Supportive environments for health

Item

Title
Supportive environments
for health
extracted text
SUPPORTIVE
ENVIRONMENTS FOR
HEALTH

Supportive environments
for health

Major policy and research issues
involved in creating health
promoting environments

by

Kathxyn Dean, WHO Collaborating Centre for
Health Promotion Research, Copenhagen
and

Trevor Hancock, Public Health Consultant,
Ontario, Canada

1992

HPR-1

All rights in this document are reserved by the WHO Regional
Office for Europe. The document may nevertheless be freely
reviewed, abstracted, reproduced or translated, but not for sale
orforuse in conjunction with commercial purposes. The WHO
name and emblem are protected and may not be used on any
reproduction or translation of this document without permis­
sion. Any views expressed by named authors are solely the
responsibility of those authors.
The Regional Office would appreciate receiving three
copies of any translation.

Keywords

- HEALTH PROMOTION
-HEALTH POLICY
- SOCIOECONOMIC FACTORS
- ENVIRONMENTAL HEALTH
- LIFE STYLE
-EUR

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CONTENTS

Page
Introduction....................................................................................

1

Promoting health environmentally - Trevor Hancock..................

3

Introduction .............................................................................
Health - environment - economy...........................................
Health promotion and health protection..................................
Environmental health promotion projects...............................
Conclusion...............................................................................
References ...............................................................................

3
4
6
15
20
20

Health and social environments: facing complexity in health
promotion research - Kathryn Dean .............................................

23

Pathways of influence.............................................................
Exploring the research issues ..................................................
Facing or avoiding complexity in research on health.............
Contextual research: the health promotion challenge.............
References ...............................................................................

24
25
29
30
33

The Sundsvall Declaration on Supportive Environments..............

35

Introduction
Creating supportive environments is one of the cornerstones of
health promotion. This booklet is about environments: the
contexts in which human health is improved, maintained or
harmed. Its three parts are intended to stimulate discussion and
action on subjects that are important not only for human health but
also for human survival on a deteriorating planet.
Daily concerns with making ends meet make it difficult to
maintain an awareness that the environments in which we live and
work shape our health and wellbeing. Faced with the threats of no
or slow economic growth, unemployment and poverty, we can
easily overlook the fact that human survival is not only unimpor­
tant but also threatening to the stability of the biosphere. It is also
easy to be deluded by blind demands for growth, demands that fail
to recognize the interconnectedness of not only the elements of
the biosphere but also the economic circumstances of nations and
localities.
The interaction of environment and economy can no longer be
ignored. It is the focus of sustainable development. People are
only beginning to face the consequences of overdevelopment and
underdevelopment in the world; these two extremes must be
reconciled in sustainable development that will allow health
promoting societies.
In health promotion, the fundamental concept of the notion of
environment is context, and the focus is on the contexts in which
people live their daily lives. Such a context includes the social as
well as the physical environment. The social environment is the

1

web of personal relationships and resources that underpin human
nurture and development. It is equally as important for life and
health as the physical environment. People seldom think of the
social environment in relation to sustainable development. This
oversight needs to be redressed. Excessive demands on social
environments lead as surely to their deterioration and breakdown
as do the overdevelopment and abuse of physical environments.
This booklet highlights major policy and research issues
involved in creating health promoting environments. The first
paper focuses on general subjects in environmental policy and
research, concentrating on the physical environment and particu­
larly the major environments of everyday life. The second paper
discusses issues in research on human health. It focuses on
research on social support and health, but the basic issues and
arguments are equally relevant to research on the physical envi­
ronment.

Kathryn Dean
Trevor Hancock

2

Promoting health
environmentally
Trevor Hancock1'
Introduction
One of the key issues in the new public health is the creation of
healthy and supportive physical and social environments. This
need was recognized in the Ottawa Charter for Health Promotion
and by the choice of the theme of supportive environments for the
3rd International Conference on Health Promotion, held in
Sundsvall, Sweden in June 1991. Towards the end of the 1980s.
the global agenda increasingly shifted towards the need to address
the quality and sustainability of (he physical environment and
ultimately the global ecosystem. This is evidenced in the World
Commission on Environment and Development report, Our com­
mon future (J), and the earlier report of the International Union for
the Conservation of Nature, which proposed a world conservation
strategy (2). The links between health and the environment have
become ever more obvious. The environmental movement has
recognized that (he health effects of environmental problems
carry great social and political punch, while the health sector has
increasingly recognized the health consequences of local and
global enviroiunental problems. A recent Canadian workshop on
the health dimensions of enviroiunental issues (3) noted that “the

“ Public health consultant. Klcinburg. Ontario. Canada.

3

1

primary reason for being concerned about the environment is
human health".
Environmental health thus seems likely to be a vital area of
concern in the 1990s. There is a unique opportunity to apply the
lessons learned from health promotion Io the business of protect­
ing the health of the environment and that of the people living in
it. Two of the pillars of public health - health promotion and
health protection - need to be fused to form a new public health,
which should then be linked to the issue of sustainable develop­
ment. Health must be an issue in sustainable development and
sustainability in health.
This paper summarizes the links between health and sustain­
able development, using the model that has evolved from the
York conference on health, the environment and the economy (4).
It addresses some of the fundamental differences between health
promotion and health protection and some of the issues that they
raise, and reviews the themes and strategies that might be used in
promoting environmental health. The paper ends with specific
proposals for projects to promote environmental health.

Health - environment - economy
The interaction of the environment and the economy is the subject
matter of sustainable development. How can an economy be
fashioned that is indefinitely sustainable in environmental terms?
An economy that is not indefinitely sustainable dooms future
generations to ecological decline or collapse, with accompanying
economic and social decline or collapse.
The term sustainable development has been criticized for its
apparent focus on economic development, although it really
refers to economic development that is environmentally sustain­
able. Osberg (5j, among others, has suggested that economic
development needs also to be socially sustainable. Perhaps it
would be even better, in fact, to focus on human development, and
to say that what is needed is a form of environmentally and
socially sustainable economic activity that enhances human de­
velopment.

4

Fig. I shows the relationship between health, the environment
and the economy. From the point of view of the planetary
biosphere of which we humans are a part, ourcontinued wellbeing
and even our continued survival arc unimportant. Indeed, from
such a perspective, ourcontinued existence threatens the stability
of the planetary biosphere that is Gaia (6), because of the current
unsustainable nature of our economy. What human health re­
quires, however, is an environment that is viable, that sustains
human life. To the extent that the unsustainable nature of
economic activity reduces the viability of the environment, hu­
mankind tlueatens its own wellbeing and survival, as well as
(hose of thousands, even millions of other species in the web of
life.

