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Promoting Healthy Policy Decisions: Can the Focus be Improved?

I Introduction

I would like to thank the Symposium Planning Committee for giving me the opportunity to share some of my thoughts on the challenge of promoting healthy public policy to politicians, senior bureaucrats and other decision makers. I would also like to thank Dr. Irving Rootman, the outgoing Director of the Centre for Health Promotion, who served as the

source of inspiration for the title of this presentation. Yesterday, as some of you will recall, Irv opened the symposium with a power point slide depicting an elaborate logic model linking the action areas of the Ottawa Charter to a related set of health promotion strategies, goals, activities, objectives and indicators. The initial comment from the audience was 'Can you improve the focus?' That request for audio-visual clarity is a nice summation of a key challenge facing health promotion: in order to increase the adoption of health promotion policies by decision makers, we need to 'improve the focus' of our key messages to this audience.

My presentation touches on two key areas. First, I want to review some of the key factors affecting the capacity of the health promotion field to influence decision makers. Second, I want to share some ideas for persuading decision makers. These ideas are based on my familiarity with the field of health communication, persuasion and advocacy, as well as my 'lived experience' as someone who has advocated for the adoption of health promotion policies.

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II Factors Affecting the Capacity of Health Promotion to Influence Decision Makers

i Position of Health Promotion Within the Health Sector

One of the key factors affecting the ability of health promoters to influence decision makers is the position of health promotion within the health sector. Health promotion evolved as an 'offshoot' of public health, which, in turn, occupied a small yet significant niche within the broader health care sector.

While health promotion's place within a well established health sector has provided it with infrastructure, credibility and resources it would not otherwise have, it has also served as a restraining influence. It is interesting to contrast the evolution of the health promotion 'movement' with the evolution of the environmental movement. It can be argued that

the environmental movement was better positioned to affect policy, as environmental activists were operating in the absence of formal, established organizational structures. For example, the federal and provincial ministries of environment, as we know them today, did not exist during the 1970s when public concern about air, water and social

quality prompted calls for legislative change. This 'organizational vacuum' provided environmental activists with an opportunity to shape an organizational infrastructure amenable to their policy agenda. To appreciate the magnitude of that opportunity, imagine where health promotion would be today if we had the opportunity to design our health care system from the bottom up!

A second implication of health promotion's place in the health sector is its limited ability to act on, and influence, issues outside the purview of the health care sector. And, as everyone with more than a nodding acquaintance with the determinants of health is aware, many of these issues -- income, housing, transportation, education, social support,

and parks and recreation, to name but a few -- have a greater impact on health than the issues that the formal health sector is mandated to address.

ii Breadth of Health Promotion: A 'beautiful curse'

During his tenure as President of France, Charles DeGualle was once said to have remarked 'How can anyone govern a nation that makes 3,000 different kinds of cheese?' As someone who has tried to convince decision makers of the inherent value of health promotion, I can appreciate the frustrations prompting his outburst.

Health promotion, as we know it today, is a broad and diverse field, encompassing a range of disciplines, strategies and priority issues. This breadth creates opportunities in the form of access to a broad range of partnerships, resources and collaborations. At its best, health promotion can serve as a rallying point through which the broader determinants of health can be addressed.

Conversely, the breadth and diversity of health promotion makes it difficult to articulate clear, concise messages for decision-makers. Specifically, promoting the value of a field that has such a diverse range of opinions regarding standards of evidence, appropriate strategies for practice, or even what constitutes health promotion in the first place, can be a daunting task at the best of times.

And because health promotion is not always clear about its core concepts it is potentially open to co-option by decision makers. In particular, neo-conservative governments have often adopted health promoting rhetoric, such as 'greater community control' or 'decentralized decision- making' as a smokescreen for spending cuts.

iii 'Bureaucrats in Advocates' Clothing'

As I noted earlier, a unique feature of health promotion is that it is the only discipline I know of that emerged from the public sector rather than from academia. Health promotion in Canada owes much to the foresight and dedication of federal civil servants, such as Ron Draper, Lavada Pinder and our own Irv Rootman, as well as public servants based

at municipal health units, such as Peter Cole, Trevor Hancock, Fran Perkins and Ron Labonte, who saw the limitations of the health care, or, as Trevor puts it, 'sickness care', system for taking action on the factors that really have an impact on the health of individuals and communities.

