ACHIEVING HEALTH FOR ALL: A FRAMEWORK FOR HEALTH PROMOTION

Item

Title
ACHIEVING HEALTH
FOR ALL:
A FRAMEWORK
FOR HEALTH PROMOTION
extracted text
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Health and Welfare
Canada
\

Santd et Bien-etre social
Canada

ACHIEVING HEALTH
FOR ALL:
A FRAMEWORK
FOR HEALTH PROMOTION

The Honourable Jake Epp
Minister of National Health and Welfare

Canada

ACHIEVING HEALTH
FOR ALL:
A FRAMEWORK
FOR HEALTH PROMOTION

The Honourable Jake Epp
Minister of National Health and Welfare

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CONTENTS
I

Introduction

2

II A New Vision of Health

III National Health Challenges

IV Health Promotion as a Response

V Hie Health Promotion Framework

VI Conclusion

12

PREFACE

I took office with a commitment to further improve the
quality of life for Canadians. On June 17,1986, at the 77th
Annual Conference of the Canadian Public Health
Association, I affirmed that commitment by announcing my
intention to explore ideas for the future which would
address the emerging challenges in health. It was my belief
that in order to continue to improve the health of Canadians
we would have to move forward with new policies and
solutions.
This document represents the ideas that have come
forward as a result of our search for a realistic course of
action. “Achieving Health for All: A Framework for Health
Promotion” reflects the direction I am proposing in our
endeavour to attain equity' in health.
It is with pleasure that 1 have chosen the occasion of the
International Conference on Health Promotion to share this
thinking. I trust that the concepts, challenges and strategies
elaborated in the framework will serve to inspire reflection,
discussion and action with respect to the health and quality
of life of Canadians.
1 invite and welcome your comments.

Jake Epp
Minister of National Health and Welfare
Ottawa, Canada
November 1986

I INTRODUCTION

Canada has built a strong health care
system, and has achieved for its
people a level of health of which we
are all proud. We want to continue in
this tradition. While it is true that the
prospects for health of the average
Canadian have improved over recent
decades, there nevertheless remain
three major challenges which are not
being adequately addressed by
current health policies and practices:
• disadvantaged groups have
significantly lower life expectancy,
poorer health and a higher prevalence
of disability' than the average
Canadian:
• various forms of preventable
diseases and injuries continue to
undermine the health and quality of
life of many Canadians;
• many thousands of Canadians suffer
from chronic disease, disability, or
various forms of emotional stress, and
lack adequate community support to
help them cope and live meaningful,
productive and dignified lives.
The times in which we live are
characterized by rapid and irreversible
social change. Shifting family'
structures, an aging population and
wider participation by women in the
paid work force are all exacerbating
certain health problems and creating
pressure for new kinds of social
support. They are forcing us also to
seek new approaches for dealing
effectively with the health concerns of
the future.
This paper proposes an approach
that is intended to help Canadians
meet emerging health challenges. We
are calling this approach “health
promotion". It is an integration of
ideas from several arenas - public
health, health education and public
policy' - and it represents an
expansion of the traditional use of the
term “health promotion”. We regard
health promotion as an approach that
complements and strengthens the
existing system of health care.