Fig. 1. The relationship between health, the environment and
the economy

5

Fig. 2. The mandala of health: a model of the human ecosystem

Source: Hancock, T. & Perking, F Th© mandala of health. Health education. 24(1):
8-10 (1985).

environmental health requires adding the strengths of the health
promotion approach to the health protection approach, without
losing the strengths of the latter. First, however, some substantive
issues have Io be addressed. These include philosophical issues
related to the concept of the environment, the nature and practice
of science and the nature of democracy, as well as the nature of the
challenges of environmental health.
7

The concept of the environment
In health protection, the environment has usually meant the
physical environment (natural and built) and the concept includes
the physical, mechanical, chemical and biological hazards within
that environment. As Fig. 2 indicates, however, the health
promotion concept of the environment includes both the physical
and the social environments, the latter including psychological.
social, economic, political and cultural influences within families.
communities and society as a whole.
These broader influences within the social environment are
increasingly recognized within health protection. Thus, the par­
ticipants at a 1984 Canadian workshop on environmental health
issues for the twenty-first century (7) took particular note of the
psychosocial influences on health in the workplace, the links
between urban design and health, and the need for society
to establish goals for its future through a participatory process.
These ideas fit well with ideas of healthy work, healthy commu­
nities, participation and empowerment that have emerged in
health promotion.
Changing nature of science
The changing understanding of the world challenges the conven­
tional scientific method in a number of ways. The analytic
approach looks at parts of the whole and seeks single causes and
single effects in controlled environments. It is being challenged
by the need to take a holistic approach that looks at whole systems
and conditions with multiple causes and multiple effects in the
context of real life. The objective approach of science portrays the
scientist as a value-free observer of quantifiable facts. This is
challenged by the need to recognize that scientists are influenced
by their culture and can never be simply dispassionate observers.
This need is particularly important when such value-laden issues
as human health and environmental quality are concerned. Peo­
ple’s subjective experience is just as important as the objective
measurement of their condition.
Further it is believed that only trained scientists do science and
that they report their results to an untrained populace. This notion

8

is being replaced by the recognition that research in communities
needs to be participatory in nature. The community should
participate in defining topics, carrying out the research and
interpreting the results. The experience and wisdom of the
community should be valued.
Finally, the limits to science need to be recognized and
clarified. On the one hand, the public needs to understand the
limitations of science - what it can and cannot do - and, on the
other hand, scientists need to learn to generalize, to give advice
and to take part in the process of decision-making in the face of
uncertainty and with open recognition of the limits of science."
Recent advances in the physical and natural sciences under­
score these needs and priorities. Research now being conducted
under the rubric of chaos theory is leading to a review of the
understanding of the world, and in particular of complex systems
such as ecosystems and living organisms. In an excellent guide to
(he new science of chaos, Gleick (9) makes several important
points about the old science:

Most practising scientists shared a set of (unstated] beliefs
about complexity ...
Simple systems behave in simple ways ... as long as these
systems could be reduced to a few perfectly understood,
perfectly deterministic laws, their long-term behavior would
be stable and predictable.
Complex behavior implies complex causes ... a wildlife popu­
lation, a fluid flow, a biological organ, ... an atmospheric
storm or a national economy - a system that was visibly
unstable, unpredictable or out of control ... must either be
governed by a multitude of independent components or sub­
ject to random external influences.

" A paper by Yvonna Lincoln (<S) gives an excellent review of the points
made here in the context of health promotion research and evaluation. It is all
the more notable since Lincoln was President of the American Evaluation
Society when she delivered it.

9

Different systems behave differently ... Scientists ... knowing
that the components of their disciplines were different, took it
for granted that the complex systems made of billions of these
components must also be different.
These beliefs, of course, still have wide currency in daily
social and political life; people assume that they cannot under­
stand or manage complex systems, that they have to reduce
everything to simple models in order to understand and control it.
and that different disciplines have little in common and little to
learn from each other. Other common beliefs are: that change is
essentially linear, that complex systems are relatively stable and
robust, and that minor differences in input to a system have little
effect on its behaviour.
The scientific concept of chaos has turned all that on its head.
Research based on chaos theory' is providing evidence of (he
underlying order in disorder: stable patterns emerge out of
irregularity. Newer evidence shows the need to see the pattern and
the whole, rather than the parts. Chaos is “the end of the
reductionist program in science"; “a science of process rather than
state, of becoming, rather than being" is emerging. In particular,
the science of chaos means recognizing that:

Simple systems give rise to complex behavior. Complex systems
give rise to simple behavior. And most important, the laws of
complexity hold universally ...
Chaos means that change in complex systems can be non-linear
and that “tiny differences in input could quickly become over­
whelming differences in output"; complex systems turn out to be
less robust and stable than we like to believe (9).
Recognition of this new understanding of nature is only
slowly spreading from the realm of natural science to that of social
science and politics; the implications for people’s understanding
of the world and the decisions they make are profound. In short.
the new science that is emerging has holistic, qualitative, subjec­
tive and participatory qualities and acknowledges its limitations
m the face of uncertainly.
10

Implications for health research
The recent gains in knowledge outlined above have implications
for the health sciences. For example, research on (he health
impact of environmental influences will have to consider effects
on the ecosystem as a whole, including the range of species and
organisms as a whole, over their entire lifetimes. This will mean
using wildlife markers of health effects (such as birth abnormali­
ties in birds and tumours in fish), looking at lifetime exposure and
paying much more attention to a wider range of health variables in
both animals and humans, including behavioural, neurological
and immunological effects.
Research on human health needs to pay more attention to
people’s perceptions and self-reported health. This is an area in
which health promotion research can contribute its experience in
self-assessment of health. Another important area in which health
promotion can contribute is the process of community develop­
ment. and particularly the processes of adult and popular educa­
tion. These lie at (he heart of the participatory research approach
(hat the new science will require.

Democracy: representation or participation?
Health protection is based on a model of democracy in which
experts and elected politicians make decisions on behalf of the
general public. This somewhat paternalistic and frequently secre­
tive style of decision-making is a legacy of the democratic system
developed in the eighteenth and nineteenth centuries and strength­
ened throughout most of the twentieth century.
Times have changed. The populace is better educated and.
through the mass media, better informed about conditions in their
communities and matters of scientific and national concern.
Distrust has grown out of decisions made by experts and politi­
cians behind closed doors, and demands have increased for
greater public participation in all aspects of society. People want
not merely to be represented but to participate. This is particu­
larly true of matters that affect their health, their quality of life and
the quality of their environment, at the community level in
particular. The twenty-first century will be “(he age of participa­
tory democracy’’ (7).
11

Health promotion’s commitment to public participation and
community empowerment challenges the more traditional deci­
sion-making processes of health protection. Health promotion is
thus very much in tune with the new approach to democracy. This
is clear in the definition of health promotion as “the process of
enabling people to increase control over and improve their health”.
a statement that is as true for the health of the environment as for
personal health.
Key issues in environmental health promotion
A synthesis of health protection and health promotion suggests
four levels at which the physical and social environments are
brought together in the settings of everyday life. These settings
are:

individuals and what (hey breathe, drink and eat;
the building, including the home, the school, the workplace,
the health care institution and other built environments;
• the community, whether it is a city, a neighbourhood, a
town, a village or a hamlet; and
• the natural environment and the global ecosystem.

