Health studies: The Ottawa charter for health promotion

HEALTH STUDIES

THE OTTAWA CHARTER FOR HEALTH PROMOTIONIMPLICATIONS IN PHYSICAL ACTIVITY:

Taking the first charter to global health

Westerberg, V.M.

Date: 3 May 2010

THE OTTAWA CHARTER FOR HEALTH PROMOTION

WESTERBERG, VMPage 2 of 15

IMPLICATIONS IN PHYSICAL ACTIVITY:

Taking the first charter to global health.

“Health can be judged by which people take two at a time - pills or stairs”

(Welsh, as quoted in Housman, 1994)

The first International Conference on Health Promotion was held in Ottawa,

Canada, in 1986, as a response to growing expectations for better public health.

The purpose of the conference was to continue to identify action to achieve the

objectives of the World Health Organization (WHO) “Health for All by the Year

2000” initiative, launched in 1981. The Ottawa Conference was preceded by the

Alma Ata Primary Health Care Conference in 1978, and followed by further

similar conferences in Adelaide (1988), Sundsvall (1991), Jakarta (1997), Mexico

(2000) and Bangkok (2005). Each conference continues to strengthen health

promotion in an effort to overcome inequities.

The promotion of health focused on physical activity is an issue of social concern

because many of the non-communicable diseases that lead the causes of death in

developed countries are preventable and one key determinant of prevention is

precisely physical activity, a cheap, cost-effective, everyday resource available for

all (Ministry of Health [MOH], 2003).

Sedentarism has established itself in today´s societies. Individuals who are not

physically active are usually blamed for choosing the wrong kind of lifestyle

without taking into account limitations which range from those emanating from

macro (sociopolitical, environmental, cultural) levels of intervention to

intermediate levels (communities) to micro levels (age, diseases) .


“Healthy Eating - Healthy Action” is New Zealand’s Ministry of Health’s (MOH)

nutrition, physical activity and healthy weight strategy (MOH, 2009). It focuses

on five priority areas: environments, children, lower socioeconomic groups,

workforce and communication, and takes into account the contents of the Ottawa

Charter for Health Promotion, which defines health promotion as:

The process of enabling people to increase control over, and to improve

their health. To reach a state of complete physical, mental and social well-

being, an individual or group must be able to identify and to realise

aspirations, to satisfy needs, and to change or cope with the environments.

Health is, therefore, seen as a resource for everyday life, not the objective

of living. Health is a positive concept emphasizing social and personal

resources, as well as physical capacities. Therefore, health promotion is

not just the responsibility of the health sector, but goes beyond healthy

lifestyles to wellbeing (WHO, 1986).

The key features of the Ottawa charter include eight pre-requisites or

determinants of health (WHO, 1986), which are the sine qua non conditions for

the development of the charter contents. The three most important ones are:

income, employment and education, the remaining ones are: peace, shelter, food,

social justice, a stable ecosystem and equity (Baum, 2008).

The Ottawa charter aims to reduce inequities in health and for that reason special

attention must be paid to indigenous population´s health, people with disabilities,

the poor, the diseased, the elderly, the unemployed, that is, people at the lower

end of the social ladder, who are most at risk of having bad health outcomes and

who tend to ignore health promotion messages (WHO, 1986).


The Ottawa Charter for Health Promotion identifies five areas of priority:

1. Build healthy public policy: Health promotion policy combines multiple,

complementary approaches, including legislation, fiscal measures,

taxation and organisational changes action (WHO, 1986). Health

promotion requires the identification of obstacles to make healthy choices

for people easy to achieve by policy makers and the development of ways

to remove those obstacles. Examples of building healthy public policies

are: Launching information campaigns about the benefits of incorporating

physical activity as part of daily life, pointing out the dangers of inactivity,

promote physical activity at home (housework as a fitness activity,

gardening), at schools (with incentives like “take part in sport

competitions or sports summer camps and get a free ticket to see the All

Blacks play”), at work (with incentives like: “take 30 minutes of your lunch

hour to practice your favourite indoor exercises at work and get one more

day of paid holiday per month), provide funding for community-based

initiatives to promote physical activity, ensure action across institutions

(councils, education and health ministries, etc.), promote social protection

against impoverishment, isolation, malnutrition, disease and addictions

that hamper or limit the practice of physical activity (SPARC, 2010).

