Promo Flashcards
According to Ottawa charter, health is
health is a resource for social, economic and individual progress
1986
Prerequisites for Health
- peace, shelter
- education
- food
- income
- justice
- equity
Ottawa charter, 1986
Axis of interventions
Ottawa charter
- Build healthy public policy
- Create supportive environments
- Strengthen community action
- Develop personal skills
- Reorient health services
Ottawa charter, 1986
Bangkok Chater
Globalization – policy must be coherent across all levels, integrated policy approach (link in HiAP) development, government, community, society, private sector (intersectoral action)
2005
Obstacles to prevention
- Success Is Invisible
- Lack of Drama
- Long Delay Before Rewards Appear
- Persistent Behavior Change May Be Required
- Acceptance of Avoidable Harm as Normal
- Commercial Conflicts of Interest
- Conflicts With Personal, Religious, and Cultural Beliefs
- Complexity of intervention : how to measure success when the delays are so long, success is invisible
- Politics, policies and time
Fineberg, 2013
What is critical race theory
- Framing racism as a determinant of health that is a modifiable and NOT as a biological entity.
- Studies how racism is embedded in society and institutions using an historical perspective
AMA Center for Health equity, 2022; Krieger N
Adelaide statement
“Health is a political choice”
HiAP
2010
What is health promotion
- Interdisciplinary field of action
- Sensitive to participation, complexity and context
- 2 features: positive definition of health and orientation towards action
- 3th revolution: health is as social phenomenon as well as a biological and psychological one.
- that aspect of public health practice that is particularly concerned with the equity of social arrangements
- It imagines that social arrangements can be altered to make things better for everyone and seeks to achieve this in collaboration with citizens
- Health promotion = Health Education x Healthy Public Policy
*
McQueen, 2007; Carter, 2012
Public health revolutions
- ID
- chronic
- health as social
Objectives of promo
- ↑ health as ressource
- ↓ health and social inequities
- Empower individuals to take control
McQueen, 2007
How to balance agency and structure
in promo
- From dualism to duality
- Health is not only social, but that it is the product of a complex system between structure (social) and agency (individual)
- Easier to conceptualize the integrated, multi-level, multi-strategy approach.
- Agonism: epistemological tension between structure and agency cold be channel into productive opportunities.
- This will prevent over-socialize and over-psychologized health.
- We don’t have to choose between social and psychology, between group and individual, just recognize that they both play a role*.
Carroll
2017
Purpose of promo research
- Epistemic purpose
- Transformative purpose
Values of promo
- Empowerment
- Participation
- Social justice (good society is a just society)
- Equity
- Health as a right
- Intersectorial action
- Holism
- Contextualism
How are interventions understood in promo
Health program: defined as a set of planned and organized activities carried out over time to accomplish specific health-related goals and objectives
Critical realism
* Cannot be reduced to a hierarchical sequence of procedures; rather, they function as systems of action designed to transform social reality.
* Interventions as routines, relationships, resources, power structures, symbols, forms of talk, “powerful ideas,” and sets of values (instead of programs, technology, product
Potvin, Hawe
How is evidence understood in promo
What is the epistemology of promo
- We need to have a broad vision of evidence that embraces the inherent complexity of health promotion
- Epistemologies of the south: the world is much broader than the Western understanding of the world.
- Co-learning between academic and popular knowledge
- starting point is the recognition of mutual ignorance, and its endpoint is the shared production of knowledge
- “All knowledge is incomplete”
- Promo is open to many paradigms
- Decision making – based on client population characteristics, practitioner expertise, best evidence – all within environment and organizational context (Evidence alone is not enough)
De soussa Santos, 2016; McQueen, 2001; Satterfield JM et al.
Strategies used in promo
- Enabling
- Advocacy
- Mediation (with other sectors)
Ottawa chartter, 1986
Paradigms in promo research
- Critical realism: assessment of the relationship between context and program/intervention, and the mechanism of this relationship (i.e., agency vs structure, power relations, emplacement/time/space)
- Complexity paradigm: non-reductive, reflexive, relative conception of health and its problemization. Human health is complex
- Transformative paradigm: - Dissemination of findings in ways that encourage use of the results to enhance social justice and human rights
What are social policies?
From a promo perspective
Policies and political choices are the causes of the causes of the causes: Policies shape opportunities for a healthy life and the importance of social determinants (eg, education, race) of health.
Distal causes
Montez, 2020
How do social policies work?
Politics –> labour market + welfare state (e.g., PH coverage and expenditure)–> economic equity –> health equity
Social policies are a buffer against labour market’s health consequences
Navarro, 2006; Shahidi, 2016
What evidence do we have about the impact of social policies?