•
•

Affecting all of these, however, is another key issue for environ­
mental health promotion: the need to reduce inequalities in health
(and thus in environmental quality) in these settings.

Environmental inequity
In health promotion, the environment is both physical and social,
and the two are not easily divorced; poor physical environments
are usually associated with poor social environments. No matter
the hazard-general environmental pollution, dangerous working
conditions, poor quality housing or unsafe products - the poor in
society usually suffer the worst and have the most adverse health
consequences: it is the poor who live downhill, downstream or
downwind. Recognizing that the environment has a social dimen­
sion is a major issue in health promotion, and a major contribu­
tion that health promotion can make to health protection. Access
12

to a clean, safe, health promoting environment is a fundamental
determinant of good health, and inequities in access to such an
environment have to be addressed and corrected at the personal,
community and global levels.

The individual
People are exposed to a wide variety of chemicals in utero, by
ingestion (via air, water, food and soil) and by contact. What most
concerns them is the cumulative effect of the multitude of chemi­
cals they breathe, drink and eat in what has become an ecotoxic
enviroiunent (JO)". The protection of individuals needs to be
combined with health promotion strategies that enable them to
have greater control over their environments and greater choice
about what they breathe, drink and eat.
The building
Health promotion is concerned with the qualities of key environ­
ments (such as the home, the workplace, the school and the health
care institution) that can promote and protect health. Recognizing
that all of these environments have both a physical and a social
nature, however, health promotion is equally concerned with the
extent to which they are socially 01 psychologically hazardous
and how people can control and improve their environments.
The urban community
Health promotion, through the movement to promote healthy
communities, seeks to address a broad range of environmental
issues, including air and waler quality, the environmental conse­
quences of urban design, transport, waste management, energy
use and a host of related topics. Again, the focus is as much on the
process of creating a healthier environment as on the actual
changes required. An adaptation of Fig. 1, Fig. 3 shows how the
environment, the economy and the community are interrelated
with one another and with health.
a Ecotoxicity is the contamination of entire ecosystems and the organisms
in them (including humans) with low levels of many persistent toxic chemicals
and heavy metals.

13

Fig. 3. Interrelationships: the environment, the economy,
the community and health

For good health, people need an environment that is viable, an
economy that generates enough resources to enable them to be
healthy, and a community that is convivial. The community
needs to construct environments that are livable and to ensure the
equitable distribution of resources while maintaining environ­
mental sustainability.

The natural environment
Health promotion recognizes that achieving health for all requires
a worldwide shift to an environmentally sustainable form of
economic development. Links between health promotion and
sustainable development, and, more explicitly, between health,
the environment and the economy, are of particular interest, and
reflect the social, economic and political nature of health promo­
tion. The health costs of unsustainable economic development
14

have (o be spelled oul and (he health benefit of sustainable
development determined. In short, a health promotion agenda in
environmental health would include four interrelated issues in the
way that people experience their daily lives:
— healthy air, water, soil and food (and ecotoxicily);
— healthy built environments (such as homes, schools,
workplaces and institutions);
— healthy communities;
— healthy ecosystems (including both sustainable develop­
ment and ecotoxicily).

Environmental health promotion strategies
The Ottawa Charter for Health Promotion, along with Canada's
health promotion framework (JI), provides a framework and
strategies for promoting environmental health;
— establishing healthy public policies
— reducing inequalities in environmental health
— strengthening community action and fostering public par­
ticipation
— developing personal coping and self-care skills.

The following discussion highlights these strategies.

Environmental health promotion projects
This section describes projects for environmental health that
health promotion groups could carry out in conjunction with
health protection groups and other partners within and outside
government. Il specifically excludes the toxicological aspects of
exposure to contaminants in air, food, soil and water (except as a
consequence of the action proposed below), since (his area is
clearly within the mandate and technical expertise of the health
protection authorities. Rather, the projects focus on how to
promote physical and social environmental health in particular
settings: the home, the school, the workplace, the hospital and

15

the community. Knowledge, skills, processes and technology
need Io be developer! in each of these areas to create healthier
environments.

Healthy homes
North Americans spend 75-90% of their time indoors, much of it
in their own homes. These homes present a variety of health
hazards, including unsafe design and construction, energy ineffi­
ciency (or the opposite, sealed buildings), and toxic construction
materials, fabrics and furnishings, to name but a few. In addition.
housing design is often harmful to mental and social wellbeing.
Further, people use a vast array of household products that
present varying degrees of hazard to human or environmental
health. Two major environmental health promotion projects
would encourage and support the building of healthy homes and
the development, marketing and use of less toxic household
products.
A healthy housing project should begin by examining existing
building codes and health standards in the light of current knowl­
edge and new practices about the effects of housing on physical.
mental and social wellbeing. This would lead to proposals to
change public policy on and standards for housing design at all
levels of goveriunent. Particular attention should be paid to the
housing conditions of the most disadvantaged groups in society.
Public policies and community development strategies should
enable such groups first to obtain shelter and then to increase their
control over (heir housing conditions and to take part in designing
or redesigning their living conditions, a process known as com­
munity architecture (12). Potential partners in this project would
include: national and other authorities responsible for housing
standards, national associations and local groups of architects,
academics concerned with housing and the built enviroiunent.
local governments, developers and key tenant and householder
groups. The United Nations Centre for Human Settlements would
be an obvious international partner.
A healthy products project would encourage public policy
incentives (and regulations if need be) Io encourage healthier
16

household products. Au obvious place to begin is the growing
number of programmes that review products for their environ­
mental “friendliness”; it would be comparatively simple to add an
assessment for their health effects. Ministries of consumer
affairs, consumers' associations and the associations of people in
the household products industry would obviously be key partners.
At the local level, public education to increase awareness of the
relative merits of different products, particularly adult education
of the self-help or mutual aid type, should be supported. Mecha­
nisms to do this with groups with low literacy should be explored.
These effoits could perhaps be coupled with education about the
availability of cheaper alternatives.