The 1988 Adelaide Conference on Healthy Public Policy, in which 42 countries

took part, continued in the direction set at Alma Ata and Ottawa, and the several

strategies for healthy public policy action were proposed (WHO, 1988): Health

must be regarded as a social investment by governments and institutions, equity,

access and development are to be promoted for risk populations (indigenous


peoples, ethnic minorities, immigrants, women and dependent people) with

particular attention to the impact of new technologies on health outcomes, public

health promotion policies should have a positive health impact on developing

countries, governments and all other controllers of resources (macro-level

decision-makers) are ultimately accountable to their people for the health

consequences of their policies or lack of policies and must find multi-level

alliances (with institutions, corporations, NGOs, trade unions, academic

associations and religious leaders) to provide the impulse for health action.

The promotion of physical activity has been recognized as a key public health

policy issue by the international community (Pate et al., 1995). Great concern is

being shown in developed countries in this regard given the alarming rate at

which non-communicable diseases are growing, namely: cardiovascular diseases,

type II diabetes mellitus, some cancers like colon and breast, osteoarthritis,

osteoporosis, obesity, anxiety and depression (MOH, 2003). Additionally, Harris

and Cale (1997) consider that the success of strategies for promoting physical

activity resides in their effectiveness to provide equality, opportunities,

incentives and reinforcements for all people, especially young people.

Looking at New Zealand, one in three adults is not physically active at levels

sufficient to benefit their health (MOH, 2009). Physical inactivity is second to

smoking as a modifiable risk factor for poor health and it is associated with 8 %

of all deaths, with over 2000 deaths per year. Improving the level of participation

in relevant physical activity so as to almost reach the maximum heart rate for age

(220 - age) for at least 30 minutes a day is a priority health objective for the New

Zealand government in cooperation with Sports and Recreation New Zealand

(SPARC) and District Health Boards (DHBs). Target populations are inactive

adults, children, adolescents, women, elderly people, Maori people and risk


populations (people with chronic diseases, dependent people) (MOH, 2003).

Physical activity does not lack risks, which range from musculoskeletal lesions to

heart failure, but the risk / benefits ratio is overwhelmingly in favour of the

benefits (SPARC, 2009).

2.- Create supportive environments: The relationship between people and

their environment is the basis for a socio-ecological approach to health

promotion. Protection of the environment (natural and built), the conservation of

natural resources, safe, satisfying and stimulating living and working

environments and the impact of rapidly changing technological, working,

urbanisational and energy production environments must be addressed

strategically. Having an adequate supporting environment, individuals may find it

easier to select healthier options for healthier living (WHO, 1986). Some

examples have been mentioned in the previous point, as the development of

public health policies is closely related to the creation of supporting

environments. Examples in this line include the improvement of conditions and

infrastructures, building sport facilities near or in / at schools, malls or office

buildings, reducing environmental hazards to outdoor sport practice, the creation

of safe walking areas in parks and forests, the creation of an extensive bicycle

lane network with a good amount of strategically located parking places for

bicycles, and the presence of information offices handing out maps indicating

“exercise friendly zones”.

The Third International Conference on Health Promotion: Supportive

Environments for Health, the 1991 Sundsvall Conference, reflected the result of

the growing public concern about sustainable development in view of the

increasing threats to the global environment. Representatives from 81 countries

took part in it. Many approaches were identified for creating supportive


environments that should be used by policy-makers, decision-makers and

community activists in the health and environment sectors (WHO, 1991). The

Conference recognized that everyone has a role in creating supportive

environments for health and urge powerful influential organizations like WHO,

UNEP, the World Bank and International Monetary Fund to strengthen their

efforts to develop codes of conduct on the trade and marketing of substances

harmful to health and the environment (WHO, 1991). Social and economical

inequity is regarded as unacceptable and industrialised nations are compelled to

help developing countries meet the eight pre-requisites for health mentioned in

the Ottawa charter (WHO, 1986). Action to create supportive environments has

many dimensions: physical, social, spiritual, economic and political. Action must

be coordinated at local, regional, national and global levels to achieve solutions

that are truly sustainable. The Sundsvall Conference says that proposals to

implement the Health for All strategies must reflect two basic principles: Equity

and public action. Empowerment of people, specifically women, is emphasized as

key to social health development. Worldwide action based on global partnership

is regarded as the way to ensure the future of our planet, ourselves and our

health (WHO, 1991).