II A NEW VISION OF HEALTH

In the past, when infectious disease
was the predominant cause of illness
and death, health was defined in terms
of the absence of disease. By the mid
1900s, however, we had reduced the
incidence of many of these infections,
and health had come to mean more
than simply not being ill. It was now
defined as a state of complete
physical, mental and social well-being.
In 1974. a federal publication entitled
A New Perspective on the Health of
Canadians put forward the view that
people's health was influenced by a
broad range of factors: human biology,
lifestyle, the organization of health
care, and the social and physical
environments in which people live.
This representation of the factors
contributing to health legitimized the
idea of developing health policies and
practices within a broader context.
Today, we are working with a
concept which portrays health as a
part of everyday living, an essential
dimension of the quality of our lives.
"Quality of life” in this context implies
the opportunity to make choices and
to gain satisfaction from living. Health
is thus envisaged as a resource which
gives people the ability to manage and
even to change their surroundings.
This view of health recognizes
freedom of choice and emphasizes the
role of individuals and communities in
defining what health means to them.
Viewed from this perspective.
health ceases to be measurable strictly
in terms of illness and death. It
becomes a state which individuals and
communities alike strive to achieve,
maintain or regain, and not something
that comes about merely as a result of
treating and curing illnesses and
injuries. It is a basic and dynamic force
in our daily lives, influenced by our
circumstances, our beliefs, our
culture and our social, economic and
physical environments.
This new vision of health does not
represent a sudden or dramatic shift
in our thinking. It is a view which
revisits and embraces earlier ideas.
and seeks to make them relevant to
contemporary problems.

Ill NATIONAL HEALTH

CHALLENGES

As we broaden and deepen our
understanding of health, we begin to
perceive with greater clarity the
importance and magnitude of the
challenges now looming in the field of
health. Wc also draw the conclusion
that our system of health care as it
presently exists does not deal
adequately with the major health
concerns of our time.
The challenges we face today are
not new. They have been identified
separately on various occasions in the
past. However, looking at these
challenges together enables us to
discern certain trends. These trends
suggest that we move toward the
approach we call health promotion.
Before exploring the practical
meaning of health promotion, let us
examine in more detail the nature of
the health challenges facing
Canadians. For the purposes of this
document, we shall confine our
attention to those challenges deemed
to be of national importance. It is
anticipated, however, that some
communities may find these generic
national challenges overridden by
problems of a uniquely regional or
local character

Challenge I:

Among low-income groups,
people are more likely to die as a
result of accidental falls, chronic
respiratory disease, pneumonia,
tuberculosis and cirrhosis of the liver.
Also, certain conditions arc moreprevalent among Canadians in lowincome groups; they include mental
health disorders, high blood pressure
and disorders of the joints and limbs.
Within the low-income bracket,
certain groups have a higher chance
of experiencing poor health than
others. Older people, the unem­
ployed, welfare recipients, single
women supporting children and
minorities such as natives and
immigrants all fall into this category.
More than one million children in
Canada are poor. Poverty affects over
half of single-parent families, the
overwhelming majority' of them
headed by women. These are the
groups for whom “longer life but
worsening health” is a stark reality.
So far, we have not done enough
to deal with these disparities. As we
search for health policies which can
take this country confidently into the
future, it is obvious that the reduction
of health inequities between highl­
and low-income groups is one of our
leading challenges.

Reducing Inequities
'rhe first challenge we face is to find
ways of reducing inequities in the
health of low- versus high-income
groups in Canada.
There is disturbing evidence
which shows that despite Canada's
superior health services system.
people’s health remains directly
related to their economic status. For
example, it has been reported that
men in the upper income group livesix years longer than men with a low
income. The difference is a few years
less for women. With respect to
disabilities, the evidence is even morestartling. Men in upper income groups
can expect 14 more disability-free
years than men with a low income; in
the case of women, the difference is
eight years.

^Challenge II:
^increasing the
Prevention Effort
Our second challenge is to find new
and more effective ways of preventing
the occurrence of injuries, illnesses,
chronic conditions and their resulting
disabilities.
Prevention involves identifying
the factors which cause a condition
and then reducing or eliminating
them. Immunization and the chlorina­
tion of drinking water are prime­
examples of measures introduced to
prevent and reduce the incidence of
infectious disease. In the last century',
through the efforts of public health,
the practice of prevention gained
wide acceptance. In fact, many
prevention measures we take for

