M&E and could include, for example, scientific research and trials, epidemiological studies, household surveys, analysis of policy processes, interviews and project case studies. ### 3. Analyzing data - This means **interpreting the data** and can involve preparing summary statistics, modelling, literature reviews and political analysis of policy processes and issues such as the social determinants of health and barriers to health care access. ### 4. Reporting results - Reporting can come in many forms, ranging from internal memos to press releases, technical reports and academic publications, each including various methods of presenting data (such as tables, graphs, maps or text). - The goal should be to ensure that the results of the monitoring process are **communicated effectively**, and can be **used to inform policies, programs and practice**. ### 5. Implementing changes - 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**.  B. Health Impact Assessment - Given many of the determinants of health and health inequities in populations have social, environmental and economic origins that extend beyond the direct influence of the health sector and health policies, it is important to ***monitor the activities of other sectors for significant health consequences***. - As the WHO's Commission on Social Determinants of Health recommends, routine consideration of health and health equity impacts in policy development is one way to achieve a reduction in health inequalities. - A common approach to achieve this is using a health impact assessment. - **HEALTH IMPACT ASSESSMENT (HIA)** is a combination of procedures, methods and tools that ***assesses the potential effects of a policy or project on the health*** of a population and the distribution of those effects within the population. - HIAs also ***identify appropriate actions to manage those effects***. - HIA is an important and useful tool within HiAP as it ***provides a tangible way for government departments to actually work together*** ***rather than just talking about working together***. - HIA can be used on projects, programs (groupings of projects) and policies, though it has most commonly been used on projects. - The flexibility of HIA allows these projects, programs and policies to be assessed at either a local, regional, national or international level -- making HIA suitable for almost any proposal. - A caveat: - HIAs are not simply for fault-finding. - They look ***not only for negative impacts*** (to prevent or reduce them), but also for impacts favorable to health. - This provides decision-makers with options **to strengthen and extend the positive features of a proposal**, with a view to improving the health of the population. C. Health Lens Analysis - The **HiAP Health Lens Analysis** (HLA) process builds on traditional health impact assessment methodology by incorporating a suite of additional methods (e.g., economic modelling) to allow the process to deliver both rigor and flexibility that accommodates the operational culture and policy imperatives of the partner agency. - As a consequence, the methodology employed for a health lens is modified for each target area. - **EVALUATION**, an essential component of the HiAP process, ***is built into each individual health lens***.  - 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. 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 - Here\'s the bright side: - The past 200 years actually brought dramatic improvement in life expectancy throughout the world, much thanks to significant advancements in medicine, science and technology. - In the video episode below from 'The Joy of Stats\', Professor Hans Rosling tells the story of how the health status of 200 countries has progressed over 200 years using 120,000 numbers - in just four minutes! - Link: - Plotting life expectancy against income for every country since 1810, Rosling captures quite well how the level of health and well-being we find ourselves now, though far from ideal, is definitely leaps and bounds from how the world used to be. - But as he has also outlined in the video, some huge disparities (or inequalities) in health remain. And depending on where you are and \'the circumstances by which you are born, where you live, learn work, and age\', the level of your health (and overall life expectancy) may also vary significantly across various socio-economic determinants. Burden of Disease\' concept - The **[BURDEN OF DISEASE]** is a ***measurement of that gap between a population's current health and the optimal state where all people attain full life expectancy without suffering major ill-health***. - **DISABILITY-ADJUSTED LIFE YEAR** (DALY) is one measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death.  - Of 56.9 million global deaths in 2016, 40.5 million, or 71%, were due to noncommunicable diseases (NCDs). - The four main NCDs are cardiovascular diseases, cancers, diabetes and chronic lung diseases. - The burden of these diseases is rising disproportionately among lower income countries and populations. - In 2016, over three quarters of NCD deaths \-- 31.5 million \-- occurred in low- and middle-income countries with about 46% of deaths occurring before the age of 70 in these countries. - Communicable, maternal, perinatal and nutrition conditions collectively were responsible for a quarter of global deaths, and injuries caused 9% of all deaths. B. IHME\'S Global Burden of Disease Visualization Tool - Link: C. Globalization and Health - The 21st century brings many complex and interacting challenges\--all of which impact health in many ways. - The world is more and **more economically and culturally interconnected** than before. - Between 1950 and 2000, the volume of trade between countries increased by a factor of nearly 200. - Trade as a share of economic activity is also increasing. - Between 1960 and 2007, the value of trade in goods and services as a share of global GDP increased from 12% to 28%. - The **number of people travelling and migrating** is also exponentially increasing between 1995 and 2012, the number of international tourist arrivals annually doubled from 530 million to 1.1 billion. - In 2010, the number of international migrants was 214 million, and based on current trends could reach 405 million by 2050. - Over the past several