3.-Strengthen community actions: Community development focuses on pre-

existing human and material resources to increase self-help and social support,

developing flexible systems to strengthen public participation in health issues.

This requires complete and continuous access to information and learning

opportunities for health, as well as support regarding funding (WHO, 1986).

Community fun runs, physical activity groups and classes, school based programs

(walk-a-thons, walking or cycling school buses), and community awareness

meetings are but a few examples of how to strengthen community actions. In a


multicultural society like New Zealand´s, the creation of community traditional

and indigenous dance groups in schools and communities would not only

improve physical condition of participants while having fun, it would also

strengthen ties among community dwellers and neighbours. It should be noted

that it is not enough that people are kept active through participation in health

promoting activities, people should be acknowledged as “the main health

resource, accepting the community as the essential voice in matters of its health,

living conditions and wellbeing” (WHO, 1986). The strengthening of community

action is conceived as a source of information, community (decentralised)

decision capacity, and as a resource for implementing health promotion actions,

so that health promotion is seen as something shared and not imposed in a

unidirectional way (Spicer & Fleming, 2007).

4.- Develop personal skills: Achieving personal and social development through

information, education and enhancement of life skills. People should be enabled

to learn throughout life to prepare themselves for all of its stages and to deal with

chronic illness and injuries (WHO, 1986). This has to be facilitated in school,

home, work and community settings. Personal skills development is targeted

through the widespread use of education and information through, for example,

on-site classes or conferences (schools, work places, health centres, etc.),

advertising, videos, books, etc., and, in so doing, promoting health equality and

health access to all. A specific example would be to teach classes of rehabilitation

movements, yoga, tai chi or Pilates exercises, that people can practice at home, at

work or outdoors. No specific clothing, equipment or fitness levels are required

for the practice of these activities.

5.- Reorient health services: The role of the health sector must move towards a

health promotion direction beyond its micro, biomedical level of intervention,


that is, the responsibility for providing clinical and curative services towards a

macro, social, holistic level of intervention. Reorienting health services also

requires attention to health research, as well as changes in professional

education and training (WHO, 1986). Examples of reorientation of health services

include: Increase the number of training facilities, ensure that target groups have

access to advice / information regarding what physical activity and level of

training are adequate for their age and physical condition and characteristics

(SPARC, 2009). This must lead to a change of attitude and organisation of health

services, which refocuses on the total needs of the individual as a whole person. It

moves the health sector beyond providing only medical/clinical services towards

meeting the more holistic needs of people using a multi-sectoral, multi-cultural

approach. Examples in practice include encouraging and resourcing Maori

providers to develop physical activity programmes by Maori with and for Maori

(Health Promotion Forum of New Zealand, 2010)

Motivators and barriers have been identified in relation with physical activity

(MOH, 2003). Motivators: Awareness that physical activity is good for health,

desire to keep in shape, encouragement from others and wanting to role model

physically active behaviours. Barriers: Lack of time and/or energy, lack of

encouragement or support from others, health problems.

The Ottawa charter identified three basic strategies for health promotion (WHO,

1986):

Advocate: Good health is essential to achieve social, economic and personal

development, and an adequate quality of life. Political, economic, social, cultural,

environmental, behavioural and biological factors can impact health either

positively or negatively. Health promotion aims to make these conditions


favourable, through advocacy for health (WHO, 1986). Examples of advocacy for

physical activity include: Request that the city council construct clearway bicycle

lanes in local communities so that people will be able to ride their bicycles safely,

work with local educational and labour-related institutions to provide after-

hours and weekend access to recreation facilities, gyms, and soccer, cricket,

rugby fields and work with the city council to create or extend and keep clean

walking paths in local community parks.

Enable: Health promotion focuses on achieving equity in health. Health

promotion action aims to reduce differences in health status and ensure the

availability of equal opportunities and resources to enable all people to achieve

their full health potential (WHO, 1986). This includes a supportive environment

(availability of facilities for the practice of physical activity), access to information

(where to practice sports, “physical activity friendly” premises: office buildings,

malls, neighbourhoods), life skills and opportunities to make healthy choices easy

choices. People cannot achieve their fullest health potential unless they are able

to control those things that determine their health. Building the capability of

health promoting partners with systems, processes and tools, providing experts

and research and providing sector training and development are all key to enable

promotion of health (SPARC, 2009).

