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Part I: Looking forward / looking back – reflections from across the province and the country on the year that was, and what lies in store

I Introduction
II Good King Wenceslas: An Annotated Carol for the 2010 Season
III Is the Renaissance of Health Promotion at Hand?
IV Public Health Agency of Canada – Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention
V 100 Years of Public Health
VI Canadian Virtual Health Promotion – Marketing Risk Reduction or Collaborative Action?
VII  Reflections on Behaviour Change and Interventions that Work

I Introduction

Each year the OHPE invites organizations and individuals working in health promotion in Ontario and across the country to reflect on the past 12 months and muse about the coming year. This is the first part of the reflections piece and the final OHPE feature for 2010. The second half of the reflections will run on the January 7, 2010.

II Good King Wenceslas: An Annotated Carol for the 2010 Season
 – Traditional lyrics, with notes from Michael Shapcott, Director, Affordable Housing and Social Innovation, The Wellesley Institute

Sing brightly:
Good King Wenceslas looked out on the feast of Stephen
When the snow lay round about deep and crisp and even
Brightly shone the moon that night though the frost was cruel
When a poor man came in sight gath'ring winter fuel

The cruel reality:
Winter fuel – and energy through the rest of the year – is a growing concern. Statistics Canada reported in October 2010 that the cost of energy is the fastest growing component of inflation. Energy prices rose 9.1% year-over-year – four and one-half times higher than the overall Consumer Price Index. Sky rocketing energy costs make it harder for lower-income households to heat their homes in the winter, and to cool them during extreme heat in the summer. Energy poverty is a growing concern for Canadians anxious to maintain healthy housing.

Sing brightly:
“Hither, page, and stand by me if thou know'st it, telling
Yonder peasant, who is he? Where and what his dwelling?”
“Sire, he lives a good league hence underneath the mountain
Right against the forest fence By Saint Agnes' fountain.”

The cruel reality:
Finding a good, healthy home is an increasing challenge. The Wellesley Institute’s Precarious Housing in Canada 2010 reported in August 2010 that 1.5 million households are living in substandard, unaffordable and/or inadequately housing. The REACH3 research alliance reported in November 2010 that for every person sleeping in a homeless shelter, there were 23 others in vulnerable circumstances.

Sing brightly:
“Bring me flesh and bring me wine bring me pine logs hither
Thou and I will see him dine when we bear him thither.”
Page and monarch forth they went forth they went together
Through the rude wind's wild lament and the bitter weather

The cruel reality:
HungerCount2010 in November of 2010 reported that 867,948 Canadians were forced to use food banks in March of 2010 – an increase of 9% over the previous year and the highest number ever on record. Toronto’s Daily Bread Food Bank reported in September a record-breaking 1.2 million client visits to food banks in the GTA in the most recent year.

Sing brightly:
“Sire, the night is darker now and the wind blows stronger
Fails my heart, I know not how, I can go no longer.”
“Mark my footsteps, my good page Tread thou in them boldly
Thou shalt find the winter's rage freeze thy blood less coldly.”

The cruel reality:
The REACH3 study in November 2010 found that people who are vulnerably housed face the same severe health problems as those who are homeless, including: Serious physical and mental health problems; problems accessing the health care they need; hospitalization; assault; and going hungry. The Wellesley Institute’s Precarious Housing in Canada 2010 summarizes a large number of research and policy reports that link poor housing to poor health, and also research that shows that good housing leads to better health outcomes.

Sign brightly:
In his master's steps he trod where the snow lay dinted
Heat was in the very sod which the Saint had printed
Therefore, Christian men, be sure wealth or rank possessing
Ye who now will bless the poor shall yourselves find blessing.

The cruel reality:
Campaign 2000 reported in November 2010 that 412,000 children and youth under 18 were living in poverty in 2008 across Ontario, and that the number would likely be higher today due to the impact of the recession. The Ontario Association of Food Banks (OAFB) reported in November of 2008 that poverty has a significant cost for governments, estimating that the federal and Ontario government are losing at least $10.4 billion to $13.1 billion a year due to poverty, a loss equal to between 10.8 to 16.6 per cent of the provincial budget. OAFB also reported that poverty has a very significant total economic cost in Ontario. When both private and public (or social) costs are combined, the total cost of poverty in Ontario is equal to 5.5 to 6.6 per cent of Ontario’s Gross Domestic Product (GDP). Meanwhile, the Organization for Economic Co-operation and Development reported in October of 2008 that poverty and income inequality increased rapidly in Canada starting in the mid-1990s, adding: “In the last 10 years, the rich have been getting richer leaving both middle and poorer income classes behind. The rich in Canada are particularly rich compared to their counterparts in other countries.”