granted today were initiated during
the 19th century.
In recent years, the preventive
effort has been extended into the area
of individual lifestyle and behaviour.
The realization that smoking, alcohol
consumption and high-fat diets were
contributing variously to lung cancer,
cirrhosis of the liver, cardiovascular
disease and motor vehicle accidents,
led us to turn our attention to
reducing risk behaviour and trying to
change people’s lifestyles.
Unfortunately, the causal relation­
ships between behaviour and health
are not nearly as clear-cut as they arc
between “germs” and disease. Today’s
illnesses and injuries and the disabili­
ties to which they give rise are the
result of numerous interacting factors.
This means that prevention is a far
more complex undertaking than we
may at one time have imagined.
In spite of this, there is consider
able scope for prevention. Already,
children have been among the main
beneficiaries. In prenatal and neo natal
care, preventive measures have
brought about a marked reduction in
infant mortality. Notable progress has
also been achieved in preventing
learning disabilities, and preventive
measures are helping, for example, to
overcome the difficulties associated
with dyslexia, hyperactivity and
speech and hearing impairments.
With regard to adults, it is estimated
that the use of preventive measures
can lead to a future 50 per cent
reduction in the incidence of lung
cancer and heart disease.

Challenge HI:
-^Enhancing People’s
Capacity to Cope
In this century, chronic conditions
and mental health problems have
replaced communicable diseases as
the predominant health problems
among Canadians in all age groups.
Our third challenge is to enhance
people’s ability to manage and cope
with chronic conditions, disabilities
and mental health problems.

Conditions such as arthritis,
hypertension, respiratory ailments,
dependence on drugs and chronic
depression can all limit people's
capacity to work, to take care of
themselves, to perform the activities
of daily living and to enjoy life.
Canada is experiencing an “age
boom”, and the number of older
people in this country will more than
double within the next thirty-five
years. Thus, for Canada’s older
population, coping with chronic
conditions and the disabilities to
which they give rise, is a particular
concern. It is often hard for those
seniors who are incapacitated by
disabilities to function independently.
Everyday tasks, such as taking a
shower or opening a jar, become
difficult or even unmanageable.
It is particularly important to
ensure that people are supported in
the area of mental health. Obviously,
we cannot afford to diminish our
efforts to assist those who are
suffering from serious mental illness;
however, it is essential that we assign
equal priority to helping people
remain mentally healthy.
Surveys indicate that many
Canadians find their lives stressful.
Women are more vulnerable in this
regard. The fact that women are
prescribed tranquillizers and anti­
depressants more than twice as often
as men is a telling sign of the
emotional strain women are
experiencing. For some, it may be the
changing and uncertain nature of
their role that is unduly stressful
Others may be overwhelmed by the
burden of caring for family members.
particularly those who are chronically
ill or disabled. For both men and
women, job burnout is taking an
increasing toll. The changing nature
of social roles and factors such as
unemployment have also had a
bearing on the emotional well-being
of men, who may encounter health
problems including ulcers, depend­
ence on alcohol and depression.
We know that anxiety, tension.
sadness, loneliness, insomnia and

fatigue are often symptoms of mental
stress which find expression in many
forms, including child abuse, family
violence, drug and alcohol misuse and
suicide. Problems associated with
mental stress may occur in times of
crisis, or be the result of accumulated
life circumstances.
Our challenge is to provide the
skills and the community support
needed by people with disabilities and
mental health problems if they are to
manage effectively, lead stable lives
and improve the quality of their lives.
We must also recognize the
importance of ensuring that informal
care-givers have access to the support
they need. Many people, especially
women, care for others on a regular
basis. The health and capacity of these
individuals to manage is no less
important than the health of those for
whom they care. Homemakers, home
care nursing, respite care and postal
alert are services which enhance the
coping capacity of both those with
disabilities and their care givers.
Reducing inequities, widening
the prevention effort and enhancing
people's ability to cope are the
principal challenges confronting us as
Canada enters the 21st century. It is
toward these challenges that we must
dedicate our efforts and resources.