While the presence of health promotion 'champions' within the bureaucracy has resulted in access to resources that health promotion would not otherwise have enjoyed, the extensive public financing of health promotion initiatives has fostered a certain level of trepidation about 'biting the decision-maker that feeds you.' The seeming disconnect

between the vision of social justice, community empowerment and healthy public policy espoused by health promotion advocates and the narrow parameters of state-supported health promotion practice does lend some credence to Stevenson and Burke's* harsh dismissal of health promotion as "not a social movement, but a bureaucratic tendency; not a movement against the state but one within it."

iv Lack of a Citizen Constituency Mobilized for Health Promotion

Another impediment to the ability of health promoters to influence decision makers is the lack of broad public support for health promotion. No one, to the best of my knowledge, has ever trampled the lawns of Queen's Park or Parliament Hill demanding 'more health promotion!' although many groups lobby for action on the issues that health promotion professes to address.

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III Suggestions for Influence

Here are some practical steps that can be taken to enhance the ability of health promoters to influence decision makers.

1. Emphasize the health issue, not the health promotion solution

In his influential article, "Accentuating the Negative", Peter Cole argues that health promotion would have a greater degree of support if it was framed as an anecdote to specific diseases and health risks instead of an amalgam of concepts (e.g., empowerment, environmental supports, healthy public policy) that are difficult to explain to a

professional audience let alone the general public. While I do not agree that an entirely negative focus is appropriate, we do need to do a better job of emphasizing the ways in which health promotion can address the issues of concern to individuals and communities, such as housing, safety, violence, poverty, and employment.

2. Conduct more research into how health-related issues and health promotion strategies are viewed by decision-makers and effective communication strategies to sway decision-makers

Understanding your audience is a critical prerequisite for any health communication campaign. All too often, health promoters operate under the assumption that the evidence 'speaks for itself,' while disregarding the beliefs, attitudes, social norms and contexts that shape the way in which the evidence is viewed by decision makers.

3. Be careful about the use of cost-effectiveness arguments to 'sell' the value of health promotion

Health promotion has long presented itself as the 'magic ingredient' needed to reduce hospital expenditures and health care costs. But is it true? Does health promotion 'prevent' health care expenditures or merely delay these expenditures? Will taking action on the determinants of health cost more money or less? What is the 'cost-benefit' associated with a longer life and a greater quality of life? What are the costs? Until we are in a better position to articulate thoughtful responses to these and other tricky questions, I would tread warily around the 'dollars and cents' argument as the primary selling point for health promotion.

4. Use concrete examples of how health promotion has made real differences in the lives of real people

Nothing sways decision makers more than a compelling story about how a health promotion initiative has helped an individual. Collated statistics are a poor substitute for a human face.

5. Explore the possibilities of creating organizations better placed to advocate for health promotion

To increase the scope of our influence, we need an organization devoted exclusively to the 'promotion' of health promotion. This will go a long way towards fostering the identity and level of recognition needed to effectively advocate for health promoting policies.

In closing, the field of health promotion needs to embrace these and other innovations to do a better job of 'speaking truth to power.' I am well aware that innovation, more often than not, is accompanied by failure and repercussions. But, as Joseph Conrad once noted, "if you don't make mistakes, you don't make anything." I am hopeful that you will join me in embracing innovation, learning from our collective mistakes, and, who knows, maybe celebrating a success or two along the way.

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IV References

* Stevenson, M.H. and Burke, M. (1991) "Bureaucratic logic in new social movement clothing: the limits of health promotion research." Health Promotion International 4 (2), 282.

** Cole, P. (1997) "Accentuating the negative: repackaging the public health image." Health Promotion in Canada 34 (3), 29-30.

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