Health Promotion: Trajectory and Current Perspectives

Abstract

Health promotion is linked to the living conditions of populations. In the last 40 years, health promotion reappears as a promising strategy for the field of Public Health. The health promotion movement emerged more vigorously from the 1970s onwards in developed countries—Canada, the United States and Western Europe. It is particularly in Canada that the concept of health promotion was revived, with the publication in 1974 of the Lalonde Report (A New Perspective on the Health of Canadians). This document placed health promotion at the level of strategic planning. The Lalonde Report has had a significant impact, providing insights into the recent health promotion movement across the world. Later, in 1978, the World Health Organization (WHO) held the 1st International Conference on Primary Health Care in Alma-Ata. This conference emphatically reaffirmed a broad concept of health. Health as a state of complete physical, mental and social well-being, not merely the absence of disease. This reconceptualization of health was fundamental in this process, as it served as the basis for the current health promotion movement. In this chapter, we intend to recover the trajectory and developments of the concept of health promotion and point out its future perspectives.

1. Introduction

The first authors who made reference to the concept of health promotion were Winslow and Sigerist. Both related the term health promotion to the living conditions of populations. Leavell & Clark appropriated the concept when formulating the model of the natural history of the disease. According to the authors, preventive medicine would comprise three levels of prevention and health promotion would be included in the primary level, related to the health and well-being of individuals. In fact, the discourse of social medicine in the ninteenth century also maintained an approximation with health promotion, by correlating health and living conditions, through the works of authors such as Villermé, in France and Chadwick, in England. In this sense, the term health promotion is not recent [1].

The health promotion movement emerged more vigorously from the 1970s onwards in developed countries: Canada, the United States and Western Europe. It is particularly in Canada that the resumption of the concept of health promotion can be observed, with the publication in 1974 of the Lalonde Report—A New Perspective on the Health of Canadians [2]. This document placed health promotion at the level of strategic planning. This proposal aimed, above all, to face the high costs of medical care in the country. The Lalonde Report had a significant impact, enabling the unfolding of the modern health promotion movement around the world. Later, in 1978, the World Health Organization (WHO) held the First International Conference on Primary Health Care in Alma-Ata. This event had a significant impact on health systems around the world, establishing the goal of Health for All in the Year 2000. This conference emphatically reaffirmed a broad concept of health. Health as a state of complete physical, mental and social well-being and not merely the absence of disease. This reconceptualization of health was fundamental in this process because it served as the foundation for the current health promotion movement [3, 4].

Subsequently, the Canadian Ministry of Health and the WHO began to structure concepts and practices on health promotion, favoring the holding of the First International Conference on Health Promotion held in Ottawa, Canada, in 1986. This meeting resulted in the Charter of Ottawa, considered a benchmark for health promotion [2]. The conference brought together participants from all over the world and aimed to share experiences in the sector.

The Ottawa Charter defined five priority areas for action in health promotion: (1) healthy public policies; (2) creating healthy environments; (3) reinforcement of community action; (4) development of personal skills and (5) reorientation of health services. Also in this Charter, the prerequisites for health are described: peace, education, housing, food, income, healthy ecosystem, social justice and equity. Health promotion therefore incorporates an expanded notion of health and comes closer to the idea of quality of life. In this approach, health would be the result of a broad spectrum associated with quality of life, comprising a set of values, such as: social justice, education, income, housing, food, nutrition, work, among others [5, 6].

Quality of life, in turn, would be a notion related to the degree of satisfaction of individuals with their family, social and environmental environment. For Minayo et al. ([7], p. 8) “the term encompasses many meanings, which reflect knowledge, experiences and values of individuals and collectivities that report to it in different times, spaces and histories, being, therefore, a social construction with the mark of cultural relativity “.