IV HEALTH
PHOMOTION AS A

RESPONSE

So far. we have described a global,
positive vision of health and outlined
three health challenges of major
national importance. Our ultimate
responsibility is to ensure that the
health of Canadians is preserved and
enhanced, a goal which can only be
achieved if each of us can be assured
of equitable access to health It is
clear, however, that existing policies
and practices are not sufficiently
effective to ensure that Canadian men
and women of all ages and back­

grounds can have an equitable chance
of achieving health.
In our quest for solutions to this
problem, we asked ourselves two
questions: “What mechanisms arc
needed to effectively respond to the
emerging challenges?’’ and “What
strategies or processes can we
implement in order to meet these
challenges?"
We conclude that these questions
can best be answered by a wider
application of health promotion. A
health promotion approach would.
with the necessary effort and
resources, integrate easily into the
present health system. We believe that
just as health care is acknowledged as
a cornerstone of the Canadian health
system, health promotion is positioned
to become another, equally important
cornerstone of that system.
People often associate health
promotion with posters and pamph­
lets Ulis is a simplistic view akin to
associating medical care with white
coats and stethoscopes. In the words
of the World Health Organization.

“health promotion is the process
of enabling people to increase
control over, and to improve, their
health”. It "represents a mediating
strategy between people and their
environments, synthesizing personal
choice and social responsibility in
health to create a healthier future”.
It is quite true that, until recently,
health promotion has relied heavily
upon the dissemination of health
information, targeting health messages
to the public in the expectation that
this would somehow bring about the
desired changes in people’s lifestyles.
Although this approach did produce
some shifts in attitudes and health
behaviour, these have been slight and
slow. It became increasingly evident
that to be effective, information
campaigns should not take place in
isolation; they had to be combined
with a variety of other activities.
Health promotion became a multi­
faceted exercise which included
education, training, research.

legislation, policy coordination and
community development. This
perspective gained fairly wide accep­
tance with many professionals and the
voluntary community. By the mid
1970s. health promotion activities
were becoming more visible in
schools, community health services,
drug and alcohol commissions and in
the workplace.
Less than a decade later, several
programs of national scope were in
operation. Covering a variety of
themes, these major initiatives were
the result of cooperative efforts
among several levels of government
and the voluntary sector. They
included Dialogue on Drinking; the
Breast-Feeding Program; It’sJust
Your Nerves, a program on women’s
use of alcohol and tranquillizers;
Time to Quit, a smoking-cessation
program; Stay Real, a drug
information program; and Break
Free, a recent collaborative initiative
aimed at reducing smoking among
young people.
Communities and voluntary
groups committed to undertaking
health promotion activities at the
local level were able to tap into
financial resources, including federal
funding through New Horizons,
sustaining grants for voluntary
associations, and the Health
Promotion Contribution Program.
Across Canada, organizations and
groups as diverse as the Canadian
Institute of Child Health, the Disabled
Individuals' Alliance, Le Centre des
Femmes de I'Estrie, the Alzheimer
Society of Canada and many more
contributed significantly to this
country’s growing record of
achievement in health promotion.
The experience of the past ten
years has confirmed our view that
health promotion provides an avenue
for dealing with emerging challenges,
an approach which supports
Canadians in improving the quality of
their health. In summary, it offers a
means of achieving health for all
Canadians.