Increased social spending is favourably associated with:
* life expectancy
* infant mortality
* potential years of life lost
* obesity prevalence
* acute myocardial infarction
* mental health
* days off work.
Most beneficiaries: those with the lowest incomes
Dutton, 2018; Navarro, 2006
Theoretical bases of the relationship between income inequality and health
Economic inequality –> health
* Absolute individual income increase has a non-linear relationship with health gains
* Relative income: Perceptions of one’s income compared to others leads to stress
* Society hypothesis: The relationship is mediated by violence crime, public spending, and social capital/trust
Health –> economy inequality
* Labor market: Poor health leads to unemployment and it impacts economy
* Education: Poor health leads to poor education outcomes and thus lower social position and thus social disparities
No relationship
Leigh, 2011
The relationship between welfare, economy, and health is not only complex but also contextualized. These factors are mutually related, and a unidirectional relationship seems unlikely. The balance between them is perhaps what matter the most and that balance is in fact highly contextualized.
Target trial steps
- Protocol
- Emulate that procol + adjustment of confounders at time 0 (emulates randomization)
Hernan
C-word vs T-word
Hernan, 2021
* Be more explicit about causation
* Ask the right questions
* We infer causaltion by using the right methods (=/= from methos of association)
Jones, 2018
* The use of theory to disentangle causal mechanisms
Limitations of causal inference
- No blinding
- No randomization
- No possible with new treatments
What is implementation science?
Methods to promote uptake of research findings into routine practice including community settings
Why is evidence often not implemented?
“Lack of evidence is often not the main barrier to change/action, more oftern is lack of political will”
Equity in all policies to change political will
Brownson, 2021
What is the goal of implementation science?
Some will say to narrow the research-practice gap (including community settings).
Brownson will way that the goal is Equity!
Equity in all policies –> to change political will
What do health differences often reflect?
Health differences often reflect social injustice
“Equity begins with justice”
Brownson, 2021
What is a moderator?
Changes/alters the effect that a variable has on another (ex., gendre, age)
Answer to the questios “for where” and “for whom”
What is a mediator?
Explains the relationship
Answers the question “why”
The path between intervention and outcome
Lewis
Prepost with Non-equivalent Control Group
Interrupted time series
Stepped-wedge design
What is sutainable development/suitainanility?
Cultural and ecological systems maintain their full functionality—not only for the benefit of present generations, but also for future generations; not only for the benefit of the human component but for the benefit of all species.
Rapport, 2007
Neoliberal vision of promo
Individuals at the centre of promo (instead of social systems)
* Minimal government intervention
* Individualistic and individual responsibility
* Instead of determinants, free people choosing goods/services
* Inequality is inevitable
Ayo, 2012
Sustainable promo
From neoliberal vision (Ayo, 2012) –> Sustainable promo (Spenser, 2019)/Indigenous promo (Ratima, 2019)
* Address structural causes (power, colonialism)
* Health as a right
* Empowerment
* Partnerships
* Human as interconnected with other species and evironment
Sustainable health promotion incorporates rights, partnerships and empowerment (salutogenic) (Spencer G et al. 2018)
Sustainability + promo is a duality (Jelsoe)
Ecosystem distress syndrome
- reduced productivity
- leaching of soil nutrients
- loss of endemic species
- increased presence of contaminants
Rapport
Environmental racism
Racism as a driver from environmental issues
Racism embedded in society as a determinant of health
Low SES, poverty, gender, race particularly affected by climate change
Northridge, 1997
How does it relate to (negative) health outcomes
Adverse negative experiences/toxic stress
Life-course approach
Adverse negative experiences –> social, emotional, learning challenges –> risky behaviours –> health and social problems –> early death
Pickett
Lifecourse approach
Biology of adversity
- Toxic stress = adverse neg. exp. + absence of support/buffer
- Cummulative exposure to toxic stress –> risky behaviours –> ↓ health –> early death
- Biological embedding
- Inner child
- Adversity has intergenerational effects
Shonkoff; Kinner; Sjöblom
What is biological embedding?
Early experiences can influence key biological systems over the long term, producing gradients. Examples of such systems:
* the hypothalamic-pituitary-adrenal (HPA) axis and its accompanying secretion of cortisol
* the autonomic nervous system (ANS) in association with epinephrine and norepinephrine
* the development of memory, attention, and other executive functions in the prefrontal cortex
* the systems of social affiliation involving the primitive amygdala and locus coeruleus, mediated by serotonin and other hormones
Hertzman, 2010
Normative vs toxic stress
- Toxic stress = adverse neg. exp. + absence of support/buffer
- Normative stress = adverse neg. exp + support/buffer/coping
U-shape graph: Reactivity vs exposure to toxic stress, normative stress and no stress
It’s not about eliminating stress but promoting nurturing care (Lancet)
Shonkoff; Hertzman
What is nurturing care?
a stable environment that promotes children’s health and nutrition, protects children from threats, and gives them opportunities for early learning, through affectionate interactions and relationships
The Lancet, 2016
Nurturing care could be targeted to the family but also at a more strctural level (e.g. child-friendly cities: play, active transport, safe spaces, greenspace)
Inner child
Instead of dividing people by age group, the concept of the inner child to explain that human beings’ life journey includes all the past life experiences impacting human beings lives.