Healthy schools
In dealing with health, schools have primarily if not exclusively
emphasized its physical and behavioural determinants. As is the
case for housing, much could be done to improve the physical
environment of schools, and to promote education about environ­
mental health (13).
\ project on healthy school environments would share many
of the concerns of the first two projects. Particular attention
should be paid to the effects of (he environment on children's
development and behaviour, ami to the provision of green space
and a sense of connectedness with nature. Particular attention
should also be paid to conditions in schools with large numbers of
disadvantaged children. The concepts of community architecture
should be applied by. for example, involving children in examin­
ing (licit schools and redesigning them to be both healthier and
friendlier to the environment. Likely partners would include
associations of school boat ds. teachers and parents at the local.
provincial and national levels, and ministries of education, in
addition Io the partners in (he healthy housing project.
An environmental health education project would build on
existing links with the school health education community to
develop curricula and materials that emphasize the links between
health ami the environment. Projects to involve children in
examining the health of their environments in school, al home and

17

in the neighbourhood would be both educational and empowering
if linked to action to improve environmental health. Scientists
and environmental science teachers would be important addi­
tional partners here, and the project could be linked to healthy
housing and healthy community projects.
Healthy workplaces
Occupational health and safety programmes tend to focus on
physical, chemical and mechanical hazards in the workplace.
Increasing evidence, however, shows that the psychological and
social environments of work affect not only mental and social
wellbeing but also physical health (14). Clearly, the workplace is
an area in which the marriage of health promotion and health
protection would be beneficial.
A project to create the healthiest workplace possible would
address the physical, mental and social components of work,
including industrial hygiene, occupational medicine, ergonom­
ics, worker participation and empowerment, and workplace health
promotion. The project should obviously enable workers to
increase control over and improve their health. It could be
developed and implemented in selected pilot sites. Key partners
would include ministries of labour, occupational health ami safety
agencies, key employer organizations and trade unions, organiza­
tions concerned with the quality of working life and academics.

Healthy hospitals
If any environment created by humans should promote health, it
is the hospital. Yet hospitals often do just the opposite. They
suffer from problems of unsafe design and problems with indoor
air quality compounded by the use of many toxic or irritant
substances. They often provide noisy, unfriendly, badly lit and
alienating social environments. They use vast quantities of
disposable products, do not use energy efficiently and have
problems with waste disposal and incineration practices. In short,
hospitals are often less than the healing and sustainable environ­
ments that they should be.
Now, however, health professionals, particularly those work­
ing in hospitals, are showing an unprecedented interest in
18

environmental health and sustainable development. A healthy
hospitals project would build on this interest by bringing together
key players in this vital sector of the economy (which accounts for
some 6-12% of GNP in industrialized countries) to devise healthy
and environmentally sustainable hospitals. The project would
cover topics that included products, policies and procedures.
Hospital staff, patients and the public should be involved in the
process, which in effect would apply community architecture to
hospital design. Important partners would include national and
local associations of health professionals, the pharmaceutical
industry, the medical and surgical supply industry and hospital
architects.
Healthy communities
Projects for healthy communities (such as the WHO Healthy
Cities project and various Healthy Communities projects) are
now well established in many countries. They provide a useful
vehicle for addressing the environmental components of a healthy
city or community, and particularly the links between sustainable
development and health. This of course interests the environmen­
tal movement, but also attracts local governments, which ate
increasingly environmentally aware.
A project for a healthy and sustainable community would
focus specifically on the integration of health, environmental and
economic concerns at the local level. New communities should
certainly be designed to do this, but the greatest challenge would
be to redesign existing communities. Such a project would entail
collaborative research, workshops, conferences and the develop­
ment and application of new policies, criteria and codes for
existing and proposed urban development. The people, especially
those experiencing the worst environments, need to be involved in
redesigning their communities. It is particularly important that
the movement to “green” communities not neglect social
sustainability in this work.
In addition to national and local healthy city or community
projects, important partners would include the national ministries
of environment and municipal affairs, related ministries and their

19

local or regional equivalents. Other partners would include
municipal politicians, “green" business, the environmental move­
ment. urban planners and the development industry.

Conclusion
The links between health and the environment, and between
health for all and sustainable development, are of great public and
political interest. It is vital that the lessons learned in health
promotion be applied to the protection and improvement of the
health of the environment and the people living within it. Promot­
ing environmental health calls for the development of healthy and
environmentally sustainable public policies (including the reduc­
tion of inequalities in environmental health), the strengthening of
community action and public participation in the creation of
healthier environments, and the development of personal skills in
the protection and promotion of environmental health. Projects
should be developed that address the environments that people
experience every day in their homes, schools, workplaces, institu­
tions and communities. This will call for the establishment of
broad coalitions including the architectural, planning, design and
development sectors of society, which currently play little role in
the promotion of environmental health.

References
1.

World Commission on Environment and Development.
Our common future. Oxford. Oxford University Press. 1987.
2. International Union for Conservation of Nature and Natu­
ral Resources. World conservation strategy: living resources
conservation for sustainable development. New York. NY.
UNIPUB. 1980.
3. Health dimensions of environmental issues. Ottawa, Cana­
dian Public Health Association. 1990 (document).
4. Hancock, T. Sustaining health. Ottawa, Health and Welfare
Canada (in press).
20

Osberg, L. Sustainable social development. Halifax. Depart­
ment of Economics, Dalhousie University, 1990 (document).
6. Lovelock, J.E. Gaia: a new look at life on earth. Oxford.
Oxford University Press, 1979.
7. Environmental health issues for the 21st century. Ottawa,
Health and Welfare Canada. 1986.
8. Lincoln. Y. The paradigm revolution: fourth generation
evaluation and health promotion. Toronto. Centre for Health
Promotion. University of Toronto. 1990.
9. Gleick, J. Chaos: making a new science. New York, NY.
Viking Penguin, 1987.
10. Chant, D. & Hall, R. Ecotoxicity. Ottawa, Canadian Envi­
ronmental Advisory Council. 1978.
11. Achieving health for all. Ottawa. Health and Welfare Canada.
1986.
12. Knevitt, C. & Wates, N. Community architecture. London.
Penguin, 1987.
13. Healthy schools. Edinburgh. Scottish Health Education Group.
1990.
14. Karasek, R. & Theorell, T. Healthy work. New York. NY.
Basic Books. 1989.
5.

Ok-6t o

21

Health and social environments:
facing complexity
in health promotion research"
Kathryn Deanh
My topics are the social network and the social support derived
from networks, and my task to address issues debated by research­
ers concerned with how the social environment affects health.
The source of the debate is disagreement about whether health
benefits derived from the social environment arise primarily from
being integrated — embedded is a term often used - in a network
of social relationships or from support and help provided in the
social network when needed.
The research issue inherent in this manner of posing the
question is the long-debaled subject of whether the health benefits
of social support are direct or buffering effects. This issue seems
to be well resolved. Cohen & Syme (1) interpreting the findings
in their overview of the literature on social support, conclude (hat
enough evidence is available to document both direct effects from
social support and buffering effects derived from social networks'
reducing the consequences of stress. They point out that the direct
effects generally occur when the measure of support assesses the
"Tins paper was originally prepared for the Social Support and Health
Symposium of the XIV World Conference on Health Education. Helsinki.
Finland. 16—21 June 1991.
Senior Researcher. Institute of Social Medicine. University of Copen­
hagen, Denmark.