References:

Statistics Canada: Consumer Price Index, October 2010
http://www.statcan.gc.ca/daily-quotidien/101123/dq101123a-eng.htm

The Wellesley Institute: Precarious Housing in Canada 2010
http://www.wellesleyinstitute.com/news/affordable-housing-news/new-repor...

REACH3: Health in Housing Transition Study, November 2010
http://www.homelesshub.ca/ResourceFiles/HousingVulnerabilityHealth-REACH...

Canadian Association of Food Banks: Hunger Count 2010
http://foodbankscanada.ca/main2.cfm?id=107185CB-B6A7-8AA0-6FE6B5477106193A

Daily Bread Food Bank: Who’s Hungry 2010
http://www.dailybread.ca/learningcentre/documents/DBFB-0015-10WhosHungry...

Campaign 2000 Ontario: 2010 Report Card
http://www.campaign2000.ca/reportCards/provincial/Ontario/2010OntarioRep...

Ontario Association of Food Banks: The Cost of Poverty
http://www.oafb.ca/assets/pdfs/CostofPoverty.pdf

Organisation for Economic Co-operation and Development: Growing Unequal
http://www.oecd.org/dataoecd/44/48/41525292.pdf

III Is the Renaissance of Health Promotion at Hand?
– Submitted by Dr. Irv Rootman

Last year, my reflections on health promotion were entitled “2009: A bad year for health promotion? Will 2010 be better?” The short answers to these two questions were “yes” and “perhaps.” As I reflect on my answers, one year later, I think that I was correct on both counts. Nothing happened in 2010 that would make me change my mind about 2009 and some of the things that happened in 2010, for example, the fact that there was no 2010 Ontario Health Promotion Summer School, confirm my sense that some of the happenings in 2009 would have negative reverberations into the future.

On the other hand, various organizations and health promotion initiatives in Canada that I noted as positive features of the field continued to operate in 2010 giving the field some presence and influence. However, as far as I know, no individual or organization stepped forward into the national leadership gap that I expressed concern about, although Trevor Hancock and the Population Health Promotion Committee that he chairs did do some good work. Having said that, I still remain hopeful that “there will be a renaissance in health promotion in this country and that it will take its rightful place among the key strategies for creating a healthier Canada.”

One of the reasons for this optimism is the fact that health promotion may find some of the momentum for its renewal in Canada through a growing interest in “health literacy,”  which Don Nutbeam suggested was an outcome of health promotion which people in the field could and should be held accountable for. As an active participant and observer of work going on in health literacy in Canada and internationally, it is very encouraging to see that Canada is considered to be a leader in this area and that there are a number of recent and current innovative initiatives in Canada which will help to confirm this leadership role. One example is the BC Health Literacy Prototype Collaborative in Health Literacy which developed a model and some useful tools for integrating health literacy in primary care practice and is currently being considered for adoption in other provinces. Another example is the Public Health Agency of Canada funded and Nova Scotia led project on embedding health literacy in existing initiatives which is being carried out in sites in three different provinces. In addition, over the past year, there have been initiatives to establish coordinating bodies for health literacy at provincial and national levels. Moreover, all of these initiatives have a very strong health promotion perspective that emphasizes the context and environment in which individuals are asked to make health decisions. Thus health literacy could very well be a “Trojan Horse” for increasing the influence of health promotion in Canada.  Finally, the Conference celebrating the 25th Anniversary of the Ottawa Charter for Health Promotion in June 2011 may put health promotion back on the national stage and contribute to its renaissance.

IV Public Health Agency of Canada – Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention
– Submitted by Nina Jetha

Over the past year, the Canadian Best Practices Portal (CBPP) team has been working hard to further develop the content included on the site, including both the expansion and addition of current “hot topics” in public health in Canada. Most recently, we have added a collection of interventions and programs geared towards health promotion and chronic disease prevention in Lesbian, Gay, Bisexual, Transgender, and Transsexual, 2-Spirit, Intersex, Queer, and Questioning (LGBTT2IQQ) populations.

We also enhanced the area of injury prevention interventions with the completion of two contracts related to falls prevention: falls prevention for seniors in residential care facilities, and falls prevention for adults during everyday activities and on snow and ice. Other content added over the past year includes interventions in the fields of senior’s mental health promotion, family violence prevention, gambling prevention, food security, and oral health promotion.