* Each developmental age is not left behind but rather forms a small part of all that we are.
* taking care of your inner child at a micro- (yourself as a person), meso- (in the family and near surrounding) and macrolevel (in the society) may promote health through the life-course.
Sjöblom
Stigma definition
“co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised” Link and Phelan (2001)
“societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized” (Hatzenbuehler & Link, 2014)
Stigma as a SDoH
Fields of health according to Lalonde (1974)
- biology
- lifestyle habits (origins of lifecourse)
- environment
- health care system
Strategies to overcome challenges of promo/preventive strategies
Tiple-A solution:
* Advocacy (with evidence)
* Analyze (anticipate budget cuts, maintain core functions of surveillance and protection of health)
* Alignment (align with other priorities, esp. economic)
Fineberg, 2013
Promo 4.0
4th industrial revolution
AI and virtual space as a health determinant
Kickbusch I, 2019
HiAP is important gatekeeper to responsible use and development of AI – eg. Access to health data, inclusion of users
Risks of AI for promo
misinformation
unintended consequences
widening inequities
Kickbusch I, 2019
Montreal declaration of Responsible Development of AI (2018)
- Well-being principle (must help individuals improve their living conditions)
- Respect for autonomy (empowerment of citizens and foster literacy and critical thinking)
- Protection of privacy and intimacy
- Solidarity principle (among people and generations)
- Equity (just and equitable society)
- Democratic participation (democratic scrutiny)
- Diversity inclusion (maintaining diversity)
- Sustainable development
- Prudence (anticipating the adverse consequences)
- Responsibility (must not contribute to lessening the responsibility of human beings)
Industrial revolutions
Kickbusch I, 2019
Levels of participation
Types of participation
- none
- token
- authentic
MacDonald M & Mullett, 2009
Challenges of participatory approaches
- ownership and control
- time orientations
- funding priorities
- competition for community resources
Potvin L & Mullet J, 2008 ;MacDonald M & Mullett, 2009
How’s evaluation understood from a critical realist perspective?
Critical realism – looks at the mechanism and process for what works and what doesn’t (methods are mixed, case studies to look at causal explanation and underlying structure) – points to the importance of theory underlying methods
Not about whether it is right or wrong, but if it is useful, is it enough to create change – to fit with the transformative Health promotion vision of research
Poland B et al. 2008
Implementation outcomes
- acceptability
- adoption
- appropriateness
- cost
- feasibility
- fidelity
- penetration
- sustainability
Threats to internal validity
Confounding
Selection bias – groups not comparable
Information bias
* measurement reliability and validity
* Instrumentation – types of tools, keeping them consistent
* Social interaction or desirability – eg. Hawthorne (being studied) Pygmalion (researcher influence)
* Recall bias
* Regression to the mean – people response tend to the mean
* Time or Maturation – outcomes vary with time
Attrition bias – drop out
Threats to external validity
People
Places
Time
How to prevent threats to internal validity
Comparable control group
Large sample size,
Tools with masked purpose -
Randomization
Masking – for participants, for researchers, for analysis
Matching
What is a confounder?
related to exposure and outcome, but not part of causal mechanism, eg.smoking as a confounder between alcohol and lung cancer
Hill’s criteria
(Rothman KJ et al. 2008
Complexity theory
Non-reductive and reflexive, relative conception of health
Contextualism, (McQueen D et al. 2007)
* Bottom-up interventions
* Holism, Systems – where the sum is greater than its parts
* Epistemology – reflexivity, acceptance of ambiguity
* Challenge of Causal generalizations – which implies reduction
* Evaluation - look at process in context, developmental evaluation (critical realism)
* Medical vs social public Health (causation is less relevant and the focus is on patterns of change and complexity is expected)
Hawe, 2015; Tremblay MC & Richard L, 2014;
McQueen D et al. 2007;
Bases of social determinants of health as a theory
Health outcomes/disparities are not random, but are influenced by underlying social factors
* Social epidemiology studies how disparities are distributed in communities.
* The idea is to identify strategies to improve population health.