23

degree to which people arc integrated in networks, while buffer­
ing effects are found when the measure focuses on the availability
of resources for help in responding to stressful events.

Multiple dimensions of supportive social environments
While research has provided apparently conclusive evidence of
both direct and stress-buffering benefits from social support, the
distinction between integration in and support from a network
covers far more than the traditional issue of direct or indirect
statistical effects. Integration in a network of social relationships
is not a simple, straightforward matter, but involves complex.
multidimensional processes of belonging; these in turn have
equally complex and multidimensional consequences. For exam­
ple. people’s personal behavioural ami emotional characteristics
influence their integration and participation in social networks.
This touches on another issue in the social support research
literature. There is evidence that variables representing personal
functioning, depression or psychological distress may account for
relationships between social support and health (2). Further, the
type and extent of integration depend on the cultural and struc­
tural aspects of particular networks, such as the role of the family.
the position of women, the distribution of income and the avail­
ability of public support services.
The consequences of integration in a social network are also
multidimensional. Networks can affect health negatively as well
as positively, constraining rather than improving personal func­
tioning, for example.

Pathways of influence
The multiple dimensions mentioned above are reflected in the
inconsistencies and contradictions in the research literature on
social support and health, particularly (he fundamental variations
in the findings according to sex. race and geographic location.
The evidence on cardiovascular diseases is the most confusing
and contradictory. The subgroup differences in mortality risk.
particularly those according to sex and race, are serious research
issues (3.4).
24

The nature of any causal influence, and questions about
intervening influences or the possibility that spurious statistical
correlations account for the findings are still issues in assessing
the evidence on the influences of the social network and social
support on health. The possible pathways of influence arc
extensive. In an earlier paper, I outlined five different potential
pathways through which social support variables might influence
health variables. Over the course of life, these options are pro­
bably parallel and alternating, rather (han alternative pathways (5).
I. Network contact and support may directly benefit physio­
logical and psychological variables.

2. Health benefits may arise from protection against stress
achieved by preventing or reducing the amount of stress
experienced or protecting against the effects of stress when it
occurs.

3. Elements of the larger social environment (such as in­
come, employment and other forms of opportunity or barrier
created by the social structure) that affect health may also
influence the network variables or be spuriously correlated
with them.
4. Personal characteristics (such as personality factors or
communication skills) may both reduce stress and create
social support.
5. Lifestyle patterns that involve stressful daily routines or
the use of harmful substances may either account for the
statistical associations between social support and health or
interfere with suppot live human interaction.

Exploring the research issues
In the research literature, explanations for the inconsistencies and
contradictions in the findings on social support and health are
generally speculations about group cohesiveness, the ability to
maintain ties, or some other possible characteristic of the subgroup
25

for which tlie expected statistical relationships are not found
(6.7). It has also been suggested that the critical dimensions of
social networks have not been measured in people for whom
support is particularly important or that, in cohesive groups,
social contacts may be so much a part of everyday life that they are
not reported (3).
These explanations build on the assumption that the statistical
correlations between social network and morbidity or mortality
(particularly the latter) tap some particular causal influence.
When methodological issues are raised, they generally concern
the possible inadequacy of measures of social support for specific
subgroups. Another possibility, however, is that the measures
and the way they are used in the analysis of population data may
result in distortions in the findings.
We have been exploring these research issues in data from
samples of the populations of Denmark and the United States.
The latter data set, now the focus of attention, is based on
information provided by a sample of the non-institutionalized
civilian population between 20 and 64 years of age. The investi­
gation was designed Io study behavioural and social network
influences on health in a national sample to see whether the
findings from earlier studies in different geographical areas would
be replicated in a study of the national population.
The major goal of the analysis of these data is to elaborate the
interrelationships of socioeconomic, social support, behaviour
and health variables. Central research questions have to do with
whether behavioural variables modify statistical relationships
between social support and health variables, and how socio­
economic status affects the interrelationships of social network,
behavioural and health variables. Thus, the concern is not (he
prediction of independent statistical associations, but the elabora­
tion of levels of influence and interactions between types of
influence. We already know that correlations exist between
social network and health variables. It is now important to
focus research on conditions of influence, the characteristics of
networks and individuals that combine to damage or protect
health (8).
26

The first task was to make sure that the tool used to study
network support is a valid measure. To study the United States
sample, the tool to measure social support was a composite index
constructed from both subscales and individual items based on
single questions. Three subscales, called group membership.
sociability and intimate contacts, were used to create this compos­
ite measure. The group membership subscale was based on
questions about membership in social and community groups.
The sociability subscale combined information from questions
about the number of friends and relatives a person has and the
frequency of contact with the relatives. Sociability scores were
then combined with marital status to make the intimate contacts
subscale. Finally, the composite index was created by combining
the intimate contacts and group membership subscales and adding
a question about church membership. The index was an attempt
to create a single measure of integration in and support from social
networks.

Measurement, the basic tool of science
The validity and meaningfuhiess of the relationships found
between social support and health depend on the soundness
of the instruments used to measure the variables, and on the
appropriate use of the instruments in the analysis of the data
collected in the study. Therefore, the composite social support
scale had to be assessed as a measure of (he theoretical concept
of social support, and to find out whether using it in the analysis
of the data would change or hide the effects of other causal
influences.
Examining the scale as a measure of the theoretical domain of
social support led to questions about what the composite index
actually measured. Network structure, network participation and
social contact were combined in a manner that might create
conceptual overlap that would interfere with the validity of the
composite scale as a measure of any of the different dimensions of
the social network. Further, the structure of the network or the
amount of social contact does not necessarily assure stress­
mitigating network support.
27

The theoretical concerns were reinforced by the validation
procedures to detect item bias and the potential distorting effects
of using the scale in multivariate analyses (0). The results of the
validation showed that both the items of the subscales ami the
subscales themselves were correlated with health, psychosocial
and socioeconomic variables in ways that would seriously distort
the outcome of an analysis employing the scale to represent social
support. This meant that, in addition to the problem of confusing
network structure, integration and support, using the scale could
hide the effects of other influences on health. For example, the
items of the group membership subscale were systematically
correlated with education, income and employment status. In
interpreting the results of an analysis that included (his scale, it
would be impossible to determine the extent to which the effects
of social situation and socioeconomic status variables were dis­
torted or hidden. The same problem was found with perceived
health status.
Similar problems were found in the assessment of the socia­
bility subscale, and the intimate contacts subscale that builds on
it. Individual items were confounded with employment status.
income and sex, meaning that the sociability subscale could hide
the effects of these fundamental influences in (he analysis of the
data. Finally, in addition to the consistent problems with social
situation variables, there were also sporadic signs of item bias in
relation to morbidity variables: bed days, functional ability and
psychological distress.
In light of the theoretical concerns and the results of the
validation analysis, it was necessary to conclude (hat the indi­
vidual items rather than the composite scale or the subscales.
would have to be included in the multivariate analyses for a valid
study of relationships between social network, social support.
socioeconomic status and health variables.
Elaboration of levels and types of influence
Since the goal of this research is to study direct and indirect
relationships among different types of variables, statistical meth­
ods are needed that can elaborate interrelationships among many
complex categorical variables and test for levels of influence.
28