Mediate: The prerequisites and prospects for health cannot be ensured by the

health sector alone. Health promotion demands coordinated action by all

concerned, including governments, health and other social and economic sectors,

non-government and voluntary organisations, local authorities, industry,

information technology companies and the media (WHO, 1986). The media play a

key role in today´s society and government funded promotion of physical activity

on TV and the internet could prove an effective mediator between health


promoting organizations and the general public, between governments and

communities.

But the Ottawa charter also has weak points. One of them is that it was designed

to meet the needs for health promotion of industrialised countries and focuses on

the prevention of non-communicable diseases (NCDs). Developing countries are

struck by communicable (infectious) diseases instead, as the lifespan of people in

those countries is too short to develop NCDs.

Another weakness of the Ottawa charter is that it may create rather than

eliminate inequities in society in favour of the middle classes, as lower

socioeconomic groups tend to ignore health promotion campaigns (WHO, 1986).

Finally, the Ottawa charter does not take into account environmental threats

coming not from the physical but from the political, economic and social

environment. Neoliberal economics and the globalization of trade and economy

have led to a reduction in the degree of maneuverability of national and local

governments to establish social, environmental and health standards, leading to

increasing inequities in income and health service distribution, with consequent

environmental and social deterioration. Governments keep reducing the budget

for the public sector, resulting in increasingly scarce resources dedicated to

government funded health promotion (Arya, 2003). Old time and also indigenous

population values of solidarity and mutual aid that led people to seek collective

solutions to shared problems are in danger of being replaced by US-style

individualism with the help of the media (Arya, 2003). Clearly, the dichotomy

individual versus community interests and solutions to health creates tension.

Tension between the individualist health promotion programmes (IHP) and the

social health promotion programmes (SHP) is almost inevitable. An


interventionist government can be labelled as “nanny state” and some claim that

individual choices are hampered by such governments (Jochelson, 2005).

Conversely, some governments claim that citizens should decide, without

impositions or “counselling”, what is more convenient for them, therefore

relieving themselves of the burden of their responsibilities towards society. The

latter situation means that governments will keep in good terms (collecting

money) from large pharmaceutical and food industries that are, to a considerable

extent, responsible for people´s bad health in developed countries, where the

biomedical model of health predominates and generates handsome amounts of

“benefits”.

Arguably, laypeople lack the critical knowledge, the overall view, the data to

decide on something as complex as how different factors (medication, surgery,

junk food, lack of exercise, etc.) can impact their health outcome (Wang, 2000).

Governments and institutions have a global view of society and it is their

responsibility to take action in order to promote and preserve its wellness (WHO,

2000). Local communities and sociopolitical activists must claim their right to

health education and to be informed about and to take part in decisions and

actions involving their communities, more so when there are underprivileged

minorities in them.

The concept of “stewardship state” (versus “nanny state”) introduced by the

WHO (2000) states that governments should not press people or restrict their

freedom without a reason. It also emphasizes that governments have a

responsibility to provide the conditions under which people can lead healthy

lives. The “stewardship state” also has a particular responsibility for reducing

health inequalities and protecting the health of vulnerable groups such as

women, children and minorities (WHO, 2000).


The Ottawa charter dream of “health for all by the year 2000” (WHO, 1986) still

remains a dream. Health promotion deterioration accelerated by environmental

hazards, sociopolitical inactivity and globalization of economies can produce

trans-generational inequities even greater than those seen now among countries,

regions, ethnic groups and classes. The physical, economical and social well-being

of the “health for all” society of the future will be affected by decisions made

today by individuals, communities and governments. It is necessary to make sure

that the policies advocated from the other sectors influencing health (transport,

housing, finance, etc.) do not sacrifice the health of future generations for a short-

term gain.

Physical activity is a key factor in health promotion as it reduces the rate and

impact of non-communicable diseases, which are gradually becoming the leading

cause of death in developed countries (WHO, 2000). Solutions to the

development, implementation and control of physical activity as part of health

promotion initiatives should come in the first place from community level actions

due to their proximity to individuals, coordinated with subsequent macro levels

of intervention from the highest instances of society (governments and

institutions). Let’s get moving!

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Health studies: The Ottawa charter for health promotion