V THE HEALTH

PROMOTION
FRAMEWORK

We have taken a backward glance at
our efforts in health and assessed our
progress. We have looked ahead and
seen trends toward serious inequities
in health, particularly for
disadvantaged groups and coming
generations of seniors. We have
reviewed ten years of experience in
health promotion. Our conclusion is
that the health promotion approach
offers considerable potential and
scope to meet the complex health
challenges that face Canadians.
The Framework for Health
Promotion described here provides a
means of linking the ideas and actions
we regard as fundamental to the
achievement of health for all, the aim
to which we aspire.
Earlier, we identified the national
health challenges which need to be
overcome as we pursue this aim.
Other key components of the
framework are a set of health
promotion mechanisms and a
series of implementation strategies.
We now present these mechanisms
and strategies, elaborating on their
relationship to each other and to the
health challenges within the
Framework for Health Promotion.
Fora visual representation of all
these components and the relation­
ships among them, the reader is
referred to the diagram entitled “A
Framework for Health Promotion".
We believe that the three
mechanisms intrinsic to health
promotion are:
° self-care, or the decisions and
actions individuals take in the interest
of their own health;
° mutual aid, or the actions people
take to help each other cope; and
° healthy environments, or the
creation of conditions and surround­
ings conducive to health.
When we speak of self-care, we
refer to the decisions taken and the
practices adopted by an individual
specifically for the preservation of his
or her health. An older person using a
cane when the sidewalks are icy, a
diabetic self-injecting insulin, a person

choosing a balanced diet, someone
doing regular exercises: these are all
examples of self-care. Factors such as
beliefs, access to appropriate
information, and being in
surroundings that arc manageable
play an important role in such
situations. Simply put, encouraging
self-care means encouraging healthy
choices.
The second health promotion
mechanism, mutual aid. refers to
people’s efforts to deal with their
health concerns by working together.
It implies people helping each other,
supporting each other emotionally,
and sharing ideas, information and
experiences. Frequently referred to as
social support, mutual aid may arise in
the context of the family, the
neighbourhood, the voluntary
organization, or the self-help group.
Informal netw'orks are recognized
as a fundamental resource in the
promotion of health. There is strong
evidence that people who have social
support are healthier than those who
do not. The value of such support lies
in its emotional and practical nature:
it enables people to live interdependently within a community while still
retaining their independence. A
parent with a handicapped child, an
older person enduring arthritic pain.
an adolescent using drugs: these are
people who need not only
professional services, but under­
standing and the sense of belonging
that comes with being socially
supported.
In Canada, the “self-help
movement" provides us with an
abundance of illustrations of mutual
aid in action. Alcoholics Anonymous
(AA), One Voice of Seniors, Block
Parents, the Coalition of Provincial
Organizations of the Handicapped
(COPOH), and rape crisis centres are
some examples. 'ITirough self-help,
people come together to deal with
the consequences of being unwell,
overburdened, bereaved, disabled, or
in a situation of crisis.
The third health promotion

A FRAMEWORK FOR HEALTH PROMOTION

ACHIEVING HEALTH
FOR ALL

AIM

HEALTH
CHALLENGES

HEALTH
PROMOTION
MECHANISMS

IMPLEMENTATION
STRATEGIES

ENHANCING
COPING

SELF-CARE

MUTUAL AID

HEALTHY
ENVIRONMENTS

FOSTERING
PUBLIC
PARTICIPATION

STRENGTHENING
COMMUNITY
HEALTH SERVICES

COORDINATING
HEALTHY PUBLIC
POLICY

mechanism is the creation of
healthy environments. This means
altering or adapting our social,
economic or physical surroundings in
ways that will help not only to
preserve but also to enhance our
health. It means ensuring that policies
and practices are in place to provide
Canadians with a healthy environment
at home, school, work or wherever
else they may be It means commu­
nities and regions working together to
create environments which are
conducive to health.
From this perspective, the
environment is all-encompassing; the
concept of boundaries is
inappropriate when we speak of the
promotion of health. The environment
includes the buildings where we live,
the air we breathe and the jobs we do.
It is also, for example, the education,
transportation and health systems.
Because of the breadth and scope of
the environment thus understood,
environmental change becomes by far
the most complex and the most
difficult of the three mechanisms or
kinds of action required for the
promotion of health.
The public sector and others arc
already engaged, to varying degrees, in
encouraging people to care for
themselves, to come together for
mutual support, and to change the
circumstances and surroundings
which act as barriers to the achieve­
ment of health. Yet, to the extent that
there are in place policies and
practices which support the concept
of health promotion, these tend to be
implicit rather than explicit. In most
instances, they arc not the result of
deliberate strategic planning. In our
view, it is time to clearly articulate a
direction which is designed expressly
to promote the health of Canadians.
To do so means establishing a set
of strategies, the implementation of
which will enable us to attain our aim
of achieving health for all. At the 77th
Annual Conference of the Canadian
Public Health Association, we
presented six strategies for health

