OHPE Bulletin #186.1, "Poetic in its Simplicity".... the Application of the Ottawa Charter to Shape Health Promotion Practice
As influential documents go, the Ottawa Charter for Health Promotion is not especially formidable in appearance - a few pages of text sandwiched between a cardboard cover with a two-colour logo reminiscent of the crest for a now defunct NHL team. And, unlike certain other blueprints for the realization of better people living in a better world (insert your religious tome of choice here if you have one), the Charter is also notable for its brevity. It can be read in a minute. But reading it is the easy part......
Those toiling in the health promotion field have been challenged by the practice implications of the Charter from the time of its release in November 1986. At an Ontario Public Health Association (OPHA) Health Promotion Division workshop in January 1987, D'Arcy Farlow, a health promoter in Kitchener, Ontario, noted the effective implementation of the Charter depended on the ability of practitioners to:
"read the political climate of the day and capitalize on it.the Ottawa Charter for Health Promotion provides us with the language of the framework that we can then use to achieve the tools that we require for community empowerment. Some of us in this room may feel uncertain as to how we can implement the ideas that are presented in the Charter. Others of you may say that there is nothing new in this Charter; it simply reflects what you are already doing in your work. In some circumstances, the Charter may not represent what you are doing; the framework that it offers may be too limiting in scope.....the Charter is not new - it has come out of real experiences. We are the creators of this Charter."
D'Arcy's observations have been validated by over 14 years of efforts to apply the Charter as a guide post for health promoting actions. In spite of the challenges that have emerged in the wake of the Charter's release -- such as a "political climate of the day" characterized by an erosion of the social safety net and an ongoing discrepancy between core health promotion values and the regulated parameters of public health practice - health promoters in Ontario and elsewhere have made effective use of the Charter to shape health promotion practice. To illustrate the ways in which the Charter has influenced the nature and scope of health promotion services, I will draw on two Ontario-based examples: one from a public health unit and one from a community health centre.
B. A "Charter-based" approach to program planning: The Ottawa-Carleton Health Unit Experience.
To briefly recap what successive generations of health promotion students can recite from memory, the Ottawa Charter defines health promotion as the "process of enabling people to increase control over, and to improve, their health." To assist with the implementation of this process, the Charter offers a menu of three strategies (advocate, enable and mediate) and five action areas: build healthy public policy, create supportive environments, strengthen community action, develop personal skills and reorient health services.
Achieving the vision of health promotion set out in the Charter cannot be realized in the absence of intersectoral collaboration. If there's one thing that the field of health promotion has learned through its struggles to 'walk the talk' of the Charter, it's that any meaningful action on the social, economic and environmental determinants of health requires the formation of partnerships from a range of sectors, including recreation, housing, education, agriculture, social services, labour and business.
And therein lies the dilemma. Efforts to involve other sectors in health promotion efforts have, time and again, run smack into the organizational barriers of accountability, conflicting mandates and the problem of setting objectives and outcomes when every partner comes to the table with different conceptions of "success".
This was the challenge addressed by the Adult Health Division of the Region of Ottawa-Carleton Health Department. A 1994 strategic planning exercise culminated in the creation of "Planning Strategically: A Framework for Health Department Programs" that was instrumental in assisting the Division with the adoption of a population health promotion approach to its work.
By applying the Framework, which outlines public health practice in terms of individual and family health action, collective health action, and the environments that support health, the Division was able to operationalize the concepts outlined in the Charter for Health Promotion. This shift in orientation is reflected in the Adult Health Division plan for 1996-2005, which includes a revised mission and vision statement, principles, areas of focus and community health impacts. The mission of the Division is to:
"build capacity for health and reduce need for treatment through the promotion of healthy living, safety and independence among adults, senior adults, their families and their communities."
To support this mission, the Division will:
* provide programs and services for adults that foster healthy living, safety and independence at each stage of life;
* promote collective health action through collaboration and the formation of partnerships, and through support for community health action by groups, neighbourhoods and communities; and
* advocate for healthy public policies at all levels of government, in all sectors, and in all settings in which people spend their daily lives.