Most widely used statistical procedures cannot achieve this goal.
The procedures used in (he study are based on mathematical graph
models (10). These procedures allow a theoretically derived
structure to be given to the analysis of the data. Using a
theoretically derived analytical model permits an examination ol
complex relationships, while minimizing the number of falla­
cious correlations that can be produced by statistical modelling.
Only preliminary results are now available, but they allow
some conclusions to be drawn about the inconsistencies in the
social support literature. The most relevant findings concern the
interrelationships among the social support and social situation
variables. Married people reported a greater number of close
relatives and more often were members of a church. They also
reported higher incomes. Being a member of a church was in turn
independently related to the total number of friends and relatives.
to the number ol close relatives and to the number of close friends.
Church membership was also related to alcohol and tobacco
consumption, but not to health variables.
The nature of the relationships differed considerably lot
women and men. While the relationship between marital status
and income held for both women and men, a smaller proportion of
women was married. Also, marital status and financial problems
were related for women, but not for men. Interactions among
behavioural, social network and socioeconomic variables also
differed in fundamental ways for men and women.
In short, social network variables that had been included as
items in the subscales of the composite scale were related to
socioeconomic variables. At the same time, both types of variable
were statistically related to behavioural habits that may affect
health. The findings illustrate clearly how easily different types
of influences in the life situation arc confounded in statistical
scaling and modelling.

Facing or avoiding complexity in research on health
What conclusions can be drawn from these preliminary findings
about the major issues in the social support literature? Does
29

integration in a social network predict health outcomes? Is
integration more or less important than network support in buff­
ering stress? Do relationships between social network variables
and morbidity or mortality remain after controlling for personal
functioning? The most important conclusion to draw from the
findings is that these are the wrong questions. These questions
and similar ones in discussions of inconsistent findings from
research on other types of risk factor arise from a narrow scientific
model that concentrates on direct causal effects. The deductive
experimental model has been viewed as the method providing the
greatest scientific rigour in most research on health in the twenti­
eth century. This method, borrowed from the natural sciences.
seeks to predict cause-and-effect relationships.
In survey research on populations, the influence of (he
reductionistic scientific model has taken the form of analysing
risks or predicting outcomes while controlling for other factors
that might account for the findings. Most research on health now
acknowledges that the factor under consideration is not the only
causal influence. Nevertheless, it remains the focus of attention in
most instances. Even when several factors are examined, they ate
generally treated as independent. This happens both because of
the focus on cause and effect in positivistic thinking and because
widely used statistical models are incapable of dealing with
complexity.
It is not surprising that social support has become both a
popular and a disputed subject in health research. Intuitively,
everyone who has worked in health realizes the importance of the
social network. At the same time, it is the type of research topic
least amenable to cause-and-effect thinking and to static quantita­
tive analytic models.

Contextual research: the health promotion
challenge
Contextual research is both extremely important for promoting
the health of populations and particularly vulnerable to confound­
ing in measurement. The natural sciences, from which reductionistic
30

methods were adopted, have moved beyond the type of causal
thinking still prevalent in research on health. Since Niels Bohr
illustrated the illusion of controllable measurement processes, it
has been recognized that the parts of a phenomenon cannot
meaningfully be separated. Discrete causes and discrete out­
comes, useful to consider for some heuristic purposes, have little
to do with the dynamic, complex processes that create and
maintain human health (11). Research on social support and
health may be taken as a case in point.
Tire composite scale described above is an attempt to create a
tool for use in predicting health outcomes. Such a scale is used in
many investigations of the influence of the social network on
health. The goal of predicting health outcome is often achieved,
particularly when the outcome is death. This is not at all
surprising, since, as the scale validation findings show, this type
of scale hides or distorts the effects of other types of variables that
either affect health or are affected by declining health.
These considerations highlight two issues in health promotion
research. The first has to do with the confusion created by the
excessive preoccupation with prediction in health research. The
overemphasis on predicting statistical effects, in contrast with the
elaboration of the interrelationships of variables, has limited
rather than expanded knowledge.
Numerous risk factors for disease have been identified (over
246 for coronary heart disease alone (12). In research and
programmes concerned with these risks, causation is often im­
plied, even though it is well known that finding a statistical
relationship between a factor and a pathological deviation (even
when major confounding or contributing factors are controlled
for, which is seldom done) does not mean that the factor causes
the deviation. Multicausal processes lead to disease, and a single
factor may be either part of the interacting processes or simply
spuriously correlated with some causal influence not included in
the study (13).
The public intuitively recognizes these problems. Popular
reactions to the escalation of risk factors have begun to appear,
exemplified by an article in a Danish newspaper with tire headline

31

Ol(-6lO

“informationssyge skadersundheden" (a play on words, meaning
that sickness in health information damages health). The subject
of (he article was the contusing information with which the
population is constantly bombarded. A drawing showed a man
with his eyes shut tightly and ears covered, surrounded by a
printed message growing larger and larger and saying that smok­
ing causes lung cancer. A similar report recently appeared on an
international television broadcast. A car bumper sticker with the
message “life is a risk for cancer" had begun to appear in the
United States. The report pointed out that the sticker revealed that
the more important messages can no longer get through the
barrage of confusing information. The general population may
not have access to information on the research issues, but people
know well that spry' old Aunt Jane and Cousin Tom have been
exposed to risks A, C or Z for 30 to 40 years or more.
Ironically, the message on the bumper sticker calls attention
to another issue that needs to be considered in health promotion
research: the meaningfulness of mortality as a health indicator.
Mortality might be a useful indicator in studies of traffic accidents
or suicides. Death rales, particularly in infants, can tell a great
deal about the level of development of a society, but almost
nothing about the processes involved in the preservation or
breakdown of human health. At best, death can be seen as the
final consequence of multiple assaults on the biopsychosocial
organism" over the course of life (14).
These are reasons why research on social support and health
should focus on processes of influence rather than predicting
statistical effects. An understanding of the parallel and relative
influences on health of the social network and social support
requires that network structure, social contact, instrumental sup­
port. psychosocial support and other aspects of the social environ­
ment be disentangled from each other and from variables measur­
ing personal social functioning. Thereafter, they can be fruitfully

“ Ttiis term, which is coming into use, reflects tlie social and psychologi­
cal as well as the biological aspects of human beings.