promotion: ensuring access to health
information; encouraging consensus
about particular health ideas;
initiating research in support of health
promotion; fostering public­
participation; advocating a strong role
for the health care system, particularly
for community health services; and
coordinating policies between
sectors.
Of these six strategies, there arcthree which provide a central focus,
and under which the others can be
subsumed. In our view, the leading
strategies or processes whereby we
can act decisively in response to the
health challenges confronting Canada
are:
° fostering public participation;
o strengthening community health
services; and
° coordinating healthy public policy.
Let us explore the strategies
which we are proposing as a basis for
action in the field.

Strategy I:
Fostering

Public Participation
Health promotion means ensuring
that Canadians are able to act in ways
that improve their own health In the
national quest for health, people
constitute a major resource, both
individually and in groups. Our
experience confirms that people
understand and are interested in the
circumstances and events that
influence their health. We know that
they are seeking opportunities to take­
responsibility.
Encouraging public participation
means helping people to assert
control over the factors which affect
their health. We must equip and
enable people to act in ways that
preserve or improve their health. By
creating a climate in favour of public
participation, we can channel the
energy, skills and creativity of commu­
nity members into the national effort
to achieve health.
The enduring impact of public
participation on health is well

documented. In the Vancouver "Be
Well” program, a network of seniors
established a self-help model to
encourage participants to preserve
their own health. Crocus Co-operative
in Saskatoon offers programs and
counselling for post-mentally ill
adults. In Quebec, a multi-ethnic asso­
ciation provides information and
assists handicapped children and
adults in making use of services. The
Canadian Sickle Cell Society has
grown from a handful of volunteers
into a national organization dedicated
to educating, testing and counselling
Canadians affected by sickle cell
anemia. In a small rural Ontario
community, seniors came together to
organize meal services, friendly
visiting and home help for their less
able older neighbours.
These examples illustrate how
fostering public participation can help
us respond to one of our leading
challenges, that of enhancing people's
capacity to cope. We could, in fact,
take any of the national challenges and
produce evidence that endeavours

initiated by the public can provide
effective responses to health concerns.
Tlte conclusion is inescapable: public
participation is not only valuable, but
essential to the achievement of health
for all Canadians.

Strategy II:

Strengthening
Community Health Services
Community health services arc
already playing an indispensable role
in preserving health. We believe that
there should be an expansion of this
role and that it should be expressly
oriented toward promoting health
and preventing disease. At the sanie
time, we recognize that adjusting the
present health care system in such a
way as to assign more responsibility to
community-based services means
allocating a greater share of resources
to such services.

health promotion and disease
prevention orientation means that
community health .services will have
to focus more on dealing with the
major health challenges we have
identified. For example, it assumes
that there will be a greater emphasis
on providing services to groups that
are disadvantaged. It further takes for
granted that communities will
become more involved in planning
their own services, and that the links
between communities and their
services and institutions will be
strengthened.
In these ways, community health
sendees will become an agent of
health promotion, assuming a key role­
in fostering self-care, mutual aid and
the creation of healthy environments.
This will involve coordinating pro­
grams much more closely with those
of social sendees in order to maintain
momentum in the health promotion
effort. Given the present range of their
responsibilities, it is only logical that
community health sendees should
play this expanded role in promoting
the health of communities.
We consider it especially
important that community health
services become more active in
helping people to cope with disabili­
ties. If people are to manage effec­
tively, there must exist a continuum of
care which is flexible enough to meet
their needs for support - whether
temporary or long term - without
making unnecessary; and perhaps
unsettling changes in their lives. To
accomplish this, it is vital that there be
coordination of available sendees.
Community health sendees provide a
natural focal point for coordinating
sendees such as assessment, home
care, respite care, counselling and the
valuable work of volunteers.
People who are trying to cope
with mental health problems would
also benefit from the strengthening of
community health services. While­
psychiatric treatment sendees clearly
remain appropriate for the seriously
ill, those who are finding it difficult to
manage because of life circumstances