The development of the framework and strategic plan took a great deal of time, and required extensive research and information gathering. Short-term outcomes, and the related activities, were closely linked to the requirements of the Mandatory Health Programs and Services Guidelines (MHPSG). A lot of indicators of community and environmental change were not available, and had to be generated by the health department. This has become a growing trend in recent years as health promotion services providers seek performance indicators that reflect the impact of broader, intersectoral change strategies.
The Adult Health Division's experience in 'operationalizing' the Charter was an insightful exercise that also resulted in a number of useful spinoffs. For example, the same planning concepts were subsequently applied by the Public Health Research Education and Development Group (PHRED) to develop an accountability framework for the MHPSG based on the application of Ottawa Charter action areas.
~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ *
C. Good work if you can get it.... the 'health promoting' job description.
The second example comes courtesy of my friend Daniel McSweeney, a health promoter at the LAMP Health and Community Service Centre (formerly known as the Lakeshore area Multi- Service Project), a community health centre serving South Etobicoke. His challenge: to foster the adoption of health promotion principles and concepts throughout the organization, which is a key criterion for the CHC peer accreditation process. His solution? Include health promotion in the job description of every staff member.
Daniel started this process by meeting with each staff member to build a common understanding of health promotion. This included an overview of the Ottawa Charter and the application of the Charter strategies and action areas to health-related issues. Each staff person was then asked to describe how they, through their existing role at LAMP, promoted health. As part of this reflective process, staff completed a written exercise that required them to provide an example of how they applied, or could apply, the Ottawa Charter strategies in their day-to-day interactions with clients, colleagues, community stakeholders and partner organizations.
This exercise proved to be a useful way of enabling CHC staff to adopt a health promotion orientation towards their work, and think of their contribution in terms of health promoting outcomes. For example, the Chiropodist at LAMP expanded her work-related success indicators from clinical outcomes around improved mobility to broader, quality of life objectives (e.g., helping seniors to maintain their independence). Physicians were asked to think of how their patient interactions could aid in the development of personal skills or the creation of supportive environments.
Daniel then worked with staff members to review the "fit" between their self-identified health promotion objectives and their existing job descriptions. Daniel helped staff to include health promotion tasks in their job descriptions. Each staff person was asked to incorporate at least one determinant of health issue, two Charter strategies and one external partner organization into her/his existing job description.
The end result was the incorporation of health promotion practices and values into every program and service offered by LAMP. Rather than vesting responsibility for health promotion with a few individuals, the standard practice of many health agencies, LAMP made an organization-wide commitment to implementing the Ottawa Charter. As one of the peer reviewers commented when LAMP was reviewed for accreditation, the process was "poetic in its simplicity."
~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ *
These are but two examples of how the Ottawa Charter has served as a helpful road map for the achievement of health promoting goals. It is, in many ways, a checklist of the ideals that health promotion efforts should aspire to and a blueprint for what the field could become. As health promoters (i.e., those who periodically consult the Charter, promote it, struggle to apply it, and, when necessary, reinvent it), we have all benefited from the short, yet insightful, document that guides us our actions in the settings where health is created, where we learn, work, help, play and love.... not a bad legacy for a set of ideas conceived in Ottawa of all places!
Ottawa Charter for Health Promotion 1986 World Health Organization http://www.who.dk/policy/ottawa.htm
Personal correspondence from Alison Stirling, with notes from her presentation "Using the Ottawa Charter for Health Promotion in Public Health Practice" to the Waterloo Region Community Health Department October 13, 2000
N. Edwards, M. Murphy, A. Moyer, & A. Wright "Building and Sustaining Collective Health Action: A framework for community health practitioners" Regional Municipality Ottawa-Carleton & Community Health Research Unit. 1995 Publication DP95-1
"An Evidence Based Approach to Planning Strategically" PHERO vol 10 #1 January 1999
Public Health Research, Education & Development Group [PHRED] "Toward an Accountability Framework for Ontario Boards of Health" April 2000
For more information about the LAMP initiative, please contact Daniel McSweeney, health promoter, LAMP Health and Community Service Centre, at (416) 252-6471 or email@example.com