Other international conferences were held and provided further discussion on the topic of health promotion, as presented below:

• II International Conference on Health Promotion was held in Adelaide, Australia in 1988, whose central theme was healthy public policies. This meeting discussed the impact of public policies on the health of populations. The conference identified four priority areas to promote immediate action on healthy public policies: support for women’s health; food and nutrition; tobacco and alcohol and the creation of health-friendly environments.

• III International Conference on Health Promotion was held in the city of Sundsval, Sweden in 1991, where the theme of favorable environments for health or healthy environments was discussed, not restricted to the physical or natural dimension, but the political, social, economic and social dimensions. More favorable to the health of populations.

• IV International Conference on Health Promotion took place in Jakarta, Indonesia in 1997. The theme defined for the meeting was “health promotion in the 21st century”. The role of health determinants in identifying the directions and strategies needed to face the dilemmas and challenges of the twenty-first century was discussed.

• V International Conference on Health Promotion, held in Mexico in 2000, chose the theme “health promotion: towards greater equity” in which the responsibility of governments in proposing health policies was recognized. It was also highlighted the persistence of problems that demanded an urgent solution and, therefore, actions aimed at health, especially public health, were established.

• VI International Conference on Health Promotion held in Bankok, Thailand in 2005. The topic discussed was “health promotion in a globalized world” which sought to identify actions and commitments to address the determinants of health. The establishment of partnerships to promote social improvement was defended as a requirement of global development. In addition, the values and strategies of the Ottawa Charter were reaffirmed.

• VII International Conference on Health Promotion held in Nairobi, Kenya, in 2009, the impasses for implementation were discussed, inserting an effective mechanism for income distribution into the political and development agendas.

• VIII International Conference on Health Promotion held in Helsinki, Finland, in 2013. The Meeting was based on the Alma Ata Declaration on Primary Health Care (1978) and the Ottawa Charter for Health Promotion (1986). These documents identified intersectoral action and healthy public policies as central elements for health promotion and for achieving equity in health.

• IX International Conference on Health Promotion was held in 2016 in Shanghai, China. And its focus was to promote health through the adoption of measures consistent with achieving the Sustainable Development Goals (SDGs). The Declaration of the event contains four major themes and a series of commitments: (1) the adoption of political decisions in favor of the rights of women, displaced populations and the growing number of people affected by humanitarian and environmental crises. (2) Using governance strategies to promote well-being. (3) Recognition of cities and communities as essential environments for health. (4) Recognition of knowledge in health as a fundamental element for the promotion of equity in health. The Declaration ends with a “call to action” for the commitments made to accelerate the implementation of the SDGs through political commitment and financial investment in health promotion.

It is important that some conferences take place in different periods of time, but stand out as important events in the field of health promotion, among them: the Declaration of Santa Fé de Bogotá (1992); I Caribbean Health Promotion Conference, in the Caribbean (1993); Population Health Promotion in Canada (1996); Network of Mega Countries for Health Promotion (1998); V Latin American Conference on Health Promotion and Health Education (2021). In addition to these, the United Nations Millennium Declaration held in New York in 2000 was equally important, where leaders set a goal to tackle and eliminate poverty in the world [4, 8]. Table 1 below summarizes these events.

1974: A New Perspective on the Health of Canadians.

1977: Health for all in the year 2000—30th World Health Assembly.

1978: International Conference on Primary Health Care—Declaration of Alma Ata.

1986: I International Conference on Health Promotion (Canada)

1988: II World Conference on Health Promotion (Australia)

1991: III World Conference on Health Promotion (Sweden)

1992: I International Conference on Health Promotion in the Region of the Americas—Declaration of Bogotá (Colombia)

1993: I Conference on Health Promotion in the Caribbean (Caribbean)

1996: Population Health Promotion in Canada (1996)

1997: IV World Conference on Health Promotion (Indonesia)

1998: Network of Mega Countries for Health Promotion (Switzerland)

2000: V World Conference on Health Promotion (Mexico)

2000: United Nations Conference on the Millennium Development Goals (SDGs).