could be assisted and supported by
community health sendees.
For all those seeking to take­
responsibility for their own health,
whether in groups or as individuals,
community health sendees are well
situated to assume a far more promi­
nent role in the health promotion
effort.

Strategy' HI:
Coordinating
Healthy Public Policy
The potential of public policy to
influence people's everyday choices is
considerable. It is not an overstate­
ment to say that public policy has the
power to provide people with
opportunities for health, as well as to
deny them such opportunities. All
policies, and hence all sectors, have a
bearing on health. What we seek is
healthy public policy.
We believe that health promotion
is an appropriate way of achieving our
ultimate aim. that of equitable access
to health. We know that self-care,
mutual aid and healthy environmental
change are integral to health
promotion, and that they are morelikely to occur when healthy public­
policies are in place. Policies that are
healthy help to set the stage for health
promotion, because they make it
easier for people to make healthy
choices.
All policies which have a direct
bearing on health need to be
coordinated. The list is long and
includes, among others, income
security, employment, education,
housing, business, agriculture, trans­
portation, justice and technology'. It
will not be an easy' undertaking to
coordinate policies among various
sectors, all of which obviously have
their own priorities. We must bear in
mind that health is not necessarily a
priority for other sectors. 'Ibis means
that we have to make health matters
attractive to other sectors in much the
same way that we tty to make healthy
choices attractive to people.

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Conflicting interests may exist
between sectors. Such conflicts arcintrinsic to our society. Take the
example of tobacco. We arc propo­
nents of a smoke-free environment.
On the other hand, there are Canadian
farmers who cultivate this product for
their livelihood. Changes in tobacco
policies have implications for farmers
and smokers alike. In this instance the
creation of healthy public policy
necessitates responding to a situation
with serious health as well as
economic implications.
The federal government has
already begun the process of creating
a healthy public policy on tobacco. In
October 1985, a cooperative national
program to reduce smoking was
endorsed by the federal and provincial/territorial Ministers of Health and
seven non-govemment organizations.
There have also been consultations
with the federal departments
responsible for agriculture, justice,
transport, revenue, and with the
Treasury Board. As a result, several of
these departments are now reviewing
their policies in relevant areas, such as
smoking in the workplace, crop
substitution, tobacco marketing
practices and smoking on public­
transportation.
Impaired driving is another issue
which is leading to inter-governmental
coordination at the provincial and
federal levels. From a health
promotion perspective, the
responsibility is to make it socially
unacceptable for people to drive
while under the influence of alcohol,
and to reduce the often tragic
consequences of doing so. Other
equally important responsibilities
include amending the criminal code,
improving road safety’, making police
enforcement more efficient and
controlling the availability of alcohol.
In this context, coordinated changes
to public policy are being achieved
through consultation and consensus
among the federal departments of
Health and Welfare, Justice, Trans­
port and the Solicitor General, and
their provincial counterparts.

Tobacco and impaired driving
are only two examples of attempts to
ensure that public policy’ is coordi­
nated. The fundamental point is,
however, that for public policies to be
healthy, they’ must respond to the
health needs of people and their
communities. This is so whether they
are developed in government offices,
legislatures, board rooms, church
halls, union meetings or centres for
seniors.
The mutually-reinforcing
strategies, taken together with the
mechanisms. comprise the basic
elements of the Health Promotion
Framework. It is important to state
that one strategy’ or mechanism on its
own will be of little significance. Only
by putting these pieces together,
assigning resources, and setting
priorities, can we be certain that
health promotion carries meaning and
comes alive. We believe the approach
we propose allows us to respond
effectively and ethically to current and
future health concerns.