Examples of social determinants of health
- income – impacts education – influences job
- discrimination and stigma
- Working conditions – physical hazards, psychosocial stressors, shift work and long working hours
- Toxic environment
- Behaviours
- Psychosocial stress
- Embedding, lifecourse perspective
However, having a systemic vision implies more than just social determinants. Consider also:
* Political determinats (Mackenbach JP, 2014) - windows of opportunity
* Commercial determinants (Kickbusch I, 2014)
Reverse causality – poor health predicts poor SES
Social policy: improve social conditions (housing, education, employment, interdisciplinary approach) rather than individual problems
Examples of social ressources
- social networks: the ties that people have with each other
- social capital: the confidence that gives communities a common purpose
- social hierarchies: which influence people’s ability to relate to others
- social narratives: shared meanings that play into the construction of a collective identity, cultural repertoires
Berkman LF et al. 2014; Lamont and Hall, 2009
Criteria of rigour/trustworthiness in qualitative research
Instead of quantitative terms of internal and external validity
* Credibility: The “truth” of the findings, as viewed through the eyes of those being observed or interviewed and within the context in which the research is carried out
* Transferability: The extent to which findings can be transferred to other settings (similar contexts)
* Dependability: The extent to which the research would produce similar or consistent results if carried out as described
* Confirmability: Researchers need to provide evidence that corroborates the “findings”
Instead of quantitative terms of internal and external validity
Lincoln & Guba, 1985
How to conceptualize public policy as a promo intervention
- the causes of the causes of the causes: Policies shape opportunities for a healthy life and the importance of social determinants (Bambra et al., 2019)
- Public policy – a major determinant of health (Clavier D et al. 2013)
- Public health practitioners have little experience with the policy process, it is not just a document or a law (it’s institutions, organizations, actors, ideas)
- Multiple streams theory (Kingdon, 1984) -windows of opportunity, need for policy entrepreneurs
- Objective: Make the healthy choice the easy one (Puska P, 2014)
- Helsinki statement (WHO, 2014)– whole of government approach
Examples: major reduction in mortality and morbidity in 19th century England was 2e to improved living conditions, rather than biomedical treatments (McKeown); HiAP in South Australia
What is the importance of public policy as promo interventions?
In terms of social ressources
Policy/institutions/organizations is social resource creation, they have the power to influence people’s capacities and social mobilization, to have a buffer for stressful events for “wear and tear of everydaylife” .
Hall P and Lamont M, 2009
Health is produced outside the healthcare system
but budgets do not reflect this, with many spending just 2-3.5% on prevention and public health, Canada spending around 6%
(Clavier D and de Leeuw E, 2013)
Examples of social policies and their impact on health
- major reduction in mortality and morbidity in 19th century England was 2e to improved living conditions, rather than biomedical treatments (McKeown)
- Social spending more positively associated with population health measures than health spending in terms of life expectancy, infant mortality, obesity, heart disease, mental health (Dutton, 2018)
Mechanism of social policies and their impact on health
- provides a buffer against adverse health (Shahidi et al. 2006)
- redistributive, provides a buffer against risks of loss of income- Jacques & Alain, 2021
Errors in promo interventions
Forgetting values of Health Promotion
* Context
* Complexity
* History
* Power relations
* Equity
What problems do public health and promo generally deal with
Wicked promles!
* We address wicked problems upstream – develop policies that foster an environment which addresses problems at the root before they start
* Wicked problems do not lend themselves to technical solutions; they require political attention from governments
* The need of media advocacy – blends communications, science, politics - To move policy entrepreneurs
Dorfman L and Krasnow I, 2014
“Lack of evidence is often not the main barrier to change/action, more oftern is lack of political will” (Brownson, 2021)
Urban health
50% of the world lives in cities, this will rise to 60% by 2030
Intervene within neighborhoods and postal code
Complexity thinking: 3 components
* Local experimentation – sensitive to circumstance and resources – city government with a range of stakeholders (eg. Urban planning, community representation)
* Assessment – based on dialogue, deliberation and discussion, understand policy overlaps
* Forums – for consultation and debate of ethical dimensions of different approaches with a full range of community representatives
Rydin, 2012
Components of a logic model for health program planning
- Objective(s): desired change in health outcome
- Input: Ressources needed (staff, funding, time, equipment)
- Activities: Actions of the program
- Target poopulation
- Output: Indicators of program implementation/realization
- Results: indicators of program effects
- Other: context, hypotheses, extenal fx
Ladder of interventions
Nuffield Council on Bioethics
Helath belief model
Behaviour change
Limitation: Works better for actions that hapen at one point in time (e.g., vaccination)
Reasoned action approach
Behaviour change
Social cognitive theory
Behaviour change
Bandura
Transtheoretical model
Behaviour change
COM-B model
Behaviour change
Behaviour change wheel
Michie et al. 2011
Types of stigma
- Lived
- Interiorization
- Anticipated
- Secondary lived by family