2002: III Latin American Conference on Health Promotion and Health Education (São Paulo, Brazil)

2005: VI World Conference on Health Promotion (Bangkok)

2008: Report of the Global Commission on Social Determinants of Health (WHO)

2009: VII World Conference on Health Promotion (Nairobi)

2012: United Nations Conference on Sustainable Development (Rio de Janeiro, Brazil)

2013: VIII World Conference on Health Promotion (Helsinki)

2015: United Nations Conference on Sustainable Development Goals (SDGs) and launch of Agenda 2030.

2016: IX World Conference on Health Promotion (Shanghai)

Table 1.

Chronology of events in health promotion.

Source: adapted from Buss et al. [9].

From the holding of international and regional conferences, it is observed that health promotion places the issue of health on the global public agenda as a priority for leaders at all levels and sectors, drawing attention to the consequences that the decisions taken by these countries have on global health. Thus, health promotion points to the need to build healthy public policies around the world; of creating favorable environments for people’s health, alongside the development of personal skills and the reinforcement of community action [10]. It is important to emphasize that strategies and programs in the area of health promotion must adapt to the local needs and possibilities of each country and region, as well as taking into account the differences in their socio-cultural and economic systems.

Particularly, in the context of the organization of health policies, health promotion is understood as a powerful device for reformulating public policies that aim at the quality of life of populations. Health promotion would be a field of articulation with several areas that aim at people’s quality of life within two approaches. The first emphasizes the autonomy and accountability of individuals using health education as a strategy with a view to behavioral change. And the second, whose focus is broader and more comprehensive, seeking to identify and address the macro-determinants of the health-disease process through intersectoral actions. Health promotion therefore seeks to change the living conditions of people and populations so that they are dignified and adequate [6, 11].

For public policies to have coherence and practical effectiveness aimed at health promotion, they must be articulated to the different segments of society, involving civil society, the public and private sectors. The participation of society in this process implies the fight for health with the reduction of existing inequities in the access to infrastructure goods and services. For this, it is necessary to exercise empowerment, understood as an important strategy for strengthening and empowering people to claim their social rights [12].

In this direction, in order to achieve the objectives proposed by the health promotion strategy, coordinated action is necessary in the different sectors and among the multiple social actors: government, the health sector and other social and economic sectors, voluntary and non-governmental organizations, local authorities, industry and the media. Thus, people in all walks of life must be involved in this process as individuals, families and communities. Mediation between the population and the government, as well as training for the exercise of citizenship and social control are invaluable contributions to health promotion [5, 9].

We believe that it is through responsible public policies and initiatives to tackle the social determinants of health that health promotion takes place. Undoubtedly, its theoretical foundations and practices are directly related to governance, social responsibility and the fulfillment of global commitments assumed such as the 2030 Agenda and the Sustainable Development Goals—SDGs [9, 13], including the new challenges posed by the current COVID-19 pandemic.

2. Health promotion in the COVID-19 scenario

The COVID-19 pandemic, the biggest global health problem of this century, challenges scientific and political authorities to identify the most appropriate approaches from a clinical, epidemiological, political and socioeconomic point of view for its control and prevention. The main strategies adopted to face the COVID-19 pandemic involve: structuring and expanding hospital care in health systems, the use of telemedicine and the restriction of social contact.

Faced with the high pathogenicity and virulence of SARS-CoV-2, the governments of several countries seek to expand clinical beds and intensive care units dedicated to the treatment of severe cases of COVID-19 [14]. The use of telemedicine, in turn, aims to improve the response of health systems to the ongoing crisis. Its results show a greater capillarity and expansion of monitoring and health care, thus helping to monitor, detect and prevent, and to mitigate the impacts on health care indirectly related to COVID-19. In this way, such initiatives can reconfigure the future space of telemedicine in the practice of health services [15]. That is, when the pandemic is over, telemonitoring can continue to be used to provide more convenient and cost-effective care to patients. And yet, better prepare health systems for other pandemics that may arise in the future [16].