32

examined, along with socioeconomic and cultural influences,
using research designs and methodological approaches that can
study the social contexts that create and maintain health.
The statistical analysis of complex forces affecting health
should be conducted with methods that can focus on the interrela­
tionships of variables. The limits of all statistical procedures need
to be recognized in testing and reformulating theories. Only
interdisciplinary work and a range of methodological approaches
can build a body of knowledge on the complex influences shaping
health.

References
I.

2.
3.

4.

5.
6.
7.
8.

Cohen, S. & Syme. S. Issues in the study and application of
social support. In: Cohen. S. & Syme, S., ed. Social support
and health. Orlando. FL. Academic Press, 1985.
Henderson, S. Interpreting the evidence on social support.
Social psychiatry, 19: 49 (1984).
Berkman, L. Assessing the physical health effects of social
networks and social support. Annual review ofpublic health,
5: 413 (1984).
Berkman, L. Social networks, support and health: taking the
next step forward. American journal of epidemiology. 123:
559 (1986).
Dean, K. Social support and health: pathways of influence.
Health promotion. /: 33 (1986).
Schoenbock, V. et al. Social ties and mortality in Evans
County. American journal of epidemiology, 123: 577 (1986).
House, .1. et al. Social relationships and health. Science. 241:
540 (1988).
U.S. National Center of Health Statistics. Public use data
tape documentation. National survey ofpersonal health prac tices and consequences. Hyattsville. MD. Office of Health
Research, Statistics and Technology, US Department of Health
and Human Services. 1982.

33

Kreiner, S. Validation of index scales for analysis of survey
data. Paper presented to the Workshop on Methodological
Problems and New Methods for the Analysis of Population
Survey Data. April 1990. Copenhagen. WHO Regional Office
for Europe. 1990 (document).
10. Whittaker. J. Graphical models in applied multivariate sta­
tistics. New York. NY. John Wiley & Sons, 1990.
11. Kickbusch. 1. & Dean, K. Research for health: challengefor
the nineties. Amsterdam. Elsevier (in press).
12. Hopkins, P. & Williams. R. A survey of 246 suggested
coronary risk factors. Atherosclerosis, 40: 1 (1981).
13. Dean, K. Nutrition education research in health promotion.
Journal ofthe Canadian Dietetic Association. 51: 481 (1990).
14. Dean, K. Research for health promotion: issues for the future.
In: Kelleher. C.. ed. The futut e of health promotion: Proceed­
ings of the Launch Conference of the Cent/ e for Health
Promotion Studies. Galway. Social Science Research Centre
Publications (in press).

9.

34

The Sundsvall Declaration on
Supportive Environments
Sundsvall statement on
supportive environments for health
The Third International Conference on Health Promotion: Sup­
portive Environments for Health — the Sundsvall Conference —
fits into a secpience of events which began with the commitment of
WHO to the goals ofHealth For All (1977). This was followed by
the UN1CEF/WHO International Conference on Primary Health
Care, in Alma-Ata (1978), and the First International Confer­
ence on Health Promotion in Industrialized Countries, in Ottawa
(1986). Subsequent meetings on Healthy Public Policy, in
Adelaide (1988) and a Call for Action: Health Promotion in
Developing Countries, in Geneva (1989) have further clarified
the relevance and meaning of health promotion. In parallel with
these developments in the health arena, public concern over
threats to the global environment has grown dramatically. This
was clearly expressed by the World Commission on Environment
and Development in its report Our Common Future, which
provided a new understanding of the imperative of sustainable
development.

The Third International Conference on Health Promotion:
Supportive Environments for Health - the first global conference
on health promotion, with participants from 81 countries — calls
upon people in all parts of the world to engage actively in making
environments more supportive to health. Examining today’s
35

health and environmental issues together, the Conference pointed
out that millions of people are living in extreme poverty and
deprivation in an increasingly degraded environment that threat­
ens their health, making the goal of Health For All by the Year
2000 extremely hard to achieve. The way forward lies in making
the environment - the physical environment, the social and
economic environment, and the political environment — support­
ive to health rather than damaging to it.
The Sundsvall Conference identified many examples and
approaches for creating supportive environments that can be used
by policy-makers, decision-makers and community activists in
the health and environment sectors. The Conference recognized
that everyone has a role in creating supportive environments for
health.

A call for action
This call for action is directed towards policy-makers and deci­
sion-makers in all relevant sectors and at all levels. Advocates and
activists for health, environment and social justice are urged to
form a broad alliance towards the common goal of Health For All.
We Conference participants have pledged to take this message
back to our communities, countries and governments to initiate
action. We also call upon the organizations of the United Nations
system to strengthen their cooperation and to challenge each other
to be truly committed to sustainable development and equity.
A supportive environment is of paramount importance for
health. The two are interdependent and inseparable. We urge that
the achievement of both be made central objectives in the setting
of priorities for development, and be given precedence in resolv­
ing competing interests in the everyday management of govern­
ment policies.
Inequities are reflected in a widening gap in health both within
our nations and between rich and poor countries. This is unaccept­
able. Action to achieve social justice in health is urgently needed.
Millions of people are living in extreme poverty and deprivation
in an increasingly degraded environment in both urban and rural
36

areas. An unforeseen and alarming number of people suffer from
the tragic consequences of armed conflicts for health and welfare.
Rapid population growth is a major threat to sustainable develop­
ment. People must survive without clean water or adequate food,
shelter and sanitation.
Poverty frustrates people’s ambitions and their dreams of
building a better future, while limited access to political struc­
tures undermines the basis for self-determination. For many,
education is unavailable or insufficient, or, in its present forms,
fails to enable and empower. Millions of children lack access to
basic education and have little hope of a better future. Women, the
majority of the world’s population, are still oppressed. They are
sexually exploited and suffer from discrimination in the labour
market and many other areas which prevents them from playing a
full role in creating supportive environments.
More than a billion people worldwide have inadequate access
to essential health care. Health care systems undoubtedly need to
be strengthened. The solution to these massive problems lies in
social action for health and the resources and creativity of indi­
viduals and their communities. Releasing this potential requires
a fundamental change in the way we view our health and our
environment and a clear, strong political commitment to sustain­
able health and environmental policies. The solutions lie beyond
the traditional health system.
Initiatives have to come from all sectors that can contribute to
the creation of supportive environments for health, and must be
acted on by people in local communities, nationally by govern­
ment and nongovernmental organizations, and globally through
international organizations. Action will involve predominantly
such sectors as education, transport, housing and urban develop­
ment, industrial production and agriculture.