New features that have been added to the Portal to create a more interactive experience include a tool to help users choose the evidence-related website needed to meet their planning and evaluation needs, and a simultaneous search link to Health-Evidence.ca to enable a larger variety of resource options. The resource section on the Portal has also been revised to include resources that are “how-to” tools aligned around the National Collaborating Centre for Methods and Tool’s Evidence-Informed Public Health Framework.

As the CBPP moves towards Phase 3.0 of development, focus will be on enhancing the content to ensure it is the highest standard possible. A number of content areas have been identified as priorities for further development including social determinants of health (e.g., prevention of poverty); obesity prevention and mental health promotion across the lifespan. Providing the CBPP user with succinct summaries of the evidence coupled with examples of interventions will be offered in the coming year.

Please visit the Canadian Best Practices Portal for Health Promotion and Chronic Disease Prevention to see and take part in this dynamic site: http://www.phac.gc.ca/cbpp

V 100 Years of Public Health
– Submitted by Peggy Edwards, health promotion consultant

In 2010 the Canadian Public Health Association led a campaign to celebrate 100 years of public health in Canada. The materials produced for this occasion are remarkable. Don’t miss the Centenary web site (http://www.cpha100.ca) where you can view videos, profiles, the marvelous virtual exhibit, sound bites from the past and in depth information about Canada’s great 12 public health achievements and some of the milestones for each achievement. You can download for free and read online the interactive e-book This is Public Health: A Canadian History. This book provides a chronological history from the early colonial period until 1986, when the Ottawa Charter for Health Promotion launched what many consider to be a new era in public health. The epilogue, written by Dr. John Last, takes a look at more recent years.

The development of Canada’s Top 12 Achievements in Public Health (1910 – 2010) was an engaging and central piece in documenting the history of public health. Why 12 when the US came up with 10 in a similar exercise in the Year 2000? Because – I am proud to say – universal policies and acting on the social determinants of health were an important part of Canada’s history and the progress that was made.

Since the early 1900s, the average lifespan of Canadians has increased by more than 30 years, and 25 of those years are attributable to advances in public health. Here are the 12 great achievements that helped to make this happen (not in order of importance):
* Safer and healthier foods
* Control of infectious diseases
* Healthier environments
* Vaccination
* Recognition of tobacco use as a health hazard
* Motor-vehicle safety
* Decline in deaths from coronary heart disease and stroke
* Healthier mothers and babies
* Acting on the social determinants of health
* Universal policies
* Safer workplaces
* Family planning.

Reflections on the Future

Albert Einstein said, ”People who believe in physics know that the distinction between past, present, and future is only a stubbornly persistent illusion.” These words make sense to me, though I am not a physicist or even a scientist. As I read This is Public Health: A Canadian History I was struck by the many ways that history does repeat itself, and how the nature of Canada and its geographic and political landscape will continue to shape the future of public health. Even though some of the greatest advances in public health occurred at the community and city levels, a lack of recognition and adequate support for this level persists. So too does the tendency to treat public health as an inconsequential second sister to healthcare until an emergency occurs, the persistent tension between the public good and individual entitlements, and the continuing political wrangling between levels of government.

Regretfully, some of the inequities that were addressed with universal policies and programs in the ‘60s and ‘70s are back with a vengeance. For example, short-sighted policies in housing and employment over the last 30 years have to a large extent negated many of the earlier gains made by low-income families. The shameful inequities in health status and living conditions faced by many Aboriginal Canadians persist.

Other philosophers like Edmund Burke say, “You can never plan the future by the past.” Who could have predicted the massive changes that we have seen and will continue to see related to globalization, breakthrough findings in genomics and other sciences, demographic shifts, climate change, migration patterns and the digital revolution.

I think a lot more now about how we all live on one planet. And how we cannot let inequities ruin the potential of anyone’s present and future well-being, regardless of their age, sex or birthplace. In public health, this means paying more attention to health equity and gender equality, and to ecosystem health, including the built environment in our rapidly urbanizing world. It means increased efforts to protect democracy and make it work, and to combat violence and ensure peace—the very first determinant of health identified in The Ottawa Charter for Health Promotion. The public health infrastructure must work hard to ensure that the vision and actions include meaningful work on the social determinants of health, despite political and sometimes scientific pressure to focus solely on disease, epidemics and emergencies.

Public health activists fought for all of these in the past 100 years, at the same time that researchers, practitioners and educators made remarkable progress in the science and art of public health. Can the future be any different?