VI CONCLUSION

This, then, is our proposal for a health
promotion framework: a vision of
health as a dimension of the quality of
life; an artieulation of the current and
future health challenges confronting
this country; an understanding of
health promotion as a process
enabling people to increase control
over their health; an identification of
three mechanisms which can
"energize" health promotion, and.
finally, an elaboration of the three
implementation strategics which we
believe will make it possible for all
Canadians to achieve equitable access
to health.
In summary’, health promotion
implies a commitment to dealing with
the challenges of reducing inequities.
extending the scope of prevention.
and helping people to cope with their
circumstances. It means fostering
public participation, strengthening
community' health senices and
coordinating healthy public policy.
Moreover, it means creating environ­
ments conducive to health, in which
people are better able to take care of
themselves, and to offer each other
support in solving and managing
collective health problems.
There is a certain timeliness
about health promotion. The signs are
evident across the country. Regional
boards of health, professional
organizations, provincial and national
councils and voluntary associations
are all articulating policies that
support the concept of health promo­
tion. Tile most convincing evidence is
the voice of public support. People
everywhere are demonstrating a
willingness to act on matters of
health. Each year, for example, federal
funding programs receive thousands
of applications for resources to be
used in community health projects.
Low-income women, seniors, native
people, the disabled, immigrant
groups and many others are express­
ing their own ideas on the health
needs of their communities, as well as
their eagerness to find ways of
meeting those needs.

We are aware that there are
certain dilemmas inherent in health
promotion. For example, we cannot
invite people to assume responsibility
for their health and then turn around
and fault them for illnesses and
disabilities which are the outcome of
wider social and economic circum­
stances. Such a “blaming the victim”
attitude is based on the unrealisticnotion that the individual has ultimate
and complete control over life and
death.
Secondly, there is the question of
allocating resources during times of
scarcity. The availability of financing is
obviously a critical question for each
of us. Canada has performed fairly
well in controlling the growth of
health care costs; however, cost con­
trol is a matter of continuing concern.
The pressures created by an aging
population and the growing incidence
of disabilities in our society will take a

heavy toll on our financial resources.
We believe, however, that the health
promotion approach has the potential
over the long term to slow the growth
in health care costs.
Every day, individual Canadians
face difficult situations. We secunhappy pregnant teenagers, abused
children, women who are depressed,
seniors who are lonely, men in midlife
incapacitated by heart disease, and
people suffering from incurable­
diseases such as multiple sclerosis or
arthritis. There is, however, another
side to this story. We also see
transition homes, family counselling,
drug treatment centres, self-help
groups, efforts in the workplace to
hire the disabled and, above all,
people moving voluntarily to help
themselves and to reach out to others.
This is what we want to see and this is
what we want to encourage.
The Health Promotion
Framework helps us formulate ways of
dealing with day-to-day health issues.
We can use it to visualize the kinds of
mechanisms and strategies that arcneeded to support and encourage
Canadians as they strive to live
healthy, full lives. The framework links
together a set of concepts, providing
us with a particular way of thinking
about and taking action toward
achieving our aim of health for
everyone in this country. Above all,
health promotion is an approach
which can develop alongside and be
integrated into our sophisticated
system of health care. Already, in our
private and professional lives, many of
us arc thinking and behaving in ways
that are consistent with the concept
of health promotion

It will take time to give meaning
to health promotion. A vital element
in the process will be nationwide
discussion. This will enable Canadians
to assess the implications of health
promotion. The body of knowledge
and experience is accumulating
rapidly: individuals and groups in
many parts of the country arc already
familiar with the approach we arc­
calling health promotion.
We have the foundations upon
which to build. Let us continue our
efforts to achieve health and improve
the quality- of life of the people and
communities of Canada.
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