As for measures to restrict social contact, the most recommended are social distancing for the general population, isolation of confirmed and suspected cases, and the need to quarantine the contacts of those affected. Such restriction measures depend on the awareness and involvement of the population, as happened with countless other diseases of community control [14].

In this direction, experiences of articulation between scientific projects and the community to prevent the transmission of COVID-19 in the most vulnerable communities and the promotion of quality of life have been positive at this current moment. Such projects seek to build new health promotion practices and forms of knowledge production among the various social actors involved—epidemiologists, social scientists, infectologists, health professionals, patients and members of community groups, developing health actions of collective interest, enabling active participation of society in controlling this pandemic and other health problems. The actions involve health education, visits to scientific spaces, courses and workshops aimed at bringing science and society together in teaching, research and care spaces. These new forms of intervention in the COVID-19 epidemic may expand the scope of future public health actions because they broaden the look at the recent processes of social determination of health and the production of knowledge [17, 18].

Within this context, it is worth reflecting on the relevance not only of experiences of this nature, but on the other damage caused by COVID-19. Unemployment, hunger, social and psychological problems, violence and an increase in other diseases have been observed during the course of the pandemic [14].

According to PAHO [19], the pandemic intensified the weaknesses related to the guarantee of social rights in Latin American countries, impacting on the increase in unemployment rates, the reduction of income and the increase in situations of hunger and poverty. Also according to data from the Economic Commission for Latin America and the Caribbean—CEPAL [20], even before the Covid-19 pandemic, socially vulnerable groups such as rural women and the black population made up the indicators of poverty and extreme poverty in the American continent. The indigenous population was also affected by this situation, with a poverty rate of 46.7% in 2019 and extreme poverty at 17.3%. This poverty scenario intensified with the pandemic, and in 2020, the projection for the extreme poverty rate was 12.5% and 33.7% for the poverty rate, representing 209 million poor people by the end of that year in these countries. Countries. Such numbers have a direct influence on the increase in hunger of this population, as they impact on the purchasing power of food and all basic and essential human needs (CEPAL, 2020).

The complex social, ethical and political dimensions of the COVID-19 pandemic today serve as future lessons for building a more critical, ecological and democratic global health [21]. The reduction of social, health and environmental inequalities and injustices and the promotion of health and well-being are irremediable goals. And, therefore, they are characterized as enormous challenges for health systems around the world today.

3. Conclusion

Finally, to reach a potential for health and quality of life in contemporary times, it is necessary to increase investments in strategic health promotion actions. Thus, in the current context of the COVID-19 pandemic, investments in health have been mostly directed towards preventive and intervention measures. The priority has been to follow the recommendations of health organizations regarding the prevention of transmission of the new coronavirus: respiratory etiquette, social distancing, hand and space hygiene [22]. In addition, they involve risk prevention actions for chronic diseases that, as the literature reveals, increase the severity and lethality of COVID-19 [23]. However, health promotion strategies are fundamental and should be encouraged at this time, due to the complex nature of the disease and the extension of the pandemic. Such strategies impose the establishment of a network of co-responsibilities in favor of life. And, they involve actions of reorganization and expansion of health services; Health education; encouraging healthy lifestyles and safe behaviors and creating healthy environments. In this direction, actions such as the one proposed by the World Health Organization [24]—“Food and nutrition tips during self-quarantine” to promote healthy eating during social isolation, is an example of the importance of health promotion actions in the current context. They reveal the new contours of the health promotion strategy during the COVID-19 health crisis around the world.

Health, as a social production of multiple and complex determination, requires public policies anchored in the perspective of health promotion. It fundamentally involves the establishment of a network of commitments and co-responsibilities in favor of life and the creation of the strategies necessary for it to be dignified and with quality [25]. Currently, due to the COVID-19 pandemic, investments have been increasing in curative and individual medical care, although it is identified that preventive measures, health promotion and improvement of living conditions are also being implemented, pointing out the new contours of actions of health promotion [9].