decades, global trade and relationships have **rapidly urbanized many low- and middle-income economies**. - In contrast to many high-income countries, this economic transition has been far more rapid with more dramatic consequences in terms of rural to urban migration, urbanization and socioeconomic change. - This globalization is impacting health in multiple ways. - On the positive side, the **global connectedness of transportation and the communications revolution** has enabled a **more efficient exchange of health information and resources**. - A clear example is the international network of institutions coordinated by the World Health Organization (WHO) via global telecommunications which can readily detect and rapidly respond to changes in the influenza virus --- such a capacity was unavailable after the First World War, when an estimated 20 million people died of influenza worldwide. - On the other hand, the internationalization of trade, migration and travel also **increases the risks of global epidemics and the spread of health hazards** ***through imports and exports of contaminated 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. - The increased movement of people and other items creates a complex equation of advantages and disadvantages for each society. - The health impacts of globalization are simultaneously positive and negative, and the magnitude of these impacts to populations will vary according to factors such as geographical location, sex, age, ethnic origin, education level, and socioeconomic status. D. The Changing Environment and Health - In the Philippines, the state of the environment is a major cause and contributor to morbidity and mortality. - In 2006, 22% of reported diseases and 6% of deaths in 2006 were found to be caused by environmental factors. - **Lack of attention to environmental health** exacerbates both communicable and non-communicable diseases, and induces epidemics and public health emergencies. - And as emerging issues on ***worsening pollution***, ***climate change*** and ***rapid urbanization*** usher in, the gravity of environmental health issues facing Filipinos will only worsen if left unaddressed. - Needless to say, the relationship between humans and the environment is a close and intimate link. - Human activity affects the environment which, in turn, plays a role in the health and well-being of the population. - The **DPSEEA framework** (below), adopted by the World Health Organization (WHO) in 1992, illustrates well this environment-human connection:  - The framework thus sees health impacts as originating from driving forces (D), which lead to pressures on the environment (P) in the form of production, consumption, waste generation etc, and their consequent releases into the environment. - These contribute to changes in the state of the environment (S) - for example, as environmental pollution or increased risks of natural hazards. - Exposures (E1) occur when humans come into contact with these hazards, leading to potential health effects (E2). - Policy and other actions (A) are taken to control adverse health effects. - These may be targeted at different points in the causal chain. - Later interventions (aimed at reducing exposures or mitigating the health impacts) may appear to be more directly effective and sometimes cheaper, because they can be targeted more directly at specific population groups and health outcomes. - **[Preventive measures]**, in contrast, tend to involve somewhat blunter tools - but with the major advantage that they can control the problems at source, and often offer a wide range of other environmental and social benefits. Quiz **1. Advances in the identification of infectious disease agents and the development of vaccines were the milestones of the 20th century and were pursued using what conceptual framework?** **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 course of the past 2 decades?** a\. New models are much more sensitive to the realities of poor and developing countries compared to the realities of developed countries. **b. New frameworks offer a more nuanced understanding of the determinants of health and wellbeing, based on research and empirical data.** c\. New frameworks are the result of globalization. d\. Older frameworks have become obsolete and have lost their usefulness. Rationale: **4. Wrong fundamentals on health lead to misconceptions, distortions and misallocations, and eventually the disconnectedness of and within the health sector. Examples of this disconnectedness include the following:** a\. The desire of political leaders to set up structures like hospitals and health centers without an eye on the human resources required to run these facilities and the sustainability of their operations. **b. All of these statements are manifestations of wrong fundamentals on health.** c\. The building of a patronage system where constituents depend on political leaders for medicines and hospitalization expenses. d\. The propensity to spend on medicines and to dispense them injudiciously. **5. What is the value of using the Social Determinants Framework in understanding health problems and in framing the response to these problems?** a\. The framework identifies contextual causes that determine the social standing and mobility of individuals, 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/B9780123739605006730 **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 **d. As an intermediary determinant of health** **8. In the Brazil Bolsa Familia Program (BFP) and the subsequent Proximo Passo, and in our own 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 **9. Enumerate the advantages of the Wagstaff Matrix over the Bio-Medical Framework in terms of understanding health and wellbeing. \[Answer in bullet form; four short bullet points expected.\]**  **10. In the SDH Framework, how does the health system act as a mitigating factor in the health and well- being of individuals, families and communities? (Answer in 1-2 sentences only; 40 words)** Sample Outline for written Discussion 1\. CSDH Framework - What is CSDH Framework? - What are the structural determinants of health? - Socioeconomic and political context - Socioeconomic position - What are the intermediary determinants of health? - Impact on health equity and well-being