VI Canadian Virtual Health Promotion – Marketing Risk Reduction or Collaborative Action?
– Submitted by Alison Stirling

This year I was asked to contribute a brief section on the ‘virtual realm as a health promotion setting’ to the third edition of the Health Promotion in Canada textbook. With a Quebec colleague, we scanned hundreds of Canadian health promotion websites and social media initiatives, reviewed literature and talked with creators and users of virtual HP tools.

We found that most health promotion organizations are using the Internet as a communication tool to promote health, market risk communications and provide expert-selected quality resources. “Quit to Win / Défi J'arrête, j'y gagne!” and similar tobacco control campaigns crossed multiple web media sites to wide-ranging ages and types of audiences. Heart and Stroke Foundation of Ontario offered an extensive online healthy weights behaviour change program, and government, private and non-profit agencies marketed similar campaigns to convince people to reduce their risks and take action on health.

A smaller number, particularly youth serving groups, health foundations and social marketing enterprises, are using interactive Web 2.0 platforms and multi-channel strategies such as blogs, online videos, social networking and virtual forums to share stories, spread news and build action with their community. For example, the Canadian Breast Cancer Foundation (CBCF) uses their Finding Hope blog, videos on YouTube and Twitter to seek support and spread news, and online communities in Facebook and the virtual Wall of Hope for sharing stories and hope among breast cancer survivors.

Although Canadian health promoters are not yet using cell-phones or mobile technologies beyond simple health texting prompts, the future is calling. There are vast opportunities for combining social networking, information alerts and collaboration using these devices and all the tools and sites the virtual realm offers.

Let’s look forward to a scenario in which a non-profit health group receives research findings about the health-enhancing impact of their environmental program. The group goes into action, sending out microblogs (tweets) and SMS text messages to members, posting on its blog and to the social networking site, providing news and asking for input.  The online community responds quickly sharing research, personal stories, health policies and links. An awareness campaign is organized, the main website updated with fact sheets and links to research, a video of stories posted on a sharing site, donations begin through text messaging, and provincial chapters begin to educate and take action, with members contacting policy-makers and researchers by phone, email and SMS. This is the emerging story of Canadian health promotion in the virtual setting.

VII  Reflections on Behaviour Change and Interventions that Work
– Submitted by Larry Hershfield, The Health Communication Unit

The hostess asked how often I do this.

I said “once in a lifetime!”

Why did I do it?

I was away from home. There was social pressure from my colleagues. Others had recommended it to me. The media is saturated with advertising about it.

So what does my getting a pedicure at an Aveda Institute in Denver have to do with my year-end reflections about health promotion?

Because in looking back at my 36 years in the health promotion prevention field, the questions about how and why behaviors change and how to create interventions that work and are adopted, have always been and continue to be burning questions for me and you, my colleagues.

THCU has been hard at work developing tools related to these areas, and we are moving towards releasing some more sophisticated tools.

Creating learning tools has been my passion since 1977 when I was chosen by Health Canada, to join a group of Canadian trainers in a 40-day training and collaboration program.

In developing all the initial THCU workshops and consultations, I was blessed to draw upon the specific content expertise of incredibly talented and experienced practitioners, as well as the many lessons learned during my own in-service training. With my talented THCU colleagues we moved into creating a variety of tools, checklists, tip sheets, and case studies to complement the first wave of our THCU workbooks and the workshops we delivered to bring them to life.

More recently, we have begun developing and expanding online interactive tools, including our very successful Online Health Program Planner (OHPP) which we launched in 2009. We are now working on tools that build upon the OHPP, but add a whole new level of advice-giving and decision supports that manifest the wisdom of many health promotion experts. Relevant work includes the expansion of OHPP to include sample plans guiding the implementation of the Ministry of Health Promotion and Sport’s Ontario Public Health Standards, an initiative supported by the Ontario Agency for Health Protection and Promotion. We are also working on tools that will capture the wisdom of the field through expert panels and ongoing input from our users.

We have reached out to key partners to help further the work, including Drs. Larry Green (Precede-Proceed Model - http://www.lgreen.net/precede.htm) and Kay Bartholomew (Intervention Mapping Approach - http://interventionmapping.com OR http://www.josseybass.com/WileyCDA/WileyTitle/productCd-078797899X.html)

I heartily recommend Intervention Mapping Approach to you: this systematic method incorporates the well known and very helpful Precede-Proceed diagnostics, offers a range of theories at all ecological levels, and resolutely addresses adoption/implementation/sustainability issues.

So, next year, all things being equal, I hope to reflect on more pro-health personal lifestyle changes, as well as the release of exciting and useful new tools.