Dimensions of action
on supportive environments for health
In a health context the term supportive environments refers to
both the physical and the social aspects of our surroundings. It
37

encompasses where people live, their local community, their
home, where they work and play. It also embraces the framework
which determines access to resources for living, and opportunities
for empowerment. Thus action to create supportive environments
has many dimensions: physical, social, spiritual, economic and
political. Each of these dimensions is inextricably linked to the
others in a dynamic interaction. Action must be coordinated at
local, regional, national and global levels to achieve solutions that
are truly sustainable.
The conference highlighted four aspects of supportive envi­
ronments:

1. The social dimension, which includes the ways in which
norms, customs and social processes affect health. In many
societies traditional social relationships are changing in ways that
threaten health, for example, by increasing social isolation, by
depriving life of a meaningful coherence and purpose, or by
challenging traditional values and cultural heritage.
2. The political dimension, which requires governments to
guarantee democratic participation in decision-making and the
decentralization of responsibilities and resources. It also requires
a commitment to human rights, peace, and a shifting of resources
from the arms race.
3. The economic dimension, which requires a re-channelling of
resources for the achievement of Health For All and sustainable
development, including the transfer of safe and reliable technol­
ogy-

4. The need to recognize and use women’s skills and know­
ledge in all sectors, including policy-making, and the economy,
in order to develop a more positive infrastructure for supportive
environments. The burden of the workload of women should be
recognized and shared between men and women. Women’s com­
munity-based organizations must have a stronger voice in the
development of health promotion policies and structures.
38

Proposals for action
The Sundsvall Conference believes that proposals to implement
the Health For All strategies must reflect two basic principles:
1. Equity must be a basic priority in creating supportive envi­
ronments for health, releasing energy and creative power by
including all human beings in this unique endeavour. All policies
that aim at sustainable development must be subjected to new
types of accountability procedures in order to achieve an equitable
distribution of responsibilities and resources. All action and
resource allocation must be based on a clear priority and commit­
ment to the very poorest, alleviating the extra hardship borne by
the marginalized, minority groups, and people with disabilities.
The industrialized world needs to pay the environmental and
human debt that has accumulated through exploitation of the
developing world.

2. Public action for supportive environments for health must
recognize the interdependence of all living beings, and must
manage all natural resources taking into account the needs of
coming generations. Indigenous peoples have a unique spiritual
and cultural relationship with the physical environment that can
provide valuable lessons for the rest of the world. It is essential
therefore that indigenous peoples be involved in sustainable
development activities and negotiations be conducted about their
rights to land and cultural heritage.

It can be done: strengthening social action
A call for the creation of supportive environments is a practical
proposal for public health action at the local level, with a focus on
settings for health that allow for broad community involvement
and control. Examples from all parts of the world were presented
at the Conference in relation to education, food, housing, social
support and care, work and transport. They clearly showed that
supportive environments enable people to expand their capabili­
ties and develop self-reliance. Further details of these practical
proposals are available in the Conference report and handbook.
39

Using die examples presented, the Conference identified four
key public health action strategies to promote the creation of
supportive environments at community level.

1. Strengthening advocacy through community action, par­
ticularly through groups organized by women.
2. Enabling communities and individuals to take control over
their health and environment through education and empower­
ment.

3. Building alliances for health and supportive environments in
order to strengthen the cooperation between health and environ­
mental campaigns and strategies.

4. Mediating between conflicting interests in society in order to
ensure equitable access to supportive environments for health.
In summary, empowerment of people and community partici­
pation were seen as essential factors in a democratic health
promotion approach and the driving force for self-reliance and
development.
Participants in the Conference recognized in particular that
education is a basic human right and a key element to bring about
the political, economic and social changes needed to make health
a possibility for all. Education should be accessible throughout
life and be built on the principle of equity, particularly with
respect to culture, social class and gender.

The global perspective
Humankind forms an integral part of the earth’s ecosystem.
People’s health is fundamentally interlinked with the total envi­
ronment. All available information indicates that it will not be
possible to sustain the quality of life, for human beings and all
living species, without drastic changes in attitudes and behaviour
at all levels with regard to the management and preservation of the
environment.

40

Concerted action to achieve a sustainable, supportive envi­
ronment for health is the challenge of our times.
At the international level, large differences in per capita
income lead to inequalities not only in access to health but also in
the capacity of societies to improve their situation and sustain a
decent quality of life for future generations. Migration from rural
to urban areas drastically increases the number of people living in
slums, with accompanying problems including a lack of clean
water and sanitation.
Political decision-making and industrial development are too
often based on short-term planning and economic gains, which do
not take into account the true costs to our health and the environ­
ment. International debt is seriously draining the scarce resources
of the poor countries. Military expenditure is increasing, and war,
in addition to causing deaths and disability, is now introducing
new forms of ecological vandalism.
Exploitation of the labour force, the exportation and dumping
of hazardous waste and substances, particularly in the weaker and
poorer nations, and the wasteful consumption of world resources
all demonstrate that the present approach to development is in
crisis. There is an urgent need to advance towards new ethics and
global agreement based on peaceful coexistence to allow for a
more equitable distribution and utilization of the earth’s limited
resources.

Achieving global accountability
The Sundsvall Conference calls upon the international commu­
nity to establish new mechanisms of health and ecological ac­
countability that build on the principles of sustainable health
development. In practice this requires health and environmental
impact statements for major policy and programme initiatives.
WHO and UNEP are urged to strengthen their efforts to develop
codes of conduct on the trade and marketing of substances and
products harmful to health and the environment.
WHO and UNEP are urged to develop guidelines based on the
principle of sustainable development for use by Member States.
41

All multilateral and bilateral donor and funding agencies such as
the World Bank and International Monetary Fund are urged to use
such guidelines in planning, developing and assessing develop­
ment projects. Urgent action needs to be taken to support develop­
ing countries in developing their own solutions. Close collabora­
tion with nongovernmental organizations should be ensured
throughout the process.
The Sundsvall Conference has again demonstrated that the
issues of health, environment and human development cannot be
separated. Development must imply improvement in the quality
of life and health while preserving the sustainability of the
environment.
The Conference participants therefore urge the United Na­
tions Conference on Environment and Development (UNCED),
to be held in Rio Janeiro in 1992, to take the Sundsvall Statement
into account in its deliberations on the Earth Charter and Agenda
21, which is to be an action plan leading into the 21st century.
Health goals must figure prominently in both. Only worldwide
action based on global partnership will ensure the future of our
planet.

This Statement was adopted on 15 June 1991 in Sundsvall,
Sweden, by participants at the Third International Conference on
Health Promotion: Supportive Environmentsfor Health, the first
global conference on the interdependence between health and
environment in its physical, cultural, economic and political
dimensions.

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